Link : https://youtu.be/y7c6qrCNmHQ

Discussion

There have been numerous attempts to establish useful prognostic indicators for congenital heart disease. Some indices that have shown good prognostic value include the McGoon ratio, Nakata index, pulmonary arterial index, and TNPAI. More recently, the PVI has been indicated as a predictor for early outcomes during the surgical treatment of patients with TOF. In this study, we determine the predictive value of PVI. Yuan et al, in their study, indicated that a reduced PVI is a significant risk factor for early death and prolonged postoperative recovery. They estimated the cut-off point of PVI at 300.3 mm2/m2. In our case, PVI is 368.12 mm2/m2, which resulted in a smoother and uneventful postoperative recovery.
Pulmonary blood flow has a major effect on the prognosis of patients with CHDs, and PA parameters, such as the McGoon ratio and Nakata index, are the most commonly used parameters for the evaluation of pulmonary blood flow and as prognostic indicators for the successful surgical repair of TOF. However, it has been shown that PVI provides a more accurate indicator of pulmonary blood flow than that of the PAs.
Another objective of this case report was to assess the performance of PTFE-MVs. Construction of the PTFE-MV is an inexpensive and straightforward way to create a competent RVOT in a variety of RVOTO anomalies [16,17]. Moreover, reports show that PTFE-MVs appeared equal or superior to biologic monocusp valves, providing perioperative RVOT competence and improved right ventricular functional characteristics, reduced ICU stay, and decreased operative morbidity and mortality in patients with TOF [17].
Although the literature has been inconclusive regarding the perioperative function and clinical benefit of PTFE-MV for RVOT reconstruction, PTFE-MV has proven to be a simple and reproducible technique demonstrating excellent early postoperative function with minimal pulmonary insufficiency [18]. All types of monocusps have shown, particularly in the immediate postoperative period, to significantly reduce or prevent pulmonary insufficiency. The elimination of pulmonary insufficiency is associated with faster recovery of RV function, a lower central venous pressure, and less postoperative chest tube drainage [19]. A review of 196 patients demonstrated only mild to moderate insufficiency in 58% of patients at 10 years, and no significant RVOT stenosis. In our study, we show that PVI with PTFE-MV reconstruction for RVOT is a valuable preoperative predictor for early prognosis in TOF.
The patient in our case report underwent a detailed cardiological evaluation with electrocardiogram, 2D echocardiography, and cardiac CT dynamic study. Cardiac CT is a noninvasive technique that offers several approaches to establish the hemodynamic severity of coronary artery obstructions, demonstrates a good correlation with directly measured coronary flow and fractional flow reserve [20], and provides incremental diagnostic value over coronary CT angiography alone for the identification of hemodynamically significant coronary artery disease [21].

Conclusions

In this case report, we determine how the PVI will impact the postoperative outcome of surgically treated patients with TOF, and whether we can correlate the indices and postoperative recovery. The other aspect of the study is the performance of PTFE-MV. The PTFE-MV does not calcify in the membrane but rather a well-vascularized layer of nonobstructive fibrocollagenous tissue is incorporated within the PTFE with focal areas of endothelialization. Thus, the PTFE-MV integrates with the RVOT patch to a variable degree.
Reconstruction of the RVOT with a PTFE MO valve has proven to be a simple and reproducible technique demonstrating excellent early postoperative function with minimal PR. Moreover, there is a degree of early clinical benefit in patients reconstructed with a PTFE-MV when compared with TAP repairs. Hence, PVI with PTFE-MV for RVOT reconstruction is a valuable preoperative predictor for early prognosis of patients with TOF. In addition, cardiac CT dynamic study is a valuable tool recommended as it is a noninvasive technique that can pin-point the morphology of extra-cardiac vessels.
ACKNOWLEDGEMENTS
We are thankful to –
Mr. Naresh Jayantibhai Fumakiya, Echo-Cardiographer, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Karamsad.
Mr. Khushal N. Vankar, Office Assistant, Department of Diagnostic Services, Shree Krishna Hospital, Bhaikaka University, Karamsad.Email : khushalnv@charutarhealth.org

References

  1. Gott VL: Total correction of tetralogy of Fallot. Ann Thorac Surg. 1990, 49:328-332. 10.1016/0003-4975(90)90167-5
  2. Lillehei CW, Cohen M, Warden HE, et al.: Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentalogy of Fallot and pulmonary atresia defects. Reports of the first 10 cases. Ann Surg. 1955, 142:418-442. 10.1097%2F00000658-195509000-00010
  3. Sarris GE, Comas JV, Tobata Z, et al.: Results of reparative surgery for tetralogy of Fallot:data from the European Association for cardio-thoracic surgery congenital database. Eur J Cardiothorac Surg. 2012, 766:74. 10.1093/ejcts/ezs478
  4. Kirklin JW, Ellis FJ, McGoon DC, et al.: Surgical treatment for the tetralogy of Fallot by open intracardiac repair. J Thorac Surg. 1959, 22:51. 10.1016/S0096-5588(20)30094-5
  5. Chowdhury UK, Jha A, Ray R, et al.: Histopathology of the right ventricular outflow tract and the relation to hemodynamics in patients with repaired tetralogy of Fallot. J Thorac Cardiovasc Surg. 2019, 1173:83. 10.1016/j.jtcvs.2019.03.118
  6. Karamlou T, McCrindle BW, Williams WG, et al.: Surgery insight: late complications following repair of tetralogy of Fallot and related surgical strategies for management. Nat Clin Pract Cardiovasc Med. 2006, 3:611-22. 10.1038/ncpcardio0682
  7. Jia Q, Cen J, Zhuang J, et al.: Significant survival advantage of high pulmonary vein index and the presence of native pulmonary artery in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries: results from preoperative computed tomography angiography. Eur J Cardiothorac Surg. 52:225-32. 10.1093/ejcts/ezx064
  8. Kawahira Y, Kishimoto H, Kawata H, et al.: Diameters of the pulmonary arteries and veins as an indicator of bilateral and unilateral pulmonary blood flow in patients with congenital heart disease. J Card Surg. 1997, 253:60. 10.1111/j.1540-8191.1997.tb00136.x
  9. Yuan H, Qian T, Huang T, et al.: Pulmonary vein index is associated with early prognosis of surgical treatment for tetralogy of Fallot [Internet]. Frontiers in pediatrics. Frontiers Media S.A.; July. 2021, 9:705553-2021. 10.3389%2Ffped.2021.705553
  10. Garekar S., Dhobe P.,Chokhandre M, et al.: Estimation of Z-Scores of Cardiac Structures in Healthy. Indian Pediatric Population, Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging : Volume 2 : Issue 3 : September-December. 2018, 10.4103/jiae.jiae_48_18
  11. R. Krishna Kumar: Accuracy of a New Echocardiographic index to predict need for Trans-annular patch in Tetralogy of Fallot. Pediatric Cardiology40:161-167. 10.1007/s00246-018-1973-x
  12. Choi KH: A Novel Predictive value for the Transannular patch enlargement in repair of Tetralogy of Fallot. Ann Thorac Surg. 2016, 101:703-7. 10.1016/j.athoracsur.2015.10.050
  13. Stewart RD, Backer CL, Young L, et al.: Tetralogy of Fallot: results of a pulmonary valve-sparing strategy. Ann Thorac Surg. 2005, 80:1431-9. 10.1016/j.athoracsur.2005.04.016
  14. Awori MN, Leong W, Artrip JH, et al.: Tetralogy of Fallot repair: optimal z-score use for transannular patch insertion. Eur J Cardiothorac Surg. 2013, 43:483-6.
  15. Frigiola A: Pulmonary Regurgitation is an important determinant of Right Ventricular Contractile Dysfunction in Patients with Surgically Repaired Tetralogy of Fallot. Circulation. 2004110, 153:157. 10.1161/01.CIR.0000138397.60956.c2
  16. Turrentine MW, McCarthy RP, Vijay P, et al.: Polytetrafluoroethylene monocusp valve technique for right ventricular outflow tract reconstruction. Ann Thorac Surg. 2002, 74:2202-5. 10.1016/S0003-4975(02)03844-4
  17. Turrentine MW, McCarthy RP, Vijay P, et al.: PTFE monocusp valve reconstruction of the right ventricular outflow tract. Ann Thorac Surg. 2002, 73:871-80. 10.1016/S0003-4975(01)03441-5
  18. Turrentine MW, Rodefeld MD, Brown, JW: Polytetrafluoroethylene monocusp valve reconstruction of the right ventricular outflow tract. Oper Tech Thorac Cardiovasc Surg. 2008, 13:250-9. 10.1053/j.optechstcvs.2008.11.002
  19. Brown JW, Ruzmetov M, Vijay P, et al.: Right ventricular outflow tract reconstruction with a polytetrafluoroethylene monocusp valve: a twelve-year experience. J Thorac Cardiovasc Surg. 2007, 133:1336-43. 10.1016/j.jtcvs.2006.12.045
  20. Nieman K, Balla S: Dynamic CT myocardial perfusion imaging. J Cardiovasc Comput Tomogr. 2020, 14:303-6. 10.1016/j.jcct.2019.09.003
  21. Nous FM, Geisler T, Kruk MB, et al.: Dynamic myocardial perfusion ct for the detection of hemodynamically significant coronary artery disease. JACC Cardiovasc Imaging. (In. 2021101016202107021, 10.1016/j.jcmg.2021.07.021