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Problems with the right ventricular outflow tract: a review of morphologic features and current therapeutic options

Published online by Cambridge University Press:  21 January 2005

Luca A. Vricella ,
Mazyar Kanani ,
Andrew C. Cook ,
Duke E. Cameron  and
Victor T. Tsang
Luca A. Vricella
Affiliation:
Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, USA
Mazyar Kanani
Affiliation:
Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust and Institute of Child Health, London, UK
Andrew C. Cook
Affiliation:
Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust and Institute of Child Health, London, UK
Duke E. Cameron
Affiliation:
Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, USA
Victor T. Tsang
Affiliation:
Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust and Institute of Child Health, London, UK
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Abstract

Repair of complex malformations that necessitate restoration of continuity between the right ventricle and the pulmonary arteries can now safely be performed with low morbidity and mortality. Major concerns still remain on the long-term outlook for these patients, and about the durability of the different prostheses used to restore that continuity, whether during initial correction or at the time of reintervention for failure of the conduit or pulmonary regurgitation. In this review, we discuss the salient morphologic features of the right ventricular outflow tract, and then focus on the indications for early and late intervention, current therapeutic options, and outcomes.

Keywords

Ross procedurepulmonary atresiaconduitshomografttetralogy of Fallot
Type
Continuing Medical Education
Information
Cardiology in the Young , Volume 14 , Issue 5 , October 2004 , pp. 533 - 549
Copyright
© 2004 Cambridge University Press

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References

Van Praagh R, David I, Van Praagh S. What is a ventricle? The single ventricle trap. Pediatr Cardiol 1982; 2: 79–84.Google Scholar
Hosseinpour AR, Anderson RH, Ho SY. The anatomy of the septal perforating arteries in normal and congenitally malformed hearts. J Thorac Cardiovasc Surg 2001; 121: 1046–1052.Google Scholar
Anderson RH, Webb S, Brown N, Lamers W, Moorman A. Development of the heart: (3) Formation of the ventricular outflow tracts, arterial valves, and intrapericardial arterial trunks. Heart 2003; 89: 1110–1118.Google Scholar
Gonzalez-Lavin L, Metras D, Ross DN. Anatomic and physiologic bases for the Ross procedure. J Heart Valve Dis 1996; 5: 383–390.Google Scholar
Anderson RH, Allwork SP, Ho SY, Lenox CC, Zuberbhuler JR. Surgical anatomy of tetralogy of Fallot. J Thorac Cariovasc Surg 1981; 81: 887–896.Google Scholar
Becker AE, Connor M, Anderson RH. Tetralogy of Fallot: A morphometric and geometric study. Am J Cardiol 1975; 35: 402–412.Google Scholar
Anderson RH, Becker AE, Van Mierop LHS. “What shall we call the ‘crista.’ ” Br Heart J 1977; 39: 856–859.Google Scholar
Vobecky SJ, Williams WG, Trusler GA, et al. Survival analysis of infants under age 18 months presenting with tetralogy of Fallot. Ann Thorac Surg 1993; 56: 944–949.Google Scholar
Parry AJ, McElhinney DB, Kung GC, Reddy VM, Brook MM, Hanley FL. Elective primary repair of acyanotic tetralogy of Fallot in early infancy: overall outcome and impact on the pulmonary valve. J Am Coll Cardiol 2000; 36: 2279–2283.Google Scholar
Reddy VM, Liddicoat JR, McElhinney DB, Brook MM, Stanger P, Hanley FL. Routine repair of tetralogy of Fallot in neonates and infants less than three months of age. Ann Thorac Surg 1995; 60 (6 Suppl): S592–S596.Google Scholar
Hennein HA, Mosca RS, Urcelay G, Crowley DC, Bove EL. Intermediate results after complete repair of tetralogy of Fallot in neonates. J Thorac Cardiovasc Surg 1995; 109: 332–344.Google Scholar
Di Donato RM, Jonas RA, Lang P, Rome JJ, Mayer JE, Castaneda AR. Neonatal repair of tetralogy of Fallot with and without pulmonary atresia. J Thorac Cardiovasc Surg 1991; 101: 126–137.Google Scholar
Singh GS, Greenberg SB, Yap YS, Delany DP, Keeton BR, Monro JL. Right ventricular function and exercise performance late after primary repair of tetralogy of Fallot with the transannular patch in infancy. Am J Cardiol 1998; 81: 1378–1382.Google Scholar
Harrison DA, Harris L, Siu SS, MacLoghlin CJ, Connelly MS, Webb GD. Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot. J Am Coll Cardiol 1997; 30: 1368–1373.Google Scholar
Marie PY, Marcon F, Brunotte F, et al. Right ventricular overload and induced sustained ventricular tachycardia in operatively “repaired” tetralogy of Fallot. Am J Cardiol 1992; 69: 785–789.Google Scholar
Atallah-Yunes NH, Kavey RW, Bove EL, et al. Postoperative assessment of a modified surgical approach to repair of tetralogy of Fallot: long-term follow-up. Circulation 1996; 94 (9 Suppl): II22–II26.Google Scholar
Karl TR, Pornivvilwan S, Mee RB. Tetralogy of Fallot: favorable outcome of nonneonatal transatrial, transpulmonary repair. Ann Thorac Surg 1992; 54: 903–907.Google Scholar
Dietl CA, Cazzaniga ME, Dubner SJ, Perez-Balino NA, Torres AR, Favaloro RG. Life threatening arrhythmias and RV dysfunction after surgical repair of tetralogy of Fallot. Comparison between transventricular and transatrial repairs. Circulation 1994; 90: II7–II12.Google Scholar
Cho JM, Puga FJ, Danielson GK, et al. Early and long-term results of the surgical treatement of tetralogy of Fallot with pulmonary atresia, with or without major aortopulmonary collateral arteries. J Thorac Cardiovasc Surg 2002; 124: 70–81.Google Scholar
Kanter KR, Budde JM, Parks WJ, et al. One hundred pulmonary valve replacements in children after relief of right ventricular outflow tract obstruction. Ann Thorac Surg 2002; 73: 1801–1806.Google Scholar
Thompson LD, McElhinney DB, Reddy M, Petrossian E, Silverman NH, Hanley FL. Neonatal repair of truncus arteriosus: continuing improvement in outcomes. Ann Thorac Surg 2001; 72: 391–395.Google Scholar
Brown JW, Ruzmetov M, Okada Y, Vijay P, Turrentine MW. Truncus arteriosus repair: outcomes, risk factors, reoperation and management. Eur J Cardiothorac Surg 2001; 20: 221–227.Google Scholar
Horneffer PJ, Zahka KG, Rowe SA, et al. Long-term results of total repair of tetralogy of Fallot in childhood. Ann Thorac Surg 1990; 50: 179–185.Google Scholar
Carvalho JS, Shinebourne EA, Busst C, Rigby ML, Redington AN. Exercise capacity after complete repair of tetralogy of Fallot: deleterious effects of residual pulmonary regurgitation. Br Heart J 1992; 67: 470–473.Google Scholar
Wessel HU, Paul MH. Exercise tolerance studies in tetralogy of Fallot: a review. Pediatr Cardiol 1999; 20: 39–47.Google Scholar
Owen AR, Gatzoulis MA. Tetralogy of Fallot: late outcomes after repair and surgical implications. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2000; 1: 216–226.Google Scholar
Oechslin EN, Harrison DA, Harris L, et al. Reoperation in adults with repair of tetralogy of Fallot: indications and outcomes. J Thorac Cardiovasc Surg 1999; 118: 245–251.Google Scholar
Norgaard MA, Lauridsen P, Helvind M, Pettersson G. Twenty to thirty-seven-year follow-up after repair of tetralogy of Fallot. Eur J Cardiothorac Surg 1999; 16: 125–130.Google Scholar
Katz NM, Blackstone EH, Kirklin JW, Pacifico AD, Bargeron Jr LM. Late survival and symptoms after repair of tetralogy of Fallot. Circulation 1982; 65: 403–410.Google Scholar
Discigil B, Dearani JA, Puga FJ, et al. Late pulmonary valve replacement after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2001; 121: 344–351.Google Scholar
Connelly MS, Webb GD, Somerville J, et al. Canadian Consensus Conference on Adult Congenital Heart Disease. Can J Cardiol 1998; 14: 533–597.Google Scholar
Deanfield JE, McKenna WJ, Presbitero P, England D, Graham GR, Hallidie-Smith K. Ventricular arrhythmia in unrepaired and repaired tetralogy of Fallot. Relation to age, timing of repair and haemodynamic status. Br Heart J 1984; 52: 77–81.Google Scholar
Gatzoulis MA, Till JA, Somerville J, Redington AL. Mechano-electrical interaction in tetralogy of Fallot: QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death. Circulation 1995; 92: 231–237.Google Scholar
Fredriksen PM, Therrien J, Veldtman G, et al. Aerobic capacity in adults with tetralogy of Fallot. Cardiol Young 2002; 12: 554–549.Google Scholar
Redington AR, Oldershaw PJ, Shinebourne EA. A new technique for the assessment of pulmonary regurgitation and its application to the assessment of right ventricular function before and after repair of tetralogy of Fallot. Br Heart J 1998; 60: 57–65.Google Scholar
Heush A, Rubo J, Krogmann, Bourgeois M. Volumetric analysis of the right ventricle in children with congenital heart defects: comparison of biplane angiography and transthoracic 3-dimensional echocardiography. Cardiol Young 1999; 9: 577–584.Google Scholar
Vogel M, Gutberlet N, Dittrich M, Hosten N, Lange PE. Comparison of transthoracic three dimensional echocardiography with magnetic resonance in imaging right ventricular volume and mass. Heart 1997; 78: 127–130.Google Scholar
Therrien J, Siu S, McLaughlin PR, Liu PP, Williams WG, Webb GD. Pulmonary valve replacement in adults after repair of tetralogy of Fallot: are we operating too late? J Am Coll Cardiol 2000; 36: 1670–1675.Google Scholar
Warner KG, Anderson JE, Fulton DR, Payne DD, Geggel RL, Marx GR. Restoration of the pulmonary valve reduces right ventricular volume overload after previous repair of tetralogy of Fallot. Circulation 1993; 88: II189–II197.Google Scholar
Bach DS, David T, Yacoub M, et al. Hemodynamics and left ventricular mass regression following implantation of the Toronto SPV stentless porcine valve. Am J Cardiol 1998; 82: 1214–1219.Google Scholar
Eyskens B, Reybrouck T, Bogaert J, et al. Homograft insertion for pulmonary regurgitation after repair of tetralogy of Fallot improves cardiorespiratory performance. Am J Cardiol 2000; 85: 221–225.Google Scholar
Therrien J, Siu SC, Harris L, et al. Impact of pulmonary valve replacement on arrhythmia propensity late after repair of tetralogy of Fallot. Circulation 2001; 103: 2489–2494.Google Scholar
Zhao HX, Miller DC, Reitz BA, Shumway NE. Surgical repair of tetralogy of Fallot. Long-term follow-up with particular emphasis on late death and reoperation. J Thorac Cardiovasc Surg 1985; 89: 204–220.Google Scholar
Norgard G, Gatzoulis MA, Josen M, Cullen S, Redington AN. Does restrictive right ventricular physiology in the early postoperative period predict subsequent right ventricular restriction after repair of tetralogy of Fallot? Heart 1998; 79: 481–484.Google Scholar
Brawn WJ, Barron DJ, Stumper O, et al. Repair of truncus arteriosus: a considered approach to right ventricular outflow tract reconstruction. Eur J Cardiothorac Surg 2001; 20: 95–103.Google Scholar
Aeba R, Kashima I, Moro K, et al. Left atrial appendage insertion for right ventricular outflow tract reconstruction. Ann Thorac Surg 2001; 71: 501–505.Google Scholar
Turrentine MW, McCarthy RP, McConnell KW, McConnell KW, Brown JW. PTFE monocusp valve reconstruction of the right ventricular outflow tract. Ann Thorac Surg 2002; 73: 871–879.Google Scholar
Izutani H, Gundry S, Vricella LA, Xu H, Bailey LL. Right ventricular outflow tract reconstruction using Goretex membrane monocusp valve in infant animals. ASAIO J 2000; 46: 553–555.Google Scholar
Gundry SR, Razzouk AJ, Boskind JF, Bansal R, Bailey LL. Fate of the pericardial monocusp valve for right ventricular outflow tract reconstruction. Early function, late failure without obstruction. J Thorac Cardiovasc Surg 1994; 107: 908–912.Google Scholar
Tweddell JS, Pelech AN, Frommelt PC, et al. Factors affecting longevity of homograft valves used in right ventricular outflow tract reconstruction for congenital heart disease. Circulation 2000; 102: III130–III135.Google Scholar
Gundry SR. Pericardial and synthetic monocusp valves: indications and results. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 1999; 2: 77–82.Google Scholar
Iemura J, Oku H, Otaki M, Kitayama H, Matsumoto T. Reconstruction of right ventricular outflow tract by pedicled pericardial valved conduit. Ann Thorac Surg 1997; 64: 1849–1851.Google Scholar
Schlichter AJ, Kreutzer C, Mayorquim RC, et al. Long-term follow-up of autologous pericardial valved conduits. Ann Thorac Surg 1996; 62: 155–160.Google Scholar
Stark J, Bull C, Stajevic M, Jothi M, Elliott M, de Leval M. Fate of the subpulmonary homograft conduits: determinants of late homograft failure. J Thorac Cardiovasc Surg 1998; 115: 506–516.Google Scholar
Bando K, Danielson GK, Shaff HV, Mair DD, Julsrud PR, Puga FJ. Outcome of pulmonary and aortic homografts for right ventricular outflow tract reconstruction. J Thorac Cardiovasc Surg 1995; 109: 509–517.Google Scholar
Schorn K, Yankah AC, Alexi-meskishvili A, Weng Y, Lange PE, Hetzer R. Risk factors for early degeneration of allografts in pulmonary circulation. Eur J Cardiothorac Surg 1997; 11: 62–69.Google Scholar
Gerestein CG, Takkenberg JJ, Oei FB, et al. Right ventricular outflow tract reconstruction with an allograft conduit. Ann Thorac Surg 2001; 71: 911–917.Google Scholar
Willelms TP, Bogers AJ, Cromme-Dijkhuis AH, et al. Allograft reconstruction of the right ventricular outflow tract. Eur J Cardiothorac Surg 1996; 10: 609–614.Google Scholar
Javadpour H, Veerasingam D, Wood AE. Calcification of homografts in the pulmonary circulation – is it device or donation related? Eur J Cardiothorac Surg 2002; 22: 78–81.Google Scholar
Bielefeld MR, Bishop DA, Campbell DN, Mitchell MB, Grover FL, Clarke DR. Reoperative homograft right ventricular outflow tract reconstruction. Ann Thorac Surg 2001; 71: 482–488.Google Scholar
Dacey LJ. Pulmonary homografts: current status. Curr Opin Cardiol 2000; 15: 86–90.Google Scholar
Caldarone CA, McCrindle BW, Van Arsdell GS, et al. Independent factors associated with longevity of prosthetic pulmonary valves and valved conduits. J Thorac Cardiovasc Surg 2000; 120: 1021–1030.Google Scholar
Sardari F, Gundry SR, Razzouk AJ, Shirali GS, Bailey LL. The use of larger size pulmonary homografts for the Ross operation in children. J Heart Valve Dis 1996; 5: 410–413.Google Scholar
Koirala B, Merklinger SL, Van Arsdell GS, et al. Extending the usable size range of homografts in the pulmonary circulation: outcome of bicuspid homografts. Ann Thorac Surg 2002; 73: 866–869.Google Scholar
Santini F, Mazzucco A. Bicuspid homograft reconstruction of the right ventricular outflow tract in infants. Ann Thorac Surg 1995; 60: S624–S625.Google Scholar
Carr-White GS, Kilner PJ, Hon JK, et al. Incidence, location, pathology, and significance of pulmonary homograft stenosis after the Ross operation. Circulation 2001; 104: I16–I20.Google Scholar
Yankah AC, Alexi-Meskhishvili V, Weng Y, Berger F, Lange P, Hetzer R. Performance of aortic and pulmonary homografts in the right ventricular outflow tract in children. J Heart Valve Dis 1995; 4: 392–395.Google Scholar
Raanani E, Yau TM, David TE, Dellgren G, Sonnenberg BD, Omran A. Risk factors for late pulmonary homograft stenosis after the Ross procedure. Ann Thorac Surg 2000; 70: 1953–1957.Google Scholar
O’Brien MF, Golstein S, Walsh S, Black KS, Elkins R, Clarke D. The SynerGraft valve: a new acellular (nonglutaraldehyde-fixed) tissue heart valve for autologous recellularization: first experimental studies before clinical implantation. Semin Thorac Cardiovasc Surg 1999; 11: S194–S200.Google Scholar
Clarke DR, Bishop DA. Allograft degeneration in infant pulmonary valve allograft recipients. Eur J Cardiothorac Surg 1993; 7: 365–370.Google Scholar
Razzouk AJ, Williams WG, Cleveland DC, et al. Surgical connections from ventricle to pulmonary artery. Comparison of four types of valved implants. Circulation 1992; 86: II154–II158.Google Scholar
Cleveland DC, Williams WG, Razzouk AJ, et al. Failure of cryopreserved homograft valved conduits in the pulmonary circulation. Circulation 1992; 86: II150–II153.Google Scholar
Yemets I, Williams W, Webb G, et al. Pulmonary calve replacement late after repair of tetralogy of Fallot. Ann Thorac Surg 1997; 64: 526–530.Google Scholar
Dearani JA, Danielson GK, Puga FJ, et al. Late follow-up of 1095 patients undergoing operation for complex congenital heart disease utilizing pulmonary ventricle to pulmonary artery conduits. Ann Thorac Surg 2003; 75: 399–411.Google Scholar
Aupecle B, Serraf A, Belli E, et al. Intermediate follow-up of a composite stentless porcine valve conduit of bovine pericardium in the pulmonary circulation. Ann Thorac Surg 2002; 74: 127–132.Google Scholar
Lange R, Weipert J, Homann M, et al. Performance of allografts and xenografts for right ventricular outflow tract reconstruction. Ann Thorac Surg 2001; 51: S365–S367.Google Scholar
Homann M, Haehnel JC, Mendler N, et al. Reconstruction of the RVOT with valved biological conduits: 25 year experience with allografts and xenografts. Eur J Cardiothorac Surg 2000; 17: 624–630.Google Scholar
Dittrich S, Alexi-Meskishvili AC, Yankah A, et al. Comparison of porcine xenografts and homografts for pulmonary valve replacement in children. Ann Thorac Surg 2000; 70: 717–722.Google Scholar
Schoof PH, Hazekamp MG, van Krieken HH, Huysmans HA. Pulmonary root replacement with the stentless aortic xenograft in growing pigs. Ann Thorac Surg 1998; 65: 1726–1729.Google Scholar
Vicella LA, Coady MA, Black MD. Initial experience with stentless porcine bioprosthesis for right ventricular outflow tract reconstruction in children. J Thorac Cardiovasc Surg 2003; 125: 727–728.Google Scholar
Breymann T, Thies WR, Boethig D, Goerg R, Blanz U, Koerfer R. Bovine valved venous xenografts for RVOT reconstruction: results after 71 implantations. Eur J Cardiothorac Surg 2002; 21: 703–710.Google Scholar
Chang Y, Tsai CC, Liang HC, Sung HV. Reconstruction of the right ventricular outflow tract with a bovine jugular vein graft fixed with a naturally occurring crosslinking agent (genipin) in a canine animal model. J Thorac Cardiovasc Surg 2001; 122: 1208–1218.Google Scholar
Ichikawa I, Noishiki Y, Kosuge T, Yamamoto K, Kondo J, Matsumoto A. Use of a bovine jugular vein graft with natural valve for right ventricular outflow tract reconstruction: a one-year animal study. J Thorac Cardiovasc Surg 1997; 114: 224–233.Google Scholar
Corno AF, Hurni M, Griffin H, Jeanrenaud X, von Segesser LK. Glutaraldhyde-fixed bovine jugular vein as a substitute for the pulmonary valve in the Ross procedure. J Thorac Cardiovasc Surg 2001; 122: 493–494.Google Scholar
Levine AJ, Miller PA, Stumper OS, et al. Early results of right ventricular-pulmonary artery conduits in patients under one year of age. Eur J Cardiothorac Surg 2001; 19: 122–126.Google Scholar
Rosti L, Murzi B, Colli M, et al. Mechanical valves in the pulmonary position: a reappraisal. J Thorac Cardiovasc Surg 1998; 115: 1074–1079.Google Scholar
Kawachi Y, Masuda M, Tominaga R, Tokunaga K. Comparative study between St. Jude Medical and boprosthetic valves in the right side of the heart. Jpn Circ J 1991; 55: 553–562.Google Scholar
Sanatani S, Potts JE, Human DG, Sandor GG, Patterson MW, Gordon Culham JA. Balloon angioplasty of right ventricular outflow tract conduits. Pediatr Cardiol 2001; 22: 228–232.Google Scholar
Boudjemline Y, Bonhoeffer P. Percutaneous valve implantation: past present and future. Heart Views 2002; 3: 55–60 [not indexed].Google Scholar
Bonhoeffer P, Boudjemline Y, Saliba Z, et al. Percutaneous replacement of pulmonary valve in a right ventricle to pulmonary artery prosthetic conduit with valve dysfunction. Lancet 2000; 356: 1403–1405.Google Scholar
Bonhoeffer P, Boudjemline Y, Saliba Z, et al. Transcatheter implantation of a bovine valve in pulmonary position: a lamb study. Circulation 2000; 102: 813–816.Google Scholar