Right RVOT Reconstruction in Very Challenging Operation with Pulmonary Homograf

In patients with a history of truncus arteriosus repair who now require redo RVOT reconstruction after degeneration of a pulmonary homograft, a “four-do” operative strategy provides a systematic approach to safe re-entry and effective reconstruction. The procedure begins with redo sternotomy under meticulous dissection to free the heart and great vessels from dense adhesions while protecting the homograft and ascending aorta. After establishing redo cardiopulmonary bypass, usually via aortic and bicaval or femoral cannulation depending on the adhesions, the surgeon performs redo excision of the calcified or stenotic pulmonary homograft, including removal of obstructive patches or conduit remnants while preserving the native branch pulmonary arteries. The operation is completed with redo RVOT reconstruction, typically using a valved conduit or large bioprosthetic pulmonary homograft tailored to the patient’s anatomy, ensuring unobstructed forward flow and a tension-free anastomosis to both the RV outflow and distal PA bifurcation. This standardized “four-do” sequence - redo sternotomy, redo bypass, redo excision, and redo reconstruction - helps optimize safety, maintain right ventricular function, and achieve durable repair in complex reoperative truncus patients.