“V-PLASTY”: a novel technique to reconstruct pulmonary valvular and annular stenosis in patients with right ventricular outflow tract obstruction

Right ventricular outflow tract (RVOT) reconstruction had always become a challenge in congenital heart diseases for the surgeons. Since Rastelli first described surgical repair for pulmonary valve [1], surgeons performed various techniques up to anatomic situation of the RVOT and pulmonary valve. In all these surgical approaches preventing the pulmonary insufficiency has become the key point. Turrentine et al. reported that patients who only underwent to transannular patch enlargement without valve-sparing exhibits early perioperative morbidity which is manifest by right ventricle dysfunction, low cardiac output, and inotrope dependency causing prolonged ventilation requirements and intensive care unit (ICU) admissions [2]. Therefore, transannular enlargement of pulmonary annulus alone may not be sufficient and pulmonary valve sparing may be necessary to prevent complications related to pulmonary insufficiency such as right ventricle dysfunction and arrhythmia. Thus we aimed to reconstruct the RVOT obstruction with enlarging the anterior leaflet and pulmonary annulus with a patch while preserving its coaptation surface which will grow up with the patient’s age and will preserve native valve coaptation. In this study we present early term results of our new technique that we call “V-Plasty” to reconstruct pulmonary valve and enlarge pulmonary annulus in patients with mild or moderate pulmonary valvular and annular stenosis.

Institutional Review Board approval was obtained for the conduct of this retrospective study. Between January 2006 and January 2010, we performed V-plasty pulmonary valve reconstruction in 10 patients. We entitled this technique as “V-plasty” because anterior pulmonary leaflet forms a V shape after the incision for pulmonary annular patch enlargement (Figure 1c). The mean age of the patients was 5.2 (ranging from 2 to 11). Eight patients (5 males, 3 females) had tetrology of Fallot (TOF) and 2 patients (1 male, 1 female) had atrial septal defect concomitant with pulmonary valve stenosis. Demographic data of the patients were listed in Table 1. Dysplastic and bicuspid valves were excluded because these valve anomalies are not inappropriate to reconstruct with V-Plasty. Therefore, reconstruction with V-Plasty was performed for only mild and moderate annular – valvular stenosis with tricuspid pulmonary valve anatomy. In these patients also infundibular stenosis relieved with muscle band resection and patch augmentation. Ethic aproval was obtained from Gaziantep Universty clinical investigations ethic committee with reference number 22.11.2011/239.

All procedures were performed with transesophageal echocardiography guidance.

The operative repair of RVOT obstruction generally requires either resection of the dysplastic valve or widening of the pulmonary valve annulus using a transannular patch. However patch augmentation of pulmonary valve alone leads to pulmonary insufficiency which causes right ventricle volume overload, right ventricle failure and fatal arrhythmias. Borowski and colleagues reported that pulmonary insufficiency develops in up to 30% of patients at a follow-up of 20 years [7]. Therefore, a lot of various techniques were performed and developed since Kirklin first described transannular reconstruction in 1959 [8]. Rastelli first described repair of pulmonary valve in 1965 [1]. Then, various types of patch materials were used for reconstituting blood flow from the right ventricle to the pulmonary artery such as autologous pericardium, Dacron polyester fabric, polytetrafluoroethylene (PTFE), glutaraldehydetreated bovine pericardium, bovine jugular vein, cryopreserved allografts or homografts, and engineered tissue grafts. Each of these materials has substantial advantages and disadvantages including stenosis, thromboembolization, calcium deposition, and risk of infection [9–12]. We preferred bovine pericardium instead of autologous pericardium in our cases due to its easier application. At the same time, native pericardium was spared to close mediastinum to reach heart easily when a re-operation necessitated.

On the other hand, the nonvalved conduit without a pulmonary valve is not physiological and this contributes to the occurrence of postoperative mortality and morbidity [13]. Besides, pericardial monocusp or homograft monocusp reconstruction to provide pulmonary coaptation, valve function decreases over time as the RVOT grows and the homograft tissue undergoes structural deterioration [14]. Therefore, we suggested that creation of a functional pulmonary valve is the key point of the RVOT reconstruction in proper patients. In our study, we performed the surgical technique of enlargement of the pulmonary annulus and the anterior pulmonary leaflet with a transannular patch of bovine pericardium in 10 consecutive patients who had non-dysplastic valve structure and mild or moderate pulmonary valvular/annular stenosis. The major key points of this technique are preserving pulmonary anterior leaflet coaptation surface while performing annulus enlargement, minimized surgical incision to preserve infundibulum function, infundibular muscle band resection to relieve RVOT stenosis, infundibular augmentation and construction of a new pulmonary sinus with a pericardial patch after enlargement of the anterior leaflet and annulus. The most important advantage of this technique is preserving the native valvular coaptation surface which will grow up with the patient’s age.

In our follow-up period we have not seen neither moderate nor severe pulmonary insufficiency in our selected patient group. Our early results are encouraging, but long term follow-up results are needed with large case series.