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How to Make a Valve for the RVOT from the Right Atrial Appendage

Tuesday, October 18, 2022

Amirghofran AA, Nirooei E. How to Make a Valve for the RVOT from the Right Atrial Appendage. October 2022. doi:10.25373/ctsnet.21354825.v1

Preventing chronic pulmonary insufficiency (PI) is a huge challenge in Tetralogy of Fallot (TOF) repair. Right ventricular dysfunction and arrhythmias secondary to chronic pulmonary insufficiency (PI) are the major causes of long-term morbidity in patients with previous surgical repair of TOF and its related conditions. Many techniques have been introduced to prevent chronic PI in these patients. However, none of these efforts have achieved satisfactory long-term results or gained general acceptance.

The authors of this article and their team introduced the novel technique of creating a bicuspid valve from the native tissue of the right atrial appendage in 2019 (1), followed by encouraging short to midterm results published in 2020 (2). Other centers have used this technique and published good results (3, 4).

This latest video demonstrates and explains the technical details of the right aortic arch (RAA) valve creation procedure as standardized and performed in more than 120 patients. The authors hope it will help to shorten the learning curve, as well as provide a more uniform population of patients for future comparative follow-up studies.



Further Insights

Although this procedure was designed for TOF patients, the encouraging results have led to use of the technique, with small modifications, for any type of congenitally malformed or defective right ventricle outflow tract (RVOT). It can also be used for pulmonary artery (PA) connections in patients who need repair of truncus arteriosus, pulmonary atresia correction, or Nikaidoh operation.

Although cardiac catheterization is routinely performed in TOF patients, CT angiography, which is best demonstrates the RAA anatomy, is performed only in selected cases. The authors have gradually learned that almost any right atrial appendage may be used for RAA valve construction. Nevertheless, the tall and quadrangular shaped appendages with a width one and a half times their height are the most suitable candidates.

The authors perform the RAA harvesting and preparation after repairing the intracardiac defect—such as VSD closure and complete evaluation of the anatomy of the RVOT. To be placed in its position, the RAA needs an opened RVOT bed with ideal annulus width of approximately half the circumference of the mean proper size for the patient’s body surface area. However, this is not a strict number and a range is acceptable. The anterior half of the RV-PA pathway is then constructed symmetrically using a piece of bovine patch from the right ventriculotomy to the PA bifurcation.

After the procedure, patients were regularly followed up with using echocardiography. The short- and mid-term results for the RAA valve function have been quite satisfactory, with 90 percent of patients having no or trivial PI soon after the operation or at the follow up. Being a native and live tissue—the major advantage of the RAA valve—may offer the possibility of growth in the future and eliminate or postpone the need for further re-interventions, such as frequent pulmonary valve replacements. Of course, more follow-ups and further studies are needed to come to a final conclusion.


  1. Amirghofran AA Using Right Atrial Appendage (RAA) to prevent pulmonary insufficiency after Tetralogy of Fallot repair. First world report of RAA valve. The 33rd European Association for Cardio-Thoracic Surgery Annual Meeting; 2019 October 3-5; Lisbon, Portugal. (video presentation, abstract ID: 000559)
  2. Amirghofran A, Edraki F, Edraki M, Ajami G, Amoozgar H, Mohammadi H, Emaminia A, Ghasemzadeh B, Borzuee M, Peiravian F, Kheirandish Z, Mehdizadegan N, Sabri M, Cheriki S, Arabi H. Surgical repair of tetralogy of Fallot using autologous right atrial appendages: short- to mid-term results. Eur J Cardiothorac Surg. 2021 Apr 13;59(3):697-704. doi: 10.1093/ejcts/ezaa374. PMID: 33164039.
  3. Onan IS, Ergün S, Özturk E, Çelik EC, Ayyıldız P, Onan B. Early results of neopulmonary valve creation technique using right atrial appendage tissue. J Card Surg. 2020 Oct;35(10):2640-2648. doi: 10.1111/jocs.14860. PMID: 33043664.
  4. Schulte, Linda J., et al. "Evolution of Pulmonary Valve Management During Repair of Tetralogy of Fallot: A 14-year Experience." The Annals of Thoracic Surgery (2022).


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Hi. Many thanks from you and other colleagues for the kind comments. Regarding your question although our mean age for operation is around 1 year old , we have had many patients less than 6 months old too . The procedure and the results has been the same, nevertheless, it is of course a bit more demanding in smaller patients.
Congratulations,I enjoyed your creativity and the sophisticated surgical technique. It helps to overcome one of the most important challenges in pediatric cardiac surgery.
Fantastic video and explanations! I have done this operation 8 times with disappointing results (too much residual gradients). Therefore, I stopped doing it. But now, thanks to these explanations, I understand what my mistakes were. It is now clear to me why I did not have good results. I look forward to my next Fallot case and I will use this technique. Thank you very much my dear colleagues for this great contribution.

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