Case report
A 77-year-old woman underwent mitral valve replacement (MVR) and
tricuspid annuloplasty (TAP) for severe mitral valve stenosis and severe
tricuspid regurgitation complicated with pulmonary hypertension and
atrial fibrillation. Atrial fibrillation was not corrected because of
severe dilation of both atria and disappearance of the f-wave on the
electrocardiogram. Mitral annular calcification at the posteromedial
site was debrided using an ultrasound aspirator. A bioprosthesis and a
rigid prosthetic ring were used for the MVR and TAP, respectively. The
patient was discharged without adverse events. Three months after the
operation, the patient suddenly complained of shortness of breath on
exertion and severe peripheral edema. A new harsh pansystolic murmur was
auscultated at the 4th left sternal border. Although
there was an interventricular shunt on the transthoracic echocardiogram,
transesophageal echocardiography revealed that the jet was not an
interventricular shunt but from the LV to the RA (Fig.1). The
bioprosthetic valve functioned normally and no paravalvular leakage was
detected. After intensive medical treatment for congestive heart
failure, the LV-RA communication was repaired. A defect, 6mm in
diameter, was located just cephalad to the anterosepatal commissure of
the tricuspid valve. The lower margin of the defect was bordered by the
annulus of the tricuspid valve (Fig.2). The anterior edge of the rigid
prosthetic ring was detached to achieve single stitch width. Close
inspection of the tricuspid valve revealed no interventricular
communication. 15mm of the anterior edge of the rigid prosthetic ring
was resected, because that part of the ring interfered with defect
repair. The defect was closed using a xenopericardial patch with five
pledget mattress sutures. The inferior part of the patch was fixed using
two mattress sutures, that were anchored to the interventricular septum
and then passed through the annulus of the tricuspid valve to avoid the
conduction system. No intracardiac shunt was detected on transesophageal
echocardiography after repair. The patient recovered uneventfully and
has been doing well with no signs of congestive heart failure after
discharge.