Repair of truncus arteriosus: a considered approach to right ventricular outflow tract reconstruction

In repair of truncus arteriosus the accepted methods of establishing right ventricle (RV) to pulmonary artery (PA) continuity utilize an allograft or xenograft valved conduit. Alternatively, the PA confluence may be directly anastomosed to the RV with anterior patch augmentation, which may allow growth and delay or avoid subsequent RVOT obstruction. These methods of RVOT reconstruction were evaluated in infants undergoing truncus arteriosus repair.

A retrospective analysis of 61 infants undergoing repair of truncus arteriosus between November 1988 and June 2000 was performed. Median age was 34 days (range 1 day to 6.4 months). The patient cohort was subdivided into two groups (1) Valved conduit group: RV to PA continuity performed with a conduit in 38 patients using allograft (28) or xenograft (10). (2) Direct anastomosis group: direct RV-PA anastomosis performed in 23 patients, augmented anteriorly with monocusp (15) or simple pericardial patch (eight).

There were eight hospital deaths (13%, 95% confidence limits 5--21%). Hospital mortality did not differ significantly between group 1 and 2 (three patients (8%) versus five patients (22%) respectively, P=0.23). By multivariate analysis, low operative weight (P=0.023), severe truncal regurgitation (P=0.022) and major coronary abnormalities (P=0.018), were independent risk factors for hospital death. Hospital survivors were followed-up from 1.3 months to 11.8 years (mean 4.2+/-3.4 years). There were eight late deaths with survival of 73+/-6% at 2 years and beyond. Survival was not influenced by method of RVOT reconstruction (Conduit versus direct RV-PA anastomosis, 2.76+/-7%, 63+/-10%, respectively, P=0.23). Freedom from surgical RVOT reintervention was 56+/-10% in group 1 and 89+/-10% in group 2 at 10 years (P=0.023). The use of a xenograft conduit was an independent risk factor for reintervention (P<0.001).

In truncus arteriosus repair, RV to PA continuity established by a direct anastomosis was associated with a low incidence of surgical RVOT re-intervention. This technique has the potential for RVOT growth and may be a useful alternative when an appropriate allograft is unavailable, particularly in the neonate where the risk of pulmonary hypertension are lower.