Angiocardiography Tetralogy of Fallot MASAOKI MITSUSHIGE
after Total Correction of Using Large Homograft Arteries
FUJINO,’ OHTA,’
CHOKEN
TAKAHIRO
YASUNARU
OHYAMA,2
KOZUKA,’
TAKASHI
American Journal of Roentgenology 1977.128:243-248.
atresia
hypoplasia valves [1,
either
of 2]
the
have of the
valve
tried.
segment
The
valve
Somerville ventricular
or with
with
cusps valve,
aorta below,
above was
and
first
the
of
by
for reconstruction in pulmonary atresia.
of
of Fallot
Outflow
homografts. was
changes outflow
We
report
and
eight
reconstruction pulmonary
patients
in
so-called
a
was in cases
of
8).
All to
seen
in
and
catheterization
prior
the
outflow
tract
dilatation.
mobility
Mobility
slight
in
was
was
While
the
other
six.
prominent showed the
slight
In
paradoxic
of the changes
the
angiocardiographic were seen between
valve
cases In
opening
in four
normal
of the was
1 and 3, there the remaining
observed
seen
near
thickening
the
was
rather cases
seen in the outflow tract 2 and 6, no morphologic
right were
patients
under-
examinations, the two studies.
too
was four
accurately
determined were
(figs. small
in
of Pulmonary
Preoperative
38).
systolic
valve 2
despite
and
a
While
phase
dome formation. mobility was
and
of separation TABLE
Type
in the
cases
two
2, 3A,
However,
suggestive
1 , 3, 6, and
(cases latter
no apparent cases, valve
radiographically.
findings
cases
in the
valve
of the this
5,
of Homograft
Valve 8).
right then
whom
2,
Ventricle
dilatation
in any phases
Valve
and
with
Pulmonary
(cases
not
position 4
(fig.
was 4),
of valvular
in
and
leaflets.
1 Stenosis
Seen
at
Angiocardiography
accomplished. Subjects
operative illustrates
and
Methods
angiocardiography the
type
of
are
listed
reconstructive
in
table
surgery
1
carried
.
Figure
out
Case
Sex and Age
No
1
1
M.
2
in each
case. For seven patients a homograft aorta with a valve was used. In the remaining case (no. 7), it was a homograft pulmonary artery with a valve. The homografts were obtained from cadavers, sterilized with betapropiolactone, and stored at 4#{176}C. Postoperative angiocardiography was performed once for cases 1 , 3, 6. and 7 and twice in the remainder. The period between surgery and the first angiocardiographic examination was 2-1 3 months, and 23/-3Y years for the second. All patients
.
.
2
Department Department
of Radiology. of Surgery.
3
Department
of Radiology.
J Roentgenol
Osaka University Osaka University
1 28:243-248,
Osaka
Prefectural
February
Medical Medical Hospital.
1977
School, School,
1-150 Osaka,
Osaka.
Fukushima, Japan
Japan
243
Pulmonary Infundibulum
Valve
Trunk
14
None
Severe
Hypoplastic
Severe
Hypoplastic
7
Moderate Moderate
Severe
Hypoplastic
Moderate Mild
None
Hypoplastic Pulmonary
F. 5
.
3
M,
4 5
M. 1 5 F, 1 1
6’
F,17
...
M,7
.
Severe
bifurcation 7#{149}.
.
8
.
.
.
M,
.
7
...
.,. ..
Severe
.
Mild
Pulmonary bifurcation
. Pulmonary
Am
of Right
aneurysmal
movement ventricle
Eight patients (six males and two females) underwent radical surgery for tetralogy of Fallot using either an aortic or pulmonary homograft with cusps. Age range at the time of surgery was 5-1 7 years. The patterns of pulmonary stenosis seen at pre-
1
cardiac
going two postoperative no significant changes
artery
three
patients (cases 2, 5, and 7), being in cases 2 and 7. However, none of the
homografts with a of a particular type
after
tract
Tract
Apparent
reports dealing with hemodynamics and angiofindings after total corrections of tetralogy are accumulating, none 19-i 9 ] document in detail
ventricular
ventriculography.
in
three
Fallot.
angiocardiographic
right
right
performed
Results
Although cardiographic the
selective
was
angiocardiography.
leaflet
the Since
SATO3
underwent
seen
with
Ross
KITAMURA,2
KENJI
biplane
patients
[3-6],
anterior
described
underwent
prosthetic homografts,
aortic
AND
arteriography
severe
or two
used aortic and pulmonary valve for the total correction
of tetralogy
Fallot
one
in 1966 [7] outflow tract
we have semilunar
of
use of a homograft
of ascending mitral
tetralogy
the pulmonary valve annulus, as well as pulmonary or aortic
whole
been
and
YOKOTA,’
SOICHIRO
TOMOKUNI,2
Postoperative angioca rdiog ra phic fin dings were examined in eight patients whose pulmonary artery was reconstructed using an aortic or pulmonary homograft with valve. Apparent dilatation of the outflow tract of the right ventricle was seen in three patients. Only four showed valve mobility, with function judged almost normal in two of them. Calcification in a valve was not seen. The pulmonary trunk showed three directional patterns, and stenosis was clearly observed in two cases. Calcification of the pulmonary trunk was seen in only one case. The most difficult problem in the reconstruction of the pulmonary artery is the high incidence of pulmonary stenosis. In pulmonary
KANJI
KAWASHIMA,2
Fukushima-ku,
atresia Osaka,
Japan
Address
reprint
requests
to
M.
Fujino.
244
FUJINO
ET AL.
1-PA
1
-
PA
Fig All
1 -Surgical
7.
PP
G. case
TP
leaflet
AH right
8
=
pericardial
=
anterior
A.
aortic
teflon
patch; of
mitral
homograft;
patch;
AMV
=
valve,
RV
=
ventricle.
G
F
American Journal of Roentgenology 1977.128:243-248.
E
technique
Cases 1 and 4; 8. case 2. C. case 3. 0. case 5. E. case 6, F. case
Fig. 2.-case at site
of anastomosis
6. Systolic between
(A) and diastolic aortic
homograft
(8) phases and
showing
original
good
pulmonary
mobility trunk.
of slightly Pulmonary
thickened trunk
valve nearly
leaflets.
normal.
Note
two
saccular
dilatations
(arrows)
American Journal of Roentgenology 1977.128:243-248.
POSTOPERATIVE
_rT
ANGIOCARDIOGRAPHY
0
245
American Journal of Roentgenology 1977.128:243-248.
246
FUJINO
ET AL.
Fig
5 -Case
Position Fig. 4.-case 2. Valve located (arrow). at any phase. Direction of pulmonary trunk text). Note stenosis near valve of homograft
4, and
6; fig.
2).
progressing outflow
almost tract
4 and
In type
5).
of
(cases trunk
radiographs
of the
in the
at a right
3 the
pulmonary
trunk
cases
(cases
2 and
the valve homograft
chest
Comparative
examination
cases studied changes in the
from
Peripheral In
case
type
decreased stenosis
pulmonary significant
stenosis, of the
left seen
artery findings
figs.
bent
and
and 6). observed
in the
In case
2 the
stenosis was seen and was presumed used in the peripheral of the
trunk
pulmonary
was trunk
in to
seen
1 in case
in the
showed no position of the
or calcification. direction of the
pulmonary
However, pulmonary
to at the
near in the
the
right
proximal
the other
was
(fig. part
bifurcation. cases.
3C). of
the
There
horizontal
(arrow).
of blood
samples
ventricular
system
left-to-right
shunt
Since
collected
from
did
show
not
angiocardiography gradiant of 6-75 and tests
pulmonary and gas
various
parts
significant
in any of the
of
are mm
trunk analysis
of the
right
evidence
of
a
patients.
Somerville
the
[7]
tetralogy
the procedure problems remain
internal
hardening
space
and
of with
due
function
performed
Fallot
has been with this
degenerative
of the is the
valve most
critical
seem consider
reconstruction In
the
present
first
valve
function
postoperative
to occur stenosis of the series,
relatively to be pulmonary stenosis
problem,
seen
examination,
occurred
as
in
nearly
changes
soon after the greatest artery
and
in valvular
others [20-23 1. in only two of our
was
abnormal
aortic
changes, resulting
cases.
at the
an
adopted elsewhere. type of surgery, in-
of
Since
radical
using
the implanted large arteries physical growth, narrowing
to
calcification
of valve
first
of
evidenced by our cases and those Normal valve function was maintained
function We
no
and extreme
cluding failure of growth or valves to correspond
Moreover, main
for
homograft, However,
all cases
were
Ross
surgery
extremely right
before pressure
Hg at rest between right ventricle was seen in all cases. Dye dilution
stenosis. Loss
1.
vasculature
nearly
Discussion.
Artery
compared was
the
5;
8.
of the
2 to type
Pulmonary 8
7,
and
Measurements
Pressure measurements listed in table 2. A systolic
linear,
with
2 and
twice by angiocardiography diameter of the homograft,
bending, degree of there was a change trunk
of case
presumed
at what was considered and the original trunk
Calcification films
was
was
valve
straight
(see
Pressure
angle
7).
of homograft
trunk
observed
2 pattern
trunk
7 and 8; figs. 3A, 3B, stenosis was clearly
homograft.
plain
type
(cases
behind of the
not
(arrowheads).
ventricle
of the pulmonary artery. In case the two bends near the bifurcation exist around the pericardial patch side
illustrates
right
of two
stenosis was just the anastomosis
movement
pulmonary
horizontally
the
In type
meandered Pulmonary
2 the
but
5. Pulmonary
in
surgery. difficulty
using
in
homografts. at
three
sites:
American Journal of Roentgenology 1977.128:243-248.
POSTOPERATIVE
Fig.
6.-Case
determined.
7. Systolic
Pulmonary
trunk
(A) and diastolic (B) phases crooked and meandering;
ANGIOCARDIOGRAPHY
showing moderate two stenotic sites
247
dilatation of right ventricular found near bifurcation (arrows)
TABLE
outflow
tract
Exact
Case
No.
valve
homograft between
of
often;
6. However, Consequently, ascertain
Value
Right
Mean
36
52
42/14
34
90
15/5
11
.
3 4 5 6 7 8
36 9 3 28
40 75 52 36
24/12 26/10 40/4 15/5
17 17 16 9
45 9
80 56
53/8 50/7
23 24
15/2 24/6
-
Values
homograft,
in mm
(2)
and the original the homograft
this
was
dome
formation pressure
its presence.
seen
be
.
.
Mean
30/12
.
.
18 .
.
.
.
24/12
.
.
.
...
...
.
.
.
.
.
.
.
.
.
.
.
.
Gradients Main Pulmonary Artery to Right Pulmonary Artery
Right Ventricle to Main Pulmonary Artery
Pulmonary Artery
Value
1
10
12
75
...
16 49 12 21
7 10
0 ... ...
27 6
38 26
Hg
anastomotic
junction
of
the
pulmonary trunk or the suture and pericardial patch, and (3)
at the bend of the pulmonary on the anastomosis. Valvular most
Systolic Pressure
Pulmonary Artery
2
Note
(1)
Main
cannot
Data
Pressure
Right Ventricular
of valve
2
Catheterization
Time after Surgery (mo)
position
trunk without direct bearing stenosis was encountered
in all of our was not seen measurement
cases
except
radiographically. is essential
In case right
valve, junction
case to
6, the
ventricle
indicating of In case
of the motic
homograft junction
pulmonary
in systole
pulmonary
trunk
stenosis
homograft
was and
2, stenosis
trunk.
with
gradient
the
the
the
trunk.
related
pressure and
was
the
seen
at
To
what
degree
gradient
not
the at
the
the
anastomotic
original
pulmonary
just
at a position thought of the homograft
the pressure
between was
behind to and
this
the
valve
be the anastothe original stenosis
is uncertain,
but
is
cor-
it
may
248
FUJINO
become
more
significant
as the
patient
ages.
In cases
ET AL.
1,
onary
was
felt
the
that
junction
trunk
or
was homograft
in the
pericardial
of
thought
to
be
because
a
residual
proved None the
pulmonary
a high problem
American Journal of Roentgenology 1977.128:243-248.
the
the
due
to
ventricular
as a result homograft
Therefore, should
the
be
use
avoided.
In
pressure
pulmonary
septal
10.
was
was
cyclic
trunk
signifying
loss
homograft
was
for
because in Japan.
of the difficulty However, we
extreme
type
diameter
not
of
Anderson
of
of
In case suggesting
[24].
We
have
and
obtained
not
Pulmonary
arteriography The
was
details
extremely
of
the
part
on
tetralogy pulmonary lateral the
slight
surgical the
in only
and
does
not
seem
angiocardiographer
to to aid
angiograms.
After
1 3. Gersony
W,
up
patients
14.
of
know
the
the
it of
total
artery
WP,
Cooper
DL:
replacement.
J
experimental
Thorac
study
Cardiovasc
21
valve
homograft
for
reconstruction
of
pul-
J
Fallot’s
of
1962 and catheafter total 91 :321 -328.
22.
of the Gross
tetralogy
aneurysm
McGoon
DC,
F:
defect.
J Thorac S. Asano
J, Moller of
24.
JW:
JH,
Fallot.
Am
A:
Aneurysms
Pasternac J
Thorac
postoperative B, Neill
CA,
right Early
Amplatz
K: after
J Roentgenol
in
Wallace
Br
HB:
Total
study
RB.
Complete
Cardiovasc K:
of
Rastelli
repair Surg
Homograft
study patch.
Thompson of the
heart.
right Surg
J
Radio!
correction 104
cases.
1965
DC:
wall
of
Cardiovasc
Taussig
Follow-up
experimental
WS.
the
changes
57:95-107, of
utilizing
Arch
WM, pulmonary
GC.
of truncus
Surg
Kasama outflow
Ongley
PA,
arteriosus
1969
pulmonary
aorta with valves as a right Surgery 56:413-420, 1968 Manhas DR. Rittenhouse EA, Mohri Merendino KA: Widening of the right
Replacement
Surg
of tetralogy of Fallot: Surg 162:578-587,
Ann
tetralogy
Fallot.
cited
Eguchi
Pierce
of
DuShane
repair
patches.
McGoon
aortic
total
1965
angiocardiographic
31:385-393,
An
follow-
Cardiovasc
95:642-654,
RE,
1972 The
of
graft
Late
1975
B:
tract.
J:
after
Thorac
ascending
23.
4. Marchand P: The use of a cusp-bearing homograft patch to the outflow tract and pulmonary artery in Fallot’s tetralogy and pulmonaryvalvularstenosis. Thorax 22:497-509, 1967 5. Rastelli GC. Titus JL, McGoon DC: Homograft of ascending aorta and aortic valve as a right ventricular outflow, Arch Surg 95:698-708, 1967 6. Weldon CS, Rowe AD, Gott VL: Clinical experience with the
.
Fallot.
RB.
outflow
Bowman
Surg
1966
the
correction
MaIm
Postoperative
and
A,
TitusJL,
F Jr.
J, Mann-Garcia
correction
63:735-740, 18. Stickland
of
1960
total
Radiology
after intracardiac of 337 patients-
L, Joransen
Circulation T: An
W:
hemodynamically
J Roentgenol Wallace
ventricular
of
2. Gott VL, Daggett DL, Koepke DE, Rowe GG, Young WP: Replacement of the canine pulmonary valve and pulmonary artery with a graphite-water valve prosthesis. J Thorac Cardiovasc Surg 44:713-723, 1962 3. Fuller ON, Marchand P. Zion MM, Zwi 5: Homograft replacement of the pulmonary valve. Thorax 21 :337-342,
use of aortic
JW,
1 7. Rosenthal
20. Cornell
40:667-672,
Bloom
123:691-702,
REFERENCES 1 . Gilbert JW, pulmonary
Fallot.
of
39:403-414, 1966 1 9. Wolf MD. Landtman
gradient.
of
1973 Am
1 6. Knight
for
otherwise position
after
S. Bowman
Roentgenographic
surgery
of
evaluated
and late results 5-year review 1965
a
pressure from the by referring to the
right ventriculograms; to correctly identify
tetralogy Batthany
FA.
1 5. Kirklin
all
be
Urquhart
study
of tetralogy
Hipona
in identifying
radical
measure the right ventricle
to
CGH.
Hemodynamic
66:209-213.
three in
Newman
of
correction
good
observed
reconstruction
of Fallot, we artery to the
pressure
performed
insufficiency
problem. for the
views of the not be possible
would
was
pulmonary
hemodynamic It is important each
H:
ventricle.
patients.
portion
1968
results.
three
IM,
correction
the Hancock conduit it in two cases of the
Fallot
outflow
tetralogy of Fallot. Am J Cardiol 9:924-932, 12. Cornell SH, VIad P. Ehrenhaft JL: Angiographic terization findings in patients with difficulties
To minimize the has begun using
operation
in obtaining recently tried
tetralogy
elasticity.
observed,
changes. Mayo Clinic
this
changes
and
tetralogy-some radiological and other findings in the first few years after total correction. BrJ Radio! 38:81-92, 1965 1 1 . Bristow J, Adroundy Z. Porter G. Menashe V. Starr A.
stenosis,
defect
valve
Circulation
ventricle.
Griswold
showed
of the
of
bent
ventricular
exclusively
conduit
at
and
large
right
degree of degenerative of calcification, the
Hancock
became
excessively
high
in these cases. of our patients
8, calcification
an
homograft
7, the
either pulmonary
homograft
in stenosis.
large
cases,
original
the
trunk
of
resulting
2, 4, and
the
pulmonary
37, suppl. 2:51-61, 1968 7. Ross ON, Somerville J: Correction of pulmonary atresia with a homograft aortic valve. Lancet 2:1446-1447, 1966 8. Kawashima Y. Naito Y, Kitamura S. Nakano 5, Miyamoto T. Fujita M, Kozuka T, Manabe H: Use of large homograft artery with semilunar valve for correction of tetralogy of Fallot. A follow-up study. J Thorac Cardiovasc Surg 67: 685-693, 1974 9. Allison PR, Gunning AJ, Hamill J. Mody SM: Fallot’s tetralogy: a postoperative study. Circulation 28:525-530, 1963
periphery.
pulmonary
an excessively
in these
and
in its
pressure
its dilatation,
cases
present
between
used
7, the
posterior
and
suture
patch
In case of
stenosis of the
artery,
right
7, and 8, there was also a pressure gradient between the pulmonary trunk and the right main pulmonary artery. It
artery
ventricular
or
outflow.
H, Reichenbach 0, ventricular outflow
a cusp-bearing
hetero-
106:202-205,
1973
S. Waldhausen tract
and
valve
JA: with
a formalin-treated porcine heterograft. An experimer.tal study in the dog. J Thorac Cardiovasc Surg 61 :924-932, 1971 Douglas OM, Ritter 0G. Davis GD. Wallace RB, Danielson GK, McGoon DC: Selection iosus for surgical correction. considerations.
Circulation
of patients Anatomic 49:144-151,
with and 1974
truncus arterhemodynamic
after Total Correction of Using Large Homograft Arteries
FUJINO,’ OHTA,’
CHOKEN
TAKAHIRO
YASUNARU
OHYAMA,2
KOZUKA,’
TAKASHI
American Journal of Roentgenology 1977.128:243-248.
atresia
hypoplasia valves [1,
either
of 2]
the
have of the
valve
tried.
segment
The
valve
Somerville ventricular
or with
with
cusps valve,
aorta below,
above was
and
first
the
of
by
for reconstruction in pulmonary atresia.
of
of Fallot
Outflow
homografts. was
changes outflow
We
report
and
eight
reconstruction pulmonary
patients
in
so-called
a
was in cases
of
8).
All to
seen
in
and
catheterization
prior
the
outflow
tract
dilatation.
mobility
Mobility
slight
in
was
was
While
the
other
six.
prominent showed the
slight
In
paradoxic
of the changes
the
angiocardiographic were seen between
valve
cases In
opening
in four
normal
of the was
1 and 3, there the remaining
observed
seen
near
thickening
the
was
rather cases
seen in the outflow tract 2 and 6, no morphologic
right were
patients
under-
examinations, the two studies.
too
was four
accurately
determined were
(figs. small
in
of Pulmonary
Preoperative
38).
systolic
valve 2
despite
and
a
While
phase
dome formation. mobility was
and
of separation TABLE
Type
in the
cases
two
2, 3A,
However,
suggestive
1 , 3, 6, and
(cases latter
no apparent cases, valve
radiographically.
findings
cases
in the
valve
of the this
5,
of Homograft
Valve 8).
right then
whom
2,
Ventricle
dilatation
in any phases
Valve
and
with
Pulmonary
(cases
not
position 4
(fig.
was 4),
of valvular
in
and
leaflets.
1 Stenosis
Seen
at
Angiocardiography
accomplished. Subjects
operative illustrates
and
Methods
angiocardiography the
type
of
are
listed
reconstructive
in
table
surgery
1
carried
.
Figure
out
Case
Sex and Age
No
1
1
M.
2
in each
case. For seven patients a homograft aorta with a valve was used. In the remaining case (no. 7), it was a homograft pulmonary artery with a valve. The homografts were obtained from cadavers, sterilized with betapropiolactone, and stored at 4#{176}C. Postoperative angiocardiography was performed once for cases 1 , 3, 6. and 7 and twice in the remainder. The period between surgery and the first angiocardiographic examination was 2-1 3 months, and 23/-3Y years for the second. All patients
.
.
2
Department Department
of Radiology. of Surgery.
3
Department
of Radiology.
J Roentgenol
Osaka University Osaka University
1 28:243-248,
Osaka
Prefectural
February
Medical Medical Hospital.
1977
School, School,
1-150 Osaka,
Osaka.
Fukushima, Japan
Japan
243
Pulmonary Infundibulum
Valve
Trunk
14
None
Severe
Hypoplastic
Severe
Hypoplastic
7
Moderate Moderate
Severe
Hypoplastic
Moderate Mild
None
Hypoplastic Pulmonary
F. 5
.
3
M,
4 5
M. 1 5 F, 1 1
6’
F,17
...
M,7
.
Severe
bifurcation 7#{149}.
.
8
.
.
.
M,
.
7
...
.,. ..
Severe
.
Mild
Pulmonary bifurcation
. Pulmonary
Am
of Right
aneurysmal
movement ventricle
Eight patients (six males and two females) underwent radical surgery for tetralogy of Fallot using either an aortic or pulmonary homograft with cusps. Age range at the time of surgery was 5-1 7 years. The patterns of pulmonary stenosis seen at pre-
1
cardiac
going two postoperative no significant changes
artery
three
patients (cases 2, 5, and 7), being in cases 2 and 7. However, none of the
homografts with a of a particular type
after
tract
Tract
Apparent
reports dealing with hemodynamics and angiofindings after total corrections of tetralogy are accumulating, none 19-i 9 ] document in detail
ventricular
ventriculography.
in
three
Fallot.
angiocardiographic
right
right
performed
Results
Although cardiographic the
selective
was
angiocardiography.
leaflet
the Since
SATO3
underwent
seen
with
Ross
KITAMURA,2
KENJI
biplane
patients
[3-6],
anterior
described
underwent
prosthetic homografts,
aortic
AND
arteriography
severe
or two
used aortic and pulmonary valve for the total correction
of tetralogy
Fallot
one
in 1966 [7] outflow tract
we have semilunar
of
use of a homograft
of ascending mitral
tetralogy
the pulmonary valve annulus, as well as pulmonary or aortic
whole
been
and
YOKOTA,’
SOICHIRO
TOMOKUNI,2
Postoperative angioca rdiog ra phic fin dings were examined in eight patients whose pulmonary artery was reconstructed using an aortic or pulmonary homograft with valve. Apparent dilatation of the outflow tract of the right ventricle was seen in three patients. Only four showed valve mobility, with function judged almost normal in two of them. Calcification in a valve was not seen. The pulmonary trunk showed three directional patterns, and stenosis was clearly observed in two cases. Calcification of the pulmonary trunk was seen in only one case. The most difficult problem in the reconstruction of the pulmonary artery is the high incidence of pulmonary stenosis. In pulmonary
KANJI
KAWASHIMA,2
Fukushima-ku,
atresia Osaka,
Japan
Address
reprint
requests
to
M.
Fujino.
244
FUJINO
ET AL.
1-PA
1
-
PA
Fig All
1 -Surgical
7.
PP
G. case
TP
leaflet
AH right
8
=
pericardial
=
anterior
A.
aortic
teflon
patch; of
mitral
homograft;
patch;
AMV
=
valve,
RV
=
ventricle.
G
F
American Journal of Roentgenology 1977.128:243-248.
E
technique
Cases 1 and 4; 8. case 2. C. case 3. 0. case 5. E. case 6, F. case
Fig. 2.-case at site
of anastomosis
6. Systolic between
(A) and diastolic aortic
homograft
(8) phases and
showing
original
good
pulmonary
mobility trunk.
of slightly Pulmonary
thickened trunk
valve nearly
leaflets.
normal.
Note
two
saccular
dilatations
(arrows)
American Journal of Roentgenology 1977.128:243-248.
POSTOPERATIVE
_rT
ANGIOCARDIOGRAPHY
0
245
American Journal of Roentgenology 1977.128:243-248.
246
FUJINO
ET AL.
Fig
5 -Case
Position Fig. 4.-case 2. Valve located (arrow). at any phase. Direction of pulmonary trunk text). Note stenosis near valve of homograft
4, and
6; fig.
2).
progressing outflow
almost tract
4 and
In type
5).
of
(cases trunk
radiographs
of the
in the
at a right
3 the
pulmonary
trunk
cases
(cases
2 and
the valve homograft
chest
Comparative
examination
cases studied changes in the
from
Peripheral In
case
type
decreased stenosis
pulmonary significant
stenosis, of the
left seen
artery findings
figs.
bent
and
and 6). observed
in the
In case
2 the
stenosis was seen and was presumed used in the peripheral of the
trunk
pulmonary
was trunk
in to
seen
1 in case
in the
showed no position of the
or calcification. direction of the
pulmonary
However, pulmonary
to at the
near in the
the
right
proximal
the other
was
(fig. part
bifurcation. cases.
3C). of
the
There
horizontal
(arrow).
of blood
samples
ventricular
system
left-to-right
shunt
Since
collected
from
did
show
not
angiocardiography gradiant of 6-75 and tests
pulmonary and gas
various
parts
significant
in any of the
of
are mm
trunk analysis
of the
right
evidence
of
a
patients.
Somerville
the
[7]
tetralogy
the procedure problems remain
internal
hardening
space
and
of with
due
function
performed
Fallot
has been with this
degenerative
of the is the
valve most
critical
seem consider
reconstruction In
the
present
first
valve
function
postoperative
to occur stenosis of the series,
relatively to be pulmonary stenosis
problem,
seen
examination,
occurred
as
in
nearly
changes
soon after the greatest artery
and
in valvular
others [20-23 1. in only two of our
was
abnormal
aortic
changes, resulting
cases.
at the
an
adopted elsewhere. type of surgery, in-
of
Since
radical
using
the implanted large arteries physical growth, narrowing
to
calcification
of valve
first
of
evidenced by our cases and those Normal valve function was maintained
function We
no
and extreme
cluding failure of growth or valves to correspond
Moreover, main
for
homograft, However,
all cases
were
Ross
surgery
extremely right
before pressure
Hg at rest between right ventricle was seen in all cases. Dye dilution
stenosis. Loss
1.
vasculature
nearly
Discussion.
Artery
compared was
the
5;
8.
of the
2 to type
Pulmonary 8
7,
and
Measurements
Pressure measurements listed in table 2. A systolic
linear,
with
2 and
twice by angiocardiography diameter of the homograft,
bending, degree of there was a change trunk
of case
presumed
at what was considered and the original trunk
Calcification films
was
was
valve
straight
(see
Pressure
angle
7).
of homograft
trunk
observed
2 pattern
trunk
7 and 8; figs. 3A, 3B, stenosis was clearly
homograft.
plain
type
(cases
behind of the
not
(arrowheads).
ventricle
of the pulmonary artery. In case the two bends near the bifurcation exist around the pericardial patch side
illustrates
right
of two
stenosis was just the anastomosis
movement
pulmonary
horizontally
the
In type
meandered Pulmonary
2 the
but
5. Pulmonary
in
surgery. difficulty
using
in
homografts. at
three
sites:
American Journal of Roentgenology 1977.128:243-248.
POSTOPERATIVE
Fig.
6.-Case
determined.
7. Systolic
Pulmonary
trunk
(A) and diastolic (B) phases crooked and meandering;
ANGIOCARDIOGRAPHY
showing moderate two stenotic sites
247
dilatation of right ventricular found near bifurcation (arrows)
TABLE
outflow
tract
Exact
Case
No.
valve
homograft between
of
often;
6. However, Consequently, ascertain
Value
Right
Mean
36
52
42/14
34
90
15/5
11
.
3 4 5 6 7 8
36 9 3 28
40 75 52 36
24/12 26/10 40/4 15/5
17 17 16 9
45 9
80 56
53/8 50/7
23 24
15/2 24/6
-
Values
homograft,
in mm
(2)
and the original the homograft
this
was
dome
formation pressure
its presence.
seen
be
.
.
Mean
30/12
.
.
18 .
.
.
.
24/12
.
.
.
...
...
.
.
.
.
.
.
.
.
.
.
.
.
Gradients Main Pulmonary Artery to Right Pulmonary Artery
Right Ventricle to Main Pulmonary Artery
Pulmonary Artery
Value
1
10
12
75
...
16 49 12 21
7 10
0 ... ...
27 6
38 26
Hg
anastomotic
junction
of
the
pulmonary trunk or the suture and pericardial patch, and (3)
at the bend of the pulmonary on the anastomosis. Valvular most
Systolic Pressure
Pulmonary Artery
2
Note
(1)
Main
cannot
Data
Pressure
Right Ventricular
of valve
2
Catheterization
Time after Surgery (mo)
position
trunk without direct bearing stenosis was encountered
in all of our was not seen measurement
cases
except
radiographically. is essential
In case right
valve, junction
case to
6, the
ventricle
indicating of In case
of the motic
homograft junction
pulmonary
in systole
pulmonary
trunk
stenosis
homograft
was and
2, stenosis
trunk.
with
gradient
the
the
the
trunk.
related
pressure and
was
the
seen
at
To
what
degree
gradient
not
the at
the
the
anastomotic
original
pulmonary
just
at a position thought of the homograft
the pressure
between was
behind to and
this
the
valve
be the anastothe original stenosis
is uncertain,
but
is
cor-
it
may
248
FUJINO
become
more
significant
as the
patient
ages.
In cases
ET AL.
1,
onary
was
felt
the
that
junction
trunk
or
was homograft
in the
pericardial
of
thought
to
be
because
a
residual
proved None the
pulmonary
a high problem
American Journal of Roentgenology 1977.128:243-248.
the
the
due
to
ventricular
as a result homograft
Therefore, should
the
be
use
avoided.
In
pressure
pulmonary
septal
10.
was
was
cyclic
trunk
signifying
loss
homograft
was
for
because in Japan.
of the difficulty However, we
extreme
type
diameter
not
of
Anderson
of
of
In case suggesting
[24].
We
have
and
obtained
not
Pulmonary
arteriography The
was
details
extremely
of
the
part
on
tetralogy pulmonary lateral the
slight
surgical the
in only
and
does
not
seem
angiocardiographer
to to aid
angiograms.
After
1 3. Gersony
W,
up
patients
14.
of
know
the
the
it of
total
artery
WP,
Cooper
DL:
replacement.
J
experimental
Thorac
study
Cardiovasc
21
valve
homograft
for
reconstruction
of
pul-
J
Fallot’s
of
1962 and catheafter total 91 :321 -328.
22.
of the Gross
tetralogy
aneurysm
McGoon
DC,
F:
defect.
J Thorac S. Asano
J, Moller of
24.
JW:
JH,
Fallot.
Am
A:
Aneurysms
Pasternac J
Thorac
postoperative B, Neill
CA,
right Early
Amplatz
K: after
J Roentgenol
in
Wallace
Br
HB:
Total
study
RB.
Complete
Cardiovasc K:
of
Rastelli
repair Surg
Homograft
study patch.
Thompson of the
heart.
right Surg
J
Radio!
correction 104
cases.
1965
DC:
wall
of
Cardiovasc
Taussig
Follow-up
experimental
WS.
the
changes
57:95-107, of
utilizing
Arch
WM, pulmonary
GC.
of truncus
Surg
Kasama outflow
Ongley
PA,
arteriosus
1969
pulmonary
aorta with valves as a right Surgery 56:413-420, 1968 Manhas DR. Rittenhouse EA, Mohri Merendino KA: Widening of the right
Replacement
Surg
of tetralogy of Fallot: Surg 162:578-587,
Ann
tetralogy
Fallot.
cited
Eguchi
Pierce
of
DuShane
repair
patches.
McGoon
aortic
total
1965
angiocardiographic
31:385-393,
An
follow-
Cardiovasc
95:642-654,
RE,
1972 The
of
graft
Late
1975
B:
tract.
J:
after
Thorac
ascending
23.
4. Marchand P: The use of a cusp-bearing homograft patch to the outflow tract and pulmonary artery in Fallot’s tetralogy and pulmonaryvalvularstenosis. Thorax 22:497-509, 1967 5. Rastelli GC. Titus JL, McGoon DC: Homograft of ascending aorta and aortic valve as a right ventricular outflow, Arch Surg 95:698-708, 1967 6. Weldon CS, Rowe AD, Gott VL: Clinical experience with the
.
Fallot.
RB.
outflow
Bowman
Surg
1966
the
correction
MaIm
Postoperative
and
A,
TitusJL,
F Jr.
J, Mann-Garcia
correction
63:735-740, 18. Stickland
of
1960
total
Radiology
after intracardiac of 337 patients-
L, Joransen
Circulation T: An
W:
hemodynamically
J Roentgenol Wallace
ventricular
of
2. Gott VL, Daggett DL, Koepke DE, Rowe GG, Young WP: Replacement of the canine pulmonary valve and pulmonary artery with a graphite-water valve prosthesis. J Thorac Cardiovasc Surg 44:713-723, 1962 3. Fuller ON, Marchand P. Zion MM, Zwi 5: Homograft replacement of the pulmonary valve. Thorax 21 :337-342,
use of aortic
JW,
1 7. Rosenthal
20. Cornell
40:667-672,
Bloom
123:691-702,
REFERENCES 1 . Gilbert JW, pulmonary
Fallot.
of
39:403-414, 1966 1 9. Wolf MD. Landtman
gradient.
of
1973 Am
1 6. Knight
for
otherwise position
after
S. Bowman
Roentgenographic
surgery
of
evaluated
and late results 5-year review 1965
a
pressure from the by referring to the
right ventriculograms; to correctly identify
tetralogy Batthany
FA.
1 5. Kirklin
all
be
Urquhart
study
of tetralogy
Hipona
in identifying
radical
measure the right ventricle
to
CGH.
Hemodynamic
66:209-213.
three in
Newman
of
correction
good
observed
reconstruction
of Fallot, we artery to the
pressure
performed
insufficiency
problem. for the
views of the not be possible
would
was
pulmonary
hemodynamic It is important each
H:
ventricle.
patients.
portion
1968
results.
three
IM,
correction
the Hancock conduit it in two cases of the
Fallot
outflow
tetralogy of Fallot. Am J Cardiol 9:924-932, 12. Cornell SH, VIad P. Ehrenhaft JL: Angiographic terization findings in patients with difficulties
To minimize the has begun using
operation
in obtaining recently tried
tetralogy
elasticity.
observed,
changes. Mayo Clinic
this
changes
and
tetralogy-some radiological and other findings in the first few years after total correction. BrJ Radio! 38:81-92, 1965 1 1 . Bristow J, Adroundy Z. Porter G. Menashe V. Starr A.
stenosis,
defect
valve
Circulation
ventricle.
Griswold
showed
of the
of
bent
ventricular
exclusively
conduit
at
and
large
right
degree of degenerative of calcification, the
Hancock
became
excessively
high
in these cases. of our patients
8, calcification
an
homograft
7, the
either pulmonary
homograft
in stenosis.
large
cases,
original
the
trunk
of
resulting
2, 4, and
the
pulmonary
37, suppl. 2:51-61, 1968 7. Ross ON, Somerville J: Correction of pulmonary atresia with a homograft aortic valve. Lancet 2:1446-1447, 1966 8. Kawashima Y. Naito Y, Kitamura S. Nakano 5, Miyamoto T. Fujita M, Kozuka T, Manabe H: Use of large homograft artery with semilunar valve for correction of tetralogy of Fallot. A follow-up study. J Thorac Cardiovasc Surg 67: 685-693, 1974 9. Allison PR, Gunning AJ, Hamill J. Mody SM: Fallot’s tetralogy: a postoperative study. Circulation 28:525-530, 1963
periphery.
pulmonary
an excessively
in these
and
in its
pressure
its dilatation,
cases
present
between
used
7, the
posterior
and
suture
patch
In case of
stenosis of the
artery,
right
7, and 8, there was also a pressure gradient between the pulmonary trunk and the right main pulmonary artery. It
artery
ventricular
or
outflow.
H, Reichenbach 0, ventricular outflow
a cusp-bearing
hetero-
106:202-205,
1973
S. Waldhausen tract
and
valve
JA: with
a formalin-treated porcine heterograft. An experimer.tal study in the dog. J Thorac Cardiovasc Surg 61 :924-932, 1971 Douglas OM, Ritter 0G. Davis GD. Wallace RB, Danielson GK, McGoon DC: Selection iosus for surgical correction. considerations.
Circulation
of patients Anatomic 49:144-151,
with and 1974
truncus arterhemodynamic
