Twenty-one Year Experience with Right Ventricle to Pulmonary Artery Conduit Interposition / 대한흉부외과학회지

BACKGROUND: The aim of this study is to evaluate the long term results of creating various right ventricle to pulmonary artery conduits for treating complex congenital heart disease. MATERIAL AND METHOD: Between June 1986 and July 2006, we retrospectively reviewed 245 patients who underwent reconstruction of the right ventricular outflow tract with various kinds of conduits. 410 operations were done in 245 patients, the mean age at operation was 3.2+/-4.9 years (range: 7 days~45 years) and the mean body weight was 12.5+/-8.7 kg (range: 2.4~76.3 kg). RESULT: We used the following conduits: Polystan conduit, Shelhigh conduit, Carpenter-Edward conduit, Dacron graft with an artificial valve, valveless Gore Tex vascular graft, homograft and hand-made bovine or autologous pericardial conduit. The mean follow up duration was 6.3+/-5.2 years. Redo operation for RV-PA conduit dysfunction was performed in 131 patients, a second redo was done in 31 and a third redo was done in 3. The reoperation free rates were 67.3%, 48.5% and 39.4% for 5 years, 10 years and 15 years, respectively. The homograft showed the best durability, followed by the Dacron graft with artificial valve and the Carpentier-Edward conduit. The larger sized conduit showed better durability. CONCLUSION: The homograft showed lowest reoperation rate and a smaller size of conduit showed the highest reoperation rate. The reoperation rate for the RV-PA conduit was about 35% at 5 years, so it is mandatory to develop the more durable conduit for RV outflow.

Aortic Translocation for Complete Transposition of the Great Arteries with a Ventricular Septal Defect and Pulmonic Stenosis / 대한흉부외과학회지

The Rastelli operation has been a standard procedure for repairing complete transposition of the great arteries combined with a ventricular septal defect and pulmonary stenosis. Yet this procedure has several shortcomings, including the risk of incurring left ventricular outflow tract obstruction on long-term follow-up. In this regard, aortic translocation has recently been regarded as a potent alternative to Rastelli's operation. We report here on a case of complete transposition of the great arteries that was combined with an inlet-extended perimembranous ventricular septal defect and pulmonary stenosis in a 2-year-old boy. All the problems were successfully repaired using the aortic translocation technique. Postoperative echocardiography showed a straight and wide left ventricular outflow tract.

Replacement of Obstructed Extracardiac Conduits with Autologous Tissue Reconstructions (Peel operation); Early and Midterm Results / 대한흉부외과학회지

BACKGROUND: Reoperation is usually required for a right ventricle to pulmonary artery conduit obstruction caused by valve degeneration, conduit peel formation or somatic growth of the patient. An autologous tissue reconstruction (peel operation), where a prosthetic roof is placed over the fibrotic tissue bed of the explanted conduit, has been used to manage conduit obstructions at our institute since May 2002. Herein, the early and midterm results are evaluated. MATERIAL AND METHOD: Between May 2002 and July 2006, 9 patients underwent obstructed extracardiac conduit replacement with an autologous tissue reconstruction, at a mean of 5.1 years after a Rastelli operation. The mean age at reoperation was 7.5+/-2.4 years, ranging from 2.9 to 10.1 years. The diagnoses included 6 pulmonary atresia with VSD, 2 truncus arteriosus and 1 transposition of the great arteries. The preoperative mean systolic gradient was 88.3+/-22.2 mmHg, ranging from 58 to 125 mmHg. The explanted conduits were all Polystan valved pulmonary conduit (Polystan, Denmark). A bioprosthetic valve was inserted in 8 patients, and a monocusp ventricular outflow patch (MVOP) was used in 1 patient. The anterior wall was constructed with a Gore-Tex patch (n=7), MVOP (n=1) and bovine pericardium (n=1). Pulmonary artery angioplasty was required in 5 patients and anterior aortopexy in 2. The mean cardiopulmonary bypass time was 154 minutes, ranging from 133 to 181 minutes; an aortic crossclamp was not performed in all patients. The mean follow-up duration was 20 months, ranging from 1 to 51 months. All patients were evaluated for their right ventricular outflow pathway using a 3-D CT scan. RESULT: There was no operative mortality or late death. The mean pressure gradient, assessed by echocardiography through the right ventricular outflow tract, was 20.4 mmHg, ranging from 0 to 29.6 mmHg, at discharge and 26 mmHg, ranging from 13 to 36 mmHg, at the latest follow-up (n=7, follow-up duration >1 year). There were no pseudoaneurysms, strictures or thrombotic occlusions. CONCLUSION: A peel operation was concluded to be a safe and effective re-operative option for an obstructed extracardiac conduit following a Rastelli operation.

Long Term Results of Rastelli Operation with a Mechanical Valve / 대한흉부외과학회지

BACKGROUND: Homografts and bioprostheses are most commonly used for Rastelli operation in congenital heart disease, but the limited durability is responsible for multiple reoperations associated with increased morbidity. This study evaluated long-term results after Rastelli operation with a mechanical valved conduit. MATERIAL AND METHOD: A total of 20 patients underwent Rastelli operation with mechanical valved conduit from January 1990 to July 1992. Operative mortality was 1 of 20 patients, and a retrospective review of 19 patients (10 males, 9 females) was done. Initial diagnosis was congenitally corrected transposition of great arteries (cc-TGA, n=4), complete TGA (n=2), ventricular septal defect with pulmonary atresia (VSD with PA, n=9), truncus arteriosus (n=2), double outlet right ventricle with pulmonary stenosis (DORV with PS, n=2). The mean age at Rastelli operation was 4.6+/-3.4 years, and mean follow-up period was 12.8+/-2.7 years. Patients underwent Rastelli opearation using 16 CarboMedics mechanical valve, and 3 Bjork-Shiley mechanical valve (17+/-2 mm). RESULT: There were 15 reoperations for failed mechanical valved conduit. The freedom from reoperation at 5 and 10 years was 53% and 37%. Most patients were received oral anticoagulation with warfarin, and maintained the international normalized ratio (INR) of 1.5 to 2.0. There was no anticoagulation or thromboembolism related complication. There was a significant difference in the causes of a conduit failure between early (within 3 years) and late (after 3 years) failure groups. The six patients reported early prosthetic valve failure, mainly due to valvular dysfunction by thrombosis or pannus formation. The other nine patients reported late prosthetic valve failure, mainly due to dacron conduit stenosis at anastomosis sites, whereas their valvar motion was normal except 1 patient. CONCLUSION: To avoid early prosthetic valve failure, strict anticoagulation therapy would be helpful. About the late development of obstructive intimal fibrocalcific peels within the Dacron conduit, an improvement of conduit material is necessary to reduce late prosthetic valve failure. In selected patients, the long term results were satisfactory.

Truncus Arteriosus associated with Interrupted Aortic Arch / 대한흉부외과학회지

A 85-day-old infant was successfully operated on for truncus arteriosus (type I) with interrupted aortic arch (type A) using one-stage anterior approach without circulatory arrest. Aortic arch was reconstructed by direct anastomosis of ascending aorta and descending aorta with regional perfusion and continuity of right ventricle to pulmonary artery was established with Shelhigh(R) pulmonic conduit. The patient experienced left bronchus compression by descending aorta immediately postoperatively, which was improved with positional change and physiotherapy. The patient had reoperation due to stenosis of valved conduit at 13 months later. The patient is currently well under follow-up of 14 months from initial repair.

Transposition of great arteries with pulmonary stenosis and remote muscular inlet ventricular septal defect / 대한흉부외과학회지

We report a successful biventricular repair of D-transposition of great arteries, pulmonary stenosis and remote muscular inlet ventricular septal defect, after modifie Blalock-Taussing shunt early in infant. A long left ventricle-to-aorta intraventricular rerouting tunnel was created without stenosis by transferring the medial papillary muscle of the tricuspid valve to the tunnel, obliterating the trabeculation of right ventricle in the course of tunnel and excising the secondary chordae of the tricuspid valve.