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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

Management of Pulmonary Regurgitation

Seoul National University Hospital

Department of Thoracic & Cardiovascular Surgery

pulmonary infundibulum
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.
pulmonary infundibulum3
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.
interaction of ventricles
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.
risk factors for late death
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
causes of sudden death
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
arrhythmia sudden death
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

right ventricular dilatation
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
pulmonary regurgitation
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

pulmonary valve replacement
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
pulmonary valve replacement11
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
subannular pvr
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

rvot reconstruction
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.
pulmonary valve replacement16
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.
monocuspid valve insertion
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
pulmonary monocuspid valve
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
preparation of valved stents
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
glutaraldehyde stabilization
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