Success and limitations of right ventricular sinus myectomy for pulmonary atresia with intact ventricular septum Roosevelt Bryant, MD, Edward R. Nowicki,

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Presentation transcript:

Success and limitations of right ventricular sinus myectomy for pulmonary atresia with intact ventricular septum Roosevelt Bryant, MD, Edward R. Nowicki, MD, Roger B.B. Mee, MB, ChB, FRACS, Jeevanantham Rajeswaran, MSc, Brian W. Duncan, MD, Geoffrey L. Rosenthal, MD, PhD, Uthara Mohan, MD, Muhammad Mumtaz, MD, Eugene H. Blackstone, MD The Journal of Thoracic and Cardiovascular Surgery Volume 136, Issue 3, Pages 735-742.e2 (September 2008) DOI: 10.1016/j.jtcvs.2008.03.039 Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Right ventricular myectomy is performed by means of a combined transatrial/transpulmonary approach. A, On the left, the dashed line indicates the intended extent of right ventricular sinus resection. On the right, the figure represents the results of sinus resection through the tricuspid valve. B, On the left, an incision is made in the pulmonary trunk. At top right, pulmonary valvotomy is shown. This reveals infundibular muscle (lower right) that will be resected (dashed line) to complete the right ventricular myectomy. RVT, Right ventricular trabecular sinus. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 735-742.e2DOI: (10.1016/j.jtcvs.2008.03.039) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Flow chart of the 43 patients progressing toward definitive repair. See Appendix E1 for details. a, Alive; BVR, biventricular repair; d, dead; RVSM, right ventricular sinus myectomy; UVR, univentricular repair; VR, ventricular repair. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 735-742.e2DOI: (10.1016/j.jtcvs.2008.03.039) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Cumulative distribution of tricuspid valve (TV) diameter on first echocardiogram, expressed in standardized Z-value format, of patients undergoing right ventricular sinus myectomy (RVSM) contrasted with those undergoing direct biventricular repair without myectomy (BVR) and the remaining patients whose intent to treat was univentricular repair (UVR). The Journal of Thoracic and Cardiovascular Surgery 2008 136, 735-742.e2DOI: (10.1016/j.jtcvs.2008.03.039) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Size of the tricuspid valve (TV) across time after right ventricular sinus myectomy. Closed circles are grouped mean values, unadjusted for repeated measures, to illustrate raw data. The solid line is an estimate of mean TV size adjusted for repeated measures, and dashed lines are confidence limits equivalent to ±1 standard deviation. A, Diameter. Average size at presentation was 1.18 ± 0.40 cm. B, Z value. Average size at presentation was −4.9 ± 1.9. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 735-742.e2DOI: (10.1016/j.jtcvs.2008.03.039) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Qualitative right ventricular (RV) size grade across time after RV sinus myectomy. Average size at presentation was −1.2 ± 3.2. Format is as in Figure 4. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 735-742.e2DOI: (10.1016/j.jtcvs.2008.03.039) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Standardized (Z value) pulmonary valve (PV) “annulus” diameter across time after right ventricular sinus myectomy. Average size at presentation was −0.51 ± 1.31. Format is as in Figure 4. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 735-742.e2DOI: (10.1016/j.jtcvs.2008.03.039) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Nonparametric competing-risks estimates of end states after the presentation described in Figure 2. A, Biventricular repair strategy. B, Univentricular repair strategy. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 735-742.e2DOI: (10.1016/j.jtcvs.2008.03.039) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions