J Thorac Cardiovasc Surg 2004;128:328-329
© 2004 The American Association for Thoracic Surgery
Reconstruction of double-outlet right ventricular outflow tract comprising a pulmonary artery flap in a child with an anomalous coronary artery
Miki Asano, MDa,
Norikazu Nomura, MDa,
Akira Mishima, MDa
a Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
To the Editor:
van Son1 provided a useful operative solution for repairing tetralogy of Fallot of anomalous origin in the left anterior descending coronary artery and small pulmonary annulus. The technique, using a pulmonary artery flap as the posterior wall of the constructed pathway, has the potential advantage of preserving growth and avoiding coronary damage for this subset. However, no interim or long-term results have been reported.
A 3-year-old boy who had been cyanotic since birth because of a double-outlet right ventricle with a subaortic ventricular defect and infundibular-valvular pulmonary stenosis (z value2 of 3.6) underwent a definitive operation according to the instructions of the proposed technique at our institute. The right coronary artery originated from the aorta, transversing the right ventricular outflow tract (RVOT) very near the main pulmonary trunk because of l-transpositioned great arteries. Seven years postoperatively, the pressure gradient across the RVOT had increased to 80 mm Hg from 20 mm Hg, even though the native pulmonary valve annulus and a patchy reconstructed tract orifice had grown by 11 mm (z = 2.8) and 15.5 mm (z = +1.2), respectively (Figure 1). Meanwhile, the right coronary artery beneath the constructed pathway showed no distortion.
View larger version (68K):
[in this window]
[in a new window]
Figure 1. A, Angiogram 4 years postoperatively: the right ventricular angiogram demonstrates the development of reconstructed and native pathways. B, Angiogram 7 years postoperatively: the native outflow tract bulged centrifugally, and the posterior wall protruded into the pulmonary outflow tract as a transverse fold (black arrows) with a pressure gradient of 80 mm Hg.|
The growth of the RVOT without harmful influence on the coronary artery was proved in this case, and the problem involved in leaving the native outflow tract open was elucidated. The anatomic stenosis advanced concomitant with development of the native pathway. The bloodstreams from both pathways probably created turbulence at the merging point, making the outflow tract bulge centrifugally. The dilated native posterior wall rose up and protruded into the pathway as a transverse fold. Although we still support the early definitive repair of Fallot-type cyanotic disease, we conclude that complete repair should be deferred until the child is 6 to 7 years old to confirm whether the pulmonary valve annulus has sufficiently developed. Various techniques3,4 for repair must be chosen individually for this subset of anomalies.
- van Son JAM. Repair of tetralogy of Fallot with anomalous origin of left anterior descending coronary artery. J Thorac Cardiovasc Surg. 1995;110:561562[Free Full Text]
- Shimazaki Y, Blackstone EH, Kirklin JW, Jonas RA, Mandell V, Colvin EV. The dimension of the right ventricular outflow tract and pulmonary arteries in tetralogy of Fallot and pulmonary stenosis. J Thorac Cardiovasc Surg. 1992;103:692705[Abstract]
- Brizard CPR, Mas C, Sohn YS, Cochrane AD, Karl TR. Transatrial-transpulmonary tetralogy of Fallot repair is effective in the presence of anomalous coronary arteries. J Thorac Cardiovasc Surg. 1998;116:770779[Abstract/Free Full Text]
- Lecompte Y, Neveux JY, Leca F, et al. Reconstruction of the pulmonary outflow tract without prosthetic conduit. J Thorac Cardiovasc Surg. 1982;84:727733[Abstract]