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Repair of Pulmonary Valve Insufficiency Using an Autologous Monocusp
Repair of Pulmonary Valve Insufficiency Using an Autologous Monocusp L. Douglas Cowgill, M.D., David N. Campbell, M.D., Leslie Kelminson, M.D., and DaGd R. Clarke, M.D.
ABSTRACT A 3%-year-old boy experienced right ventricular failure approximately two years after an operation for critical pulmonic stenosis. Severe pulmonary and tricuspid valvular insufficiency was documented echocardiographically and at cardiac catheterization. Treatment consisted of a tricuspid valve annuloplasty and creation of an autologous monocusp valve using the anterior wall of the pulmonary artery. The procedure was well tolerated, and early competence of the pulmonary valve was shown intraoperatively by pressure recordings and postoperatively by Doppler echocardiography. However, at recatheterization one year later, there was no evidence that the monocusp valve was functioning. This experience does not support the prior successful application of this technique in animals. Pulmonary valve insufficiency following operations on the pulmonary valve is usually well tolerated. There is a subset of patients, however, including those with distal pulmonary stenosis, pulmonary hypertension, associated tricuspid insufficiency, or poor right ventricular function, who may experience right ventricular failure secondary to pulmonary regurgitation. Methods of repair, such as valve replacement, valve conduits, or monocusp patches, create another set of problems. A technique reported by Iacobone and colleagues [l]involved construction of an autologous monocusp pulmonary valve in a series of dogs. We report the application of this technique in a child.
A 3%-year-old boy was seen with progressive cardiomegaly noted on routine chest roentgenogram. Past medical history was important for critical pulmonic stenosis that had been treated surgically at another institution when the child was 14 months of age. Preoperative cardiac catheterization at that time revealed severe pulmonic stenosis, no tricuspid insufficiency, and patent foramen ovale. Pulmonary valvotomy with partial valvectomy and closure of the patent foramen ovale was performed, and postoperative recovery was uneventful. The child had done well, with normal growth and exerFrom the University of Colorado School of Medicine, Denver, CO. Accepted for publication Dec 21, 1985. Address reprint requests to Dr.Clarke, Cardiothoracic Surgery, University of Colorado Health Sciences Center, 4200 E. 9th Ave XC310, Denver, CO 80262.
587 Ann Thorac Surg 42587-589, Nov 1986
cise tolerance, until the follow-up examination revealed the severe cardiomegaly. Physical examination showed a healthy-appearing 14.4-kg child with a blood pressure of 80/50mm Hg, a pulse of llO/min, and respirations of 20/min. Chest examination revealed a median sternotomy scar, lung fields clear to auscultation, and a to-and-fro murmur loudest along the left sternal border. The liver was palpable 4 cm below the right costal margin. Chest roentgenogram and electrocardiogram revealed right atrial and ventricular enlargement. Echocardiography and cardiac catheterization confirmed the presence of severe pulmonary and tricuspid regurgitation without significant stenosis. Pressures were 2316 mm Hg in the main pulmonary artery (mean, l l ) , 30/8 mm Hg in the right ventricle, and 9 (mean) mm Hg with a V wave of 14 in the right atrium. Operation was performed electively using total cardiopulmonary bypass, moderate hypothermia, and potassium cardioplegic myocardial preservation. The level of the incision to be made in the pulmonary artery was determined by first noting the diameter of the main pulmonary artery and then measuring an identical distance from the pulmonic valve annulus to the level of arteriotomy. An arching incision was then made transversely along the anterior aspect of the pulmonary artery, halfway around its circumference (Fig 1).The proximal flap created was then reflected posteriorly, where it would serve subsequently as a monocusp valve. A previously prepared pericardial patch was then used to cover this defect; the patch was sewn well down toward the annulus proximally to allow a sufficient anterior pulmonary artery flap to approximate the posterior wall during diastole (Fig 2). During placement of this patch, attention was directed toward folding both corners of the monocusp to fix the "valve" tissue in a diastolic position. A DeVega tricuspid annuloplasty completed the procedure. Right ventricular and pulmonary artery pressures following termination of bypass revealed a slight gradient with restoration of pulmonary valve competence, indicated by a pulmonary artery diastolic pressure of 13 mm Hg and a right ventricular diastolic pressure of 1 mm Hg (Fig 3). Postoperative recovery was smooth, and predischarge Doppler echocardiography revealed a competent pulmonic valve with minimal gradient and slight tricuspid regurgitation. However, at catheterization one year postoperatively, there was no evidence of a functioning pulmonary valve. The pulmonary artery diastolic blood pressure equaled the right ventricular end-diastolic
588 The Annals of Thoracic Surgery Vol 42 No 5 November 1986
L
Fig 1. An arching transverse incision is made in the main pulmonary artery. (Inset) The midpoint of the arch is a distance above the pulmonary valve annulus (a' to b') that is equivalent to the diameter of the main pulmonary artery (a to b).
Fig 2. The proximal portion of the anterior wall of the main pulmonary artery is folded posteriorly, and a pericardial patch is sutured in place to reconstruct the pulmonary artery.
589 Case Report: Cowgill, Campbell, Kelminson, Clarke: Autologous Monocusp Pulmonary Valve
30 15 0 PA
RV
Fig 3. Pressure tracings of pullback from pulmonary artery (PA) to right ventricle (RV) indicating clear difference in diastolic pressure.
blood pressure, and angiography showed wide open pulmonary insufficiency.
Comment Pulmonary insufficiency following operations on the right ventricular outflow tract, though usually well tolerated, may lead to right ventricular failure when associated with increased afterload, tricuspid insufficiency, or decreased right ventricular contractility. The reduced right ventricular function may be caused by marked pulmonary insufficiency, as Bove and colleagues [2] recently demonstrated in a group of patients studied with radionuclide angiography following repair of tetralogy of Fallot lesions. Standard methods to prevent or repair pulmonary insufficiency have included valve replacement, valved conduits, or creation of monocusp patches. Misbach and co-workers (31 used valve replacement, mostly heterograft valves, in 12 patients with progressive pulmonary insufficiency following repair of tetralogy of Fallot with favorable early results (follow-up, 5 months to 3 years). Still, the experience of Laks and colleagues [4], showing the tendency of heterograft valves to calcify and degenerate prematurely in children,
causes some skepticism for its use in the pediatric age group. As reported by Trusler and associates [5], the use of pericardial monocusp valves to repair pulmonary insufficiency also resulted in uniform late failure. Stimulated by the experience of Iacobone and coworkers [l] in a group of dogs, we applied their method of creation of an autologous monocusp valve in the pulmonic position in a child to repair pulmonary valve insufficiency. Advantages of this method include its simplicity and avoidance of the inherent hazards of tissue or mechanical valves. Additionally, the valve is created without incising the right ventricle, which may already be compromised. However, the long-term function of this monocusp valve in our patient was inadequate despite the experience by Iacobone and associates [l]in laboratory animals. With this result, we cannot recommend clinical use of the technique until much more work and long-term follow-up are available in animals. This topic, however, remains an interesting area of study.
References 1. Iacobone G, Mussini C, Noera G, et al: Autologous monocusp pulmonary valve: preliminary results of a new surgical technique. J Thorac Cardiovasc Surg 86:930, 1983 2. Bove EL, Byrum C, Thomas FD, et al: The influence of pulmonary insufficiency on ventricular function following repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 85:691, 1983 3. Misbach G, Turley K, Ebert P: Pulmonary valve replacement for regurgitation after repair of tetralogy of Fallot. Ann Thorac Surg 36:684, 1983 4. Geha A, Laks H, Stansel H, et al: Late failure of porcine valve heterografts in children. J Thorac Cardiovasc Surg 78:351, 1979 5. Trusler G, Iyengar SR, Mustard WT. Reconstruction of the pulmonary valve and outflow tract. J Thorac Cardiovasc Surg 65:245, 1973
ABSTRACT A 3%-year-old boy experienced right ventricular failure approximately two years after an operation for critical pulmonic stenosis. Severe pulmonary and tricuspid valvular insufficiency was documented echocardiographically and at cardiac catheterization. Treatment consisted of a tricuspid valve annuloplasty and creation of an autologous monocusp valve using the anterior wall of the pulmonary artery. The procedure was well tolerated, and early competence of the pulmonary valve was shown intraoperatively by pressure recordings and postoperatively by Doppler echocardiography. However, at recatheterization one year later, there was no evidence that the monocusp valve was functioning. This experience does not support the prior successful application of this technique in animals. Pulmonary valve insufficiency following operations on the pulmonary valve is usually well tolerated. There is a subset of patients, however, including those with distal pulmonary stenosis, pulmonary hypertension, associated tricuspid insufficiency, or poor right ventricular function, who may experience right ventricular failure secondary to pulmonary regurgitation. Methods of repair, such as valve replacement, valve conduits, or monocusp patches, create another set of problems. A technique reported by Iacobone and colleagues [l]involved construction of an autologous monocusp pulmonary valve in a series of dogs. We report the application of this technique in a child.
A 3%-year-old boy was seen with progressive cardiomegaly noted on routine chest roentgenogram. Past medical history was important for critical pulmonic stenosis that had been treated surgically at another institution when the child was 14 months of age. Preoperative cardiac catheterization at that time revealed severe pulmonic stenosis, no tricuspid insufficiency, and patent foramen ovale. Pulmonary valvotomy with partial valvectomy and closure of the patent foramen ovale was performed, and postoperative recovery was uneventful. The child had done well, with normal growth and exerFrom the University of Colorado School of Medicine, Denver, CO. Accepted for publication Dec 21, 1985. Address reprint requests to Dr.Clarke, Cardiothoracic Surgery, University of Colorado Health Sciences Center, 4200 E. 9th Ave XC310, Denver, CO 80262.
587 Ann Thorac Surg 42587-589, Nov 1986
cise tolerance, until the follow-up examination revealed the severe cardiomegaly. Physical examination showed a healthy-appearing 14.4-kg child with a blood pressure of 80/50mm Hg, a pulse of llO/min, and respirations of 20/min. Chest examination revealed a median sternotomy scar, lung fields clear to auscultation, and a to-and-fro murmur loudest along the left sternal border. The liver was palpable 4 cm below the right costal margin. Chest roentgenogram and electrocardiogram revealed right atrial and ventricular enlargement. Echocardiography and cardiac catheterization confirmed the presence of severe pulmonary and tricuspid regurgitation without significant stenosis. Pressures were 2316 mm Hg in the main pulmonary artery (mean, l l ) , 30/8 mm Hg in the right ventricle, and 9 (mean) mm Hg with a V wave of 14 in the right atrium. Operation was performed electively using total cardiopulmonary bypass, moderate hypothermia, and potassium cardioplegic myocardial preservation. The level of the incision to be made in the pulmonary artery was determined by first noting the diameter of the main pulmonary artery and then measuring an identical distance from the pulmonic valve annulus to the level of arteriotomy. An arching incision was then made transversely along the anterior aspect of the pulmonary artery, halfway around its circumference (Fig 1).The proximal flap created was then reflected posteriorly, where it would serve subsequently as a monocusp valve. A previously prepared pericardial patch was then used to cover this defect; the patch was sewn well down toward the annulus proximally to allow a sufficient anterior pulmonary artery flap to approximate the posterior wall during diastole (Fig 2). During placement of this patch, attention was directed toward folding both corners of the monocusp to fix the "valve" tissue in a diastolic position. A DeVega tricuspid annuloplasty completed the procedure. Right ventricular and pulmonary artery pressures following termination of bypass revealed a slight gradient with restoration of pulmonary valve competence, indicated by a pulmonary artery diastolic pressure of 13 mm Hg and a right ventricular diastolic pressure of 1 mm Hg (Fig 3). Postoperative recovery was smooth, and predischarge Doppler echocardiography revealed a competent pulmonic valve with minimal gradient and slight tricuspid regurgitation. However, at catheterization one year postoperatively, there was no evidence of a functioning pulmonary valve. The pulmonary artery diastolic blood pressure equaled the right ventricular end-diastolic
588 The Annals of Thoracic Surgery Vol 42 No 5 November 1986
L
Fig 1. An arching transverse incision is made in the main pulmonary artery. (Inset) The midpoint of the arch is a distance above the pulmonary valve annulus (a' to b') that is equivalent to the diameter of the main pulmonary artery (a to b).
Fig 2. The proximal portion of the anterior wall of the main pulmonary artery is folded posteriorly, and a pericardial patch is sutured in place to reconstruct the pulmonary artery.
589 Case Report: Cowgill, Campbell, Kelminson, Clarke: Autologous Monocusp Pulmonary Valve
30 15 0 PA
RV
Fig 3. Pressure tracings of pullback from pulmonary artery (PA) to right ventricle (RV) indicating clear difference in diastolic pressure.
blood pressure, and angiography showed wide open pulmonary insufficiency.
Comment Pulmonary insufficiency following operations on the right ventricular outflow tract, though usually well tolerated, may lead to right ventricular failure when associated with increased afterload, tricuspid insufficiency, or decreased right ventricular contractility. The reduced right ventricular function may be caused by marked pulmonary insufficiency, as Bove and colleagues [2] recently demonstrated in a group of patients studied with radionuclide angiography following repair of tetralogy of Fallot lesions. Standard methods to prevent or repair pulmonary insufficiency have included valve replacement, valved conduits, or creation of monocusp patches. Misbach and co-workers (31 used valve replacement, mostly heterograft valves, in 12 patients with progressive pulmonary insufficiency following repair of tetralogy of Fallot with favorable early results (follow-up, 5 months to 3 years). Still, the experience of Laks and colleagues [4], showing the tendency of heterograft valves to calcify and degenerate prematurely in children,
causes some skepticism for its use in the pediatric age group. As reported by Trusler and associates [5], the use of pericardial monocusp valves to repair pulmonary insufficiency also resulted in uniform late failure. Stimulated by the experience of Iacobone and coworkers [l] in a group of dogs, we applied their method of creation of an autologous monocusp valve in the pulmonic position in a child to repair pulmonary valve insufficiency. Advantages of this method include its simplicity and avoidance of the inherent hazards of tissue or mechanical valves. Additionally, the valve is created without incising the right ventricle, which may already be compromised. However, the long-term function of this monocusp valve in our patient was inadequate despite the experience by Iacobone and associates [l]in laboratory animals. With this result, we cannot recommend clinical use of the technique until much more work and long-term follow-up are available in animals. This topic, however, remains an interesting area of study.
References 1. Iacobone G, Mussini C, Noera G, et al: Autologous monocusp pulmonary valve: preliminary results of a new surgical technique. J Thorac Cardiovasc Surg 86:930, 1983 2. Bove EL, Byrum C, Thomas FD, et al: The influence of pulmonary insufficiency on ventricular function following repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 85:691, 1983 3. Misbach G, Turley K, Ebert P: Pulmonary valve replacement for regurgitation after repair of tetralogy of Fallot. Ann Thorac Surg 36:684, 1983 4. Geha A, Laks H, Stansel H, et al: Late failure of porcine valve heterografts in children. J Thorac Cardiovasc Surg 78:351, 1979 5. Trusler G, Iyengar SR, Mustard WT. Reconstruction of the pulmonary valve and outflow tract. J Thorac Cardiovasc Surg 65:245, 1973