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Common arterial trunk repair: with conduit or without?

^a Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
^b Department of Pediatric Cardiology, University Paris Descartes and Sick Children Hospital, Paris, France

Received 2 September 2008; received in revised form 19 March 2009; accepted 24 March 2009.

^_* Corresponding author. Address: Chirurgie Cardiaque Pédiatrique, Hôpital Necker, Enfants Malades, 149 rue de Sèvres 75015 Paris, France. Tel.: +33 1 44 38 18 67; fax: +33 1 44 38 19 11. (Email: pascal.vouhe{at}nck.aphp.fr).

Objective: To compare the mid-term results of two techniques used for the reconstruction of the pulmonary outflow tract during common arterial trunk repair in infancy, with special attention paid to re-operation rate and pulmonary arterial growth. Methods: Between 2000 and 2006, 32 consecutive neonates or infants underwent common arterial trunk repair. In 15 patients, the pulmonary outflow tract was reconstructed using an extracardiac valved conduit (conduit group). In 17 patients, right ventricle to pulmonary artery connection was achieved without conduit, using the left atrial appendage and including a monocusp valve (non-conduit group). The decision regarding the type of ventricle to pulmonary artery connection was at the discretion of the attending surgeon. The two groups were similar in terms of age, weight, type of common arterial trunk, truncal valve dysfunction and coronary abnormalities. Follow-up was 93% complete and included echo-Doppler evaluation, catheterisation and CT scan imaging. Results: Hospital mortality (five patients – 16%) was increased by coronary abnormalities and preoperative ventilation but did not differ between the two groups (13.3% in the conduit group vs 18% in the non-conduit group). The mean follow-up was 40 ± 25 months. There were six late deaths (three in each group), yielding an actuarial survival of 76% at 5 years. One late death was procedure related (percutaneous dilatation for obstructive monocusp patch). Re-operation for right ventricular outflow tract obstruction was necessary in seven patients (five in the conduit group and two in the non-conduit group); the actuarial freedom from re-operation was higher in the non-conduit group (p = 0.026). At last follow-up, the right ventricle–pulmonary artery gradient and the right ventricle/left ventricle pressure ratio were higher in the conduit group (p = 0.006 and p = 0.007, respectively). At late computed tomography (CT)-scan evaluation, the growth of the proximal pulmonary arterial tree had improved in the non-conduit group, as shown by a higher Nakata ostial index and right ventricular outflow tract growth. Conclusions: Repair of common arterial trunk without conduit for right ventricular outflow tract reconstruction (1) does not increase mortality and morbidity, (2) decreases the need for re-intervention and (3) promotes a better growth of the proximal pulmonary arteries. These preliminary results need confirmation by further experience.

Key Words: Congenital heart disease (CHD) • Truncus arteriosus (surgical repair)