Preserving the pulmonary valve during early repair of tetralogy of Fallot: Anatomic substrates and surgical strategies Vladimiro L. Vida, MD, PhD, Annalisa.

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Preserving the pulmonary valve during early repair of tetralogy of Fallot: Anatomic substrates and surgical strategies Vladimiro L. Vida, MD, PhD, Annalisa Angelini, MD, Alvise Guariento, MD, Carla Frescura, MD, Marni Fedrigo, MD, Massimo Padalino, MD, PhD, Stephen P. Sanders, MD, Gaetano Thiene, MD, Giovanni Stellin, MD The Journal of Thoracic and Cardiovascular Surgery Volume 149, Issue 5, Pages 1358-1363.e1 (May 2015) DOI: 10.1016/j.jtcvs.2015.01.030 Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 The drawing shows the various types of PV plasty procedures that can be performed in addition to PV balloon dilation: (A) dysplastic PV with commissure fusion (effective PV opening); (B) PV commissurotomy (true initial PV annulus diameter); (C) PV balloon dilation and (D) final PV annulus diameter; (E) simple additional PV plasty (including PV leaflet repair and resuspension); (F-G) complex additional PV plasty, including PV leaflet delamination (F) and patch augmentation when needed and resuspension (G). The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1358-1363.e1DOI: (10.1016/j.jtcvs.2015.01.030) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Histogram showing the percentage of patients who underwent PV preservation during tetralogy of Fallot repair, since 2007, in our institution (including PV balloon dilation only, and PV balloon dilation in association with simple and complex PV plasty). PV, Pulmonary valve; TAP, transannular patch. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1358-1363.e1DOI: (10.1016/j.jtcvs.2015.01.030) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 The box-plot shows the difference between the preoperative, 2-dimensional, echocardiographic PV Z-score in (A) patients who had a bicuspid PV, compared with patients with a tricuspid PV (P = .009), and (B) patients who underwent a PV balloon dilation only, or an additional PV plasty procedure (P = .04). Preop, Preoperative; 2D, 2-dimensional; ECHO, echocardiographic; PV, pulmonary valve. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1358-1363.e1DOI: (10.1016/j.jtcvs.2015.01.030) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Histologic examination of (A) a normal PV, and (B) a dysplastic PV in TOF: At histology, the dysplastic PV in TOF shows enlargement of spongiosa, fragmentation of fibrosa, and fibrotic thickening of the free edge (magnification ×1, elastic fiber Van Gieson staining). The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1358-1363.e1DOI: (10.1016/j.jtcvs.2015.01.030) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 The histogram shows the relationship between the number of pulmonary valve cusps and the presence of mucoid dysplasia in TOF (including 79 anatomic specimens of patients who had not undergone operation, and 75 patients who underwent early TOF repair in our institution). no., Number. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1358-1363.e1DOI: (10.1016/j.jtcvs.2015.01.030) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 A-D, An excised bovine heart model was used to better understand the delamination plasty technique that was used to extend the PV cusp coaptation area, especially in patients with a hypoplastic PV annulus. In this model, the normal PV was exposed and examined through a longitudinal incision in the pulmonary trunk. After excision of 1 cusp of the tricuspid PV (creating a gap in coaptation mimicking the gap after PV balloon dilation in patients with a very hypoplastic PV annulus), a delamination plasty was performed on the other 2 cusps, thus extending their coaptation surface. Both cusps were then extended with triangles of biological tissue substitute and resuspended from the sinotubular junction, resulting in complete coverage of the PV annular area, simulating a bicuspid PV. A, Normal tricuspid PV; (B) removal of 1 PV cusp; (C) PV cusp delamination and leaflet extension, and (D) functionally bicuspid PV. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1358-1363.e1DOI: (10.1016/j.jtcvs.2015.01.030) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 A, Anatomic view of the bovine valve after PV delamination, showing the cutting edge of the ventricular myocardium at the base of the pulmonary sinus with enlargement of the leaflet produced by the ventricular myocardium; (B) histologic view of the same specimen with delaminated fibrous leaflet, annulus, and sinus (magnification ×1, elastic fiber Van Gieson staining); (C) close-up showing the delaminated area (original magnification ×5, elastic fiber Van Gieson staining). The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1358-1363.e1DOI: (10.1016/j.jtcvs.2015.01.030) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions