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Management of Pulmonary Regurgitation

Management of Pulmonary Regurgitation. Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery. Pulmonary Infundibulum. Roles of interrelation The pulmonary infundibulum might not be limited to its systolic function.

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Management of Pulmonary Regurgitation

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  1. Management of Pulmonary Regurgitation Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery

  2. Pulmonary Infundibulum • Roles of interrelation • The pulmonary infundibulum might not be limited to its systolic function. • The fact that it remains contracted until late in diastole is probably essential to pulmonary valve competence • Pulmonary valve has the peculiarity of being inserted inside the inner shell of an exclusively muscular cylinder. • Contraction of this cylinder inevitably approximates the pulmonary cusps to each other and increases their coaptation length • The pulmonary pressure that the pulmonary valve could withstand without leaking was greater when the pulmonary infundibulum was stimulated by adrenergic stimulation.

  3. Pulmonary Infundibulum • Functional roles • The outlet portion of the right ventricle had not only a passive role in right ventricular contraction, and the peristaltic mode may be crucial to achieving a complete emptying of the right ventricular cavity. • The delayed opening of the pulmonary valve might be more suitably explained by the peristaltic mode of function of the right ventricle than by its intrinsic power • The pulmonary infundibulum ejecting the blood that it had accumulated at a time when the rest of the right ventricle was already relaxing.

  4. Interaction of Ventricles • RV-LV-cross talk- • While the deeper layer of myocardial fibers are separated, there are shared superficial fibers that encircle the normal LV and RV. • Furthermore, in some forms of CHD, such as TOF, the deeper layers of RV and LV may be contiguous within the interventricular septum. • The function of the two ventricles is therefore linked, in both the structurally normal and abnormal heart.

  5. Risk Factors for Late Death • Causes after TOF repair • Residual VSD • Residual RV outflow stenosis • Severe PR • Severe TR • Older age at repair • Previous Potts, or Waterston shunt

  6. Causes of Sudden Death • Approaches after TOF repair • Bradyarrhythmias such as complete AV block, bifascicular block, SSS • VT and residual RVOTO and RV dysfunction • Complex ventricular arrhythmias by Holter monitoring • Monomorphic VT and severe PR, peripheral PS, RV dilation, QRS duration more than 180ms

  7. Arrhythmia & Sudden Death • Approaches after TOF repair • QRS Easy to measure Reflects RV size Dynamic nature, QRS change important New QRS cutoff values for contemporary cohorts • QT dispersion Refines risk stratification Less dynamic May reflect initial ventriculotomy scar/ VSD closure

  8. Right Ventricular Dilatation • Predictive factors • Degree of pulmonary insufficiency • Duration of pulmonary insufficiency • Identification of akinetic or dyskinetic area in right ventricular outflow tract • Right ventricular outflow tract damage

  9. Pulmonary Regurgitation • Indications of PVR 1. Free pulmonary regurgitation with progressive or moderate right ventricular dilation 2. Sustained arrhythmias & or symptoms 3. Important tricuspid regurgitation 4. Symptoms of deteriorating exercise performance

  10. Pulmonary Valve Replacement • Indications • 1. Impaired pulmonary artery runoff (Mayo) • 1) Peripheral stenosis • 2) Vascular obstructive diseases • 3) Single pulmonary artery • 4) Absent valve with aneurysm of central PA • 2. Functional impairment (Ilbawi) • 1) Progressive cardiomegaly & TR • 2) Evidence of RV dilation or dysfunction

  11. Pulmonary Valve Replacement • Indication after TOF repair • History of VT( especially sustained), syncope • RV hypertension(>60mmHg) • Longer QRS(>180ms) or increased QRS • Increased CTR • Increased RV volume, low RVEF (RV dysfunction) • Free PR with or without peripheral PS, • More than moderate TR • Decreased exercise tolerance • EPS inducible sustained VT • New onset atrial fibrillation or flutter

  12. Subannular PVR • After TOF Repair A; mattress suture securing the anterior SPV commissural posts to RVOT B; sutures spacing posterior posts at 120 distance C; continuous proximal suture with anterior patch

  13. RVOT Reconstruction • Medtronic freestyle valve before and after excising the coronary remnants • Generous excision of graft surrounding coronary to be oriented anteriorly. • Note that both the RVOT and neopulmonary artery have been enlarged • with a PTFE patch.

  14. PVR (CE Perimount Valve)(F/19y, PR, s/p TOF total correction)

  15. Pulmonary Valved Conduit Shelhigh Valved Conduit

  16. Pulmonary Valve Replacement • Percutaneous replacement • Surgical pulmonaryvalve replacement is associated with low morbitity and mortality;however, reoperations during mid- and long-term follow-up arevery common. • The risk of extracorporeal circulation, infection,and also special reoperation risks remain • Percutaneous pulmonary valve implantation is emerging as analternative or additional option for a successful surgical scheme,recently even being introduced into clinical practice.

  17. Monocuspid Valve Insertion • Residual or recurrent PR • 1. Long distance to be covered during • rapid closure, or irregular movement • 2. Being tailored too wide • 3. Loss of movement due to degeneration • or calcification

  18. Pulmonary Monocuspid Valve • 1. Materials • 1) Autogenic tissue • 2) Autologous pericardium • 3) Xenograft • 4) Prosthetic membrane (Gore-Tex membrane) • 2. Indications • 1) Elevated PAP • 2) Presence of multiple pulmonary stenosis • 3. Technique • 1) 30% longer than the width of the outflow tract patch • 2) Cover the upper round margin of the RVOT sufficiently • 4. Expectation • 1) Prevent PR especially immediate postoperatively • 2) Potentially improve hemodynamic function

  19. Preparation of Valved Stents • Self-expanding stents are assumed to improve preservation of • thevalve in its folded condition in the application device and • the valve’s long-term functioning

  20. Glutaraldehyde Stabilization • 1. Benefits • 1) Satisfactory hemodynamics • 2) Low thrombogenecity • 3) Reduced antigenecity • 2. Disadvantages • 1) Leaflet calcifications • 2) Cytotoxicity caused by unreacted glutaraldehyde • reagent • 3) Alteration of the natural biochemical properties • of the valve

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