Indications

Progressive RV impairment or RV dilatation with severe PR; severe PS; Consider TV annuloplasty if TR dilated.

Redo sternotomy – RV/RA may be dilated and stuck to sternum. Expose Aorta (sling), SVC (snare if TV), IVC, (snare if TV), MPA. Take care not to injure LAD as it passes behind the PA, or the left phrenic nerve as it passes very close. Cannulate aorta away from the PA. Bicaval cannulation. Root cardioplegia. If no VSD/ASD, can possibly undertake on beating heart, otherwise cross-clamp.

Longitudinal incision on the MPA towards the PA confluence, and to the RVOT, taking care not to injury LAD/conal branch/coronary artery. Resect RVOT muscle if needed. Size the valve using the cuffed side.

Place the valve with holder on the left hand side with the two struts pointing forward, and the valve upside down to be able to get forehand shots on the back of the valve. 2-0 prolene starting forehand on the annulus, with a rubber-shod, leaving more suture on the opposite side. Once the first couple of sutures are in, parachute the valve in, remove the holder and continue stitching forehand on the back wall. Come out on the annulus outside the MPA. If the MPA is wide enough, can use the anterior wall to continue stitching. If the needle goes outside the wall, can use pericardial pledget to come back inside the wall.

Usually, as the MPA is not wide enough, measure the bovine pericardium out using a silk that goes longitudinally from PA to RVOT, and the width of the valve. Fashion the pericardium with rounded edges. Using 4-0 prolene, start corner to corner on the MPA toe, and tie down. Start on the nearest edge and travel all the way to the valve. Take the opposite needle and go forehand upto the annulus.

Use the 2-0 on the opposite side to take bites on the pericarium with the cuff sandwiched inside. Meet the needle on the other side and tie down. Following this, use the 4-0 to complete the patch around the RVOT, taking care to use more pericardium to than muscle.

Rest as usual – pacing wires (RA/RV), drains (L+R), goretex, wires. TOE to assess RVOT/valve/PA/TV