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This video demonstrates a case of Tetralogy of Fallot (TOF), and after clearing the right ventricular outflow tract (RVOT) and closing the ventricular septal defect (VSD) from the right atrium, 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. Commissurotomy was performed, followed by inspection of the subvalvar aspect. If crowded, a limited incision can be made in the RVOT (right ventricular infundibulum) by dividing the muscle bundles and passing the required Hegar dilator into the pulmonary artery. The Hegar dilator can be accepted even if it is one size smaller and is able to pass across the annulus. If this fails, a transannular incision is made connecting the pulmonary artery and the infundibular incision. The native dysplastic leaflets were excised, and then the right atrial appendage was prepared.
The preparation of the right atrial appendage was performed by incising the trabecula under vision and everting the excised appendage over a Hegar dilator, ensuring that the smooth external aspect of the right atrial appendage was positioned in the path of blood. The eversion over the Hegar dilator also makes dividing the trabeculae safer and makes the repair of any inadvertent perforation easier.
The base was sutured to the annulus, specifically the relatively wider base portion. This was sutured posteriorly using a continuous suture. The top of the right atrial appendage was opened and fixed to the pulmonary artery, positioned 180 degrees apart from the lateral commissures of the valve, creating the bicuspid valve. The anterior atrial flap was sutured to the RVOT patch, which consists of either autologous treated pericardium or bovine pericardium, depending on the availability. The anterior suture line was done using interlocking sutures to avoid pursestringing. Before completing the patch suturing over the infundibular incision, the competency of the valve can be 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.
The donor atrial side was closed directly or can be closed with a patch. If the extension of the right atrial appendage is required to lengthen the atrial appendage, closing with a patch by delicately suturing over the epicardium close to the right coronary artery is advised. If no lengthening maneuvers are needed, direct closure can be performed in one or two layers.
This technique differs from the described Iranian technique in several ways: 1) everting the appendage and then thinning it over the Hegar dilator, 2) dividing the appendage without a clamp, 3) using interlocking sutures anteriorly, and 4) closing the right atrial appendage harvest site with a patch when needed.
This technique is suitable when the leaflets are very dysplastic with a narrow annulus. The authors have used it in three patients who experienced smooth postoperative recoveries. Additionally, it is also eminently suitable for patients who had RVOT stenting. The authors have also applied this technique in cases of truncus arteriosus, pulmonary root translocations, pulmonary atresia, and absent pulmonary valve, thereby reducing the need for conduits.
References
- Amirghofran, A. A., Mirhosseini, S. A., Narimani-Javid, R., Edraki, M. R., Rafati Navaei, M., Mohammadi, H., Khorshidi, S., Nozhat, S., Savand Roomi, Z., Bazrafshan Driss, H., Shafiei, S., & Arzhangzadeh, A. (2025). Tricuspid Valve Replacement Using the Right Atrial Appendage Valve: Techniques and 1-Year Results. Interdisciplinary CardioVascular and Thoracic Surgery, 40(10). https://doi.org/10.1093/icvts/ivaf207
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