Extensive Repair of an Injured Bicuspid Pulmonary Valve Following Balloon Dilatation By Using Autologous Pericardium and Repair of a Flail Tricuspid Valve

A 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.

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