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J Thorac Cardiovasc Surg 1995;110:1148-1150
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

TRUNCUS REPAIR WITH A VALVELESS CONDUIT IN NEONATES

Douglas M. Behrendt, MD, Macdonald Dick, III, MD


Iowa City, Iowa, and Ann Arbor, Mich.

From the Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa City, Iowa and the Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Mich.

In 1984, we reported the successful use of 8 and 10 mm polytetrafluoroethylene (PTFE) tubes to connect the right ventricle to the pulmonary arteries in the repair of truncus arteriosus types I and II in the neonate (Fig. 1). Go 1 These infants were operated on at the ages of 1 to 9 days because of severe heart failure. At that time, the smallest commercially available conduit was a 12 mm Dacron polyester tube containing a porcine heterograft valve. Although this device was used successfully by Ebert and coworkersGo 2 in a large series of infant truncus repairs, it was too cumbersome for insertion into the neonates in our series, who ranged in weight from 2.1 to 3.3 kg. Allografts were not in general use at that time.



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  		Fig. 1. Repair of truncus arteriosus with a PTFE conduit.

 
These PTFE tubes were technically relatively easy to insert, yet we were concerned that neonates would not be able to tolerate the pulmonary insufficiency created by unvalved conduits. Although the first successful repairs of right ventricle–pulmonary artery discontinuity had used nonvalved tubes, these operations were performed on older children, who had anatomy that restricted pulmonary blood flow and therefore had a low pulmonary resistance.Go 3 Our fears proved unfounded. Five of the seven infants survived the operation, and the two who died did so of unrelated conditions.

Our second major concern was that these small tubes would require replacement at an early age, committing these infants to multiple revisionary operations. This also has not proved to be the case. As outlined in GoTable I, PTFE tubes in the four long-term survivors lasted for 3 to 11 years, when it was possible to insert allografts of 19 to 25 mm diameter. Each patient was found to have stenosis at the origin of one or both pulmonary artery branches (Fig. 2). Revision of the bifurcation was therefore necessary at allograft replacement. Branch stenosis occurs after many conduit repairs and is not necessarily caused by these small tubes. The choice of PTFE may have been fortunate, because studies by Brown and colleagues Go 4 have demonstrated that tubes of this material are less likely to become obstructed than Dacron or Teflon tubes.


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  		Table I. Clinical courses
 




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  		Fig. 2. Representative angiograms in patients 3 (A), 4 (B), and 7 (C) at 3 months, 13 months, and 17 months after operation, respectively, demonstrating branch stenoses.

 
The ultimate outcome in these patients demonstrates the difficulties that children born with truncus arteriosus often encounter. One died after gastropexy at the age of 1 year. Postmortem examination failed to disclose a cause of death. One patient with DiGeorge's syndrome later had endocarditis of the truncal valve, which necessitated its replacement with a St. Jude Medical valve (St. Jude Medical, Inc., St. Paul, Minn.). The third patient has had hyperthyroidism with poor growth. The fourth patient has recently had exercise intolerance, with a conduit gradient of 54 mm Hg and moderate truncal valve insufficiency. Although the fifth patient wrestles competitively, he has mild allograft stenosis and insufficiency.

In conclusion, 8 or 10 mm PTFE conduits have provided surprisingly long-lasting palliation of truncus arteriosus in the neonate. The lack of a competent pulmonary valve does not appear to have been detrimental. Although allografts are the conduits of choice in current practice, it remains to be seen whether the long-term results are superior to those obtained with simple PTFE tubes. This question relates to the more general issue of when a valve should be used in right ventricle–pulmonary artery connections. McGoon, Rastelli, and Ongley Go 5 allografts in their initial successful truncus repair because a previous attempt with a PTFE tube had been unsuccessful. This decision reflected the generally held opinion that pulmonary valve competence is necessary in patients who have early pulmonary vascular obstructive disease. Valve-containing prosthetic tubes supplanted allografts for a time. Interestingly, Brown and colleagues Go 4 have shown that it is the valves in such tubes that are responsible for their deterioration. Some surgeons now use simple patches without valves when replacing degenerated allograft conduits. The results appear to be comparable to results in patients with tetralogy and transannular patches. Presumably this option will be considered when the four long-term survivors reported on here require replacement of their allografts.

Only time will tell which of these approaches provides the best long-term outcome and in which patients valved or unvalved conduits should be used. Although allografts will probably continue to be the conduits of choice in the initial repair, a simple PTFE tube may be used if an allograft is not available.

Footnotes

J THORAC CARDIOVASC SURG 1995;110:1148-50 Back

References

  1. Spicer RL, Behrendt D, Crowley DC, et al. Repair of truncus arteriosus in neonates with the use of a valveless conduit. Circulation 1984;70(3 Pt 2):I26-9.
  2. Mavroudis C, Turley K, Ebert PA. Conduit surgery for right ventricular and pulmonary artery continuity: experience in both infants and older children [Abstract]. Am J Cardiol 1981;47:467.
  3. Kiser JC, Ongley PA, Kirklin JW, Clarkson PM, McGoon DC. Surgical treatment of dextrocardia withinversion of ventricles and double-outlet right ventricle. J THORAC CARDIOVASC SURG 1968;55:6-15.[Medline]
  4. Brown JW, Halpin MP, Rescorla FJ, et al. Externally stented polytetrafluoroethylene valved conduits for right heart reconstruction: an experimental comparison with Dacron valved conduits. J THORAC CARDIOVASC SURG 1985;90:833-41.[Abstract]
  5. McGoon DC, Rastelli GC, Ongley PA. An operation for the correction of truncus arteriosus. JAMA 1968;205:59-73.



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