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J Thorac Cardiovasc Surg 1994;107:634-0635
© 1994 Mosby, Inc.

Letters to the Editor

Severe calcification of a parietal pericardial patch used in an aortic root enlargement: Case report

Department of Cardiothoracic Surgery
University of Manchester
Manchester, United Kingdom

To the Editor:

A variety of materials have been used to enlarge the anulus of the aortic root when restrictive anatomy is found during aortic valve operations These materials include autogenous parietal pericardial patches. ¹ Pericardial patch–related complications inlow-pressure cardiac chambers are well documented. ^2-4 No complications have been reported in patches used to enlarge the aortic root. In 1983, Piehler and associates ¹ analyzed the long-term follow-up (mean follow-up of 5.4 years) of 96 patients who had autogenous pericardial patches inserted during aortic valve replacement at the Mayo Clinic. There was no clinically significant calcification in any of the patches and aneurysms were universally absent.

This patient had an aortic valve replacement for congenital aortic stenosis at the age of 13 years in South Africa. This patient had a 3-week history of dizziness during periods of exertion and a single incident of loss of consciousness 9 years after the aortic valve replacement. He had had a mild paravalvular leak for the previous 2 years. Chest roentgenograms showed marked calcification of the ascending aorta (Fig. 1), which was clearly visible on the angiogram (Fig. 2). The angiogram showed normal function of the aortic valve with a transvalvular gradient of 35 mm Hg, mild paravalvular leak, and a dilated ascending aorta starting at the noncoronary cusp area.

View larger version (157K): [in this window] [in a new window]   Fig. 1. Chest roentgenogram shows marked calcification of ascending aorta.

View larger version (171K): [in this window] [in a new window]   Fig. 2. Angiogram shows normal function of the aortic valve with calcification.

The aortotomy was closed with 4-0 Prolene sutures with the Teflon strip on the inside and the outside of the thin remnant of the pericardial patch with satisfactory hemostasis. After the heart was de-aired, the crossclamp was released and the patient was weaned from bypass. The patient made an uneventful recovery and was discharged on the eighth postoperative day.

We have found no reported cases similar to this case. Ross and associates ² have reported massive calcification of a right ventricular outflow pericardial patch in the tetralogy of Fallot. They related the calcification to the residual outflow gradient. The rate of occurrence of aneurysm of pericardial patches used for enlargement of the right ventricular outflow tract ranges between 6% and 25%, ³ and this seems to be related to the size of the patch. Kawashima and associates ⁴ demonstrated that high-pressure gradient does promote the formation of an aneurysm of the parietal pericardial patch used to close ventricular septal defects in tetralogy of Fallot. In our case, it seemed that the pressure gradient across the valve (35 mm Hg) must have been present for the last 2 or 3 years because the patient had outgrown the size of the valve that was implanted when he was 13 years of age. This gradient was measured when the patient was at rest with a transseptal catheter and would obviously increase significantly during exertion, which would explain the symptoms of the patient. Also, the size of the patch used in this case was larger than the average size of patches used by Piehler and associates (the largest patch width they used was 3 cm). It seems possible that the transvalvular gradient and the large patch in this patient contributed to the massive calcification.

This case demonstrates that patients who have had aortic root enlargement with a pericardial patch are at significant risk for marked calcification, particularly if they had a large patch in the presence of a transvalvular gradient. The potential technical difficulties associated with reoperation in these cases should be noted.

References

1. Piehler JM, Danielson GK, Pluth JR, et al. Enlargement of the aortic root or anulus with autogenous pericardial patch during aortic valve replacement. J THORAC CARDIOVASC SURG 1983;86:350-8.[Abstract]
   
2. Ross EM, McIntosh CL, Roberts WC. "Massive" calcification of a right ventricular outflow tract parietal pericardial patch in tetralogy of Fallot. Am J Cardiol 1984;54:691-2.[Medline]
   
3. Seybold-Epting W, Chiariello L, Hallman GL, Cooley DA. Aneurysm of pericardial right ventricular outflow tract patches. Ann Thorac Surg 1977;24:237-40.[Abstract/Free Full Text]
   
4. Kawashima Y, Nakano S, Kato M, et al. Fate of pericardium utilized for the closure of ventricular septal defect. J THORAC CARDIOVASC SURG 1974;68:209-18.[Medline]
   

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