Reoperation for Severe Right Ventricular Dilatation after Tetralogy of Fallot Repair: Pulmonary Infundibuloplasty Should be Added to Homograft Implantation

Yves d’Udekem d’Acoz1, Agnes Pasquet2, Olivier Van Caenegem2, Catherine Barrea2, Thierry Sluysmans2, Philippe Noirhomme2, Jean Rubay2
1Cardiac Surgery Unit, Royal Children’s Hospital, Melbourne, Australia, 2Departments of Cardiovascular and Thoracic Surgery, Cardiology, Pediatric Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium

 

Background and aim of the study: Right ventricular dilatation observed after tetralogy of Fallot repair regresses after pulmonary valve implantation, unless the dilation is too severe. The presence of an akinetic patch in the right ventricular outflow tract (RVOT), a known factor promoting right ventricular dilatation, may prevent right ventricular recovery after valve implantation. The exclusion of a large akinetic RVOT area during reoperation of patients presenting with severe post-repair right ventricular dilatation was investigated.
Methods: Eight patients underwent a pulmonary infundibuloplasty between May 2000 and October 2002. Their mean preoperative cardothoracic index was 0.66 ± 0.08, and preoperative NYHA class II (n = 4), III (n = 3) or IV (n = 1). Three patients were offered heart transplantation but refused. All had severe

pulmonary regurgitation and underwent a RVOT valve implantation except one patient who had a previous homograft pulmonary valve insertion. Concomitant procedures were tricuspid ring implantation (n = 3), atrial septal defect closure (n = 2), mitral valve repair (n = 1) and modified right atrial Maze (n = 1).
Results: Median follow up time was 13 months (range: 6 -29 months). One patient suffered a fatal ventricular fibrillation at home. All patients but one were in NYHA class I. After a mean of 5 ± 3 months, their mean workload capacity rose from 115 ± 19 W to 155 ± 62 W, and mean VO2max rose from 16.5 ± 2 to 18.3 ± 2 ml/min/kg.
Conclusion: Pulmonary infundibuloplasty may be a useful adjunct in reoperation of tetralogy of Fallot patients presenting with severe right ventricular dilatation and large akinetic area of the RVOT.
 
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