Minimally Invasive Pulmonary Valve Replacement In Adolescents
Sameh M. Said, Elizabeth Braunlin, Gamal Marey, Massimo Griselli.
University of Minnesota, Minneapolis, MN, USA.
Objective. Pulmonary valve replacement (PVR) is the most common procedure in adolescents with congenital heart disease. Minimally invasive approaches are thought to be advantageous in comparison to standard sternotomy. Herein we report our experience with minimally invasive PVR. Methods. Four adolescents(3 males) with a mean age of 16.4 years(range:15-18 years), and a mean weight of 56 Kg (range:49-61Kg), required isolated PVR for increased right ventricular volume. Intracardiac shunts were excluded. Through a 4-cm left anterior thoracotomy, the chest was entered via the left third intercostal space, and the main pulmonary artery(PA) was identified. Hybrid approach was attempted in 3 and was unsuccessful due to markedly dilated PA. Cardiopulmonary bypass (CPB) was initiated via common femoral artery and vein cannulation at normothermia. With the heart beating, the main PA was incised longitudinally and valve leaflets were resected. Adequate size bioprosthesis was placed using a running prolene suture and a pericardial patch was used to augment the right ventricular outflow tract(RVOT). Patients were weaned off CPB without difficulty, the groin vessels were decannulated and the incision was closed in the standard fashion. All patients were extubated in the operating room and no inotropes were required. Results. The size of the bioprosthesis was 27 mm in three patients, and a 25 mm in the fourth one. The mean CPB time was 51 minutes (range:34 - 84 minutes). Chest tubes were removed after a mean of 33 hours (range:24 - 40) postoperatively. The mean hospital stay was 2.5 days (range:2-3 days). The postoperative peak gradient across the RVOT ranged from 10-20 mmHg. No early mortality or reoperations. No early or late interventions. Morbidities included paralyzed left-hemidiaphragm in one patient and a small common femoral artery pseudoaneurysm in another. The mean follow-up was 5 months(range:2-12). Conclusions. Minimally invasive isolated PVR via mini-left anterior thoracotomy is a feasible and a reproducible technique in adolescents. Exclusion of intracardiac shunts is a prerequisite for the procedure. It may be associated with a short hospital stay; however, long-term data and larger patient series are needed to proof its superiority to standard median sternotomy.
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