PubMed · 7614262
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M McCormick. 1995. Facing disfigurement.. https://pubmed.ncbi.nlm.nih.gov/7614262/
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Patent foramen ovale has been noted after cardiac transplantation. Rarely is surgical intervention warranted. In this communication we report a case of severe tricuspid regurgitation and paradoxical embolism secondary to a patent foramen ovale in a patient 19 months after heart transplantation. The patient underwent successful closure of the patent foramen ovale and tricuspid valve replacement.
BACKGROUND: Right ventricle-to-pulmonary artery (RV-PA) homografts and bioprosthetic conduits are commonly used to palliate various types of complex congenital heart disease. These conduits frequently develop progressive obstruction and require surgical replacement. This report reviews our experience implanting balloon-expandable stents to relieve conduit obstruction and delay reoperation. METHODS AND RESULTS: A retrospective review identified 44 patients who underwent placement of 48 stents in obstructed RV-PA conduits. Median patient age was 6.9 years (range, 7 months to 30 years), and median follow-up time was 14.2 months (range, 0 to 48 months). Stent implantation initially decreased the RV-PA pressure gradient from 61.0 +/- 16.9 to 29.7 +/- 11.9 mm Hg (P < or = .001) and the right ventricular-to-systemic arterial pressure ratio from 0.92 +/- 0.17 to 0.63 +/- 0.20 (P < or = .001). The diameter of the stenotic region expanded from 9.3 +/- 3.5 to 12.3 +/- 3.3 mm in the anteroposterior view (P < or = .001) and from 6.6 +/- 2.9 to 10.9 +/- 2.5 mm in the lateral view (P < or = .001). During the follow-up period, 2 patients had their stents redilated, 7 had additional conduit stents deployed, and 14 underwent surgical replacement of their conduits. Actuarial freedom from conduit reoperation was 65% at 30 months postprocedure. Seven patients were found to have fractured stents on follow-up, suggesting an important role for external compressive forces in conduit failure. Recatheterization in 16 patients a median of 11.8 months (3 to 48 months) postprocedure demonstrated hemodynamic evidence of recurrent obstruction despite sustained enlargement at the previously stented sites. Complications included stent displacement (n = 1), bacterial endocarditis (n = 1), and false aneurysm formation (n = 1). One patient died awaiting conduit replacement surgery. CONCLUSIONS: Stent implantation in obstructed RV-PA conduits results in significant immediate hemodynamic and angiographic improvement. In a subgroup of patients, the procedure prolongs conduit life span by several years and increases the interval between conduit reoperations. Recurrent obstruction is caused by external compression and progressive stenosis outside the stented region.
The ideal artificial heart valve still does not exist among the various cardiac valves available to the clinician. Morbidity and mortality are directly related to the valve itself. Despite the promising hemodynamic results obtained in the 70s with pericardial prosthesis, these valves were progressively abandoned due to their poor long-term resistance. Based on an analysis of the causes of failures, modifications were made in the manufacturing method and current results with pericardial valves has greatly improved, inciting new interest in their clinical use. Today, the pericardium is recognized as a valid substitution material for bioprostheses. Results of long-term series should confirm current studies. Research is under way to determine how to improve pericardium longevity since tissue deterioration remains the limiting factor.