Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot

Anagnostopoulos, Petros; Azakie, Anthony; Natarajan, Shobha; Alphonso, Nelson; Brook, Michael M.; Karl, Tom R.

doi:10.1016/j.jtcvs.2006.10.039

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 133, Issue 3 , Pages 640-647, March 2007

Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot

Read at the Eighty-sixth Annual Meeting of The American Association for Thoracic Surgery, Philadelphia, Pa, April 29-May 3, 2006.

Petros Anagnostopoulos, MD
- Division of Pediatric Cardiac Surgery, Pediatric Heart Center, University of California at San Francisco Children’s Hospital, San Francisco, Calif
Anthony Azakie, MD
- Division of Pediatric Cardiac Surgery, Pediatric Heart Center, University of California at San Francisco Children’s Hospital, San Francisco, Calif
Shobha Natarajan, MD
- Division of Pediatric Cardiology, Pediatric Heart Center, University of California at San Francisco Children’s Hospital, San Francisco, Calif.
Nelson Alphonso, MD
- Division of Pediatric Cardiac Surgery, Pediatric Heart Center, University of California at San Francisco Children’s Hospital, San Francisco, Calif
Michael M. Brook, MD
- Division of Pediatric Cardiology, Pediatric Heart Center, University of California at San Francisco Children’s Hospital, San Francisco, Calif.
Tom R. Karl, MD
- Division of Pediatric Cardiac Surgery, Pediatric Heart Center, University of California at San Francisco Children’s Hospital, San Francisco, Calif
- Address for reprints: Tom R. Karl, MD, UCSF Department of Surgery, Division of Pediatric Cardiothoracic Surgery, 513 Parnassus Avenue, Suite S-549, Box 0117, San Francisco, CA 94143-0117.

Received 21 April 2006; received in revised form 23 September 2006; accepted 9 October 2006.

Objectives

The transannular patch used to relieve right ventricular outflow tract obstruction in children with tetralogy of Fallot may result in pulmonary insufficiency. We hypothesized that pulmonary valve cusp augmentation with pericardium would decrease pulmonary insufficiency and improve the early outcome for transatrial–transpulmonary tetralogy of Fallot repair requiring transannular patch.

Methods

Since November 2001, 41 patients with tetralogy of Fallot and 2 patients with isolated pulmonary valve stenosis had relief of right ventricular outflow tract obstruction with either a transannular patch plus pulmonary valve cusp augmentation (n = 18) or a transannular patch alone (n = 25). Data were retrospectively collected.

Results

The median age (5.3 vs 3.2 months; P = .09) and weight (6.4 vs 5.2 kg; P = .3) were similar for the cusp augmentation and transannular patch groups, respectively. The diameter of the pulmonary valve annulus (6.4 vs 6.0 mm; P = .57) and the McGoon index (1.47 vs 1.69, P = .75) were also similar. The mean aortic clamp time (48 ± 18 minutes vs 52 ± 19 minutes; P = .46) and median cardiopulmonary bypass time (89 vs 91 minutes; P = .9) did not differ. One patient with a transannular patch died of multiorgan system failure. Patients with a pulmonary valve cusp augmentation had a shorter duration of intubation (1 vs 3 days; P < .001) and intensive care unit stay (2 vs 8 days; P < .001). Thirteen patients with a transannular patch and 1 patient with a pulmonary valve cusp augmentation required inotropic support for more than 72 hours (P = .001). Discharge echocardiograms demonstrated moderate or severe pulmonary insufficiency in 5 patients with a pulmonary valve cusp augmentation and in 21 patients with a transannular patch (P < .001). At 7.5 months, 3 patients (17%) with a pulmonary valve cusp augmentation had progression of pulmonary insufficiency.

Conclusions

Augmentation of a pulmonary valve cusp reduces the incidence of clinically significant postoperative pulmonary insufficiency. This technique may improve the early outcome for children with tetralogy of Fallot requiring a transannular patch.

CTSNet classification: 21, 35

Abbreviations and Acronyms: ICU, intensive care unit, PI, pulmonary insufficiency, RVOT, right ventricular outflow tract, TOF, tetralogy of Fallot, UCSF, University of California at San Francisco