Podemos Acreditar no Ecocardiograma de Rotina para Avaliar o Ventrículo Direito e a Insuficiência Pulmonar? Um Estudo Comparativo com Ressonância Magnética Cardíaca / Can we Trust in Routine Echocardiography to Assess the Right Ventricle and Pulmonary Insufficiency? A Comparative Study with Cardiac Magnetic Resonance

Resumo Fundamento A ressonância magnética cardíaca (RMC) é o método de escolha para avaliar as dimensões e a função do ventrículo direito (VD), e a insuficiência pulmonar (IP). Objetivos Avaliar a acurácia da ecocardiografia bidimensional (ECO 2D) em estimar a função e as dimensões do VD e o grau de IP, e comparar os resultados obtidos pela ECO 2D com os da RMC. Métodos Comparamos os relatórios de ECO e RMC de pacientes cuja indicação para RMC havia sido para avaliar VD e IP. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados Incluímos 51 pacientes com cardiopatia congênita com idade mediana de 9,3 anos (7-13,3 anos). Observou-se uma baixa concordância entre ECO 2D e RMC quanto à classificação da dimensão (Kappa 0,19; IC 95% 0,05 a 0,33, p 0,004) e da função do VD (Kappa 0,16; IC 95% -0,01 a +0,34; p 0,034). O tamanho do VD foi subestimado pela ECO 2D em 43% dos casos, e a função do VD foi superestimada pela ECO 2D em 29% dos casos. O grau de concordância entre os métodos quanto à classificação da IP não foi significativo (Kappa 0,014; IC 95% -0,03 a +0,06; p 0,27). Houve uma tendência de a ECO 2D superestimar o grau da IP. Conclusões A ECO 2D mostrou baixa concordância com a RMC quanto às dimensões e função do VD, e grau de IP. Em geral, a ECO subestimou as dimensões do VD e superestimou a função do VD e o grau de IP quando comparada à RMC.

Abstract Background Cardiac magnetic resonance (CMR) is the method of choice for assessing right ventricular (RV) dimensions and function, and pulmonary insufficiency (PI). Objectives To assess the accuracy of two-dimensional echocardiography (2D ECHO) in estimating RV function and dimensions, and the degree of PI, and compare the 2D ECHO and CMR findings. Methods We compared ECHO and CMR reports of patients whose indication for CMR had been to assess RV and PI. A p-value < 0.05 was considered statistically significant. Results We included 51 congenital heart disease patients, with a median age of 9.3 years (7-13.3 years). There was poor agreement between 2D ECHO and CMR for classification of the RV dimension (Kappa 0.19; 95% CI 0.05 to 0.33, p 0.004) and function (Kappa 0.16; 95% CI -0.01 to +0.34; p 0.034). The RV was undersized by 2D ECHO in 43% of the cases, and RV function was overestimated by ECHO in 29% of the cases. The degree of agreement between the methods in the classification of PI was not significant (Kappa 0.014; 95% CI -0.03 to +0.06, p 0.27). 2D ECHO tended to overestimate the degree of PI. Conclusions The 2D ECHO showed a low agreement with CMR regarding the RV dimensions and function, and degree of PI. In general, ECHO underestimated the dimensions of the RV and overestimated the function of the RV and the degree of PI as compared with CMR.

Short-term outcome of polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of right ventricular outflow tract in tetralogy of fallot: a randomized controlled trial

Abstract Introduction: Reconstruction of right ventricular outflow tract during primary repair of tetralogy of Fallot often requires the placement of a transannular patch which results in pulmonary regurgitation (PR). We compared the short-term outcomes of bicuspid polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of the right ventricular outflow tract. Methods: Thirty consecutive patients undergoing primary repair of tetralogy of Fallot were randomly allocated to two groups - polytetrafluoroethylene valve (PTFEV) group (n=15) and transannular pericardial patch (TAP) group (n=15). The two groups had similar preoperative demographic characteristics. We compared the short-term clinical and echocardiographic outcomes between these groups. The transthoracic echocardiographic follow-up was performed at one week, one month and six months after surgery. Results: The PTFEV group had significantly lower central venous pressure in the immediate postoperative period compared to the TAP group (7.60±2.06 vs. 10.13±1.73, P=0.002). Extubation time was significantly shorter in the PTFEV group compared to the TAP group (12.93±7.55 hrs vs. 22.23±15.11 hrs, P=0.04). PR in the PTFEV group was absent in five patients at 24 hours post-surgery. At the study endpoint, PR was absent in six, trivial in one and mild in eight patients in the PTFEV group compared to TAP group, where all 15 patients had severe PR. Conclusion: The bicuspid polytetrafluoroethylene membrane valves significantly decrease the central venous pressure in the immediate postoperative period, facilitate early extubation and, thus, prevent ventilator-related comorbidities. They achieve a high degree of pulmonary competence and do not increase the right ventricular outflow tract gradient in short-term follow-up.

Implante percutáneo de válvula pulmonar: a propósito de dos casos colombianos / Percutaneous pulmonary valve implant: Two Colombian case reports

Resumen Los pacientes con cardiopatías congénitas que afectan la continuidad del ventrículo derecho con la arteria pulmonar deben someterse con frecuencia a intervenciones debido a la limitada vida útil de los conductos quirúrgicos, lo que lleva al desarrollo de disfunción ventricular derecha por cambios en la geometría ventricular y predisposición a arritmias letales, con el consiguiente riesgo de reintervenciones. El implante valvular percutáneo pulmonar es una nueva alternativa terapéutica, menos invasiva en comparación con la quirúrgica, para pacientes seleccionados. Se realiza una revisión de las publicaciones médicas actuales disponibles y se describe la experiencia inicial del implante valvular pulmonar percutáneo en un centro colombiano de alta complejidad para el tratamiento de enfermedades cardiovasculares, en dos pacientes con disfunción del homoinjerto aórtico en posición pulmonar con doble lesión valvular, en los cuales el implante valvular pulmonar percutáneo fue una conducta exitosa. Se eligió a pacientes con cardiopatías congénitas, conductos quirúrgicos disfuncionales con estenosis o insuficiencia pulmonar significativa, y disfunción y dilatación ventricular derechas. Se empleó la técnica regular para el implante de la válvula pulmonar Melody, sin documentarse complicaciones durante el procedimiento ni al año de seguimiento. El implante percutáneo de la válvula pulmonar es un gran avance en el tratamiento de pacientes con cardiopatías congénitas, con resultados favorables a corto y mediano plazos, lo cual hace posible la restauración de la función ventricular con riesgo mínimo, frente al reemplazo quirúrgico en pacientes seleccionados.

Abstract Patients with congenital heart disease that involves reconstruction of the right ventricular outflow tract must frequently undergo interventions derived from the limited useful life of the surgical canals, which leads to the development of right ventricular dysfunction due to changes in the ventricular geometry and predisposition to lethal arrhythmias, with the consequent risk of reinterventions. The percutaneous pulmonary valvular implant is a new therapeutic alternative, less invasive, compared to surgery, for selected patients. A review of the available literature is made and the initial experience of percutaneous pulmonary valve implantation in a Colombian center of high complexity for the treatment of cardiovascular diseases is described, in two patients with aortic homograft dysfunction in a pulmonary position with double valvular lesion, in which the percutaneous pulmonary valve implant was a successful strategy. Patients with congenital heart disease were chosen, with dysfunctional surgical conduits with stenosis or significant pulmonary insufficiency, with dysfunction and right ventricular dilatation. The standard technique for the implantation of the Melody pulmonary valve was used, without complications during the procedure or one year of follow-up. Percutaneous implantation of the pulmonary valve is a great advance in the management of patients with congenital heart diseases, with favorable results in the short and medium term, allowing the restoration of ventricular function with minimal risk, compared to surgical replacement in selected patients.

Changes in Right Ventricular Volume, Volume Load, and Function Measured with Cardiac Computed Tomography over the Entire Time Course of Tetralogy of Fallot

OBJECTIVE: To characterize the changes in right ventricular (RV) volume, volume load, and function measured with cardiac computed tomography (CT) over the entire time course of tetralogy of Fallot (TOF). MATERIALS AND METHODS: In 374 patients with TOF, the ventricular volume, ventricular function, and RV volume load were measured with cardiac CT preoperatively (stage 1), after palliative operation (stage 2), after total surgical repair (stage 3), or after pulmonary valve replacement (PVR) (stage 4). The CT-measured variables were compared among the four stages. After total surgical repair, the postoperative duration (POD) and the CT-measured variables were correlated with each other. In addition, the demographic and CT-measured variables in the early postoperative groups were compared with those in the late postoperative and the preoperative group. RESULTS: Significantly different CT-based measures were found between stages 1 and 3 (indexed RV end-diastolic volume [EDV], 63.6 ± 15.2 mL/m2 vs. 147.0 ± 38.5 mL/m2 and indexed stroke volume (SV) difference, 7.7 ± 10.3 mL/m2 vs. 32.2 ± 16.4 mL/m2; p < 0.001), and between stages 2 and 3 (indexed RV EDV, 72.4 ± 19.7 mL/m2 vs. 147.0 ± 38.5 mL/m2 and indexed SV difference, 5.7 ± 13.1 mL/m2 vs. 32.2 ± 16.4 mL/m2; p < 0.001). After PVR, the effect of RV volume load (i.e., indexed SV difference) was reduced from 32.2 mL/m2 to 1.7 mL/m2. Positive (0.2 to 0.8) or negative (−0.2 to −0.4) correlations were found among the CT-based measures except between the RV ejection fraction (EF) and the RV volume load parameters. With increasing POD, an early rapid increase was followed by a slow increase and a plateau in the indexed ventricular volumes and the RV volume load parameters. Compared with the preoperative data, larger ventricular volumes and lower EFs were observed in the early postoperative period. CONCLUSION: Cardiac CT can be used to characterize RV volume, volume load, and function over the entire time course of TOF.

Prenatal diagnosis of absent pulmonary valve syndrome by fetal echocardiography: retrospective analysis of 12 cases / 中华围产医学杂志

Objective To summarize the echocardiographic features of fetal absent pulmonary valve syndrome (APVS).Methods Clinical data and echocardiograms of 12 cases of fetal APVS prenatally diagnosed in the Department of Pediatric Cardiology,Guangdong Cardiovascular Institute from July 2015 to April 2017 were reviewed retrospectively and the echocardiographic features of APVS were summarized.Results Aneurysmal dilation of the main pulmonary artery and branches arteries were found in all cases,causing tracheal and esophageal compression in one case and lung compression in two cases.Color Doppler revealed systolic and diastolic turbulent blood flow with "to-and-fro" blood flow in pulmonary arteries and pulmonary regurgitation.All fetuses were situs solitus and atrioventricular concordance.Eleven cases were also identified with malposition of the great arteries accompanied with ventricular septal defect,while the other one with normally related great arteries and intact ventricular septum was diagnosed with dysplasia of distal left pulmonary artery and pericardial effusion.Absent ductus arteriosus,increased cardiothoracic ratio and myocardial hypertrophy were found in four,two and five cases,respectively.Fetal umbilical arterial systolic/diastolic ratio and resistance index of all cases were normal.Conclusions Typical APVS is characterized by absent or rudimentary pulmonary valve accompanied with prominant dilated pulmonary arteries,pulmonary valve stenosis and severe pulmonary regurgitation.It is usually accompanied by conotruncal defects,but attention should also be paid to other atypical cardiac abnormalities during screening.

The reasonable use of right ventricular protection strategy in right ventricular outflow tract reconstruction / 中华外科杂志

As a result of right ventricular outflow tract reconstruction, which is the important and basic step of complex cardiac surgery, the blood flow of right ventricular outflow tract is unobstructed, while pulmonary valve regurgitation and right heart dysfunction could be happened. These problems are often ignored in early days, more and more cases of right heart dysfunction need clinical intervention, which is quite difficult and less effective. How to protect effectively the right ventricular function is the focus. At present main methods to protect the right ventricular function include trying to avoid or reduce length of right ventricular incision, reserving or rebuilding the function of the pulmonary valve, using growth potential material for surgery. The protection of the right ventricular function is a systemic project, it involves many aspects, single measures is difficult to provide complete protection, only the comprehensive use of various protection strategy, can help to improve the long-term prognosis.

Application and Assessment of CT Scanning in Percutaneous Pulmonary Valve Implantation / 中国循环杂志

Objective: To assess the application value of CT scanning in percutaneous pulmonary valve implantation (PPVI). Methods: A total of 19 patients with severe pulmonary regurgitation planed to receive PPVI in our hospital from 2014-05 to 2016-07 were studied. CT scan and transthoracic echocardiography (TTE) were conducted to collect the data of pulmonary root anatomy and to compare the difference of pulmonary annulus size measured by CT and TTE. The accuracy of pre-operative measurement was evaluated by the follow-up study at (1-26) months after the operation. Results: In all 19 patients, the mean anatomic measurements by CT were as follows: diameter of pulmonary annulus (24.3±3.5) mm, diameter of pulmonary sinotubular junction (25.4±4.0) mm, diameter at distal of main pulmonary artery (27.5±4.8) mm, diameter of right ventricular outflow tract (36.8±7.3) mm, length of main pulmonary artery (45.5±7.0) mm, diameter of left pulmonary artery (17.9±1.5) mm and diameter of right pulmonary artery (18.5±3.6) mm. The diameter of pulmonary annulus measured by CT was larger than TTE, P<0.05. During (1-26) months follow-up period, no patients suffered from stent fracture or translocation, peri-pulmonary valve regurgitation, obvious pulmonary regurgitation or coronary stenosis; 1 patient had increased flow rate at right pulmonary artery opening by stent blocking and 2 patients had residue mild stenosis of pulmonary valve. Conclusion: Pulmonary annulus size measured by CT and TTE was different; CT may precisely assess the morphology of pulmonary root with adjacent area which is important for pre-operative evaluation in PPVI patients.

Assessment of right ventricular volume and systolic function after percutaneous pulmonary valve implantation by real-time three-dimensional echocardiography / 中华超声影像学杂志

Objective To investigate the alternation of right ventricular volume and systolic function in patients with severe pulmonary regurgitation under percutaneous pulmonary valve implantation(PPVI) by real-time three-dimensional echocardiography(RT-3DE).Methods Ten patients with severe pulmonary regurgitation were enrolled.The 2D echocardiography images and real-time 3D full volume images on apical four-chamber view on a Philips IE33 system were acquired before PPVI and at 3 days,1 month,3months and 6 months after PPVI.Right ventricular end diastolic volume (EDV),end systolic volume(ESV),stroke volume (SV),ejection fraction(EF),fractional area change(FAC),tricuspid annular plane systolic excursion (TAPSE),right ventricular longitudinal strain-free wall(RVLSf) and right ventricular longitudinal strainseptum(RVLSs) were analysed using off-line TomTec software,the differences among the five groups were compared,and correlation analysis was made between the CMR and RT-3DE measurements.Results The level of pulmonary regurgitation had decreased or disappeared after PPVI.Compared with the preoperation,EDV,ESV at 3 days,1 month,3months and 6 months after operation had decreased significantly.EF,FAC,TAPSE,RVLS had increased significantly(all P ＜0.05).There were close correlation in EDV,ESV,EF between RT-3DE and CMR(pre-operation r =0.811,0.817,0.807,post-operation r =0.735,0.834,0.800,all P ＜0.055).Conclusions RV volume notably decreases while RV systolic function remarkably improves.The RT-3DE is a helpful technology in the evaluation of right ventricular volume and systolic function in patients after PPVI.

Analysis of pulmonary valve function in patients with tetralogy of Fallot after radical surgery / 中华心血管病杂志

Objective@#To analyze the pulmonary valve function in patients with tetralogy of Fallot after radical surgery.@*Methods@#Clinical data of 263 patients (119 male, mean age (33.2±11.5) years old) with tetralogy of Fallot underwent radical surgery in our hospital from January 2010 to June 2016 were retrospectively analyzed. According to age, patients were divided into 14-17 years old group (14 cases), 18-29 years old group (100 cases), 30-39 years old group (61 cases) and above 40 years old group (87 cases). The patients were divided into pulmonary regurgitation group (87 cases) and control group (176 cases) according to weather they have moderate or severe pulmonary regurgitation. Echocardiographic data were compared among groups.@*Results@#A total of 83 patients received re-operation. The median age of the primary radical operation was 9 (5, 13) years, and the median time from the primary radical operation to echocardiographic follow-up was 5 (1, 13) years. Among the 263 enrolled patients, prevalence of pulmonary regurgitation was 36.1% (95/263), and pulmonary stenosis was evidenced in 28 patients (10.6%). The ratio of moderate to severe tricuspid regurgitation was 14.3% (2/14), 27.0% (27/100), 32.8% (20/61) and 37.9% (33/87) in 14-17 years old group, 18-29 years old group, 30-39 years old group and above 40 years old group, respectively (P=0.029), while prevalence of moderate and severe pulmonary regurgitation, moderate and severe pulmonary valve stenosis, pulmonary valve transvalvular pressure >40 mmHg (1 mmHg=0.133 kPa), right atrial and right ventricular enlargement ratio were similar among groups (all P>0.05). The ratio of moderate and severe tricuspid regurgitation and right ventricular enlargement in the pulmonary regurgitation group was significantly higher than in the control group (40.2% (35/87) vs. 27.3% (48/176) and 96.6% (84/87) vs. 87.5% (154/176), all P<0.05), while left ventricular ejection fraction, right atrial enlargement, and right ventricular wall thickness were similar between the two groups (all P>0.05).@*Conclusion@#Pulmonary regurgitation is a common clinical feature among survivors of tetralogy of Fallot patients after radical surgery, and moderate to severe pulmonary regurgitation increases the risk of tricuspid regurgitation and enlargement of the right ventricle.

Cardiac Functional Changes in 8 Patients After Percutaneous Pulmonary Valve Implantation / 中国循环杂志

Objective: To evaluate the changes of left and right ventricular function in patients after percutaneous pulmonary valve implantation (PPVI). Methods: A total of 8 patients with successful PPVI in our hospital from 2014-05-27 to 2015-03-25 were studied. The patients received pre-operative evaluation including clinical symptoms, plasma BNP levels, ECG, chest X-ray, echocardiography, CT and MRI examinations. Post-operative follow-up study was conducted at 6 months after PPVI to compare the ventricular functional changes. Results: The average age in 8 patients was 14-42 (25.4±8.1) years including 7 with tetralogy of Fallot correction and 1 with pulmonary stenosis plasty for 24 years. Echocardiography found that 3 patients with mid to large pulmonary regurgitation and 5 with large regurgitation. Compared with pre-operation, at 6 months after PPIV, all patients had decreased right ventricular end-diastolic diameter (RVEDD) as (44.0±4.8) mm vs (33.6±7.1) mm, right ventricular end-diastolic volume index (RVEDVI) (150.1±25.7) ml/m2 vs (111.4±39.1) ml/m2, RVESVI (107.8±21.5) ml/m2 vs (80.7±22.2) ml/m2 and right ventricular cardiac output (RV-CO) (6.8±1.3) L/min vs (4.9±0.8) L/min, but right ventricular ejection fraction (RVEF) was similar (40.5±6.2) % vs (39.5±9.9) %, P>0.05; while increased LVEDD (42.9±4.4) mm vs (46.1±3.0) mm, P0.05. Conclusion: PPVI may decrease right ventricular preload, improve its reverse remodeling and maintain systolic function at normal level in relevant patients; while the impacts on left ventricular function and geometry should be further studied.

Experiência Inicial com o Implante Percutâneo da Válvula Melody® no Brasil / Initial Experience with Percutaneous Implantation of the MelodyTM Valve in Brazil

Introdução: Stress is associated with cardiovascular diseases.O implante percutâneo da válvula pulmonar é uma alternativa para condutos com disfunção. Descrevemos aqui a primeira experiência com o implante da válvula Melody® no Brasil. Métodos: Foram selecionados pacientes com estenose ou insuficiência pulmonar significativa em condutos de 16 a 22 mm. Foram empregadas técnicas padronizadas. Factibilidade, segurança e eficácia desse procedimento foram avaliadas. Resultados: Desde dezembro de 2013, dez pacientes (média de idade e peso de 16,5 anos e 49 kg, respectivamente) foram submetidos ao procedimento com intervalo médio de 11,9 ± 8,6 anos desde a última cirurgia. Insuficiência pulmonar foi indicação para o tratamento em três pacientes, estenose em dois e lesão mista em cinco. A válvula Melody® foi implantada com sucesso em todos os casos. A média da pressão sistólica do ventrículo direito e a relação ventrículo direito/ventrículo esquerdo diminuíram de 49,2 ± 15,9 para 35,8 ± 5,7 mmHg e de 0,55 ± 0,18 para 0,39 ± 0,08 mmHg (p < 0,01 para ambos). Não observamos estenose e nem insuficiência pulmonar residual significativa. Um paciente teve extravasamento contido requerendo um stent coberto e um segundo implante valvular. Todos os pacientes receberam alta do hospital em 72 horas. As válvulas funcionaram adequadamente ...

Background: Transcatheter pulmonary valve implantation is an alternative for dysfunctional conduits. We report the first experience with the MelodyTM valve implantation in Brazil. Methods: Patients with significant pulmonary stenosis or significant pulmonary insufficiency in conduits measuring 16 to 22 mm were enrolled. Standardized techniques were employed. The feasibility, safety and efficacy of this procedure were assessed. Results: From December 2013, ten patients (mean age and weight of 16.5 years and 49 kg, respectively) have undergone the procedure with a mean interval of 11.9 ± 8.6 years since the last surgery. Pulmonary insufficiency was an indication for treatment in three patients, pulmonary stenosis in two, and mixed lesion in five. The MelodyTM valve was successfully implanted in all cases. Mean right ventricular systolic pressure and right ventricle/left ventricle ratio decreased from 49.2 ± 15.9 to 35.8 ± 5.7 mmHg and from 0.55 ± 0.18 to 0.39 ± 0.08 mmHg (p < 0.01 for both). Significant residual pulmonary stenosis or pulmonary insufficiency was not observed. One patient had a contained conduit tear requiring a covered stent and a second valve implantation. All patients were discharged within 72 hours. The valves were properly functioning in a mean follow-up of 4.1 ± 2.2 months with no complications. Conclusions: Transcatheter MelodyTM valve implantation was feasible, safe and effective ...

Estudo experimental do implante transcateter de prótese valvada autoexpansível na via de saída do ventrículo direito em porcos / Transcatheter implantation of self-expandable valved prosthesis in outlet right ventricle an experimental study in pigs

INTRODUÇÃO: Nos pacientes portadores de cardiopatias congênitas que foram submetidos à valvotomia pulmonar ou cirurgias de ampliação com o uso do anel da válvula pulmonar, a insuficiência ou estenose pulmonar residual pode acarretar falência cardíaca direita com deterioração clínica. Essas crianças necessitam de múltiplas intervenções ao longo de suas vidas, que impõem uma elevada taxa de morbidade e mortalidade. OBJETIVO: Desenvolvimento de uma técnica menos invasiva para implante de uma prótese valvada através do ventrículo direito. MÉTODOS: A prótese valvada consiste em um anel metálico construído com nitinol autoexpansível, revestida de poliéster, onde três cúspides de pericárdio bovino foram montadas. Doze porcos foram utilizados para a realização dos implantes. Foi realizado controle ecocardiográfico imediatamente após o implante e com uma, quatro, oito e 12 semanas. RESULTADOS: Um animal apresentou refluxo de grau moderado a importante e outros três refluxo de grau leve. Os gradientes transvalvares medidos antes do implante variavam entre 3 a 6 mmHg, sendo que, logo após o implante, houve aumento dos gradientes que variaram de 7 a 45 mmHg. Houve queda desses gradientes, sendo que em apenas quatro dos 12 animais os gradientes estavam acima de 20 mmHg. Em seis animais, ocorreu a formação de trombo na prótese, sendo esta a complicação mais frequente. CONCLUSÃO: Esses achados evidenciam a necessidade da realização de estudos com a utilização de anticoagulantes e ou antiagregantes plaquetários na tentativa de diminuir esse evento. O estudo pretende apresentar subsídios para o início do emprego de próteses valvares que poderiam ser implantadas através de técnicas menos invasivas.

INTRODUCTION: Patients with congenital heart disease who underwent pulmonary valvotomy or surgery to open the pulmonary valve ring are prone to develop residual pulmonary insufficiency or stenosis that may lead to right heart failure with clinical deterioration. These children require multiple interventions throughout their lives, which impose a high rate of morbidity and mortality. OBJECTIVE: To develop a less invasive technique for implantation of a valved prosthesis through the right ventricle. METHODS: The valved prosthesis consists of an auto expanding metal stent built with nitinol, surrounded with polyester, where the three leaflets of bovine pericardium were mounted. Twelve pigs were used to perform the implants. Echocardiographic control was performed immediately after implantation and one, four, eight and 12 weeks. RESULTS: One animal showed reflux of moderate to severe and three mild reflux. Transvalvular gradients measured before implantation ranged from 3 to 6 mmHg and that soon after the implant was increased, ranging from 7 to 45 mmHg. There was a decrease in these gradients during follow up and in only four of the twelve animals the gradients were above 20 mmHg. Thrombus formation occurred in the prosthesis of six animals, and this was the most frequent complication. CONCLUSION: These findings highlight the need for studies with the use of anticoagulants and antiplatelet, an attempt to reduce this event. The study aims to contribute for the start of the use of prosthetic heart valves that could be implanted through minimally invasive techniques without the use of cardiopulmonary bypass.

Ideal Right Ventricular Outflow Tract Size in Tetralogy of Fallot Total Correction / 대한흉부외과학회지

BACKGROUND: The surgical repair of a tetralogy of Fallot (TOF) has been performed successfully with a favorable early and late outcome. However, the later development of pulmonary regurgitation and stenosis remains a problem. The development of pulmonary regurgitation and stenosis may be changed by the size of right ventricular outflow tract (RVOT) reconstruction at the initial total correction. Hence, it is necessary to investigate the ideal size of RVOT reconstruction. MATERIAL AND METHOD: This prospective study was carried out to determine how a surgical strategy and the RVOT size affect the occurrence of pulmonary regurgitation and stenosis. From January 2002 to December 2004, 62 patients underwent the TOF total correction. The RVOT size (diameter of pulmonary valve annulus) of each case was measured after the RVOT reconstruction and converted to a Z value. A pre-scheduled follow up (at discharge, 6 months, 1 year, 2 years and 3 years) was carried out by echocardiography to evaluate the level of pulmonary regurgitation and stenosis. RESULT: The patients were divided to two groups (transannular group n=12, nontransannular group n=50) according to the method of a RVOT reconstruction. The Z value of RVOT=iameter of pulmonary valve annulus) (transannular group -1, range -3.6~-0.8; nontransannular group -2.1, range -5.2~1.5) and the average pRV/LV after surgery (transannular group 0.44+/-0.09, nontransannular group 0.42+/-0.09) did not show any significant difference between two groups. The occurrence of pulmonary regurgitation above a moderate degree was more frequent in the transannular group (p0, p<0.02) and the progressing pulmonary stenosis more than mild to moderate degree developed in the patients with smaller RVOT size (Z value<-1.5, p<0.05). A moderate degree of pulmonary stenosis developed for 4 nontransannular patients. Three underwent additional surgery and one underwent a balloon valvuloplasty. Their Z value of RVOT were -3.8, -3.8 -2.9, -1.8, respectively. CONCLUSION: When carring out a TOF total correction, transannular RVOT reconstruction group has significantly more pulmonary regurgitation. In the nontransannular RVOT reconstruction, the size of the RVOT should be maintained from Z value -1.5 to 0. If the Z value is less than -1.5, we should follow up carefully for the possibility of pulmonary stenosis.

Ideal Right Ventricular Outflow Tract Size in Tetralogy of Fallot Total Correction / 대한흉부외과학회지

BACKGROUND: The surgical repair of a tetralogy of Fallot (TOF) has been performed successfully with a favorable early and late outcome. However, the later development of pulmonary regurgitation and stenosis remains a problem. The development of pulmonary regurgitation and stenosis may be changed by the size of right ventricular outflow tract (RVOT) reconstruction at the initial total correction. Hence, it is necessary to investigate the ideal size of RVOT reconstruction. MATERIAL AND METHOD: This prospective study was carried out to determine how a surgical strategy and the RVOT size affect the occurrence of pulmonary regurgitation and stenosis. From January 2002 to December 2004, 62 patients underwent the TOF total correction. The RVOT size (diameter of pulmonary valve annulus) of each case was measured after the RVOT reconstruction and converted to a Z value. A pre-scheduled follow up (at discharge, 6 months, 1 year, 2 years and 3 years) was carried out by echocardiography to evaluate the level of pulmonary regurgitation and stenosis. RESULT: The patients were divided to two groups (transannular group n=12, nontransannular group n=50) according to the method of a RVOT reconstruction. The Z value of RVOT=iameter of pulmonary valve annulus) (transannular group -1, range -3.6~-0.8; nontransannular group -2.1, range -5.2~1.5) and the average pRV/LV after surgery (transannular group 0.44+/-0.09, nontransannular group 0.42+/-0.09) did not show any significant difference between two groups. The occurrence of pulmonary regurgitation above a moderate degree was more frequent in the transannular group (p0, p<0.02) and the progressing pulmonary stenosis more than mild to moderate degree developed in the patients with smaller RVOT size (Z value<-1.5, p<0.05). A moderate degree of pulmonary stenosis developed for 4 nontransannular patients. Three underwent additional surgery and one underwent a balloon valvuloplasty. Their Z value of RVOT were -3.8, -3.8 -2.9, -1.8, respectively. CONCLUSION: When carring out a TOF total correction, transannular RVOT reconstruction group has significantly more pulmonary regurgitation. In the nontransannular RVOT reconstruction, the size of the RVOT should be maintained from Z value -1.5 to 0. If the Z value is less than -1.5, we should follow up carefully for the possibility of pulmonary stenosis.

Pulmonary Valve Replacement with Tissue Valves After Pulmonary Outflow Tract Repair in Children / 대한흉부외과학회지

BACKGROUND: Most of pulmonary regurgitation with or without stenosis appears to be well tolerated early after the repair of pulmonary outflow tract. However, it may result in symptomatic right ventricular dilatation, dysfunction and arrhythmias over a long period of time. We studied the early outcome of pulmonary valve replacement with tissue valves for patients with the above clinical features. MATERIAL AND METHOD: Sixteen consecutive patients who underwent pulmonary valve replacement from September 1999 to February 2002 were reviewed(9 males and 7 females). The initial diagnoses included tetralogy of Fallot(n=11), and other congenital heart anomalies with pulmonary outflow obstruction(n=5). Carpentier-Edwards PERIMOUNT Pericardial Bioprostheses and Hancock porcine valves were used. The posterior two thirds of the bioprosthetic rim was placed on the native pulmonary valve annulus and the anterior one third was covered with a bovine pericardial patch. Preoperative pulmonary regurgitation was greater than moderate degree in 13 patients. Three patients had severe pulmonary stenosis. Tricuspid regurgitation was present in 12 patients. RESULT: Follow-up was complete with a mean duration of 15.8+/-8.5months. There was no operative mortality. Cardiothoracic ratio was decreased from 66.0+/-6.5% to 57.6+/-4.5% (n=16, p=0.001). All patients remained in NYHA class I at the most recent follow-up (n=16, p=0.016). Pulmonary regurgitation was mild or absent in all patients. Tricuspid regurgitation was less than trivial in all patients. CONCLUSION: In this study we demonstrated that early pulmonary valve replacement for the residual pulmonary regurgitation with or without right ventricular dysfunction was a reasonal option. This technique led to reduce the heart size, decrease pulmonary regurgitation and tricuspid regurgitation as well as to improve the patients' functional status. However, a long term outcome should be cautiously investigated.