CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
AFRICA
9
similar to the pre-operative value. The child was doing well at the
two-year follow up.
Conclusion
: We describe a rare presentation of a child with CCTGA
and both subpulmonary and subaortic obstruction, relieving the
latter before symptoms of systemic obstruction became an issue and
deliberately leaving untouched subpulmonary obstruction as a natu-
ral PAB. This strategy has the following advantages: (1) leaving the
subpulmonary obstruction keeps the LV prepared for a future double
switch, (2) delays the onset of systemic AV valve regurgitation by
supporting the septum, and (3) reduces the chances of heart block
and rhythm disturbances. Whether this strategy is useful needs to be
proved by long-term follow up of the child.
100: EXTENSION OF RVOT PATCH AFTER TOF REPAIR
TECHNIQUE TO RETAIN COMPETENCE OF PREVIOUSLY
PLACED BICUSPID VALVE
Ganapathy Subramaniam
1
, Nevillle Solomon
1
, Shapna Varma
2
,
Prasad Manne
2
, CS Muthukumaran
2
1
Apollo Children’s Hospital, Chennai, India
2
Lotus Hospital, Hyderabad, India
Background
: Limiting the length of ventriculotomy has been an
accepted practice to reduce the long-term consequence of arrhythmia
and right ventricular dysfunction following tetralogy of Fallot repair.
Surgeons may increasingly find themselves in situations where
extension of a previously placed right ventricular outflow (RVOT)
patch with a mono/bicuspid valve may be necessary to relieve the
RVOT obstruction. We describe a technique where extension of a
previously placed patch can be done, retaining the competence of
the valve.
Methods
: Two patients who had had transannular patches with PTFE
bicuspid valves, needed extension of the patch to relieve infundibular
obstruction after TOF repair. The procedure was done on a beating
heart with a single large RA cannula. The lower portion of the previ-
ously placed transannular patch along with the PTFE membrane was
removed and fixed at the either end using an interrupted 6-0 prolene
suture. The incision was extended as required to relieve the obstruc-
tion. The previously placed patch and membrane was cut transverse-
ly, and a new piece of bovine pericardium of required dimensions
was used for the extension. The superior margin was sutured to the
previous PTFE patch and the pericardial membrane, forming the
neo-annulus of the bicuspid valve. The rest of the bovine pericardium
was sutured to the ventriculotomy using a 6-0 prolene suture with a
13-mm curved needle.
Results
: In both patients the RV pressure, which was suprasystemic,
fell to 50% of that of the systemic values, with competent bicuspid
valves and uneventful postoperative recovery.
Conclusion
: Extension of previously placed competent transannular
patches can be done, retaining the competence by creating a neo-
annulus at the superior margin of the newly placed extension patch.
This significantly hastens the postoperative recovery in spite of
having a long ventriculotomy incision. Disruption of the previously
working mono/bicuspid valve is not necessary for extending a previ-
ously placed transannular patch.
116: LEFT PULMONARY ARTERY PLASTY USING MAIN
PULMONARY ARTERY TURNDOWN: A TECHNIQUE IN
MANAGING LPA STENOSIS
Ganapathy Subramaniam
1
, DV Ramana
1
, Prashant Patil
2
, Ajay
Lakineni
2
, Neville Solomon
2
1
Apollo Children’s Hospital, Chennai, India
2
Lotus Hospital, Hyderabad, India
Background
: Ten to 30% of patients undergoing single or biven-
tricular repair for decreased pulmonary flow have some degree of left
pulmonary artery narrowing, attributable to ductal tissue. Surgical
relief of LPA stenosis is notoriously recurrent and a variety of
approaches have been used, including stenting to tackle this problem.
We propose a technique where, in the main pulmonary artery, tissue
is used to plasty the left pulmonary artery origin.
Report:
A three-year-old male child with bilateral SVC with right
>
left and unbalanced AV canal, PS with saturation of 65–70% was
brought in for bilateral Glenn surgery. His CT angiogram showed
severe LPA-origin stenosis with a well-developed main pulmonary
artery. During surgery, the MPA stump was divided and the good
MPA tissue was turned down on the LPA, akin to subclavian arery
turndown for coarctation repair. The Glenn pressures postoperatively
were 14-16 mmHg with a transpulmonary gradient of 7 mmHg. His
saturations improved to high 80s and he was discharged after an
uneventful postoperative course.
Results:
The 18-month follow up of the child has shown good growth
of the left pulmonary artery origin with no gradient across the Glenn
anastomosis.
Conclusion
: The MPA turndown technique can be a useful alterna-
tive to pericardial patch augmentation or stenting of the left pulmo-
nary artery, especially in the management of single-ventricle patients
with LPA-origin stenosis with well-developed MPA.
117: MANAGEMENT OF TOF WITH ABSENT PULMONARY
VALVE WITH SYMMETRIC PLICATION OF PULMONARY
ARTERIES AND INSERTION OF BICUSPID PTFE VALVE
Ganapathy Subramaniam
1
, Neville Solomon
2
, Prasad Manne, Kothai
2
1
Apollo Children’s Hospital, Chennai, India
2
Lotus Hospital, Hyderabad, India
Backgroun
d: Tetralogy of Fallot with absent pulmonary valve (TOF
with APV) is a rare condition that can present in infancy, with severe
respiratory symptoms and pulmonary anterior translocation. Use of
a homograft valved conduit has been recommended to reduce airway
compression. We propose a simpler technique of repair without the
use of a homograft.
Methods
: A 7-kg 10-month old child presented to us with a previous
history of respiratory distress requiring ventilatory support. The child
was was diagnosed with TOF with APV and was referred for surgery
after weaning from ventilation. The child had branch PAs of 24 mm
with a narrow annulus. The child underwent intra-cardiac repair with
excision of a portion of the anterior wall of the right and left pulmo-
nary arteries and
in
situ
plication of the posterior wall over a 7 Hegar
dilator. The angle of the branch of the PA with MPA was opened
up and two separate patches were used to enlarge the confluence
and RVOT. The MPA and RVOT were reconstructed with a bicuspid
PTFE valve and autologous pericardium.
Resul
ts: The child had an uneventful recovery with no respira-
tory issues in the postoperative period. Echo showed normal-sized
branches of the pulmonary arteries with a competent pulmonary
valve.
Conclusion
: Symmetric plication of the pulmonary arteries ante-
riorly and posteriorly can help tailor the size of the branch of the
pulmonary arteries without distortion and without resorting to ante-
rior translocation, which would need aortic transaction.
In
situ
plica-
tion posteriorly may prevent bleeding, and a bicuspid PTFE valve
may replace the homograft in RVOT reconstruction of TOF with APV.
118: PULMONARYATRESIAWITH SEVERE BIFURCATION
STENOSIS IN ADOLESCENCE: SURGICAL CONSIDERA-
TION AND POSTOPERATIVE MANAGEMENT ISSUES
Neville Solomon
1
, Ganapathy Subramaniam
1
, CS Muthukumaran
2
,
Shapna Varma
2
, Prasad Manne
2
, Suchitra Ranjit
2
1
Apollo Children’s Hospital, Chennai, India
2
Lotus Hospital, Hyderabad, India
Background:
Management of severely cyanotic adolescents can
prove both a surgical and postoperative challenge. We present our
experience with a 16-year-old girl with saturations of 40%.
Methods:
A 16-year-old girl from Bengal presented to us with severe
cyanosis (saturation 30–40%) and severe symptoms of hyperviscos-
