Pulmonary Valve Cusp Augmentation With Autologous Pericardium May Improve Early Outcome For Tetralogy Of Fallot.
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Objectives: The transannular patch (TAP) used to relieve right ventricular outflow tract obstruction (RVOTO) in children with tetralogy of Fallot (TOF) may result in important pulmonary insufficiency (PI). We tested the hypothesis that augmentation of native pulmonary valve tissue with an autologous pericardial patch (Sung technique) would decrease the degree of PI and lead to improved early outcomes for transatrial-transpulmonary repair of TOF.
Methods: Since April 2003 all patients with TOF (n=41) or isolated pulmonary valve stenosis (n=2) had relief of valvar RVOTO with either the cusp augmentation repair (n=18) or a TAP without valve cusp augmentation (n=25). Median age (160 days vs 97 days; p=0.09) and weight (6.1 kg vs 6.2 kg; p=0.8) were similar in the 2 groups. The diameter of the pulmonary valve annulus measured by preoperative echocardiography was also similar in the 2 groups (6.4 ± 1.6 mm vs 6.2 ±1.5 mm; p=0.7). Three patients in each group had previous palliation with a modified Blalock-Taussig shunt.
Results: Mean aortic cross-clamp time (48 ± 18 min vs 52 ± 19 min; p=0.46) and median cardiopulmonary bypass time (89 min vs TAP 91 min; p=0.9) were similar in the 2 groups. There was one death in the TAP group from right ventricular failure and multi-organ system failure on postoperative day # 86. Postoperative echocardiography demonstrated moderate, severe or unrestricted PI in 3 (17%) patients in the cusp augmentation group versus 19 (76%) patients in the TAP group (p<0.001). Postoperative outcome is shown below.| Postoperative outcome | Cusp augmentation n = 18 | Transannular patch n = 25 | p |
| Inotropic support > 72 hours | 1 (0.05%) | 13 (52%) | 0.003 |
| Supraventricular tachyarrhythmia | 1 (0.05%) | 10 (40%) | 0.01 |
| Duration of intubation | 1 day | 3 days | 0.001 |
| Duration of ICU stay | 3 days | 8 days | 0.001 |
At a median follow up of 6 months (range 14 to 864 days) 3 cusp augmentation repair patients (17%) have had progression of PI.
Conclusions: Despite the limitations of a non-randomized study, augmentation of the native pulmonary valve tissue using the cusp augmentation technique appears to reduce the incidence of clinically significant postoperative PI. This technique may improve early outcomes in children with tetralogy of Fallot and has good short term durability.
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