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Eur J Cardiothorac Surg 2004;26:1227-1228
© 2004 Elsevier Science NL
Letter to the Editor |
Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul National University Medical Research Center, Xenotransplantation Research Center, 28 Yongon-dong, Jongro-gu, Seoul 110-744, South Korea
Received 20 August 2004; accepted 24 August 2004.
* Corresponding author. Tel.: +82 2 760 2877; fax: +82 2 765 7117. (E-mail: jrl{at}snu.ac.kr).
We appreciate the comments of Dr Carlo on our article. In the Lecompte procedure, the anteriorly located pulmonary bifurcation was the possible cause of pulmonary outflow tract obstruction [1]. To solve this problem, Lecompte resected a generous part of the ascending aorta to create enough space in the anterior mediastinum for the pulmonary outflow tract. So the procedure became more complicated, involving transection of the aorta and reanastomosis. In our series, we did not use the Lecompte maneuver in any patient even when the great arteries had an anteroposterior relationship and could bring directly the main pulmonary artery to the right ventricle, because orthotopically posterior-positioned pulmonary arteries reduce the possibility of the pulmonary outflow tract obstruction as seen in arterial switch operations [2], and we wanted to simplify the procedure and reduce the risk of bleeding by avoiding the transection of aorta and reanastomosis. Tension-free anastomosis was accomplished by sufficient dissection of the pulmonary arterial branches beyond the pericardial reflection. The pulmonary arterial trunk was incised longitudinally on its anterior aspect, and then direct anastomosis was performed. If this direct anastomosis caused tension, the pulmonary artery incision was extended more distally.
It is important to decide whether the main pulmonary artery will be translocated on the right or the left of the aorta. Therefore, we believe the essential point of this procedure is the translocation of the pulmonary artery. In our series of 25 cases, 7 cases involved translocation of the main pulmonary artery to the right of the aorta, based on the initial position of the great arteries.
In all cases, we placed a monocusp valve in the pulmonary outflow tract expecting this valve to improve the immediate postoperative result by preventing a sudden hemodynamic change from a pressure-loaded right ventricle to a volume-loaded ventricle. Pulmonary regurgitation was insignificant in all patients. However, among 5 patients who had reoperations for residual pulmonary stenosis, 4 had severe calcification of the monocusp valve. In five recent cases, we used Gore-Tex membrane, which is thought to have a water-repellent nature and makes calcification less likely [3,4]. Analyzing our results, it appears that the long-term fate of the reconstructed pulmonary outflow tract depends primarily on the monocusp valve, which is prone to progressive calcification, degeneration, and subsequent valvular dysfunction over time, although this type of repair has an advantage in terms of the potential for the growth of the patient's own native pulmonary artery.
Some possible suggestions of the relatively high incidence of obstruction by the calcification of monocusp valve may exist: (1) by not applying Lecompte maneuver in our series, turbulence and vortex may develop within the pulmonary outflow tract, possibly resulting from a laterally deviated pulmonary artery by the aorta remaining in situ; (2) our technique of implantation of monocusp valve; and (3) the influence of custom-made glutaraldehyde solution.
References
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