Pulmonary Valve Replacement

Tetralogy of Fallot (TOF) is one of the most well known and studied congenital heart diseases. These patients often requires multiple surgeries after the initial correction of this defect in order to prevent associated morbidities. One such morbidity is right ventricular dysfunction caused by pulmonary insufficiency. If left untreated these patients can face not only quality of life changes due to problems such as exercise intolerance but also a severely diminished life expectancy. In order to prevent this pulmonary valve replacement (PVR) is often utilized. Pathologies involving the pulmonary valve are rare, limiting potential exposure to this procedure. Our video highlights a successful PVR in a patient with repaired TOF. We seek to not only educate the field but to also shine a light on an underappreciated operation.

Bicaval cardiopulmonary bypass, Patent was given 15ml/kg of Del Nido cardioplegia solution and kept normothermic throughout the case.

The patient was prepped and draped in normal sterile fashion. Follwoing medial sternotomy, a linear incision in the narrowed region of the RVOT was made. The patients previously placed calcififed monocusp Gore-Tex valve was excised. The valve was then appropriately sized to 25 mm. The INSPRIS 25 mm valve was then sewn in at the anatomical level of the pulmonary valve. Cardiocel patch material was used for outflow augmentation, with 1/3rd of the patch sewn into the sewing ring. The patient was then separated from cardiopulmonary bypass, and after appropriate hemostasis was closed in the usual fashion and extubated in the OR.

Post-operative imaging demonstrated no post interventional stenosis and laminar flow across the INSPIRIS valve with trivial Pulmonary Insufficiency. The patient's post-operative course was uneventful and was discharged on post-op day 3.

This video highlights a successful PVR. Replacing the pulmonary valve helps to prevent deleterious cardiac remodeling by correcting the pulmonary insufficiency. Outside of the immediate benefits provided by the surgery, we believe there is a massive benefits down the road. It is very likely that in the future catheter based valve-in-valve replacement options will be available. This will attenuate the need for future invasive surgery bypass when the valve's lifespan is reached. The risks involved in redo sternotomy and cardiopulmonary bypass are numerous, so the potential for this new option for patients such as this one is profound.

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1. Comprehensive Surgical management of Congenital Heart Disease – Richard Jonas ISBN: 978-1-4441-1215-3 2. McKenzie, E. D., Khan, M. S., Dietzman, T. W., Guzmán-Pruneda, F. A., Samayoa, A. X., Liou, A., Heinle, J. S., & Fraser, C. D., Jr (2014). Surgical pulmonary valve replacement: a benchmark for outcomes comparisons. The Journal of thoracic and cardiovascular surgery, 148(4), 1450–1453. https://doi.org/10.1016/j.jtcvs.2014.02.060 3. Tatewaki, H., & Shiose, A. (2018). Pulmonary valve replacement after repaired Tetralogy of Fallot. General thoracic and cardiovascular surgery, 66(9), 509–515. https://doi.org/10.1007/s11748-018-0931-0