JTCS Email Content Delivery
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ratna A. Magotra
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Shahani, R.
Right arrow Articles by Magotra, R. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Shahani, R.
Right arrow Articles by Magotra, R. A.

J Thorac Cardiovasc Surg 1996;112:555-556
© 1996 Mosby, Inc.

BRIEF COMMUNICATIONS

LATE FOLLOW-UP OF TRICUSPID VALVE REPLACEMENT FOR UNGUARDED TRICUSPID ANULUS

Rohit Shahani, MCh, Ratna A. Magotra, MS


Bombay, India

From the Department of Cardiovascular and Thoracic Surgery, K.E.M. Hospital and Seth G. S. Medical College, Parel, Bombay, India.

Received for publication Nov. 29, 1995 Accepted for publication Jan. 23, 1996. Address for reprints: Ratna A. Magotra, MD, Professor and Head, Department of Cardiovascular and Thoracic Surgery, K.E.M. Hospital, Parel, Bombay 400 012, India.

In 1987, a 7-year-old girl was successfully operated on for dysplasia of the tricuspid valve with severe tricuspid regurgitation. This was the first reported case in which a prosthetic valve had been inserted for a congenitally dysplastic tricuspid valve other than in Ebstein's anomaly.Go 1 We herein report the follow-up of this case.

The patient's preoperative clinical state was New York Heart Association class IV. She underwent tricuspid valve replacement for severe tricuspid regurgitation with a 31 mm bileaflet mechanical CarboMedics heart valve prosthesis (CarboMedics, Inc., Austin, Tex.). The prosthesis was implanted at the site of the native tricuspid valve with interrupted mattress sutures. As visualized on the operating table, she had gross dilatation of the tricuspid anulus without any downward displacement and virtual absence of leaflet tissue.

One year later she had evidence of right-sided heart failure after omission of warfarin therapy. A diagnosis of a thrombosed prosthesis was established and complete surgical thrombectomy of the valve was performed. During the operation both leaflets of the valve were found to be covered with thrombus and to be fixed in the semiopen position. After the operation, valve function returned to normal and the patient's condition improved. She was discharged on a regimen of warfarin therapy with a prothrombin time maintained at 11/2 times control.

Thereafter the patient remained free of symptoms for 2 years. Then, during a routine follow-up examination, rethrombosis of the prosthesis was diagnosed. She had an elevated jugular venous pressure, a tender, enlarged (4 cm) liver, and no prosthetic valve sounds. She had a long, grade 3/6 middiastolic murmur and a grade 2/6 pansystolic murmur in the tricuspid area. The patient was free of symptoms but admitted to having discontinued warfarin therapy for 2 months.

A two-dimensional echocardiogram revealed that the leaflets of the prosthetic valve were immobile and almost fully closed. Peak and mean diastolic gradients across the valve were 13 and 9 mm Hg, respectively. There was mild (grade 1/3) tricuspid regurgitation with a valve area of 0.3 cm2 (according to pressure half time). A diagnosis of chronically thrombosed prosthesis was made.



View larger version (86K):
[in this window]
[in a new window]
  		Fig. 1. Echocardiographic picture of the CarboMedics heart valve prosthesis implanted in the tricuspid position, shown in the apical four-chamber view. RV, Right ventricle; RA, right atrium; LV, left ventricle.

 


View larger version (90K):
[in this window]
[in a new window]
  		Fig. 2. Echocardiographic picture of the CarboMedics heart valve prosthesis implanted in the tricuspid position, shown in the apical four-chamber view. Two nonturbulent jets can be seen across the tricuspid valve disc prosthesis. RV, Right ventricle; RA, right atrium.

 
The patient was successfully treated with intravenous streptokinase (10,000 U/kg followed by 1000 U/kg per hour for 72 hours).Go 2 Recovery was spectacular, beginning just 12 hours after initiation of therapy. At discharge the prosthesis was functioning normally on clinical, phonocardiographic, echocardiographic, and fluoroscopic evaluation.

The girl is now 14 years old. October 27, 1995, marks 8 years since the valve replacement operation. She is in New York Heart Association class I and has mild cardiomegaly. A recent two-dimensional echocardiogram showed the prosthetic leaflets opening fully. Doppler evaluation revealed no tricuspid regurgitation, a peak gradient of 4 mm Hg, a mean gradient of 2 mm Hg across the prosthetic valve, and a valve area of 1.6 cm2 by pressure half time. M-mode echocardiograms showed evidence of mild pulmonary hypertension. On cinefluoroscopic examination the prosthetic valve leaflets opened fully. The prothrombin time is maintained at 11/2 times control with warfarin therapy.

This case is of interest because of the type of disease for which the valve replacement was warranted. Also, long-term follow-up with a mechanical prosthesis in the tricuspid position in the pediatric age group is rare, especially for a congenitally dysplastic tricuspid valve (unguarded tricuspid orifice)Go 3 other than in Ebstein's anomaly.

References

  1. Magotra RA, Agrawal NB, Mall SP, Parikh SJ. Severe dysplasia of the tricuspid valve (unguarded tricuspid anulus): clinical presentation and surgical treatment. J THORAC CARDIOVASC SURG 1990;99:174-5.[Medline]
  2. Mehan VK, Dalvi BV, Kale PA. Thrombosed prosthetic valve in tricuspid position: successful therapy with intravenous streptokinase. Chest 1992;102:1599-600.[Abstract/Free Full Text]
  3. Kanjuh VI, Stevenson JE, Amplatez K. Congenitally unguarded tricuspid orifice with coexistent pulmonary atresia. Circulation 1964;30:911-7.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Eur. J. Cardiothorac. Surg.Home page
M. Hirota, M. Kawada, K. Ishino, and S. Sano
Staged Fontan's operation for unguarded tricuspid orifice with pulmonary atresia
Eur. J. Cardiothorac. Surg., November 1, 2008; 34(5): 1111 - 1112.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Ratna A. Magotra
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Shahani, R.
Right arrow Articles by Magotra, R. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Shahani, R.
Right arrow Articles by Magotra, R. A.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS