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Letters to the Editor

Think twice while inserting a transannular patch

^a Ataturk Education and Research Hospital, Yesilyurt, Izmir, Turkey
^b Gazi Hospital, Alsancak, Izmir, Turkey

Received 29 December 2008; accepted 18 February 2009.

^_* Corresponding author. Address: Ataturk Education and Research Hospital, Department of Cardiovascular Surgery, Basin Sitesi Street, 35360, Izmir, Turkey. Tel.: +90 505 7594837. (Email: mkestelli{at}gmail.com).

Key Words: Tetralogy of Fallot • Dextroposition • Congenital heart surgery

Congratulations to the authors for this valuable study [1].

The combination of a ventriculotomy and free pulmonary insufficiency is implicated in the deterioration of right ventricular function and the development of arrhythmias after tetralogy of Fallot (TOF) repair [2]. Recently, early outcomes of TOF repair are expected to be excellent irrespective of surgical technique and timing of repair. Therefore, the aim of the surgical treatment should be the avoidance of long-term complications and reoperations.

The use of a transannular patch may result in free pulmonary insufficiency. This causes right ventricular dilation that in turn compresses the left ventricle. The functional reserve and myocardial contractility of the right (and possibly left) ventricle decreases. Chronic volume overload on right ventricle after repair of TOF causes dilation predisposing to life-threatening ventricular arrhythmias and sudden cardiac death.

It is well known that infundibular stenosis may develop secondary to VSD [3]. An infundibular patch was recommended to patients with pulmonary annular stenosis with a z-score less than –3 [4]. We conducted a study previously emphasizing the necessity to apply the diagnostic criteria of TOF more carefully in clinical practice [5]. After all these findings we felt it to be necessary to evaluate this study, since there were 18 cases with pulmonary valve replacement in group 1 whereas there were none in group 2.

a. Why were the cases with a z-score –1.5 included in this study?

b. Right ventricular wall thickness reaching the values equal to that of left ventricle and infundibular wall hypertrophy secondary to VSD could have regressed postoperatively. Regarding this; after closure of VSD and relief of pulmonary stenosis, the need for infundibular patch would obviously decrease (particularly for those with a z-score –1.5) since right ventricular and infundibular thickness would have regressed. From this point of view, would this affect the surgical treatment guidelines?

c. We conducted a study regarding the dextroposition of aorta (true dextroposition) [5]. This study made us consider that infundibular patch is necessary in case of true dextroposition.

References

1. Voges I, Fischer G, Scheewe J, Schumacher M, Babu-Narayan SV, Jung O, Kramer HH, Uebing A. Restrictive enlargement of the pulmonary annulus at surgical repair of tetralogy of Fallot: 10-year experience with a uniform surgical strategy. Eur J Cardiothorac Surg 2008;34:1041-1045.[Abstract/Free Full Text]
2. Anagnostopoulos P, Azakie A, Natarajan S, Alphonso N, Brook MM, Karl TR. Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot. J Thorac Cardiovasc Surg 2007;133:640-647.[Abstract/Free Full Text]
3. Ventricular septal defect. In: Kouchoukos NT, Blacstone EH, Doty DB, Hanley FL, Karp RB, editors. 3rd edition. Cardiac surgery. vol. 1. Churchill Livingstone; 2003. pp. 873.
4. Ventricular septal defect. In: Kouchoukos NT, Blacstone EH, Doty DB, Hanley FL, Karp RB, editors. 3rd edition. Cardiac surgery. vol. 1. Churchill Livingstone; 2003. pp. 967.
5. Kestelli M, Tulukoglu E, Karaca M, Arikan E, Abud B, Yurekli I, Gokalp O, Gurbuz A. Dextroposition of aorta in tetralogy of Fallot. Presented in 18th world congress world society of cardiothoracic surgeons. Heart surgery forum vol. II, Suppl. II. p. 329.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mert Kestelli Ismail I. Yurekli Ali Gurbuz Permission Requests Google Scholar Articles by Kestelli, M. Articles by Gurbuz, A. PubMed Articles by Kestelli, M. Articles by Gurbuz, A. Related Collections Congenital - cyanotic