Redefining RVOT Reconstruction: Right Atrial Appendage Valve for ​the ​Pulmonary Position

The preparation of the right atrial (RA) appendage was done by incising the trabeculae under vision and everting the excised appendage over a Hegar dilator, so that the smooth external aspect of the RA appendage was in the path of blood. Eversion over the Hegar dilator also made dividing the trabeculae safer and the repair of any inadvertent perforation easier. 

After clearing the right ventricular outflow tract (RVOT) and closing the ventricular septal defect (VSD) from the RA, the focus shifted to the RVOT from the pulmonary artery aspect. An initial incision was made over the pulmonary artery, and the pulmonary valve was inspected from the pulmonary artery aspect. A commissurotomy was performed.  

After this, the subvalvar aspect was inspected, and if it was crowded, a limited incision was made in the RVOT (right ventricular (RV) infundibulum). The muscle bundles were divided, and the Hegar dilator was passed into the pulmonary artery. It was accepted that even if a Hegar dilator one size lower was able to pass across the annulus, it would suffice. If this failed, the surgeons would ame a transannular incision  connecting the pulmonary artery and the infundibular incision. The native dysplastic leaflets were excised. 

In the prepared right atrial appendage (RAA) valve, the base was sutured to the annulus; this was the relatively wider base portion. The base was sutured posteriorly using continuous sutures. The apex of the RA appendage was pulled and fixed to the pulmonary artery 180 degrees apart, while the lateral part was closed, creating the commissure of the valve, which makes the bicuspid valve. The anterior atrial flap was sutured to the RVOT patch, which was ​treated with either ​autologous pericardium or bovine pericardium, depending on availability. The anterior suture line was completed with interlocking suture​s​ to avoid purse stringing.  

Before completing the patch suturing over the infundibular incision, the competency of the valve was checked by releasing the snugging sutures over the pulmonary artery or by instilling saline in the main pulmonary artery (MPA) with the branch pulmonary arteries snugged. After this, the rest of the patch was sutured to the RVOT.

This technique differs from the described Iranian technique in several ways: it involves everting the appendage and then thinning it over a Hegar dilator, dividing the appendage without a clamp, and using interlocking sutures anteriorly. This technique is suitable when the leaflets are very dysplastic with a narrow annulus. It is also eminently suitable for patients who have undergone RVOT stenting.  

The authors have used this technique in cases of truncus arteriosus, pulmonary root translocations, pulmonary atresia, and absent pulmonary valve, reducing the need for conduits. 

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