Clinical summary

A 15-year-old male with a history of tetralogy of Fallot repair in infancy using a transannular patch and a bicuspid autologous pericardial pulmonary valve presented at age 14 with exertional dyspnoea (NYHA class II). Echocardiography revealed severe pulmonary stenosis with a peak gradient of 90 mmHg (due to calcified and fixed pericardial leaflets), with preserved right ventricular function. The patient was advised of surgical intervention but was lost to follow-up for 6 months. His symptoms had progressed to NYHA class III with echocardiography revealing severe pulmonary stenosis (peak/ mean gradient 102 mm Hg/ 51 mmHg), paradoxical septum with right ventricular dysfunction (Figure 1(a)). Based on the above findings, it was decided to proceed with pulmonary valve replacement. A preoperative bubble contrast echocardiogram was performed to rule out the presence of a patent foramen ovale or residual shunt while doing the valsalva manoeuvre (Figure 1(b), Video 1). Cardiac CT was obtained to better delineate the anatomy and to assist in planning the surgical approach. The pulmonary annulus and main pulmonary artery were found to be approximately just 5-6 cm from the left mid-axillary line at the 3^rd intercostal space (Figure 1 (c), (d)).

Figure 1.

(a) Preoperative echocardiogram showing hugely dilated and dysfunctional RV. (b) Intraoperative TEE (Upper oesophageal aortic arch short axis view) showing max pressure gradient across pulmonary valve = 102 mmHg. (c) Coronal view of CT angiogram showing calcified pulmonary leaflets and previous TAP and distance from axilla. (d) Axial view of CT angiogram showing distance of pulmonary valve from axilla.

Surgical procedure

Under general anaesthesia, the patient was positioned supine with a small pad under the left shoulder to bring the left third space into prominence. The left arm was elevated and supported with adequate padding above the head, further increasing the spacing between the ribs. A vertical left axillary incision was made just behind the anterior axillary line. Following muscle plane separation, the chest cavity was entered through the 3^rd intercostal space. The femoral vessels were cannulated with a 19 Biomedicus arterial cannula (Medtronic, USA) and a 24F Edwards multistage VFEM femoral venous cannula (Edwards Lifesciences, USA) using the Seldinger technique. Vacuum-assisted venous drainage was employed (−20 mm Hg) to optimise drainage.

Under mild hypothermia and with an empty beating heart, ventilation was ceased, and the left lung was retracted posteriorly. A vertical incision was made on previous transannular patch, and its calcified edges, along with the pericardial leaflets, were excised. The pulmonary annulus was sized, and a Tilting disc mechanical valve (23 TTK Chitra Aortic heart valve) (TTK Healthcare, India) was sutured at the level of the pulmonary annulus using a continuous 3/0 polypropylene suture (Figure 2(a)). After discussing the pros and cons of mechanical and bioprosthetic valves, the patient chose a mechanical valve due to financial constraints and to reduce the likelihood of future reinterventions. An appropriately sized acellular bovine pericardial patch (SYNKROSCAFF; SynkroMax Biotech Pvt. Ltd., Chennai, TN, India) was used to augment the main pulmonary artery. This patch was sewn in place using running 5/0 Prolene suture up to the level of the proposed position of the pulmonary prosthesis. The anterior portion of the prosthesis sewing ring was then anchored to the undersurface of the pericardial patch with slight anterior tilt using the same 3-0 Prolene continuous suture. The remaining portion of the patch was sutured to the right ventricular outflow tract (Figure 2(b)). After rewarming, the patient was weaned off Cardiopulmonary bypass (CPB) uneventfully. Intraoperative Trans-esophageal echocardiography (TEE) showed a normal prosthetic heart valve with no paravalvular leak, a mean gradient of 10 mm Hg, mild tricuspid regurgitation (TR) and mild right ventricular (RV) dysfunction. (Figure 2(c), Video 2). Postoperative recovery was uneventful (Figure 2(d)).

Figure 2.

(a) Surgical view showing implantation of mechanical valve. (b) Transaxillary view showing pericardial augmentation of main pulmonary artery (MPA), post valve implantation. (c) Intraoperative TEE (Upper oesophageal aortic arch short axis view) post PVR showing max pressure gradient across pulmonary valve = 23 mmHg. (d) Skin incision post procedure.