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The application of pulmonary valve biorifice for reconstruction of right ventricular outflow tract in tetralogy of Fallot
© Yang et al.; licensee BioMed Central Ltd. 2013
Received: 20 November 2012
Accepted: 6 June 2013
Published: 11 June 2013
To introduce a new technique to create a pulmonary valve biorifice for the reconstruction of the right ventricular outflow tract in tetralogy of Fallot (TOF), and to summarize the initial clinical experiment.
The new technique of reconstructing the right ventricular outflow tract with pulmonary valve biorifice was used in 53 cases of TOF (the observation group). While the conventional technique for reconstructing the right ventricular outflow tract was used in other 50 cases of TOF (the control group). The clinical Data of all cases was reviewed retrospectively.
The ages, weights, cardiopulmonary bypass time, cardiac arrest time, as well as the post operation ventilation support time were not different significantly between groups. Unlike patients in the control group, patients from the observation group had shorter duration of ICU stay. Post- operation, in the observation group, only 2 cases had a large amount of pleural effusion, 1 case had mid-level effusion and 8 cases had a small amount of pleural effusion. While in the control group, there was 1 case of a large amount of effusion, 5 cases of mid-level effusion and 17 cases of a small amount of pleural effusion. 1 week after the operation, all patients were rechecked by echocardiography and no evidence of pulmonary valve stenosis was found. In the observation group, moderate pulmonary valve regurgitation was found in 8 cases, and mild regurgitation was observed in 15 cases. In the control group, severe regurgitation was observed in 3 cases, moderate regurgitation in 17 cases, and mild regurgitation in 16 cases. 33 cases from the observation group were rechecked six months, post-operation, and moderate-mild pulmonary regurgitation was found in 3 cases. As a follow up, 18 cases from the observation group were rechecked 1 year later, and no pulmonary regurgitation was found.
The new technique to create pulmonary valve biorifice can reduce the pulmonary valve regurgitation, reduce postoperative pleural effusion, and improve the early surgical outcome.
Tetralogy of Fallot (TOF) is one the most common cyanotic congenital heart diseases. Surgical treatment of TOF in recent years has achieved good short-term results, while the long-term results have been compromised by the pulmonary valve regurgitation. Once the radical repair indicated, usually there are two ways to enlarge the stenotic, hypoplastic right ventricular outflow tract and/or pulmonary valve: augmentation of right ventricular outflow tract and transannular patch to enlarge right ventricular outflow tract and pulmonary trunk. A ventriculotomy should be extended across the pulmonary annulus, which results in the progressive enlargement of right ventricle secondary to the pulmonary regurgitation. Consequently, right ventricular dysfunction and arrhythmia may occur. In order to prevent postoperative pulmonary regurgitation, we have used a new technique to reconstruct right ventricular outflow tract since Oct. 2009. When we perform the transannular incision, we keep the pulmonary annular intact and create a pulmonary valve biorifice for reconstruction of right ventricular outflow tract.
Preoperative dates from 2 groups
Month age (median)
Body weight (kg median)
Oxygen blood pressure (mmHg)
Pulmonary artery index (mm2/m2)
Left ventricular end diastolic volume index (ml/m2)
Data were expressed as mean ± SE and median. Staxtistical Product and Service Solutions 14.0 software (SPSS Institute) was used for all analysis. A X2 test or independent-sample t-test was performed to check for differences between the two groups. The critical alpha level for these analysis was set at p<0.05.
Two groups of children’s postoperative data
Cardiopulmonary bypass time (min)
Aortic cross clamp time (min)
Mechanical ventilation time (h)
ICU residence time (d)
Pleural effusion (No / small / medium / large)**
Tetralogy of Fallot, accounts for 12%-14% of all congenital heart diseases, is one of the most common complex cyanotic congenital heart diseases. The pathological anatomic characteristics for a tetralogy include ventricular septal defect, right ventricular outflow tract obstruction, overriding of aorta, and right ventricular hypertrophy. Recently, the one stage repair for a tetralogy was performed in many heart centers around the world and led to a satisfactory short-term outcome in children, as reported by some centers . Because of the presence of the pulmonary valve dysplasia, a transannular patch to enlarge the narrowed right ventricular outflow tract and pulmonary artery is required. The main concern for this transannular patch is that the integrity of pulmonary valve will be damaged, which results in postoperative pulmonary regurgitation. Thus, the main shortfall of the conventional transannular technique is the poor long-term outcome, and therefore, the chances of reoperation is greater . Long-term pulmonary valve regurgitation can lead to further right ventricular hypertrophy and right heart failure . And  in such conditions, additional surgical interventions (pulmonary valve replacement surgery) may be required to correct pulmonary regurgitation for the purpose of the long term outcome . It is estimated that about 10% to 15% or even higher percentages of patients may have severe pulmonary regurgitation 20 years after the first operation, and pulmonary valve replacement may be required for those patients [5, 6].
How to effectively reduce pulmonary regurgitation and reduce the necessity for a pulmonary valve replacement is one of the study focuses of cardiac surgeons. Some cardiac surgeons add single or double artificial leaflets on the autologous patch used to reconstruct the right ventricular outflow tract . The added leaflets were made by autologous pericardium, or polytetrafluoroethylene (PTFE), or other kinds of biological materials. However, all of these materials have disadvantages. For instance, PTFE is not very compatible with heart tissue and is very difficult to suture on to the surface of pericardium, which limits its further use. Other kinds of biological materials including bovine jugular vein (with valve), allograft aortic valve and pulmonary valve are used commonly. The initial results of the clinical application showed that these materials had relatively better tissue compatibility and less pulmonary regurgitation compared to PTFE. As the bovine jugular vein is easy to obtain, its usage is more common than the use of allograft of aortic or pulmonary valve. Although those biological materials have some advantages when compared with PTFE, degeneration and calcification are the main disadvantages for biological material . Meanwhile, studies related to anti-degeneration and/or anti-calcification is another important direction of current research .
In this study, we selected patients with pulmonary stenosis which must be enlarged and while the diameter of the original pulmonary valve annual was not too small. In our institution, there were more than 120 patients with TOF admitted at this study period and all those patients had been screened for the indication of biorifice technique. And approximately 40% of them were suitable for this technique. If the diameter less than 4 mm means the bi-orifice technique may not result beneficial for these patients. Due to some economic and political reasons, patients with congenital heart disease in eastern world may not come to hospital early, and this is the reason why the mean ages of this study are older when compared with studies from western world.
All cases in this study were followed-up for up to one year and no early deaths were reported. The initial findings of our study were promising, however, due to the low numbers of patients involved and the absence of longterm follow ups, further studies are necessary to to fully evaluate the benefits of the biorifice technique.
The biorifice technique of pulmonary valve can reduce pulmonary valve regurgitation, reduce postoperative pleural effusion, and improve the early surgical outcome.
We appreciate the National Natural Science Foundation of China (no. 30871424), Program for Changjiang Scholars and Innovative Research Team in University (IRT1195) and Hunan Provincial Natural Science Foundation of China (11JJ7005) for their providing funds. We also express our gratitude to professor Ju Chen and Matt Stroud MD (UCSD School of Medicine) for their guidance in the translation of this article from Chinese to English.
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