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Early experience with surgical strategies aimed at preserving the pulmonary valve and annulus during repair of tetralogy of Fallot


1 Paediatric Cardiac Surgery, Division of Paediatric Cardiac Sciences, Krishna Institute of Medical Sciences (KIMS Hospitals), Secunderabad, Telangana, India
2 Paediatric Cardiac Anaethesiology, Division of Paediatric Cardiac Sciences, Krishna Institute of Medical Sciences (KIMS Hospitals), Secunderabad, Telangana, India
3 Paediatric Cardiology, Division of Paediatric Cardiac Sciences, Krishna Institute of Medical Sciences (KIMS Hospitals), Secunderabad, Telangana, India
4 Cardiovascular and Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
5 Department of Anthropology, Overseas Observer Pre-Med student from University of Massachusetts, Massachusetts, USA

Correspondence Address:
Dr. Anil Kumar Dharmapuram
Pediatric Cardiac Surgery, Division of Paediatric Cardiac Sciences, Krishna Institute of Medical Sciences (KIMS Hospitals), Minister Road, Secunderabad - 500 003, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/apc.APC_166_20

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Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 315-322

 

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Background : During repair of tetralogy of fallot (TOF) we modified surgical strategies to preserve the valve and annulus if the pulmonary valve leaflets are pliable and not significantly dysplastic. Methods : Initially, the repair was done from the main pulmonary artery (Group-1, 215 patients) and later through an additional incision in the infundibulum of the right ventricle (Group-2, 73 patients). Recently, we changed the approach to commissurotomy of the fused leaflets by releasing the supra valvar tethering and delamination of the cuspal apparatus till the base to improve the mobility of the cusps and do a controlled commissurotomy (Group-3, 14 patients). With delamination, we could extend the limit of the repair to a z-score of -3.5. Results : There was no hospital mortality; two patients died at home after discharge. A mean follow-up of 42.01 months ± 19.25 is available for 198 patients (92%) for group 1, 16.03 ± 7.45 for group 2, and 4.07 ± 2.09 for group 3. The re-intervention-free survival is 94.4% in group 1. The z value improved from -3 (-3–-2) to -1.2 (-3 – 0), P = 0.001 in Group 1, from -2.8 (-3–-2.4) to -1 (-1.1–-0.7), P = 0.001 in Group 2 and from –3 (-4–-3) to -1, P = 0.001 in Group 3. In all the groups, there was trivial or mild pulmonary regurgitation. Conclusions : During repair of TOF, adequate valve/annulus sparing is possible if the repair is done from both the main pulmonary artery and infundibular incisions using the delamination technique.






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1 Paediatric Cardiac Surgery, Division of Paediatric Cardiac Sciences, Krishna Institute of Medical Sciences (KIMS Hospitals), Secunderabad, Telangana, India
2 Paediatric Cardiac Anaethesiology, Division of Paediatric Cardiac Sciences, Krishna Institute of Medical Sciences (KIMS Hospitals), Secunderabad, Telangana, India
3 Paediatric Cardiology, Division of Paediatric Cardiac Sciences, Krishna Institute of Medical Sciences (KIMS Hospitals), Secunderabad, Telangana, India
4 Cardiovascular and Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
5 Department of Anthropology, Overseas Observer Pre-Med student from University of Massachusetts, Massachusetts, USA

Correspondence Address:
Dr. Anil Kumar Dharmapuram
Pediatric Cardiac Surgery, Division of Paediatric Cardiac Sciences, Krishna Institute of Medical Sciences (KIMS Hospitals), Minister Road, Secunderabad - 500 003, Telangana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/apc.APC_166_20

Rights and Permissions

Background : During repair of tetralogy of fallot (TOF) we modified surgical strategies to preserve the valve and annulus if the pulmonary valve leaflets are pliable and not significantly dysplastic. Methods : Initially, the repair was done from the main pulmonary artery (Group-1, 215 patients) and later through an additional incision in the infundibulum of the right ventricle (Group-2, 73 patients). Recently, we changed the approach to commissurotomy of the fused leaflets by releasing the supra valvar tethering and delamination of the cuspal apparatus till the base to improve the mobility of the cusps and do a controlled commissurotomy (Group-3, 14 patients). With delamination, we could extend the limit of the repair to a z-score of -3.5. Results : There was no hospital mortality; two patients died at home after discharge. A mean follow-up of 42.01 months ± 19.25 is available for 198 patients (92%) for group 1, 16.03 ± 7.45 for group 2, and 4.07 ± 2.09 for group 3. The re-intervention-free survival is 94.4% in group 1. The z value improved from -3 (-3–-2) to -1.2 (-3 – 0), P = 0.001 in Group 1, from -2.8 (-3–-2.4) to -1 (-1.1–-0.7), P = 0.001 in Group 2 and from –3 (-4–-3) to -1, P = 0.001 in Group 3. In all the groups, there was trivial or mild pulmonary regurgitation. Conclusions : During repair of TOF, adequate valve/annulus sparing is possible if the repair is done from both the main pulmonary artery and infundibular incisions using the delamination technique.






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