Extensive Repair of an Injured Bicuspid Pulmonary Valve Following Balloon Dilatation By Using Autologous Pericardium And Repair of a Flail Tricuspid Valve
13 years-old, 70 kg male patient was admitted to Siyami Ersek Thoracic and
Cardiovascular Surgery Training and Research Hospital pediatric cardiac surgery
clinic with fatigue and dyspnea on exertion. He had a history of balloon
dilatation of the pulmonary valve when he was 3 years old. Preoperative
echocardiography revealed a flail tricuspid anterior leaflet with severe
regurgitation, moderate to severe pulmonary valve regurgitation, and a dilated
right ventricle. QT interval was 110 msec. The right ventricular end-diastolic
volume index was 163 ml/m2. Pulmonary valve replacement/repair and tricuspid
valve repair were planned due to his symptoms and preoperative measurements.(1)
The mediastinum was approached through a midsternal incision. The pericardium
was harvested and treated with glutaraldehyde 2% solution for 3 minutes and
rinsed with saline 3 times for 5 minutes each. Aortic and bicaval cannulation
was done. The patient was put on bypass and cooled-down to 28° Celcius. The
heart was arrested with 20-mL/kg Del Nido cardioplegia.(2) Right atriotomy was
done. The tricuspid valve was explored. The anterior leaflet’s chordea was
elongated, and the leaflet looked floating after the saline test. The height of
the anterior leaflet was adjusted by using a 4/0 PTFE stitch. After the saline
flush test, minor leaks were seen in the coaptation zone, between the anterior
and septal leaflets. The leakage in the septal leaflet was repaired with a
single prolene stitch. The anterior and septal leaflets were approximated with
a 5/0 prolene stitch. A suture annuloplasty was applied between the posterior
and septal leaflets annulus. The tricuspid valve look ed competent after the
saline flush test.
Pulmonary arteriotomy was done longitudinally. The traction sutures were placed
on both sides of the arteriotomy. The pulmonary valve was bicuspid in the 6-12
o’clock direction and there was a raphe in the medial leaflet. Both of the
leaflets looked injured, possibly due to previous balloon dilatation and there
was a significant tissue deficiency in the leaflet with the raphe. The decision
was made to repair the valve instead of replacement. A commissuroplasty stitch
was placed in the inferior commissure. After placing a traction suture to the
tips of the free edges of the torn lateral leaflet, it was repaired with a
running 6/0 prolene stitch. The raphe and the adhesions on the leaflet were
freed. Despite this maneuver, significant leaflet deficiency in this leaflet
remained. The height and width of the defienct part were measured by using silk
suture. An appropriate size autologous pericardial patch was prepared by using
the silk suture. The leaflet was augmented with the pericardial patch by using
a running 6/0 prolene stitch. A single 6/0 prolene suture was placed on the
inferior end of the patch for reinforcement. The augmented part was close to
one of the commissures. This commissure was reinforced with a 6/0 prolene
stitch. Following valve repair, it was bicuspid and looked functional. After
the cross-clamp removal, the patient was weaned from bypass. Transesophageal
echocardiography showed a well-functioning tricuspid valve with trace
regurgitation, and a well functioning pulmonary valve with trace regurgitation,
with no stenosis.
The patient was extubated 6 hours after the surgery and transferred to the
floor on postoperative day 1. He had an uneventful recovery on the floor and
was discharged from the hospital on postoperative day 6. On the 6th month of
his hospital discharge, transthoracic echocardiography revealed a trace-to-mild
tricuspid valve regurgitation, a trace pulmonary valve regurgitation, and a
peak stenosis gradient of 20 mm Hg. He has been on aspirin since the day of
surgery.
In future, we would like to compare the outcomes of bioprosthetic pulmonary
valve replacement (3) patients with the pulmonary valve repair patients’.
References
1) Geva T. Indications for pulmonary valve replacement in repaired tetralogy of fallot: the quest continues. Circulation. 2013 Oct 22;128(17):1855-7.2) Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston Children's Hospital. J Extra Corpor Technol. 2012 Sep;44(3):98-103. Erratum in: J Extra Corpor Technol. 2013 Dec;45(4):262.
3) Nomoto R, Sleeper LA, Borisuk MJ, Bergerson L, Pigula FA, Emani S, Fynn-Thompson F, Mayer JE, Del Nido PJ, Baird CW. Outcome and performance of bioprosthetic pulmonary valve replacement in patients with congenital heart disease. J Thorac Cardiovasc Surg. 2016 Nov;152(5):1333-1342
