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Technique For Pulmonary Valve Creation With Living Tissue For Complete Repair Of Atrioventricular Septal Defect And Tetralogy Of Fallot
Linda Jin Schulte, MD, Jacob R. Miller, MD, Dilip Nath, MD, Pirooz Eghtesady, MD PhD.
Washington University in St. Louis, Saint Louis, MO, USA.

Objectives: Complete repair of Tetralogy of Fallot (TOF) with complete atrioventricular septal defect (CAVSD) comes with increased importance of pulmonary valve (PV) competence in the setting of severely hypertrophied right ventricle with diastolic dysfunction and potential right-sided atrioventricular valve insufficiency. We present a novel method for pulmonary valve creation using autologous right atrial appendage (RAA) tissue that offers PV competence.
Methods: The patient was an 18-month-old infant with Trisomy 21, TOF with CAVSD who failed to present in infancy due to COVID pandemic. Preoperative saturations were in the mid-70%. TTE showed severe multi-level right ventricular outflow tract (RVOT) stenosis with peak gradient of 105 mmHg and mean gradient 68 mmHg, a hypertrophied RV with normal systolic function and hypoplastic pulmonary valve. CT showed pulmonary valve annulus of 5 mm (z-score -4.94). CAVSD was repaired using a two-patch technique and annuloplasty of the left and right atrioventricular valves (AVVs) via a right atriotomy. The RVOT was opened to the main pulmonary artery (MPA). Hypoplastic native PV tissue was removed. A previously prepared ring of right atrial appendage tissue fitting a 13 mm dilator (z-score 0) was implanted in the RVOT, creating a biscupid valve of atrial tissue. The anterior aspect of the RVOT was closed using an elliptical patch of pulmonary homograft.
Results: At one month follow-up, TTE demonstrated RVOT peak velocity of 26 mmHg, with no pulmonary insufficiency.
Conclusions: Pulmonary valve creation with RAA tissue offers a novel option for relieving RVOT obstruction while preserving PV competence using native tissue.


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