Internal mammary artery perforator flap for repair of an upper thoracic tracheo-oesophageal fistula.

Tracheoesophageal fistulas (TOF) following esophagectomy for esophageal cancer are rare but potentially fatal. There is no consensus on treatment between stenting and surgical repair, although the latter is associated with better distant survival. In surgical repair, the interposition of a flap improves healing by providing well-vascularized tissue and reinforcing the repair zone. The flaps described are usually muscular and decaying. We present the case of a malnourished fifty-year-old man who underwent intrathoracic surgical repair of symptomatic recurrent TOF using a skin flap based on the perforators of the internal thoracic artery (IMAP). The perforator flap was completely de-epidermized and tunneled under the sternum by a proximal and limited resection of the 3rd costal cartilage and placed at the posterior aspect of the trachea, with the excess tissue rolled up on either side. At 9 months, the patient showed no recurrence and improved general condition. The de-epidermized IMAP tunneled under the sternum intrathoracically is a reliable alternative to the conventional muscle flaps described in TOF management and an attractive additional tool in the plastic surgeon's surgical arsenal.

Concomitant valve-sparing aortic root replacement with tetralogy of Fallot repair in a 30-year-old patient: A case report.

INTRODUCTION AND IMPORTANCE: Aortic regurgitation and aortic root dilatation are common features in adults with both repaired and unrepaired tetralogy of Fallot (TOF). Valve-sparing aortic root replacement (VSARR) is an effective repair for aortic regurgitation due to progressive aortic root dilatation with TOF after repair. However, the effectiveness of this technique for unrepaired patients has rarely been reported. CASE PRESENTATION: We reported a case of a 30-year-old man with cyanosis and exertional dyspnea. Echocardiography and computed tomography showed unrepaired TOF with significant aortic regurgitation and massively dilated aortic root. Aortic root replacement was mandatory. He underwent successful concomitant VSARR with TOF repair. At 6-month follow-up, he remains stable with trivial aortic regurgitation on echocardiogram. CLINICAL DISCUSSION: In unrepaired TOF, the absence of sub-annular muscular rim and the unbalance of aortic sinuses make VSARR utmost challenging. If can be done successfully, VSARR preserves the native aortic valve and avoids lifelong anticoagulation therapy. CONCLUSION: Concomitant VSARR with TOF repair can be safely and effectively applied for unrepaired patients presenting with progressive aortic root dilatation and significant aortic regurgitation.

Preliminary Experience With the Use of an Extracellular Matrix to Augment the Native Pulmonary Valve During Repair of Tetralogy of Fallot.

BACKGROUND: During repair of tetralogy of Fallot (TOF), when a transannular patch is needed in case of a small annulus and dysplastic pulmonary valve, we chose to reconstruct the right ventricular outflow tract by augmenting the divided anterior leaflet with an extracellular matrix (ECM) patch to produce a competent valve. In this study, we present our preliminary experience and early outcomes. METHODS: From March 2013 to December 2015, of the 206 patients who underwent primary repair of TOF, 52 required a transannular incision. The median age was 18 months and the median weight was 8.2 kg. The native hinge mechanism of the valve was preserved by dividing only the anterior leaflet at the time of the transannular incision and augmenting it with an ECM patch that was sutured to the endocardium and to the divided leaflet. RESULTS: Two patients died due to reasons not related to the use of the patch. Intraoperative evaluation showed a competent pulmonary valve without significant outflow gradient. During early follow-up (median 20 months), all patients were doing well without any decongestive therapy. Valve regurgitation was assessed as severe in 2, moderate in 26, and mild in 22 patients. In the majority of patients, the valve appeared thin and pliable in spite of mild to moderate regurgitation. CONCLUSIONS: Early experience with the use of ECM in repair of TOF shows satisfactory outcomes. It does not show obvious growth of the material. Long-term follow-up will be required in order to assess whether the valve function is durable without acquisition of significant regurgitation.