J Thorac Cardiovasc Surg 2006;132:990-991
© 2006 The American Association for Thoracic Surgery
Reply to the Editor
Pascal A. Berdat, MD,
Thierry P. Carrel, MD
Swiss Cardiovascular Center Bern, Clinic for Cardiovascular Surgery, University Hospital, Bern, Be 3010, Switzerland
(Email: pascal.berdat{at}insel.ch).
We appreciate the comments by Schreiber and Lange. We believe that making a difference between "implantation" and "replacement" in this context is rather a semantic one. In our series of 4 patients, with 3 having had a transannular patch at tetralogy of Fallot repair and one having had a commissurotomy at repair of valvular pulmonary stenosis, all patients have had a native, although stenotic, pulmonary valve. Therefore by implanting a pulmonary valve prosthesis within the native valve, this valve and its function are being replaced. With regard to an enlarged right ventricular outflow tract (RVOT), we believe that reduction plasty is necessary in patients with a diameter of greater than 28 mm for 2 reasons. First, the Shelhigh Injectable Valve is available in a maximal size of 33 mm. Following the recommendations of Schreiber with oversizing of at least 2 mm would mean that patients with an RVOT of greater than 31 mm could not be treated with this new technique. However, it is this subset of patients with chronic pulmonary regurgitation that present typically with enlarged RVOT and profit the most from this method. Second, it is well known from the literature that an enlarged RVOT is deleterious for the function of the right ventricle1
and might be a source for ventricular arrhythmias and consecutive sudden death.2,3 Surgical treatment should therefore not only be focused on pulmonary valve replacement, but also additional problems should be addressed concomitantly. Because reduction plasty can also be done safely and easily off pump, does not lead to stenosis, and reshapes a conical RVOT to a more tubular form in which the inserted valve prosthesis finds better seating, we would still recommend it. We of course also perform an in-depth analysis of right ventricular function and the morphology of the RVOT by means of transesophageal and transthoracic echocardiography and magnetic resonance imaging preoperatively to assess the feasibility of this procedure in an individual patient.
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References
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- Redington AN, Oldershaw PJ, Shinebourne EA, Rigby ML. A new technique for the assessment of pulmonary regurgitation and its application to the assessment of right ventricular function before and after repair of tetralogy of Fallot. Br Heart J 1988;60:57-65.[Abstract/Free Full Text]
- Vogel M, Sponring J, Cullen S, et al. Regional wall motion and abnormalities of electrical depolarization and repolarization in patients after surgical repair of tetralogy of Fallot. The substrate for malignant ventricular tachycardia?. Circulation 1997;95:401-404.[Abstract/Free Full Text]
- Harrison DA, Harris L, Siu SC, et al. Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot. J Am Coll Cardiol 1997;30:1368-1373.[Abstract]
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Off-pump pulmonary valve implantation
- Christian Schreiber and Rüdiger Lange
J. Thorac. Cardiovasc. Surg. 2006 132: 990.
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