Christian Kreutzer, Christian Blunda, Guillermo Kreutzer, Andres J

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Presentation transcript:

The Autologous Pericardial Valved Conduit for Right Ventricular Outflow Tract Reconstruction Christian Kreutzer, Christian Blunda, Guillermo Kreutzer, Andres J. Schlichter Operative Techniques in Thoracic and Cardiovascular Surgery Volume 8, Issue 3, Pages 146-149 (August 2003) DOI: 10.1053/S1522-9042(03)00033-5 Copyright © 2003 Elsevier Inc. Terms and Conditions

1 The patient is positioned on the operating table in the usual fashion for a classic midline sternotomy incision. After placing a modified Finochietto retractor to open the sternum, the thymus is excised and the pericardium is dissected free. With the aid of a ruler, measurements are performed to prepare a conduit according to the body surface area of the patient (Table 1). Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

2 A rectangular piece of pericardium is resected with meticulous care to avoid injury to the right or left phrenic nerves. The serous layer of the pericardium will be the inner surface and the fibrous layer the external aspects of the conduit. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

3 The harvested pericardium is positioned on a wet drape and is trimmed into 2 different geometric forms: a rectangle (the future conduit) and a trapezoid (the future bicuspid valve). The length of the rectangle is the measured distance from the pulmonary artery to the ventriculotomy. The rectangle is secured to the wet drape with 4 stay stitches at the angles. The trapezoid is superimposed on the rectangle, with its longer base (a -a') placed 5 to 6 mm below the distal end of the rectangle. As a rule, the longer base of the trapezoid is always 10% longer than the base of the rectangle. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

4 The trapezoid (valve) is secured to the rectangle at 3 different points with 6-0 polypropylene sutures. The serosal surface of the cusps is oriented to the sinuses. Two stitches join a and a' with A and A' at both lateral ends, and a third stitch is placed in the exact middle of both pericardial pieces at point b. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

5 The trapezoid is then trimmed. Three small triangular pieces are excised to achieve 2 semilunar cusps, leaving intact the union of both in a length of 4 mm. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

6 The running suture is performed starting from A and A', suturing the trapezoid to the edge of the rectangle in the first 3 mm, and then from b to secure the cusps to the rectangle. Note that the first 4 mm of the suture started at b is double. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

7 Once the valve is constructed, a Hegar dilator of the selected conduit diameter is placed over the pericardial rectangle with the cusps. A 6-0 polypropylene double-running suture is then performed from the distal to the proximal end. This suture is started 2 mm from the distal end to leave a wider distal anastomotic orifice. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

8 The proximal end of this suture is left untied because it will be adjusted according to the exact length of the conduit at the time of the anastomosis to the ventriculotomy: Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

9 The valve function is tested with flushes of normal saline, and the conduit is ready for implantation. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

10 Once the intracardiac repair is completed, the distal end of the conduit is sutured to the pulmonary artery with 6-0 polydioxanone suture. This is interrupted in the 4 quadrants and tied over the Hegar dilator to prevent distal end narrowing. During the first 3 years of our experience to 1986, distal narrowing at the time of tying the sutures was the cause for distal stenosis. Since 1986, we have increased the width of the distal end of the pericardial rectangle by 4 mm, thus obtaining a wider anastomotic orifice. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions

11 The proximal end of the conduit is then sutured to the ventriculotomy. In only 3 cases was a polytetra fluora ethylene hood added to achieve an anastomosis without tension. Operative Techniques in Thoracic and Cardiovascular Surgery 2003 8, 146-149DOI: (10.1053/S1522-9042(03)00033-5) Copyright © 2003 Elsevier Inc. Terms and Conditions