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Ann Thorac Surg 2001;72:396-400
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Surgical management of severe truncal insufficiency: experience with truncal valve remodeling techniques

Constantine Mavroudis, MDa, Carl L. Backer, MDa

a Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, and the Department of Surgery, Northwestern University Medical School, Chicago, Illinois, USA

Address reprint requests to Dr Mavroudis, Division of Cardiovascular-Thoracic Surgery, M/C #22, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614
e-mail: c-mavroudis{at}northwestern.edu

Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Discussion
 References
 
Background. Truncal valve insufficiency has been a significant short- and long-term risk factor for repair of truncus arteriosus. Recent reports have documented the virtues of truncal valve repair. The purpose of this report is to review our experience with truncal valve repair and illustrate our techniques.

Methods. Between 1995 and 2000, 8 patients had interventions for severe truncal valve insufficiency at primary repair (3 patients) or in conjunction with conduit replacement (5 patients). One neonate had truncal valve replacement at initial repair early in the experience. The other 7 patients had truncal valve repair, 3 by valvar suture techniques. The remaining 4 patients had leaflet excision and annular remodeling in 3 (coronary reimplantation was required in 2) and commissure resuspension in 1 patient.

Results. Trivial to mild truncal valve insufficiency is present in the patients who had leaflet excision and annular remodeling (n = 3) and commissure resuspension (n = 1). Of the 3 patients who had valvar suture truncal valve repair, there was one death and 2 patients required acute valve replacement. The 7 survivors are doing well 1 month to 6 years postoperatively.

Conclusions. Truncal valve repair by valvar suture techniques has not been successful in our practice. Truncal valve remodeling by leaflet excision and reduction annuloplasty is an effective method for truncal valve repair. When leaflet excision of a coronary sinus of Valsalva is required, coronary artery translocation can be accomplished.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Discussion
 References
 
Incremental technical advances for truncus arteriosus repair have resulted in dramatically improved outcomes. Sentinel achievements have included McGoon’s introduction of the repair [1], Ebert’s successful application in infancy [2], and Bove’s neonatal approach [3]. Significant associated lesions such as interrupted aortic arch and truncal insufficiency remained major risk factors for short- and long-term survival [4–11].

Because aortic homograft replacement for truncal insufficiency has unfavorable short- and long-term results [4, 12, 13], there has been recent interest in truncal valve repair using various valvuloplastic and annuloplastic techniques [13–17]. The purpose of this article is to review our results with truncal valve repair and document the technical aspects of the various procedures.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Discussion
 References
 
Between 1995 and 2000, 8 patients underwent truncal valve repair (n = 5) or replacement (n = 3) in association with primary repair or right ventricular-to-pulmonary artery conduit replacement for truncus arteriosus. Supportive operative techniques were standard and included aortobicaval cardiopulmonary bypass with systemic cooling to 28°C, left ventricular venting (through the right superior pulmonary vein), and combinations of antegrade–retrograde cold blood cardioplegia. The various reparative truncal valve techniques are noted in Figures 1–3. Intraoperative transesophageal echocardiography was used in all patients and served to evaluate the repairs after separation from cardiopulmonary bypass. Reinterventions for re-repair or valve replacement were performed as indicated by the hemodynamic data and the results of transesophageal echocardiography.



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  		Fig 1. Series of diagrams show truncal valve repair by leaflet excision and annular remodeling (A–E). (A) The common arterial trunk is transected showing the incompetent quadricuspid truncal valve. Usually there is one leaflet that is grossly prolapsed. In this patient, the small prolapsed leaflet does not involve the coronary sinus of Valsalva. (B) The prolapsed leaflet is removed with care being taken to leave the neighboring leaflets attached. (C) The sinus of Valsalva truncal wall is resected in preparation for the remodeling procedure. (D) Pledgetted sutures are used to tighten the annulus, thereby bringing the remaining leaflets together. The remnants of the resected leaflets are sewn together (not shown) to align the newly formed commissure. The rest of the truncal wall is approximated, thereby remodeling the truncal valve into a smaller, competent, and nonstenotic neoaortic valve. (E) Lateral view of the remodeled neoaortic valve.

 


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  		Fig 2. The suture valvuloplasty technique. This is performed by attaching the edges of the prolapsed leaflet to either one or both adjacent leaflets using fine sutures, thereby creating a functional tricuspid or bicuspid semilunar valve.

 


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  		Fig 3. Occasionally the prolapsed leaflet involves the coronary sinus of Valsalva. Under these circumstances the coronary artery can be reimplanted into the neighboring sinus of Valsalva, thereby permitting prolapsed leaflet resection and annular remodeling. (A) The coronary button has been removed from the affected sinus of Valsalva. The prolapsing leaflet is excised. (B) The annulus is tightened and the coronary artery button is reimplanted, using much the same technique as for the arterial switch operation. (C) Lateral projection of the annular remodeling technique.

 

   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 Discussion
 References
 
There was one early death (12.5%) and no late deaths. The operative death occurred in a 5-day-old infant with severe hemodynamic instability. Problems with ineffective myocardial preservation and unsatisfactory valve repair resulted in postoperative myocardial dysfunction and eventual death despite extracorporeal membrane oxygenation. Significant complications occurred in 2 patients (Table 1): one required postoperative extracorporeal membrane oxygenation; the other had significant intraoperative suture line bleeding resulting in a second cardiopulmonary bypass and cross-clamp intervention. Both patients recovered ventricular function after a prolonged hospital stay. The clinical characteristics relating to the truncal valve in our patient population are noted in Tables 1 and 2.


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  		Table 1. Clinical Characteristics of Patients Undergoing Truncal Valve Repair/Replacement at Initial Repair for Truncus Arteriosus

 

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  		Table 2. Clinical Characteristics of Patients Undergoing Truncal Valve Repair/Replacement in Association With Conduit Placement

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Discussion
 References
 
The introduction and development of truncal valve repair for severe insufficiency in patients with truncus arteriosus has significantly improved short-term and midterm outcomes [13–18]. Unlike many other arterial trunk and aortic valve lesions, the truncal valve has favorable anatomy for reparative reduction techniques owing to its large size, compliant annulus, and in many cases, multiple leaflets. The concept of the reduction leaflet and annuloplasty technique takes its roots from advances in mitral and tricuspid valve repair [19, 20]. The aim is to reduce the annulus size and adjust the leaflets, by excision and suturing, to the resultant reconfiguration. The newly formed valve must be made small enough to be competent, but not so small as to become stenotic. Thus far, the reported annulovalvuloplasty techniques for truncal valve repair have successfully used these principles whether they are suture valvuloplasty repairs [13–16, 18] or annulovalvuloplasty repairs [17].

Many researchers [13–16, 18] have advocated the valvuloplasty repair, in which the most prolapsing truncal leaflet is identified and sutured at the commissure of the adjacent valve leaflet (Fig 2). In effect, the prolapsing leaflet is supported by the adjacent leaflet, thereby creating a tricuspid valve. When more support is necessary, both sides of the prolapsing leaflet can be sutured to the respective adjacent leaflets, thereby forming a bicuspid valve. With this technique, there is no need to reduce the annulus size or reimplant the coronary artery if its course proves to be an impediment. Excellent short-term results have been reported using this technique [13–16, 18], although some patients had to have homograft truncal valve replacement due to acute valvuloplasty failure [15]. Our experience with valvuloplasty suturing techniques was less favorable leading us to adopt the annulovalvuloplasty techniques advocated by Imamura and associates [17].

The annulovalvuloplasty technique downsizes and remodels the annular configuration of the new truncal (neo-aortic) valve without placing sutures in the valve leaflets. The resultant trileaflet valve (if the original valve was quadricuspid) or bileaflet valve (if the original valve was tricuspid) accepts the forward flow during systole and supports the aortic pressure during diastole without undue stress on the valvar suture lines, which are prone to disruption and other unwanted complications. The postoperative echocardiographic results of our 3 patients who underwent this annulovalvuloplasty technique have been excellent in the short- and midterm showing no signs of regurgitation, stenosis, or abnormal leaflet motion. Our contribution to the original technique of Imamura and associates [17] is the coronary artery transfer in those patients where the target prolapsing leaflet contains a coronary artery origin from the associated sinus of Valsalva. We identified a prolapsing valve leaflet in 3 patients with severe truncal insufficiency due to an abnormal quadricuspid valve. In 2 of these patients a coronary artery took its origin from the prolapsing sinus of Valsalva. We found that removal of the coronary button and reimplantation to an adjacent sinus did not present an impediment to the annulovalvuloplasty technique, even in neonates, when proper myocardial protection is used (Fig 3).

Despite these promising annulovalvuloplasty techniques, there will be occasional indications for homograft or mechanical truncal valve replacement as in those patients with severely dysplastic and thickened valves. Our experience with 1 patient, first in the series, resulted in early re-replacement at 4 months and subsequent replacement at 4.5 years. This experience, although only with 1 patient, mirrors the experience of every published report on this subject [4, 5, 16, 21, 22] and other articles involving homograft replacement in infants for aortic valve disease [23]. The favorable perioperative hemodynamic results give way to early and multiple truncal valve replacements with the attendant risks and complications. For the present time, few options exist for neonates and infants when the truncal valve is not reparable, leaving aortic homograft replacement a necessary choice under these circumstances. Future advances in bioengineered grafts may play a major role in this field.

A selected literature review of truncal valve repair in 23 patients from six institutions [13–18] reveals that a variety of techniques have been used, among them being suture valvuloplasty, commissural suspension, and remodeling techniques. As one might expect, most of the repairs involved quadricuspid valves, which have been shown by numerous investigators to be most commonly insufficient [24]. Long-term evaluation of truncal valve function after repair is lacking with only one report showing 10- and 11-year follow-up in 2 patients whom eventually required truncal valve replacement. Whether leaflet excision and annular remodeling will maintain truncal competency in the long term without subsequent truncal valve replacement remains to be seen.

Truncal valve repair can be successfully accomplished in infancy and childhood. Quadricuspid truncal valves appear to be the best substrate for optimal repair. We advocate leaflet excision and annular remodeling when possible. Coronary artery impediments can be treated by reimplantation.


   Discussion
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 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Discussion
References
 
DR TOM R. KARL (Philadelphia, PA): That is a beautiful presentation, Gus. I just wonder about the indications for this level of intervention. Can you always make the decision prospectively, before the truncus repair? How do you know when you need to use the repair?

DR MAVROUDIS: Most of these patients had severe truncal insufficiency and had significant hemodynamic impediments. Some of the neonates had acidosis, requiring pressor agents, and it was clear that classic repair without truncal valve repair would not result in a good outcome.

The older patients had moderate to severe regurgitation, and we thought that over the long term they would be served better with truncal valve repair.

DR KARL: Do you ever have a problem deciding which leaflet to exclude?

DR MAVROUDIS: That is a good question. Probably the best leaflet is the smaller one. Usually one can find a prolapsing valve leaflet. And once the prolapsing valve leaflet is identified, then that one can be excised.

I know that is easier said and sometimes there are two leaflets that are prolapsing. Under those circumstances, one would resect the smaller of the two and then try to do a leaflet resuspension when the annular reduction technique is applied. Of course, all of this experience is in a small series of patients and we should remember that the follow-up time is relatively short.

DR MICHAEL R. MILL (Chapel Hill, NC): Given your success with these repairs with the leaflet excision and remodeling, would you advocate doing this with any patient who has severe truncal insufficiency or when would you go straight to a primary valve replacement?

DR MAVROUDIS: I think for a little baby, this is a daunting operation to be sure. The cross-clamp time is not insignificant. We have been using retrograde cardioplegia, augmented by ice around the heart, which is repeated every 20 minutes during the cross-clamp time.

However, the alternatives are not very good. And so if the child has significant, that is to say, 4+ or 3+ truncal regurgitation, we would go ahead and do the repair. If the child has mild-to-moderate truncal regurgitation, we would prefer to perform the classic conduit repair without truncal valve intervention. Often, the truncal valve function improves. If not, the truncal valve can be approached at the next conduit change as it was in some of our patients.

DR MARSHALL JACOBS (Philadelphia, PA): Congratulations on an excellent presentation.

There is some variability in truncus as to the details of the ventricular septal defect. Often it is in the conal septum and surrounded everywhere by muscle, and sometimes it bears more resemblance to conal ventricular or perimembranous. Have you found severe truncal valve insufficiency to be entirely the consequence of abnormal valve morphology, or is there any relation to conal septal hypoplasia and prolapse related to the VSD?

DR MAVROUDIS: That is an excellent question. I do not have a very good answer for it. Clearly, if you look at all the pathologic studies that have been done, many of these valves are thickened, nodular, myxomatous, and so forth.

I think your point about the truncal valve insufficiency based on what kind of ventricular septal defect is very interesting, because there indeed are two main different types of ventricular septal defects associated with truncus arteriosus. We did not look at that but I am sure that your notion would be a logical substrate for a future publication.

Thank you for your question.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Discussion
 References
 

  1. McGoon D.C., Rastelli G.C., Ongley P.A. An operation for the correction of truncus arteriosus. JAMA 1968;205:69-73.[Medline]
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  12. Elkins R.C., Steinberg J.B., Razook J.D., Ward K.E., Overholt E.D., Thompson W.M. Correction of truncus arteriosus with truncal valvar stenosis or insufficiency using two homografts. Ann Thorac Surg 1990;50:728-733.[Abstract]
  13. Naito Y., Fujiwara K., Takagaki Y., Kawasaki S., Suzuki H., Uemura S. Total correction of truncus arteriosus with severe truncal valve insufficiency in neonate. Nippon Kyobu Geka Gakkai Zasshi 1992;40:330-333.[Medline]
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