CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 2, March 2012
AFRICA
e9
continuity between the apical end of the ventriculotomy and the
pulmonary artery was maintained with autogenous pericardium.
The RVOT reconstruction was performed by sewing the pericar-
dial patch to the right ventriculotomy, pulmonary artery flap and
pulmonary artery (Fig. 2).
Results
The demographics of the patients are shown in Table 1. At the
time of the total corrective operations, the pulmonary vascular
indices were normal in all three cases. In two patients, the LAD
originated from the RCA and crossed the RVOT, whereas in the
third, the RCA crossed the RVOT.
Pre-operatively, the RVOT gradients were 78, 78 and 90
mmHg, respectively. After the termination of cardiopulmonary
bypass, modified ultrafiltration was performed and then the pres-
sure ratio of the right-to-left ventricle was measured. The results
were 0.45, 0.59 and 0.60, respectively. There was no gradient
between the right ventricle and the pulmonary artery.
The postoperative course was uneventful. All three patients
were extubated on the first postoperative day, they left the ICU
on the second day and were discharged home on the sixth day.
Mean follow-up duration was 9.8
±
8 months. No gradient was
detected in the RVOT in the echocardiographic measurements
(
<
15 mmHg gradient). In all three patients, there were moderate
pulmonary insufficiencies but no right ventricular dysfunction.
Discussion
A case of an anomalous coronary artery that crosses the RVOT is
a significant problem in the total corrective operation of TOF. The
LAD artery mostly originates from the RCA.
7,8
Various techniques
such as extracardiac conduit use, transatrial or transpulmonary
muscle resection have been described to overcome this obstacle.
Klara and colleagues reported 25 cases with coronary artery
anomalies, in which they performed transatrial muscle resection.
In their study, which presented a mean follow up of 40 months,
the authors reported the results to be successful and the gradients
between the right ventricle and the pulmonary arteries as accept-
able. They also mentioned the risk of coronary artery injury
during muscle band resection with this technique. Sometimes
only limited resection can be performed and the RVOT cannot
be totally relieved, hence in the follow up of two patients, the
RVOT gradients were higher than that measured at the time of
hospital discharge.
2
Although our follow-up duration was not
long, the gradients measured with echocardiography were less
than 15 mmHg in all three patients. Therefore we concluded
that the ‘double-outflow’ technique may be more appropriate in
these cases.
There are various reports indicating the need for early total
corrective operations in the treatment of TOF. They all aimed to
prevent the organ damage and ventricular arrhythmia induced
by long-term hypoxia and to obtain better results.
9,10
However, in
order to use conduits in patients with coronary artery anomalies,
secondary operations are inevitable since the conduits have no
potential to grow. This will lead to relative stenosis in the RVOT
as the child grows.
With conduit use, the unfavorable effects of hypoxia are still
of concern, but the most important disadvantage of conduit use
is reoperation due to conduit degeneration.
1
The difficulty in
obtaining the conduits and the minor antigenicity of the conduit
material are further disadvantages. With the help of this tech-
nique, we safely enlarged the RVOT in patients with coronary
artery anomaly without using conduits. In addition, the auto-
Fig. 2. View of the RVOT reconstruction with pericardial
patch.
Fig. 1. View of the pulmonary artery flap sewn to the right
ventriculotomy and native outflow tract.
TABLE 1. PRE- AND POSTOPERATIVE DEMOGRAPHICS
Patient 1 Patient 2 Patient 3 Mean ± SD
Age (months)
5
12
18
11 ± 6.5
Weight (kg)
6
7
10
7.6 ± 2
Previous operation
none BT shunt BT shunt
PPG (mmHg)
78
79
90
82 ± 6.6
Postoperative Prv/Plv
(mmHg)
0.45
0.59
0.60 0.54 ± 0.1
Postoperative pulmonary
gradient (mmHg)
none
none
none
Postoperative pulmonary
insufficiency
moderate moderate moderate
CPB (min)
112
136
131
126 ± 12.6
ACC (min)
81
89
100
90 ± 9.5
Follow-up time
2
18
9
9.8 ± 8
PPG; pre-operative pulmonary gradient, Prv; right ventricular pressure,
Plv; left ventricular pressure, CPB; cardioulmonary bypass time, ACC;
aortic cross-clamp time.
