Pulmonary Atresia with Intact Ventricular Septum: Surgical Management Based on Right Ventricular Infundibulum

The optimal management of infants with pulmonary atresia with intact ventricular septum (PA.IVS) remains a controversy. Attempts have been made to base the surgical approach on various geometrical or morphological characteristics of the right ventricle (RV). However, the overall results remain poor...

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Veröffentlicht in:Journal of cardiac surgery 1993-05, Vol.8 (3), p.371-383
Hauptverfasser: Pawade, Ash, Capuani, Athos, Penny, Dan J., Karl, Tom R., Mee, Roger B.B.
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container_issue 3
container_start_page 371
container_title Journal of cardiac surgery
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creator Pawade, Ash
Capuani, Athos
Penny, Dan J.
Karl, Tom R.
Mee, Roger B.B.
description The optimal management of infants with pulmonary atresia with intact ventricular septum (PA.IVS) remains a controversy. Attempts have been made to base the surgical approach on various geometrical or morphological characteristics of the right ventricle (RV). However, the overall results remain poor when compared to other complex congenital heart defects. Forty‐eight neonates with PA.IVS were admitted to our unit between 1980 and 1992. The management plan has evolved to be based entirely on the echocardiographic assessment of the state of development of the infundibulum of the RV. In neonates with a well‐formed infundibulum (n = 31), the initial palliation consisted mainly of pulmonary valvotomy (without cardiopulmonary bypass) and PTFE shunt from the left subclavian artery to the main pulmonary artery. There was one death from initial palliation in this subgroup. If necessary, the RV cavity was later enlarged by excision of the hypertrophic muscle of both the trabecular and infundibular portions, before finally attempting biventricular repair. The actuarial probability of achieving a biventricular repair at 40 months of age was 60% (95% CL = 39.5% to 71.3%). Thirteen patients have undergone biventricular repairs with one late death over a total follow‐up of 1,720 patient months. In one patient, the RV failed to grow satisfactorily, necessitating a Fontan procedure. Seventeen patients without a well‐formed infundibulum were approached with a Fontan procedure in mind. The initial palliation in these patients consisted of a modified Blalock‐Taussig shunt only. Ten have undergone a Fontan procedure so far and five are awaiting such repairs. In this group there were four operative deaths: two after initial palliation, and two after Fontan procedures. In patients with a well‐developed infundibulum, the actuarial survival probability was 93% (95% CL = 74% to 98%) at 8 months with no further late deaths over 120 months follow‐up, whereas in patients without a well‐formed infundibulum it was 75% at 40 months (95% CL = 46% to 89%). The overall survival probability at 104 months was 77% (95% CL = 51% to 90%).
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Attempts have been made to base the surgical approach on various geometrical or morphological characteristics of the right ventricle (RV). However, the overall results remain poor when compared to other complex congenital heart defects. Forty‐eight neonates with PA.IVS were admitted to our unit between 1980 and 1992. The management plan has evolved to be based entirely on the echocardiographic assessment of the state of development of the infundibulum of the RV. In neonates with a well‐formed infundibulum (n = 31), the initial palliation consisted mainly of pulmonary valvotomy (without cardiopulmonary bypass) and PTFE shunt from the left subclavian artery to the main pulmonary artery. There was one death from initial palliation in this subgroup. If necessary, the RV cavity was later enlarged by excision of the hypertrophic muscle of both the trabecular and infundibular portions, before finally attempting biventricular repair. 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subjects Actuarial Analysis
Child, Preschool
Female
Heart Defects, Congenital - mortality
Heart Defects, Congenital - pathology
Heart Defects, Congenital - surgery
Heart Septum - pathology
Heart Ventricles - pathology
Heart Ventricles - surgery
Humans
Infant
Male
Methods
Palliative Care
Pulmonary Valve - abnormalities
Reoperation
title Pulmonary Atresia with Intact Ventricular Septum: Surgical Management Based on Right Ventricular Infundibulum
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