Abstract】Objective: To evaluate the clinical effectiveness of the method of reconstructing the right ventricular outflow tract of the permanent arterial trunk in pediatric patients with their own tissues. METHODS: In this paper, we reviewed a total of 86 patients with PTA admitted to our hospital from January 2000 to December 2012. 53 of them had their right ventricular outflow tract reconstructed with their own tissue from the permanent arterial trunk, and the remaining 33 had their right ventricular outflow tract reconstructed with a flap tube or a Gortex tube. 53 children aged 40 days to 2.3 years after birth (mean 0.9±0.5 years), weighing 3.5 The right ventricular outflow tract was reconstructed by pulling down the cut common pulmonary artery trunk to the right ventricular outflow tract incision on F for anastomosis by different methods. Results: 6 cases of severe pulmonary hypertension occurred early after surgery, all of which were treated with targeted pulmonary artery dilators. 2 cases died after surgery due to pulmonary hypertension crisis and right heart failure. The rest of the children were discharged from the hospital with successful recovery. Cardiac ultrasound at the time of discharge showed pulmonary regurgitation, which was mild in 5 cases, mild in 27 cases, and moderate in 21 cases. Postoperative follow-up ranged from 36 to 60 months (mean 54 months) in 36 children, without 1 death. CONCLUSION: We believe that this relatively simple method of reconstructing the right ventricle-pulmonary artery connection is appropriate and effective and, at least in terms of mid-term postoperative follow-up results, avoids the problems associated with the use of a conduit and also reduces the possibility of needing reintervention. The surgical treatment of PTA requires reconstruction of the right ventricular to pulmonary artery access, and most cardiac centers currently prefer to use a valved conduit to connect the right ventricle to the pulmonary artery. The right ventricular outflow tract reconstruction using a valved conduit connecting the right ventricle to the pulmonary artery is the preferred approach. The use of a valved conduit to correct a permanent arterial trunk is limited in source and size availability, and restenosis or regurgitation due to postoperative tissue degradation and failure of the conduit to grow will result in reoperation to replace the conduit. In the surgical management of PTA and other congenital heart diseases with pulmonary artery obstruction, avoiding the use of conduit material to reconstruct the right ventricle and pulmonary artery access may overcome these disadvantages. Currently, these reconstructions have been reported to ensure the growth potential of the outflow tract but with high early postoperative mortality, but good long-term results have been reported [1] and low reoperation rates. In order to find a procedure that better avoids the use of a valved tube and directly connects the right ventricle to the pulmonary artery, we report the follow-up results with a modified procedure as follows. Data and Methods In this paper, we reviewed a total of 86 patients with PTA admitted to our institution from January 2000 to December 2012, of whom 53 had their right ventricular outflow tract reconstructed with their own tissue from the pediatric permanent arterial trunk, and the remaining 33 had their right ventricular outflow tract reconstructed with a valved or Gortex conduit. These 53 children were 20 males and 33 females, aged 40 days to 2.3 years after birth (mean 0.9±0.5 years), weighing 3.5 Kg to 11 Kg (mean 6.3±2.1 Kg), with 8 cases operated at 1 to 3 months, 35 cases at 4 to 6 months, and the rest at 6 months or older. The preoperative diagnosis was mainly based on color Doppler ultrasound, 48 CT examinations and 5 cardiac catheterization examinations. Other combined malformations included atrial septal defect (ASD), ventricular septal defect (VSD), and single-branch coronary artery malformation. After the aortic block, the children were closed through the right ventricular incision with continuous sutures of 5-0 prolene sutures of their own pericardial pieces to close the VSD, and in 23 children, the cut pulmonary artery trunk was pulled down to the right ventricular outflow tract incision on F for anastomosis. In 6 children, because of the short common pulmonary trunk, the posterior wall of the common pulmonary artery and the superior F of the right ventricular outflow tract were connected with the posterior wall of the common pulmonary artery after dissection with the left auricle. In the remaining 30 children, the arterial trunk was transected at the superior border of the beginning of the pulmonary artery, and another transverse incision was made in the anterior wall of the proximal arterial trunk, which was extended to the posterior part of the arterial trunk, immediately below the pulmonary artery orifice. A cylindrical segment containing the pulmonary arterial trunk is removed from the ascending aorta as a sleeve underneath (Figure 1) and the ascending aorta is reanastomosed end to end. The cylindrical segment was cut down the middle and the two arterial trunks were sutured together to form the posterior wall of the pulmonary trunk (Figure 2a and Figure 2b), which was anastomosed to the superior F of the right ventricular outflow tract incision. 26 of 53 children were treated with a 0.1 mm Gortex film sheet attached to the 2/3 edge of the right ventricular outflow tract incision to form a new single pulmonary artery valve, and the anterior wall was then pericardially sliced in all patients. enlargement. In contrast to the original procedure of placing the pulmonary artery anterior to the ascending aorta by Lecompte transfer, our modified approach allows the newly formed pulmonary trunk to maintain a normal spiral relationship with the ascending aorta and avoids compression of the pulmonary trunk by the sternum after Lecompte transfer and excessive strain on both branches of the pulmonary artery. The arterial trunk valve malformation (circular structure with regurgitation) was a two-valve malformation in 5 cases, a four-valve malformation in 2 cases, and the rest were three-valve. There were 6 cases of mild to moderate regurgitation and 2 cases of moderate to severe regurgitation in the arterial stem valves. In the two cases of moderate to severe regurgitation, one case was shortened by folding of the valve junction with De Vega annuloplasty, and the other case was excised from the accessory structures of the valve leaflets in the quadruple valve malformation. Postoperatively, PaO2 of 100-120 mmHg and PaCO2 of 35-45 mmHg were maintained, and dopamine (3-10 μg?kg-1?min-1) and milrinone (0.25-0.75 μg?kg-1?min-1) were administered to all children to maintain hemodynamic stability, with epinephrine (0.05-1 μg?kg-1?min-1) added when necessary. -1). In the presence of severe pulmonary hypertension with hypoxia and/or hemodynamic instability, treatment with bosentan, vancomycin or sildenafil should be considered. One of them was treated with bosentan 1.5 mg?kg-1?day-1, and the pulmonary artery pressure dropped significantly to less than 1/2 of the body artery pressure and the related symptoms were relieved. One of them was a 3-month-old child with a permanent arterial trunk type II who died preoperatively due to severe heart failure combined with pulmonary hypertension and respiratory failure due to emphysema. The other child was 5 months old and belonged to the permanent arterial trunk type I. He died postoperatively due to pulmonary hypertension, massive pulmonary regurgitation, and right heart failure. The remaining children were discharged from the hospital without incident. Cardiac ultrasound at discharge showed pulmonary regurgitation, which was mild in 5 cases, mild in 27 cases, and moderate in 21 cases. Postoperative follow-up ranged from 36 to 60 months (mean 54 months) in 36 children, and there was no death in one case. One case was found to have moderate pulmonary regurgitation with a flow velocity of 4.9 m?s-1 at the right ventricle-pulmonary artery junction on ultrasound 45 months after surgery, and improved after reoperation to enlarge the stenosis patch. 4. For the reconstruction of the pulmonary artery and right ventricular outflow tract, the medium and long term surgical results are not satisfactory due to the limitations of homogeneous and other heterogeneous valved conduits and in a series of studies using homogeneous valved conduits [2]. In recent years, research on tissue-engineered conduits has made some progress and has been applied in clinical treatment in some hospitals. However, these types of ducts have not been allowed to be commercialized and have never been applied to neonates or small-aged infants. On the other hand, some recent controlled clinical studies suggest that the use of a valved conduit is more likely to result in postoperative reoperation than a direct right ventricular connection to the pulmonary artery [3]. Therefore, identifying a method that better maintains continuity of the right ventricle to pulmonary artery access without the use of a conduit is the trend of research. Therefore: the ideal method of direct right ventricle-pulmonary artery connection must have the same advantages as the use of a valved conduit (simplicity of approach, adequate size and provision of a fully functional valve); in addition the ideal method of direct right ventricle-pulmonary artery connection must avoid the disadvantages present with the use of a valved conduit (providing growth potential reducing the possibility of reoperation). In 1982, Lecompte et al. reported a new surgical procedure that introduced the concept of direct anastomosis of the right ventricle to the pulmonary artery by separating a portion of the pulmonary trunk from the arterial trunk and placing it anterior to the ascending aorta, followed by direct anastomosis of the pulmonary trunk to the superior border of the right ventricular incision. However, the short-term and long-term follow-up results of this surgical approach were not satisfactory. Subsequently, this procedure was further modified by Tran Viet and Neveux by separating the pulmonary trunk from the aortic wall with a columnar border structure [4]. This approach allows for the length and width of the posterior wall of the pulmonary trunk and reduces the tension between the right ventricular incision and the bifurcation of the pulmonary artery and the right and left branches. Barbero-Marcial et al. reported in 1990 a new tubeless right ventricle-pulmonary artery connection for correction of the permanent arterial trunk [5]. This surgical approach involves pulling it directly to the right ventricular incision site for anastomosis, which tends to cause shortening and stenosis of the posterior wall of the pulmonary arterial trunk. Long-term follow-up of this procedure has shown a tendency to cause distortion and deformation at the bifurcation of the pulmonary artery. In contrast, the occurrence of postoperative restenosis can be helped by inserting left auricular tissue between the pulmonary artery and the right ventricular incision. This method was also chosen in 6 cases in our group with good results. Our method of reconstructing the right ventricle-to-pulmonary artery access without a conduit is also reproducible [6] and has been demonstrated in 53 consecutive children, by which a more ideal conduit diameter of the pulmonary artery trunk can be obtained and the tension at the pulmonary bifurcation and the right and left branches can be minimized. Second, although the reconstructed Gortex single valve will lose function in the distant future, it can provide sufficient valve function in the early postoperative period, which in turn may prevent death due to severe postoperative pulmonary hypertension [7]; the right heart failure caused by the two deceased patients may also be related to the absence of a reconstructed single valve in the right ventricular outflow tract, and finally, there were no cases requiring catheter intervention or reoperation for restenosis of the reconstructed right ventricular outflow tract during our postoperative follow-up to the midterm period. Regardless of the type of direct right ventricle-pulmonary artery anastomosis used, reconstruction of a functioning single valve leaflet is important, especially in the early postoperative period when severe pulmonary hypertension is present, to help reduce pulmonary regurgitation and improve right ventricular anterior-posterior load [8], thus facilitating the maintenance of right ventricular function. In our cases, early postoperative gortex films with a single valve were active and kept pulmonary regurgitation in the mild range. The presence of a single valve may help avoid the development of severe postoperative pulmonary hypertension and thus may improve early postoperative survival. In contrast, some early direct right ventricle-pulmonary artery anastomoses without a single valve have been associated with higher early postoperative mortality when used to correct the permanent arterial trunk. Because long-term pulmonary regurgitation has been shown to lead to right ventricular failure and ventricular arrhythmias in the long-term follow-up of transvalvular annular patch repair in tetralogy of Fallot, there is a strong need to reposition a functional mechanical valve in the pulmonary position in children with a permanent trunk artery long after direct right ventricle-pulmonary artery anastomosis repair [9]. In conclusion, we believe that this relatively simple method of reconstructing the right ventricle-pulmonary artery connection is appropriate and effective and, at least in terms of mid-term postoperative follow-up results, avoids the problems associated with the use of a conduit and also reduces the possibility of requiring reintervention. Of course, we need more cases, detailed hemodynamic evaluation and long-term follow-up results at a later stage.