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Tex Heart Inst J. 2011; 38(1): 68–70.
PMCID: PMC3060751

Pulmonary Valve Leaflet Extension with Bovine Pericardium

for Treatment of Pulmonary Insufficiency

Abstract

Using a homograft in a pulmonic area is sometimes inadvisable due to the lack of optimal graft materials. We report a case of pulmonary valve insufficiency that we treated by leaflet extension using the commercially available E-Leafcon template and bovine pericardium. We suggest that this method can be an acceptable alternative for treating pulmonary valve insufficiency because the pulmonary valve area is similar to that of the aortic valve (for which application the template was designed). Further, the durability of bovine pericardium is comparable to that of a homograft or a xenograft.

Key words: Bovine pericardium, heart defects, congenital/surgery, pulmonary valve insufficiency/surgery, reoperation/methods, surgical procedures, reconstructive, tetralogy of Fallot, ventricular dysfunction, right

Pulmonary valve insufficiency is mostly related to the correction of the tetralogy of Fallot.1 Pulmonary valve insufficiency can cause right ventricular (RV) dysfunction and arrhythmia; eventually, the dilated RV compresses the left ventricle.1,2 Most surgeons use a homograft or xenograft to treat pulmonary insufficiency, and they sometimes use a mechanical prosthesis.1 However, in some regions of the world, it is not easy to obtain a homograft or xenograft. On the basis of a report on aortic valvuloplasty by Hahm and colleagues,3 we used the leaflet extension method to treat a patient with pulmonary insufficiency.

Case Report

A 25-year-old woman presented at our hospital with easily induced fatigue and dyspnea on exertion. About 20 years before, at another hospital, the patient had undergone pulmonary valvotomy, infundibulectomy, and closure of a patent foramen ovale due to pulmonary stenosis. At the present examination, auscultation revealed a regurgitant murmur. Transthoracic echocardiography revealed severe pulmonary insufficiency that was due to prolapse and incomplete coaptation of the right posterior and left posterior cusps of the pulmonary valve (Fig. 1A). The other echocardiographic findings were as follows: a left ventricular (LV) ejection fraction of 0.51, a D-shaped LV, normal-sized left chambers, enlarged right chambers, a dilated main pulmonary artery (33 mm), and an RV pressure of 24 mmHg.

figure 15FF1
Fig. 1 A ) Preoperative transthoracic color-flow Doppler echocardiography shows severe pulmonary valve insufficiency. B ) Trivial pulmonary regurgitant flow was observed upon ...

Reoperation was performed through another sternotomy, with the patient under mild hypothermic cardiopulmonary bypass by means of ascending aortic and bicaval cannulation. Cold Custodiol® solution (PHARMAPAL Overseas Ltd.; Athens, Greece) was infused at the ascending aorta. After pulmonary arteriotomy, we saw normal but small leaflets and poor commissural coaptation between the anterior cusp and left cusp. Because of the near-normal morphology of the cusps, we decided to repair them. All the leaflets were extended by using the 28-mm E-Leafcon® (ScienCity; Seoul, ROK) template (Fig. 2) to tailor the bovine pericardium. Felt-pledgeted sutures were then applied to each commissure to enhance coaptation and to anchor the commissure (Fig. 3).

figure 15FF3
Fig. 3 The pulmonary valve cusps were extended by using bovine pericardium, applied with continuous sutures of Prolene 5-0.
figure 15FF2
Fig. 2 The E-Leafcon® template, designed for the extension of aortic valve leaflets. We used it as a template for pulmonary valve extension.

There was no regurgitation after all these procedures. Pulmonary insufficiency was not detected upon intraoperative transesophageal echocardiography. Transthoracic echocardiography showed the decreased size of the right chambers and of the main pulmonary artery, and it showed improved LV systolic function. Trivial pulmonary regurgitant flow was observed during the 6th postoperative month (Fig. 1B). One year after surgery, the patient was doing well.

Discussion

Pulmonary insufficiency commonly arises from reconstruction of the RV outflow tract, especially in patients who have undergone correction of tetralogy of Fallot.1,4 The condition is well tolerated for quite a long time, but RV function progressively deteriorates. Irreversible RV dysfunction and arrhythmia can result.1,2,4 Eventually, the dysfunctional, dilated RV compresses the LV, causing LV dysfunction.2,4 Frigiola and colleagues4 have suggested surgical intervention should a patient present with significant pulmonary insufficiency (regurgitant fraction, ≥35%), evidence of progressive RV dysfunction (RV/LV end-diastolic ratio, ≥1.5 in symptomatic patients and ≥2 in asymptomatic patients), or a reduced exercise capacity.

When correcting pulmonary insufficiency, most surgeons use a homograft or xenograft1,2,4; however, they sometimes use a mechanical prosthesis or a self-expanding stented valve.1,4,5 Even the American College of Cardiology and the American Heart Association do not suggest guidelines for this procedure.1 Apart from the advantages and disadvantages of these options, a homograft or xenograft is not readily available in some parts of the world, including Korea.

We believe that treatment of pulmonary insufficiency with leaflet extension, with use of the commercially available E-Leafcon template and bovine pericardium, is reasonable because the pulmonary valve area is similar to that of the aortic valve (for which application the template was designed). With the exception of the lower-pressure pulmonic environment,1 other circumstances are similar between the aortic and pulmonic applications. Further, the durability of bovine pericardium is comparable to that of a homograft or a xenograft.6 In our patient, the immediate postoperative result was successful, and she is now under careful long-term follow-up.

References

1. Waterbolk TW, Hoendermis ES, den Hamer IJ, Ebels T. Pulmonary valve replacement with a mechanical prosthesis. Promising results of 28 procedures in patients with congenital heart disease. Eur J Cardiothorac Surg 2006;30(1):28–32. [PubMed]
2. Anagnostopoulos P, Azakie A, Natarajan S, Alphonso N, Brook MM, Karl TR. Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot. J Thorac Cardiovasc Surg 2007;133(3): 640–7. [PubMed]
3. Hahm SY, Choo SJ, Lee JW, Seo JB, Lim TH, Song JK, et al. Novel technique of aortic valvuloplasty. Eur J Cardiothorac Surg 2006;29(4):530–6. [PubMed]
4. Frigiola A, Tsang V, Nordmeyer J, Lurz P, van Doorn C, Taylor AM, et al. Current approaches to pulmonary regurgitation. Eur J Cardiothorac Surg 2008;34(3):576–82. [PubMed]
5. Schreiber C, Horer J, Vogt M, Fratz S, Kunze M, Galm C, et al. A new treatment option for pulmonary valvar insufficiency: first experiences with implantation of a self-expanding stented valve without use of cardiopulmonary bypass. Eur J Cardiothorac Surg 2007;31(1):26–30. [PubMed]
6. Duran CM, Gometza B, Kumar N, Gallo R, Bjornstad K. From aortic cusp extension to valve replacement with stentless pericardium. Ann Thorac Surg 1995;60(2 Suppl):S428–32. [PubMed]

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