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Ann Thorac Surg 2004;78:1467-1468
© 2004 The Society of Thoracic Surgeons

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Case report

Replacement of a Regurgitant Pulmonary Valve with a Stentless Bioprosthesis

^a Department of Cardiothoracic Surgery, Papworth Hospital, Papworth, Everard, United Kingdom

Accepted for publication July 10, 2003.

^* Address reprint requests to Dr Ali, 10 Sandringham Dr, Stockport, Cheshire SK4 2DD, UK
ayyaz75{at}hotmail.com

	Abstract

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Acquired surgical disease of the pulmonary valve is rare. We report a 72-year-old man who presented with subacute endocarditic pulmonary regurgitation. This lesion was surgically corrected with a stentless bioprosthesis. Previously, homografts and various xenografts have been used for replacement of the pulmonary valve both in the pediatric population and in adult patients with congenital heart disease. Pulmonary regurgitation is a rare lesion, but if it is encountered our case demonstrates that it can be successfully and easily treated with pulmonary valve replacement by using a stentless bioprosthesis.

	Introduction

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Acquired surgical disease of the pulmonary valve is rare. Replacement of the pulmonary valve with homografts and a variety of xenografts has been described [1–3]. We report a case of subacute endocarditic pulmonary regurgitation that was surgically corrected with a stentless bioprosthesis.

A 72-year-old man presented with a short history of exertional dyspnea, orthopnea, and an obvious deterioration in his exercise tolerance, with a New York Heart Association functional class of II. Six years previously, the patient had experienced an episode of streptococcal endocarditis after a dental procedure; this episode was treated with intravenous antibiotics. On examination, he was in sinus rhythm, the jugular venous pressure was increased, and there was a dominant V wave. Auscultation of the precordium revealed an early diastolic murmur and a split second heart sound. A transthoracic echocardiogram displayed severe pulmonary regurgitation with marked dilatation of the ventriculoarterial junction, which was measured to be 35 mm in diameter. The right ventricle was dilated and markedly impaired, whereas left ventricular function was preserved. Right- and left-sided cardiac catheterization was also performed, and this confirmed severe pulmonary regurgitation associated with substantial right ventricular dysfunction. Coronary angiography incidentally revealed moderate stenosis of the left anterior descending artery and a diseased right coronary artery. In view of the deteriorating right ventricular function associated with symptomatic deterioration, a decision was made to undertake combined pulmonary valve replacement and coronary artery bypass grafting.

At operation, access was established via median sternotomy. The left internal mammary artery and the left long saphenous vein were harvested concomitantly. On inspection, the right ventricle and pulmonary artery were markedly enlarged. In keeping with the severity of the regurgitation, the pulmonary artery collapsed dramatically during diastole. Cardiopulmonary bypass was established, and the main pulmonary artery was partially transected above the sinuses to visualize the pulmonary valve leaflets and the infundibulum. There was very little functional leaflet tissue; this accounted for the torrential pulmonary regurgitation. The infundibulum and what may be regarded as the functional annulus of the pulmonary valve were profoundly dilated. After inspection of the pulmonary valve and the right ventricular outflow tract, attention was diverted to the revascularization procedure. On completion of coronary artery bypass grafting, focus was returned to the pulmonary valve. In view of the markedly dilated ventriculoarterial junction, a 29-mm Prima Plus stentless porcine aortic root (the largest prosthesis available) was selected. The valve sinuses were scalloped to remove the left and right coronary arteries, and the noncoronary sinus was left intact. The noncoronary sinus was oriented to lie alongside the posterior wall of the pulmonary artery because this improved visualization of the upstream suture line and ensured correct geometric spacing for 2 of the 3 commissures. The downstream suture line was constructed with continuous 4-0 Prolene (Ethicon, Summerville, NJ) and incorporated the residual leaflet tissue of the native pulmonary valve to buttress the bioprosthesis's fixation in the right ventricular outflow tract. The upstream suture line was also constructed with 4-0 Prolene, and this was followed by closure of the pulmonary arteriotomy. Cardiopulmonary bypass was discontinued uneventfully. The right ventricle was seen to function well on transesophageal echocardiography with smaller chamber dimensions and retained contractility. In addition the pulmonary artery was no longer seen to collapse.

After the operation, the patient's recovery was unremarkable apart from an episode of atrial fibrillation, which was treated with amiodarone. A transthoracic echocardiogram was obtained and demonstrated a normally functioning bioprosthesis in the pulmonary position, with no regurgitation. The distensibility of the right ventricular outflow tract and pulmonary annulus was preserved by the stentless design of the prosthesis, and the transvalvular mean gradient was 7 mm Hg. The patient was discharged home on postoperative day 6 in sinus rhythm with good mobility and an exercise tolerance compatible with New York Heart Association functional class I.

	Comment

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Pulmonary valve replacement is an uncommon operation that is performed primarily in patients with corrected tetralogy of Fallot and residual pulmonary regurgitation [4]. Long-standing pulmonary regurgitation produces right ventricular dilatation and has been associated with an increased incidence of sudden cardiac death [5]. Previously, both homografts and various xenografts have been used for replacement of the pulmonary valve both in the pediatric population and in adult patients with congenital heart disease [1, 4, 5]. We implanted a stentless bioprosthesis to correct chronic pulmonary regurgitation associated with marked dilatation of the right ventricular outflow tract. Echocardiographically the ventriculoarterial junction was 35 mm. We found that a 29-mm Prima Plus stentless porcine aortic root prosthesis was a compatible size and was easy to implant. A pulmonary homograft of adequate size in a patient with pulmonary regurgitation and dilatation of the pulmonary annulus would be a greater challenge to obtain. Stented bioprostheses have an inferior effective orifice area, and in patients with a dilated valve annulus (such as that found in pulmonary regurgitation) the implantation of a stentless prosthesis is not technically daunting. Pulmonary regurgitation is a rare lesion, but if it is encountered our case demonstrates that it can be successfully and easily treated with pulmonary valve replacement by using a stentless bioprosthesis.

	References

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1. Dittrich S, Alexi-Meskishvili VV, Yankah AC, et al. Comparison of porcine xenografts and homografts for pulmonary valve replacement in children. Ann Thorac Surg. 2000;70:717–722[Abstract/Free Full Text]
2. Emery RW, Landes RG, Moller JH, Nicoloff DM. Pulmonary valve replacement with a porcine aortic heterograft. Ann Thorac Surg. 1979;27:148–153[Abstract]
3. Tolan M, Clarke S, Schofield P, Wells FC. Homograft replacement of the fungal endocarditic pulmonary valve. Eur J Cardiothorac Surg. 1995;9:528–530[Abstract]
4. Misbach GA, Turley K, Ebert PA. Pulmonary valve replacement for regurgitation after repair of tetralogy of Fallot. Ann Thorac Surg. 1983;36:684–691[Abstract]
5. Therrien J, Siu SC, Mclaughlin PR, Liu PP, Williams WG, Webb GD. Pulmonary valve replacement in adults late after repair of tetralogy of fallot: are we operating too late? J Am Coll Cardiol. 2000;36:1670–1675[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ayyaz A. Ali Amir-Reza Hosseinpour Sanjay Kumar John Wallwork Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ali, A. A. Articles by Wallwork, J. Search for Related Content PubMed PubMed Citation Articles by Ali, A. A. Articles by Wallwork, J. Related Collections Valve disease