Repair of Hypoplastic Right Ventricular Outflow Tract

Although there are advantages and disadvantages of outflow tract patching across the pulmonary valve annulus, adequate relief of outflow tract blockage is an important component of total repair operations for tetralogy of Fallot. A competent pulmonary valve with minimal or no residual outflow tract blockage is ideal. Significant residual pulmonary stenosis results in increased morbidity and mortality, so that a transanular patch is indicated when the valve annulus is severely restrictive. Homograft valve placement is not performed initially and is reserved for placement later in the subset of patients who do not tolerate pulmonary regurgitation.

A pericardial patch may be used for outflow tract augmentation if postrepair pulmonary artery pressure is expected to be low. It is easy to handle, and it provides better hemostasis as compared with synthetic material. If postrepair pulmonary artery pressure is not low, a synthetic outflow tract patch is used to avoid late development of a patch aneurysm. A homograft pulmonary artery wall patch is also used in many patients because it is hemostatic and does not result in late aneurysm formation. This patch may incorporate a segment of a homograft pulmonary valve, which may prevent postoperative pulmonary insufficiency in the early postoperative period.

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Goretex Patch Arterie

Figure 9-37. The high longitudinal ventriculotomy incision is extended across the hypoplastic pulmonary valve annulus and main pulmonary artery. An autologous pericardial patch is stitched to the outflow tract incision, starting the continuous suture on the distal main pulmonary artery.

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Patch Graft Pulmonary Stenosis

pulmonary valve annulus

Inner surface of pericardial patch

Figure 9-38. The smooth inner surface of the patch is placed within the circulation. The hypoplastic pulmonary valve annulus is seen.

Figure 9-37. The high longitudinal ventriculotomy incision is extended across the hypoplastic pulmonary valve annulus and main pulmonary artery. An autologous pericardial patch is stitched to the outflow tract incision, starting the continuous suture on the distal main pulmonary artery.

pulmonary valve annulus

Inner surface of pericardial patch

Figure 9-38. The smooth inner surface of the patch is placed within the circulation. The hypoplastic pulmonary valve annulus is seen.

Annulus Augmentation
patch

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Figure 9-39. Patch repair augmentation of the outflow tract is complete. The size of the patch is large enough to avoid residual blockage in the outflow tract but is not excessive; this may help avoid later development of a patch aneurysm.

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Figure 9-39. Patch repair augmentation of the outflow tract is complete. The size of the patch is large enough to avoid residual blockage in the outflow tract but is not excessive; this may help avoid later development of a patch aneurysm.

Right Ventricular Outflow Tract

Dacron patch caud

Figure 9-40. In the presence of right heart hypertension, the chance of late development of a pericardial outflow tract aneurysm can be reduced further by attaching a synthetic patch to the surface of the previously placed pericardial patch. This synthetic patch is cut from a tubular Dacron® graft, which incites a fibrous tissue reaction, resulting in a thick protective outer surface over the pericardial patch.

Dacron patch caud

Figure 9-40. In the presence of right heart hypertension, the chance of late development of a pericardial outflow tract aneurysm can be reduced further by attaching a synthetic patch to the surface of the previously placed pericardial patch. This synthetic patch is cut from a tubular Dacron® graft, which incites a fibrous tissue reaction, resulting in a thick protective outer surface over the pericardial patch.

Residual Right Outflow Tract Obstruction

Figure 9-42. When the pulmonary valve annulus is adequate and the infundibulum is hypoplastic after muscle is resected, the annulus can be spared and the proximal outflow tract is enlarged with a Gore-Tex® patch stitched to the ventriculotomy.

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Gore Tex Patch Graft

Figure 9-41. In another patient, there is hypoplasia of the annulus and stenosis of the proximal right and left pulmonary arteries. A Gore-Tex® patch is used here for extensive outflow tract reconstruction to avoid late aneurysm formation. The upper right ventricle, the main pulmonary artery, and the right and left pulmonary arteries are reconstructed with separate patches, because the use of a single large patch can be associated with twisting of the Gore-Tex® near the pulmonary artery branches, resulting in obstruction to flow.

patch on left pulmonary artery pulmonary valve annulus caud

Figure 9-41. In another patient, there is hypoplasia of the annulus and stenosis of the proximal right and left pulmonary arteries. A Gore-Tex® patch is used here for extensive outflow tract reconstruction to avoid late aneurysm formation. The upper right ventricle, the main pulmonary artery, and the right and left pulmonary arteries are reconstructed with separate patches, because the use of a single large patch can be associated with twisting of the Gore-Tex® near the pulmonary artery branches, resulting in obstruction to flow.

Figure 9-42. When the pulmonary valve annulus is adequate and the infundibulum is hypoplastic after muscle is resected, the annulus can be spared and the proximal outflow tract is enlarged with a Gore-Tex® patch stitched to the ventriculotomy.

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Gore Tex Fallot

Figure 9-43. In another patient, outflow tract reconstruction is performed using a homo-graft pulmonary wall patch.

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Figure 9-43. In another patient, outflow tract reconstruction is performed using a homo-graft pulmonary wall patch.

Pictures Plastic Pulimonary Arteries

homograft patch

Figure 9-44. In this patient, outflow tract reconstruction was performed using a segment of pulmonary artery wall homograft, including a valve cusp.

Figure 9-44. In this patient, outflow tract reconstruction was performed using a segment of pulmonary artery wall homograft, including a valve cusp.

Pulmonary Cusps

homograft pulmonary valve cusp ventriculotomy caud

Figure 9-45. The homograft is oversized so that the single pulmonary valve cusp can fill much of the new outflow tract.

Vegetation Pulmonary Valve

main pulmonary artery homograft pulmonary valve cusp homograft patch

Figure 9-46. The homograft is tailored and then sutured to the ventriculotomy.

main pulmonary artery homograft pulmonary valve cusp ventriculotomy caud

Figure 9-45. The homograft is oversized so that the single pulmonary valve cusp can fill much of the new outflow tract.

homograft pulmonary valve cusp homograft patch

Figure 9-46. The homograft is tailored and then sutured to the ventriculotomy.

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Homografts

Figure 9-47. The upper segment of the homograft is stitched to the native main pulmonary artery to complete the repair.

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Figure 9-47. The upper segment of the homograft is stitched to the native main pulmonary artery to complete the repair.

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Responses

  • Isembard
    What is autologous pericardial patch?
    8 years ago
  • MARKO
    What is right ventricular outflow ultrasound?
    7 years ago
  • cherryl
    Where is the pulmonary outflow tract?
    6 years ago
  • gabriel
    What is outflow tract augmentation?
    9 months ago

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