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Objectives
The advent of hybrid surgical options for treating cardiac disease has integrated the techniques of interventional cardiology with the techniques of cardiac surgery to provide a form of therapy that combines the respective strengths of both fields. This video demonstrates two different hybrid pulmonary valve replacement (PVR) strategies in the increasingly growing young adult population of patients with Tetralogy of Fallot and pulmonary valve dysfunction.
Case Summary
The first case involved an 18-year-old patient with a previously repaired Tetralogy of Fallot (TOF). The patient presented with significant dilatation of the right ventricle and right ventricular outflow tract (RVOT), severe pulmonary valve regurgitation, and was moderately symptomatic (on exercise testing). Under general anesthesia, the patient underwent a full median sternotomy. The main pulmonary artery (PA) was carefully sized using transesophageal and epicardial echocardiography, and measured more than 29 mm in diameter. The PA was longitudinally plicated using a 3.0 Prolene running suture to a maximal diameter of 25 mm. A valve 2 mm in diameter larger than the maximum size measured was selected (27 mm No-React Biopulmonic self-expanding). The selected valve was gently compressed into the introducer, which is similar to a giant syringe, and slid into the provided trocar. Double pledgeted purse-strings were then placed on the anterior surface of the proximal RVOT just proximal to the infundibulum/infundibular patch, avoiding calcified tissue. The location was chosen to lie immediately in line with the PA, and far enough away from the annulus of the valve to permit comfortable angulation of the trocar up to the PA. After heparinization (100 IU per kg of body weight to achieve an active clotting time of 200-300 seconds), a stab incision was made at the site of the purse-string sutures. The injector was then slid into the RVOT and advanced to the main PA. With the tip of the injector stabilized and the operator’s fingers holding the PA below its bifurcation, the valve was deployed in the main PA immediately distal to the native annulus. The trocar delivery system was then withdrawn and the purse-string sutures controlled. Transesophageal and epicardial echocardiogram was used to assess the valve position throughout the process of deployment. The valve was then secured with external Prolene sutures placed in the proximal and distal rim of the valve.
The second case involved a 15-year-old patient with the same clinical presentation as the first case. The intra-operative RVOT angiogram showed a maximal diameter of 33 mm, precluding the insertion of a trans-cutaneous Melody pulmonary valve. After a partial upper sternotomy, the RVOT was plicated, creating a tubular structure with a maximal diameter of 23 mm. The plicated RVOT acted in this way as the landing zone for a 22 mm trans-cutaneous Melody pulmonary valve implantation. The post-operative angiogram and echocardiogram showed perfectly functional pulmonary valve prosthesis with no stenosis or regurgitation.
Conclusion
Avoiding cardiopulmonary bypass and cardioplegic arrest in hybrid PVR strategies could offer significant mortality and morbidity advantages, and could become the strategy of choice for the majority of patients requiring PVR after previous TOF repair.
