Pulmonary Valve Cusp Augmentation for Pulmonary Regurgitation After Repair of Valvular Pulmonary Stenosis Yu Rim Shin, MD, Han Ki Park, MD, Young Hwan Park, MD, Jo Won Jung, MD, Young Jin Kim, MD, and Hong Ju Shin, MD Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, and Division of Pediatric Cardiology, Department of Pediatrics, Congenital Heart Disease Center, Severance Cardiovascular Hospital, and Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
A 23-year-old female patient with a history of pulmonary valvectomy for pulmonary stenosis at 2 years of age underwent pulmonary valve repair, which consisted of remnant cusp extension using a fresh pericardium and commissural resuspension. An immediate postoperative computed tomographic scan showed full movement of the extended anterior cusp during systole, yet flail motion during diastole. However, follow-up magnetic resonance imaging at 10 months postoperatively revealed a small amount of pulmonary flow regurgitation (2.0%). (Ann Thorac Surg 2015;99:e57–8) Ó 2015 by The Society of Thoracic Surgeons
P
ulmonary insufficiency after surgical or interventional relief of pulmonary stenosis can lead to progressive right ventricular dilatation, arrhythmia, exercise intolerance, or even sudden death. It usually requires surgical intervention. Unlike a lot of reports of aortic valve repair, there are few reports of attempting pulmonary valve repair. However, if the well-preserved native pulmonary valve exists, pulmonary valve repair can be attempted.
Accepted for publication Dec 2, 2014. Address correspondence to Dr Hong Ju Shin, Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 120-752; e-mail: [email protected].
We present a successful pulmonary valve repair for a 23year-old patient with good result of 10 months postoperative magnetic resonance imaging, which revealed pulmonary flow regurgitation (2.0%). A 23-year-old female patient with a history of atrial and ventricular septal defect patch repair and pulmonary valvectomy for pulmonary stenosis at 2 years of age presented with syncope. She had a history of syncope three times before admission. Electrocardiography showed a sinus rhythm and right bundle-branch block with a QRS duration of 168 milliseconds. Physical examination results were not specific, except for mention of a thyroid nodule, although a normal thyroid function test was reported. Holter monitoring indicated a normal sinus rhythm. Echocardiography revealed severe pulmonary insufficiency and right ventricular dilatation with normal systolic function and a left ventricular ejection fraction of 65%. A cardiopulmonary exercise test was performed; however, useful information could not be obtained because of an incomplete procedure, with near syncope occurring. Magnetic resonance imaging showed right ventricular enlargement with a right ventricular enddiastolic volume index of 154.4 mL/m2. The right ventricular ejection fraction was 49.8%, and the pulmonary flow regurgitant fraction was 40.5% (Fig 1A). Thus, we determined that it would be necessary to perform pulmonary valve replacement. The approach of the operation was through a median sternotomy. Under routine cardiopulmonary bypass, a vertical incision was made in the main pulmonary artery. The pulmonary valve was bicuspid, with an intact posterior cusp and an anterior cusp of limited size (a third of normal size). Anterior cusp extension was performed using a fresh autologous pericardium tailored to a slightly larger size, with 6-0 continuous polypropylene suture, and commissural resuspension was subsequently performed with 5-0 polypropylene suture and a pledget. The pulmonary arteriotomy was repaired directly with 5-0 polypropylene double continuous suture. Trivial to mild pulmonary regurgitation was observed in intraoperative transesophageal echocardiography. After weaning off the cardiopulmonary bypass, the measured right ventricular Fig 1. Velocity-encoding magnetic resonance imaging showed the (A) preoperative and (B) postoperative main pulmonary artery regurgitant fraction (RF). (MPA ¼ main pulmonary artery; RR-interval ¼ interval from the peak of one QRS complex to the peak of the next.)
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.026
e58
CASE REPORT SHIN ET AL PULMONARY VALVE CUSP AUGMENTATION
Ann Thorac Surg 2015;99:e57–8
Fig 2. Computed tomographic scans show full movement of the extended anterior cusp using a fresh pericardium (black open arrow) during (A) systole, yet flail motion during (B) diastole.
systolic pressure was 35 mm Hg, and the systolic blood pressure was 90 mm Hg. Cardiopulmonary bypass time was 81 minutes. A computed tomographic scan for checking valve motion showed full movement of the extended anterior cusp during systole, yet flail motion during diastole (Fig 2). However, an echocardiogram revealed mild pulmonary regurgitation. She was discharged home 12 days postoperatively without complication. A follow-up echocardiogram 10 months later showed good motion of the augmented anterior pulmonary valve leaflet and native posterior leaflet, as well as mild pulmonary regurgitation and mild pulmonary stenosis with a mean pressure gradient of 18 mm Hg. Magnetic resonance imaging at 10 months postoperatively showed a decreased right ventricular end-diastolic volume index of 108.9 mL/m2 and pulmonary flow regurgitant fraction of 2.0% (Fig 1B).
Comment Pulmonary insufficiency after surgical or interventional relief of pulmonary stenosis can lead to progressive right ventricular dilatation, arrhythmia, exercise intolerance, or even sudden death. It may require surgical intervention, usually pulmonary valve replacement. However, pulmonary valve replacement is associated with several disadvantages, such as limited long-term durability when using homografts or xenografts, anticoagulation-related problems when using mechanical valves, and no growth potential when performed on child patients. During planned pulmonary valve replacement, a well-preserved native pulmonary valve is occasionally observed, allowing us to attempt pulmonary valve repair. Several cases of secondary repair of incompetent pulmonary valves have been reported, which are in contrast to the large amount of data for aortic valve repair [1-4]. Various techniques have been used in pulmonary valve repair, including commissural reapproximation of the
bicuspid valve [1], implantation of a neoleaflet [2], leaflet extension with pericardial patches [3], and leaflet perforation repair and commissural resuspension [4]. Mainwaring and colleagues [1] described suitable criteria for pulmonary valve repair as follows: (1) a native bicuspid pulmonary valve, (2) preservation of the native pulmonary valve leaflets at the time of the original tetralogy of Fallot repair, (3) subsequent growth of the native leaflets, with maintenance of mobility of the leaflets, and (4) minimal gradient across the pulmonary annulus. In this report, we have described a suitable condition for pulmonary valve repair. The patient had a preserved native bicuspid valve with maintenance of mobility. Thus, we underwent cusp extension and commissural resuspension according to the techniques of others [3, 4]. Although immediate computed tomographic findings showed flail motion of the extended patch because of differences in the flexibility between the native valve and patch, follow-up magnetic resonance imaging at 10 months postoperatively revealed a small amount of pulmonary flow regurgitation (2.0%). In our case, a careful long-term follow-up will be required.
References 1. Mainwaring RD, Pirolli T, Punn R, Hanley FL. Late repair of the native pulmonary valve in patients with pulmonary insufficiency after surgery for tetralogy of Fallot. Ann Thorac Surg 2012;93:677–9. 2. Park CS, Lee CH, Lee YO, Kim GB, Kim JT, Kim YJ. Pulmonary valve repair late after right ventricular outflow tract reconstruction in children and adolescents. Interact Cardiovasc Thorac Surg 2010;10:906–9. 3. Papadopoulos N, Esmaeili A, Zierer A, Bakhtiary F, Ozaslan F, Moritz A. Secondary repair of incompetent pulmonary valves. Ann Thorac Surg 2009;87:1879–84. 4. Talwar S, Sinha P, Duebener LF, Jonas R. Pulmonary valve repair: an option for an emerging problem. J Card Surg 2010;25:87–9.
A 23-year-old female patient with a history of pulmonary valvectomy for pulmonary stenosis at 2 years of age underwent pulmonary valve repair, which consisted of remnant cusp extension using a fresh pericardium and commissural resuspension. An immediate postoperative computed tomographic scan showed full movement of the extended anterior cusp during systole, yet flail motion during diastole. However, follow-up magnetic resonance imaging at 10 months postoperatively revealed a small amount of pulmonary flow regurgitation (2.0%). (Ann Thorac Surg 2015;99:e57–8) Ó 2015 by The Society of Thoracic Surgeons
P
ulmonary insufficiency after surgical or interventional relief of pulmonary stenosis can lead to progressive right ventricular dilatation, arrhythmia, exercise intolerance, or even sudden death. It usually requires surgical intervention. Unlike a lot of reports of aortic valve repair, there are few reports of attempting pulmonary valve repair. However, if the well-preserved native pulmonary valve exists, pulmonary valve repair can be attempted.
Accepted for publication Dec 2, 2014. Address correspondence to Dr Hong Ju Shin, Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea, 120-752; e-mail: [email protected].
We present a successful pulmonary valve repair for a 23year-old patient with good result of 10 months postoperative magnetic resonance imaging, which revealed pulmonary flow regurgitation (2.0%). A 23-year-old female patient with a history of atrial and ventricular septal defect patch repair and pulmonary valvectomy for pulmonary stenosis at 2 years of age presented with syncope. She had a history of syncope three times before admission. Electrocardiography showed a sinus rhythm and right bundle-branch block with a QRS duration of 168 milliseconds. Physical examination results were not specific, except for mention of a thyroid nodule, although a normal thyroid function test was reported. Holter monitoring indicated a normal sinus rhythm. Echocardiography revealed severe pulmonary insufficiency and right ventricular dilatation with normal systolic function and a left ventricular ejection fraction of 65%. A cardiopulmonary exercise test was performed; however, useful information could not be obtained because of an incomplete procedure, with near syncope occurring. Magnetic resonance imaging showed right ventricular enlargement with a right ventricular enddiastolic volume index of 154.4 mL/m2. The right ventricular ejection fraction was 49.8%, and the pulmonary flow regurgitant fraction was 40.5% (Fig 1A). Thus, we determined that it would be necessary to perform pulmonary valve replacement. The approach of the operation was through a median sternotomy. Under routine cardiopulmonary bypass, a vertical incision was made in the main pulmonary artery. The pulmonary valve was bicuspid, with an intact posterior cusp and an anterior cusp of limited size (a third of normal size). Anterior cusp extension was performed using a fresh autologous pericardium tailored to a slightly larger size, with 6-0 continuous polypropylene suture, and commissural resuspension was subsequently performed with 5-0 polypropylene suture and a pledget. The pulmonary arteriotomy was repaired directly with 5-0 polypropylene double continuous suture. Trivial to mild pulmonary regurgitation was observed in intraoperative transesophageal echocardiography. After weaning off the cardiopulmonary bypass, the measured right ventricular Fig 1. Velocity-encoding magnetic resonance imaging showed the (A) preoperative and (B) postoperative main pulmonary artery regurgitant fraction (RF). (MPA ¼ main pulmonary artery; RR-interval ¼ interval from the peak of one QRS complex to the peak of the next.)
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.026
e58
CASE REPORT SHIN ET AL PULMONARY VALVE CUSP AUGMENTATION
Ann Thorac Surg 2015;99:e57–8
Fig 2. Computed tomographic scans show full movement of the extended anterior cusp using a fresh pericardium (black open arrow) during (A) systole, yet flail motion during (B) diastole.
systolic pressure was 35 mm Hg, and the systolic blood pressure was 90 mm Hg. Cardiopulmonary bypass time was 81 minutes. A computed tomographic scan for checking valve motion showed full movement of the extended anterior cusp during systole, yet flail motion during diastole (Fig 2). However, an echocardiogram revealed mild pulmonary regurgitation. She was discharged home 12 days postoperatively without complication. A follow-up echocardiogram 10 months later showed good motion of the augmented anterior pulmonary valve leaflet and native posterior leaflet, as well as mild pulmonary regurgitation and mild pulmonary stenosis with a mean pressure gradient of 18 mm Hg. Magnetic resonance imaging at 10 months postoperatively showed a decreased right ventricular end-diastolic volume index of 108.9 mL/m2 and pulmonary flow regurgitant fraction of 2.0% (Fig 1B).
Comment Pulmonary insufficiency after surgical or interventional relief of pulmonary stenosis can lead to progressive right ventricular dilatation, arrhythmia, exercise intolerance, or even sudden death. It may require surgical intervention, usually pulmonary valve replacement. However, pulmonary valve replacement is associated with several disadvantages, such as limited long-term durability when using homografts or xenografts, anticoagulation-related problems when using mechanical valves, and no growth potential when performed on child patients. During planned pulmonary valve replacement, a well-preserved native pulmonary valve is occasionally observed, allowing us to attempt pulmonary valve repair. Several cases of secondary repair of incompetent pulmonary valves have been reported, which are in contrast to the large amount of data for aortic valve repair [1-4]. Various techniques have been used in pulmonary valve repair, including commissural reapproximation of the
bicuspid valve [1], implantation of a neoleaflet [2], leaflet extension with pericardial patches [3], and leaflet perforation repair and commissural resuspension [4]. Mainwaring and colleagues [1] described suitable criteria for pulmonary valve repair as follows: (1) a native bicuspid pulmonary valve, (2) preservation of the native pulmonary valve leaflets at the time of the original tetralogy of Fallot repair, (3) subsequent growth of the native leaflets, with maintenance of mobility of the leaflets, and (4) minimal gradient across the pulmonary annulus. In this report, we have described a suitable condition for pulmonary valve repair. The patient had a preserved native bicuspid valve with maintenance of mobility. Thus, we underwent cusp extension and commissural resuspension according to the techniques of others [3, 4]. Although immediate computed tomographic findings showed flail motion of the extended patch because of differences in the flexibility between the native valve and patch, follow-up magnetic resonance imaging at 10 months postoperatively revealed a small amount of pulmonary flow regurgitation (2.0%). In our case, a careful long-term follow-up will be required.
References 1. Mainwaring RD, Pirolli T, Punn R, Hanley FL. Late repair of the native pulmonary valve in patients with pulmonary insufficiency after surgery for tetralogy of Fallot. Ann Thorac Surg 2012;93:677–9. 2. Park CS, Lee CH, Lee YO, Kim GB, Kim JT, Kim YJ. Pulmonary valve repair late after right ventricular outflow tract reconstruction in children and adolescents. Interact Cardiovasc Thorac Surg 2010;10:906–9. 3. Papadopoulos N, Esmaeili A, Zierer A, Bakhtiary F, Ozaslan F, Moritz A. Secondary repair of incompetent pulmonary valves. Ann Thorac Surg 2009;87:1879–84. 4. Talwar S, Sinha P, Duebener LF, Jonas R. Pulmonary valve repair: an option for an emerging problem. J Card Surg 2010;25:87–9.
