Polytetrafluoroethylene Bicuspid Pulmonary Valve Implantation

Implantation is performed using cardiopulmonary bypass usually with bicaval cannulation. Aortic cross-clamping with cardioplegic arrest is generally used, as it provides a more optimal surgical field for implantation. Patients without septal defects or a need for concomitant procedures can be operated with mild hypothermia and a beating heart. The right ventricular outflow tract is dissected from surrounding tissues and stay sutures are placed at, or just above, the level of the original pulmonary valve annulus. The main pulmonary artery (MPA) is opened from its midportion down into what is usually the old transannular patch for a distance of 3 to 4 cm. Any supravalvar reconstruction or branch pulmonary artery enlargement can be incorporated by extending this incision cephalad. The infundibular septum is inspected and the transverse diameter of the proximal MPA is measured. It is important to visualize the proposed triangular-shaped pathway for the posterior and anterior leaflet suture lines, making certain that the suture lines can be constructed without interference from structures such as a calcified ventricular septal defect (VSD) patch, or large right ventricular muscle bundles, which could result in distortion and/or perivalvar leakage.

The bicuspid leaflets are cut from a folded-over sheet of 0.1 mm PTFE in the shape of a bishop's miter. The dimension of the leading edge is approximately 1.8 times the diameter of the proximal MPA at the level where the outlet end of the valve will be sutured into place. The length is approximately 0.9 times the width. The folded edge is incised, leaving 2 to 3 mm of material intact at either end, to create the orifice of the valve. PTFE = polytetrafluoroethylene.

Implantation is begun by placing two 5-0 Prolene mattress anchoring sutures through the corners of the outlet end of the folded valve leaflets, securing them at the 3 and 9 o'clock positions in the proximal MPA just above the level of the pulmonary annulus. Ant. = anterior; Post. = posterior.

(A) The posterior leaflet is sewn from its apex toward the orifice, onto the infundibular septum, working the suture line anteriorly to end at the 3 and 9 o'clock positions of the initial anchoring sutures. (B) The anterior leaflet is sewn from its apex toward the orifice, beginning at the vertex of the infundibulotomy incision, working the suture line posteriorly and laterally along the sides of the infundibular outlet, down to the level of the initial anchoring sutures at the 3 and 9 o'clock positions. Optimally, the suture lines and leaflets should parallel each other and be side-by-side for the upper one-third of their course to maximize coaptation. The orifice and suture lines are inspected for integrity (C). An oval patch of pericardium or PTFE is used to close the resultant defect, maintaining the original measured diameter, or 24 mm as a minimum (D).

The right heart is de-aired, and the patient is rewarmed and weaned from cardiopulmonary bypass. Postoperative transesophageal echocardiography should demonstrate a competent valve with a low transannular gradient. Patients are maintained on low-dose aspirin postoperatively. Ant. = anterior; Post. = posterior.

(A) The posterior leaflet is sewn from its apex toward the orifice, onto the infundibular septum, working the suture line anteriorly to end at the 3 and 9 o'clock positions of the initial anchoring sutures. (B) The anterior leaflet is sewn from its apex toward the orifice, beginning at the vertex of the infundibulotomy incision, working the suture line posteriorly and laterally along the sides of the infundibular outlet, down to the level of the initial anchoring sutures at the 3 and 9 o'clock positions. Optimally, the suture lines and leaflets should parallel each other and be side-by-side for the upper one-third of their course to maximize coaptation. The orifice and suture lines are inspected for integrity (C). An oval patch of pericardium or PTFE is used to close the resultant defect, maintaining the original measured diameter, or 24 mm as a minimum (D).

The right heart is de-aired, and the patient is rewarmed and weaned from cardiopulmonary bypass. Postoperative transesophageal echocardiography should demonstrate a competent valve with a low transannular gradient. Patients are maintained on low-dose aspirin postoperatively. Ant. = anterior; Post. = posterior.