Pulmonary Artery Angioplasty (Main Pulmonary Artery Rotation Flap Technique) in Tetralogy of Fallot Patients With Acute-Angle Branch Pulmonary Artery Stenosis

  • Chang-Ha Lee
    Address reprint requests to Chang-Ha Lee, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, 28, 489-Gil, Hohyeon-Ro, Sosa-Gu, Bucheon-Si, Gyeonggi-Do, 14754, Republic of Korea, Office : +82-32-340-1151, Fax : +82-32-340-1236.
    Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Republic of Korea
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      Despite excellent outcomes of tetralogy of Fallot (TOF) repair, reinterventions for recurrent or residual stenosis of branch pulmonary arteries are still required in many patients. The development of these lesions may be related to 2 inherent characteristic morphologies of TOF: Pulmonary ductal coarctation and acute angulation of branch pulmonary artery, especially the left pulmonary artery. I developed a main pulmonary artery rotation flap angioplasty technique to deal with acute-angle branch pulmonary artery stenosis without using any patch. Since 1998, 68 TOF patients have undergone this technique. During a median follow-up of 13.5 years, 20 (29%) patients underwent catheter or surgical-based intervention for branch pulmonary stenosis. Overall freedom from any intervention was 87%, 76%, 70%, and 59% at 1-year, 5-year, 10-year, and 20-year periods, respectively. I believe that this technique is reproducible and provides excellent intermediate and long-term outcomes in TOF patients with complicated branch pulmonary artery stenosis.


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        • Knott-Craig CJ
        • Elkins RC
        • Lane MM
        • et al.
        A 26-year experience with surgical management of tetralogy of Fallot: Risk analysis for mortality or late reintervention.
        Ann Thorac Surg. 1998; 66: 506-510
        • Oechslin EN
        • Harrison DA
        • Harris L
        • et al.
        Reoperation in adults with repair of tetralogy of Fallot: Indications and outcomes.
        J Thorac Cardiovasc Surg. 1999; 118: 245-251
        • Hirsch JC
        • Mosca RS
        • Bove EL
        Complete repair of tetralogy of Fallot in the neonate.
        Ann Surg. 2000; 232: 508-514
        • Sharma SN
        • Sharma S
        • Shrivastava S
        • et al.
        Pulmonary arterial anatomy in tetralogy of Fallot.
        Int J Cardiol. 1989; 25: 33-37
        • Elzenga NJ
        • Suylen RJ
        • Frohn-Mulder I
        • et al.
        Juxtaductal pulmonary artery coarctation An underestimated cause of branch pulmonary artery stenosis in patients with pulmonary atresia or stenosis and a ventricular septal defect.
        J Thorac Cardiovasc Surg. 1990; 100: 416-424
        • Moon-Grady AJ
        • Teitel DF
        • Hanley FL
        • et al.
        Ductus-associated proximal pulmonary artery stenosis in patients with right heart obstruction.
        Int J Cardiol. 2007; 114: 41-45
        • Faidutti B
        • Christenson JT
        • Beghetti M
        • et al.
        How to diminish reoperation rates after initial repair of tetralogy of Fallot?.
        Ann Thorac Surg. 2002; 73: 96-101
        • Luo Q
        • He X
        • Song Z
        • et al.
        Preoperative morphological prediction of early reoperation risk after primary repair in tetralogy of Fallot: A contemporary analysis of 83 cases.
        Pediatr Cardiol. 2021; 42: 1512-1525
        • Hennein HA
        • Mosca RS
        • Urcelay G
        • et al.
        Intermediate results after complete repair of tetralogy of Fallot in neonates.
        J Thorac Cardiovasc Surg. 1995; 109: 332-344
        • McElhinney DB
        • Parry AJ
        • Reddy VM
        • et al.
        Left pulmonary artery kinking caused by outflow tract dilatation after transannular patch repair of tetralogy of Fallot.
        Ann Thorac Surg. 1998; 65: 1120-1126
        • Chowdhury UK
        • Agarwal S
        • Kothari SS
        • et al.
        Alternative approach for angioplasty of stenosed left pulmonary artery following intracardiac repair of tetralogy of Fallot.
        Heart Lung Circulation. 2002; 11: 121-125
        • Chaturvedi RR
        • Kilner PJ
        • White PA
        • et al.
        Increased airway pressure and simulated branch pulmonary artery stenosis increase pulmonary regurgitation after repair of tetralogy of Fallot: Real-time analysis with a conductance catheter technique.
        Circulation. 1997; 95: 643-649
        • Petit CJ
        • Gillespie MJ
        • Harris MA
        • et al.
        Relief of branch pulmonary artery stenosis reduces pulmonary valve insufficiency in a swine model.
        J Thorac Cardiovasc Surg. 2009; 138: 382-389
        • D'Souza GA
        • Banerjee RK
        • Taylor MD
        Evaluation of pulmonary artery stenosis in congenital heart disease patients using functional diagnostic parameters: An in vitro study.
        J Biomech. 2018; 81: 58-67
        • Rhodes J
        • Dave A
        • Pulling MC
        • et al.
        Effect of pulmonary artery stenoses on the cardiopulmonary response to exercise following repair of tetralogy of Fallot.
        Am J Cardiol. 1998; 81: 1217-1219
        • Hiremath G
        • Qureshi AM
        • Prieto LR
        • et al.
        Balloon angioplasty and stenting for unilateral branch pulmonary artery stenosis improve exertional performance.
        JACC Cardiovasc Interventions. 2019; 12: 289-297
        • Wilder TJ
        • Arsdell GSV
        • Pham-Hung E
        • et al.
        Aggressive patch augmentation may reduce growth potential of hypoplastic branch pulmonary arteries after tetralogy of Fallot repair.
        Ann Thorac Surg. 2016; 101: 1004
        • Kim H
        • Sung SC
        • Chang YH
        • et al.
        Early and midterm outcomes of left pulmonary artery angioplasty using an anterior wall flap of the main pulmonary artery in tetralogy of Fallot repair.
        J Thorac Cardiovasc Surg. 2013; 148: 2597-2601
        • Jang WS
        • Kim WH
        • Cho S.
        • et al.
        Effects of angle correction angioplasty for pulmonary artery stenosis with tetralogy of Fallot.
        Ann Thorac Surg. 2017; 103: 862-868
        • Lee CH
        • Jeon YB
        • Lee TY
        • et al.
        A new technique of angioplasty of the left pulmonary artery using an autologous main pulmonary artery flap.
        J Chest Surg. 2003; 36: 255-260