The Pericardial Membrane Pulmonary Monocusp: Surgical Technique and Early Results

Abstract

Long‐term pulmonary insufficiency resulting from simple transannular patching of the right ventricle outflow tract will ultimately lead to deterioration in right ventricular function. Previously, monocusps constructed from xenografts, homografts, fascia lata, and autologous pulmonary artery wall have been utilized to minimize pulmonary regurgitation and its deleterious effect on right ventricular function. However, these tend to degenerate in the long term, necessitating reoperation. To circumvent this problem we have used a monocusp constructed from 0·1−mm polytetrafluorethylene (PTFE, pericardial membrane) clinically demonstrated to be resistant to issue ingrowth and degeneration. Seven children (5 tetralogy of Fallot, 2 pulmonary stenosis) who required division of a small pulmonary an‐nulus underwent monocusp construction with 0.1‐mm PTFE. Three patients had previous corrective surgery. One of these patients had a bovine pericardial monocusp placed 8 years previously, which degenerated. Of the remaining two patients, one had a pulmonary valvo‐tomy as a neonate, the other repair of tetralogy of Fallot with a transannular patch. At a mean (± standard deviation) follow up to 17 ± 5·8 months all patients are alive and are New York Heart Association (NYHA) Class I. Echocardiography demonstrates mild pulmonary insufficiency (PI) in 2 patients, mild to moderate PI in 4, and moderate to severe PI in 1. The presence of a pericardial membrane monocusp in the pulmonary position may, in the long term, prevent the deleterious effects of transannular patching on right ventricular dysfunction and be more resistant to degenerative changes characteristic of monocusps constructed of native pericardium or allogeneic tissue.

Current Strategy of Repair of Tetralogy of Fallot in Children and Adults: Emphasis on a New Technique to Create a Monocusp‐Patch for Reconstruction of the Right Ventricular Outflow Tract

“…In patients with severe stenosis of the pulmonary annulus, in addition to the muscular stenosis at the right ventricular outflow tract (RVOT), transannular repair may be inevitable but may lead to pulmonary insufficiency featured by pulmonary regurgitation. It has, for a long time, been recognized that long‐standing pulmonary insufficiency after repair of TOF may adversely affect ventricular function, 1,2 and even in the modern era, pulmonary insufficiency remains a problem, particularly for late results 3‐6 . Recently, pulmonary regurgitation is reported to develop in up to 30% of patients at a follow‐up of 20 years and results in progressive right ventricular (RV) dilatation and dysfunction in an increasing number of patients 5‐7 .…”

“…It has, for a long time, been recognized that long‐standing pulmonary insufficiency after repair of TOF may adversely affect ventricular function, 1,2 and even in the modern era, pulmonary insufficiency remains a problem, particularly for late results 3‐6 . Recently, pulmonary regurgitation is reported to develop in up to 30% of patients at a follow‐up of 20 years and results in progressive right ventricular (RV) dilatation and dysfunction in an increasing number of patients 5‐7 . Further, transannular patch correlates with poor late outcome or increased reoperation rates 8 .…”

“…Different methods have been used to create a valve in the pulmonary artery annulus to resume the pulmonary valvular function. This includes valved homograft patch, 3,7 monocusp patch, 5,13‐25 or reconstructing an autologous competent 3‐cusp valve from the native tissues 26 …”

“…However, it has been reported that this monocusp, although it effectively eliminates the pulmonary insufficiency in early postoperative period, 20 does not prevent pulmonary insufficiency soon after the operation, presumably due to degeneration or absorption of the monocusp 9,29 . Efforts have been made to overcome this problem with a monocusp constructed from 0.1‐mm polytetrafluorethylene (PTFE) 5,29 . The long‐term results of this method have not been reported, and this technique leaves a foreign body in the pulmonary artery flow that is obviously undesirable.…”

Echocardiographic Parameters and Brain Natriuretic Peptide in Patients after Surgical Repair of Tetralogy of Fallot

“…The degree of PR is variable and has been responsible for the development of RV remodeling as well as diastolic and systolic dysfunction, which impair clinical conditions and predispose to arrhythmias and even sudden death 2,3 . Pulmonary regurgitation is secondary to different RV outflow tract reconstruction techniques, and a second surgical procedure with pulmonary valve replacement may be necessary to prevent the progress of RV deterioration, 4–7 but the optimal time for this procedure is difficult to determine. It is not advisable to wait for symptoms since they frequently appear later when a significant RV dysfunction is already established.…”