Tetralogy of Fallot, Presenting in Severely Substandard Healthcare Settings: Pulmonary Valve and Conduit Allograft for Right Ventricular Outflow Tract Reconstruction is Possible and Efficacious
Renzo O. Cifuentes1, Herman Montero2, David Maldonado2, Antonio Fernandez2, Melissa Oliver1, Marc Rebel1, Douglas King1, Thomas Di Sessa3, William Zeman1, Aubyn Marath1.
1Cardiostart International, Tampa, FL, USA, 2Hospital Del Niņo Dr. Francisco Icaza Bustamante, Guayaquil, Ecuador, 3University of Kentucky, Lexington, KY, USA.
OBJECTIVE: Tetralogy of Fallot (TOF) often requires reconstruction of the Right Ventricular Outflow tract (RVOT) due to pulmonary outflow tract and/or valvular insufficiency. In severely compromised clinical settings with uncertain viability, surgical options are limited; pericardial membrane or substitutes have limited applicability. Trans-annular patches provide immediate palliation, but degenerate, leading to pulmonary regurgitation, right ventricular dilation and chronic RV dysfunction. Reviewing 14 patients, without full follow-up, three patients (Ecuador (2) and Peru (1) received pulmonary valve and conduit allograft to repair the RVOT in patients with TOF.
METHODS: Case (1), a 14-year old patient living at high altitude with severe pulmonary and truncal stenosis in, emerging cardiac surgery center received a size 24mm pulmonary allograft. Case (2), a 1-year old patient underwent complete repair with 8mm pulmonary allograft conduit opened longitudinally to provide a two-cusp overlay patch closure, and three-cusp coaptation. Case (3), a 15-year old patient status post TOF repair at 4 years, complicated by surgery for mediastinitis and, later conduit replacement; received a new 24mm pulmonary allograft conduit.
RESULTS: Twenty-two years later, (1) patient's allograft shows no deterioration (by echo and exercise testing). Patient (2) and (3) have satisfactory resolution and normal RV/conduit hemodynamic function at 12 months following surgery.
CONCLUSIONS: When available, allografts have value in emerging cardiac centers with limited options for choosing patients with late-presenting pulmonary constriction and re-operation scenarios. They can be taught. The need for revision, following natural growth in which a two-cusp enlargement has been used will require careful future assessment.
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