PMC10213930_01
Transthoracic echocardiogram (TTE) pre-operation revealing the presence of severe pulmonary stenosis with the contracture of the pulmonary annulus and valves but with no sign of RVOT stenosis (A), RA enlargement, severe tricuspid regurgitation (B, arrow) and pulmonary regurgitation (C). Transesophageal echocardiography (TEE) immediately before surgery revealing severe pulmonary valvular insufficiency in the cardiac end diastolic period and end systolic period (D, arrow). LA, left atrium; PA, pulmonary artery; RA, right atrium; RPA, right pulmonary artery; RV, right ventricle; RVOT, right ventricular outflow tract; TV, tricuspid valve.
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F1
Transthoracic echocardiogram (TTE) examination revealed the following measurements: left atrium 20 mm, right atrium 56 mm, LV cavity 53 ml (end-diastolic diameter) and 19 ml (end-systolic diameter), aorta 29 mm, pulmonary trunk from 13 to 27 mm with left and right pulmonary artery both 11 mm in diameter (Figure 1A). The pulmonary annulus (4 mm) and leaflets showed severe contraction and stenosis, the Vmax with peak and mean gradient were 3.4 m/s and 45 mmHg, respectively (Figure 1A). Severe tricuspid regurgitation (Figure 1B) and pulmonary regurgitation were also detected (Figure 1C, See Supplementary Video S1). Transesophageal echocardiography (TEE) confirmed the diagnosis (Figure 1D) and showed a short and thick solid ring bulge at the site of the pulmonary annulus (Figure 1D, arrow).
Intraoperative view showing a small pulmonary annulus (A), rheumatic tricuspid stenosis with regurgitation (B) and pulmonary regurgitation with valvular contracture (C). A bileaflet bovine pericardial patch was then tailored (D) and used for reconstruction of the pulmonary trunk with the leaflets at the same high level (E, arrow). The diameter of the reconstructed pulmonary was 20 mm (F). The operation was completed (G). BBP, bovine pericardial patch; PA, pulmonary artery; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; TV, tricuspid valve.
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F2
An open-heart operation was performed through a median sternotomy (Figure 2A), and cardiopulmonary bypass was established via routine aortic, superior and inferior vena cava cannulation under mild hypothermia of 30 C. The tricuspid valve and pulmonary annulus were approached through the right atrium (Figure 2B) and a right ventricular outflow tract (RVOT) incision (Figure 2C), respectively. Ozaki's technique. Once the reconstructed pulmonary trunk had been enlarged (Figure 2F), the technique was completed (Figure 2G).
Histopathology of the tricuspid valve showed fibrous tissue hyperplasia with hyalinosis (A), mucoid degeneration (B) and the infiltrated lymphocytes (C). H&E staining, x10 for panel A and x40 for panel B,C.
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F3
Intraoperative histopathologic examination of the excised specimen revealed fibrous tissue hyperplasia with hyalinosis (Figure 3A), mucoid degeneration (Figure 3B) and a few lymph cells infiltrated without valve calcification, which confirmed the diagnosis of rheumatic valvular heart disease (Figure 3).
Transthoracic echocardiogram (TTE) at discharge (8 days post-surgery) indicated that the leaflets functioned well in both the cardiac phase of end systolic (A) and diastolic (B), with only mild regurgitation (C,D).
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F4
The TTEs performed at discharge detected good functioning of the bioprosthetic valve and the reconstructed pulmonary valves with only mild pulmonary regurgitation (Figure 4).