Ann Thorac Surg 2014;98:1447–9
CASE REPORT ROUBELAKIS ET AL TRICUSPID VALVE REPAIR USING NEOCHORDS
1447
4. Ammash M, Warnes CA. Ventricular septal defects in adults. Ann Intern Med 2001;135:812–24. 5. Nadas AS, Thilenius OG, Lafarge CG, Hauck AJ. Ventricular septal defect with aortic regurgitation: medical and pathologic aspects. Circulation 1964;29:862–73. 6. Yacoub MH, Khan H, Stavri G, Shinebourne E, Radley-Smith R. Anatomic correction of the syndrome of prolapsing right coronary cusp, dilatation of the sinus of Valsalva and ventricular septal defect. J Thorac Cardiovasc Surg 1997;113:253–60.
Isolated Tricuspid Valve Repair After Metastatic Tumor Resection Apostolos Roubelakis, PhD, Amit Modi, FRCS (C-Th), and Sunil K. Ohri, MD, FRCS (C-Th)
Fig 3. Ventricular septal defect undergoing closure by use of Yacoub’s technique.
governed by the volume overload of the left ventricle caused by aortic incompetence rather than the shunt across the VSD [4, 5]. Owing to a possible structural abnormality in the sinus and in the ascending aorta, aneurysmal dilatation of the aortic root and ascending aorta is possible in the later stages of the disease [2, 3]. Yacoub’s technique for VSD closure [6] can safely be considered in such cases, without concerns about tension on the suture line, because of the redundancy of tissues in the ventricular aspect. To the best of our knowledge, this is the first case ever reported in the literature: performance of a modified Bentall’s procedure incorporating Yacoub’s technique of VSD Closure as a part of the primary operation in a case of Laubry-Pezzi syndrome [2] and probably the first case to combine a modified Bentall’s procedure, VSD closure without a patch, and PDA closure.
References 1. Laubry C, Pezzi C. Trait e des maladies cong enitales du coeur. Paris: JB Bailliere; 1921. Quoted by Labury C, Routier D, Soulie P. Les souffles de la maladie de Roger. Rev Med Paris 1933;50:439–448. 2. Martınez-Quintana E, Rodrıguez-Gonzalez F, L opezGude MJ. Laubry-Pezzi syndrome with aortic root dilatation treated with a Bentall and De Bono procedure. World J Pediat Congenit Heart Surg 2013;4:299–301. 3. Sakakibara S, Konno S. Congenital aneurysm of the sinus de Valsalva associated with ventricular septal defect: anatomical aspects. Am Heart J 1968;75:595–603. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Isolated tricuspid valve repairs are performed in adults most commonly as a result of infective endocarditis, traumatic injury, rheumatic involvement, and ischemia. The use of neochordae made from polytetrafluoroethylene, being widespread in mitral valve operations, is gaining ground in tricuspid valve repair. We report a very rare case that describes isolated tricuspid valve repair using neochordae after resection of a right ventricular tumor involving the tricuspid valve. The tumor isolated was metastatic teratoma in a patient with growing teratoma syndrome. We further describe our technique of tricuspid neochord implantation and the rationale behind the repair. (Ann Thorac Surg 2014;98:1447–9) Ó 2014 by The Society of Thoracic Surgeons
W
e present a case of an adult patient with a diagnosis of growing teratoma syndrome, which involved the right ventricle and the tricuspid valve. For the excision of the tumor, tendinous chords of the anterior leaflet had to be excised. The tricuspid valve was repaired with artificial polytetrafluoroethylene (PTFE) neochordae. Few reports have been published presenting the above repair technique for the tricuspid valve, but in this report this technique is being used after tumor resection. A 25-year-old patient received a diagnosis of growing teratoma syndrome after neoadjuvant chemotherapy, left orchidectomy, and excision of a para-aortic lymph nodal mass and an inferior vena caval mass. During the operation, a transesophageal echocardiography (TEE) probe was deployed to identify the proximal limit of the inferior vena caval tumor extension. This scan revealed a pedunculated mobile mass of unknown origin in the right ventricle. Cardiac magnetic resonance imaging (CMR) and transthoracic echocardiography (TTE) elucidated the possible causes in the postoperative period. TTE revealed a Accepted for publication Dec 9, 2013. Address correspondence to Dr Roubelakis, Department of Cardiothoracic Surgery, Southampton University Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.057
FEATURE ARTICLES
Department of Cardiothoracic Surgery, Southampton University Hospitals NHS Foundation Trust, Southampton, United Kingdom
1448
CASE REPORT ROUBELAKIS ET AL TRICUSPID VALVE REPAIR USING NEOCHORDS
mobile, polypoid mass in the right ventricle with trivial tricuspid regurgitation. CMR demonstrated several pedunculated structures arising from the trabecular chordae of the tricuspid valve situated near the base of the right ventricular outflow tract (Fig 1). These structures were not typical of a thrombus but were suggestive of vegetations or a tumor. Biomarkers including a-fetoprotein, b-human chorionic gonadotropin, total leucocyte count, and C-reactive protein were all within normal limits. After discussion at the multidisciplinary team meeting, the patient was referred for excision of the right ventricular mass. The procedure was performed by use of a standard bypass circuit with bicaval venous return and ascending aortic return. The heart was arrested with antegrade intermittent cold-blood cardioplegia. After the right atrial incision, the tumor mass was identified entangling the chords of the septal leaflet of the tricuspid valve. It had not infiltrated into them, and we were able to unsnarl the tumor from the septal leaflet chords. The tumor had, however, seeded onto the primary chordae of the anterior leaflet of the tricuspid valve. After complete and careful excision of the tumor en bloc with the involved cords (Fig 2), a sample was sent for frozen section examination, which confirmed the presence of metastatic teratoma. The rest of the right ventricular cavity was inspected and was found to be free of disease. After the resection, the tricuspid valve was severely insufficient. It was therefore decided to repair the valve FEATURE ARTICLES Fig 1. Cardiac magnetic resonance image showing the tumor at the base of the right ventricular outflow tract (arrow).
Ann Thorac Surg 2014;98:1447–9
Fig 2. Surgical specimen showing the tumor en bloc with the associated tendinous chord.
with two 4-0 PTFE neochordae. Both ends of a PTFE suture were passed through the fibrous tip of the anterior papillary muscle over a PTFE pledget. This decision was made depending on the origin of the native cords, which were excised. Subsequently, both ends were passed from the ventricular side, 3 mm away from the free edge of the unsupported part of the tricuspid anterior leaflet. One of the two free ends was passed again from the ventricular side through the leaflet (Fig 3). This procedure was repeated for the second neochord. These neochordae were adjusted to length after distending the right ventricle with cold saline to a length that allowed the free edge to remain in the plane of the annulus before it was tied down. Given that the patient had no evidence of functional disease of the tricuspid valve, it was decided that there was no need for a supporting annuloplasty. The competence of the valve was checked, and the operation was completed in a standard manner. With the patient on
Fig 3. Schematic reproduction of the tricuspid valve repair. The attachments of the artificial chords to the anterior tricuspid leaflet and to the papillary muscle are demonstrated.
the operating table, transoesophageal echocardiography confirmed complete removal of the tumor and a competent tricuspid valve. A formal histology report identified the tumor as a mature cystic teratoma with the presence of reactive fibrous tissue. There was no evidence of high-grade germ cell tumor. The patient was discharged on the fifth postoperative day. Postoperative TTE and CMR showed a competent tricuspid valve with no residual disease. He has been followed up thoroughly by the oncologists at intervals of 3 to 4 months with computed tomography of the chest, abdomen and pelvis; TTE, and serum tumor markers, and he remains well on follow-up after 2 year. Transthoracic echocardiography on follow-up revealed only mild tricuspid regurgitation, with no further evidence of tumor recurrence.
Comment Growing teratoma syndrome is characterized by recurring solitary enlarging masses of germ cell tumors after successful treatment with chemotherapy and surgical excision leading to complete eradication of viable malignant cells and normalization of serum tumor markers [1]. These tumors are refractory to further chemotherapy and histologically are mature teratomas with absence of malignancy. This patient’s tumor markers were normal, and the histology of all resected tissue had no evidence of malignancy; therefore, there was no indication for adjuvant chemotherapy. The presence of tumors in the heart could herald distal embolization, obstruction, valve dysfunction, and arrhythmias after growth. Surgical excision would therefore prevent symptoms and deterioration of the patient’s condition. Resection is usually both diagnostic and curative, with an overall 5-year survival of 89% [2]. We have not found reviews in the current literature regarding growing teratoma syndrome that reported any intracardiac presentation [3]. In this case, the TTE and CMR proved invaluable modalities for the diagnosis and management of this tumor. Differential diagnosis should include the presence of intraventricular thrombus and the possibility of infective endocarditis. We base the resection of such tumors on oncologic principles and therefore prefer to resect involved native tissue. One has to bear in mind that the exact histologic diagnosis is not known while the resection is being performed. In this case we had to sacrifice a few native primary cords to the anterior tricuspid leaflet, rendering it severely regurgitant. Severe tricuspid regurgitation is associated with a poor prognosis. Reconstruction of this valve was not possible by conventional techniques of bicuspidization and DeVega or Carpentier annuloplasty; hence, we decided to use artificial neochordae, a technique with which we are well familiar because of our experience with mitral procedures. [4]. Isolated tricuspid valve repair with neochordae made from PTFE has been presented in the past in cases involving mainly infective endocarditis [5], trauma [6], and myocardial infarction [7]. However, repair Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
CASE REPORT DELIUS ET AL COMPLICATION OF THREE-PATCH REPAIR OF SVAS
1449
of the tricuspid valve after tumor excision and replacement of the affected native tendinous chords has not yet been reported, to our knowledge. Thinner grades of PTFE retain a natural level of flexibility after complete tissue incorporation [8]. Because a large tensile stress was not anticipated in this patient, we chose to use 4-0 PTFE cords. In the setting of a functionally normal tricuspid valve with a nondilated annulus, we do not believe that a securing annuloplasty would have added any benefit to the patient; in fact, it avoided the risk of postoperative conduction abnormalities and the possibility of injury to adjacent structures. To summarize, we report a tricuspid valve repair after a rare intracardiac tumor excision, which was performed with the use of PTFE artificial neochordae implantation without the use of annuloplasty, with an excellent outcome.
References 1. Afifi HY, Bosl GJ, Burt ME. Mediastinal growing teratoma syndrome. Ann Thorac Surg 1997;64:359–62. 2. Spiess PE, Kassouf W, Brown GA, et al. Surgical management of growing teratoma syndrome: the M. D. Anderson Cancer Center Experience. J Urol 2007;177:1330–4. 3. Seabra D, Faria E, Machado R, Quarteiro R, Teod osio R, Bianco M. The unusual and potentially fatal growing teratoma syndrome. Appl Cancer Res 2008;28:161–4. 4. Moorjani N, Viola N, Janusauskas V, Livesey S. Adjusting the length of artificial polytetrafluoroethylene chordae in mitral valve repair by a single loop technique. J Thorac Cardiovasc Surg 2009;138:1441–2. 5. Garcia-Rinaldi R. Tricuspid anterior leaflet replacement with autologous pericardium and polytetrafluoroethylene chordae, followed by edge-to-edge repair. Tex Heart Inst J 2007;34:310–2. 6. Hachiro Y, Sugimoto S, Takagi N, Osawa H, Morishita K, Abe T. Native valve salvage for post-traumatic tricuspid regurgitation. J Heart Valve Dis 2001;10:276–8. 7. Dandekar U, Sachithanandan A, Kalkat M, Ridley P, Satur CMR. Isolated severe ischemic tricuspid regurgitation: successful surgical repair. J Heart Valve Dis 2007;16:331–2. 8. Vetter HO, Burack JH, Factor SM, Frater RWM. Replacement of chordate tendineae of the mitral valve using the new expanded PTFE suture in sheep. In: Bodnar E, Yacoub M (eds). Biologic and Bioprosthetic Valves. New York: York Medical Books, 1986. p. 772–84.
An Unusual Complication of Three-Patch Repair of Supravalvar Aortic Stenosis Ralph E. Delius, MD, Henry L. Walters, III, MD, and Igor Bondarenko, MD Department of Cardiovascular Surgery, Children’s Hospital of Michigan, Detroit, Michigan
Three-patch repair of supravalvar aortic stenosis is a widely accepted surgical approach for this congenital Accepted for publication Nov 25, 2013. Address correspondence to Dr Delius, Department of Cardiovascular Surgery, Children’s Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.11.076
FEATURE ARTICLES
Ann Thorac Surg 2014;98:1449–51
CASE REPORT ROUBELAKIS ET AL TRICUSPID VALVE REPAIR USING NEOCHORDS
1447
4. Ammash M, Warnes CA. Ventricular septal defects in adults. Ann Intern Med 2001;135:812–24. 5. Nadas AS, Thilenius OG, Lafarge CG, Hauck AJ. Ventricular septal defect with aortic regurgitation: medical and pathologic aspects. Circulation 1964;29:862–73. 6. Yacoub MH, Khan H, Stavri G, Shinebourne E, Radley-Smith R. Anatomic correction of the syndrome of prolapsing right coronary cusp, dilatation of the sinus of Valsalva and ventricular septal defect. J Thorac Cardiovasc Surg 1997;113:253–60.
Isolated Tricuspid Valve Repair After Metastatic Tumor Resection Apostolos Roubelakis, PhD, Amit Modi, FRCS (C-Th), and Sunil K. Ohri, MD, FRCS (C-Th)
Fig 3. Ventricular septal defect undergoing closure by use of Yacoub’s technique.
governed by the volume overload of the left ventricle caused by aortic incompetence rather than the shunt across the VSD [4, 5]. Owing to a possible structural abnormality in the sinus and in the ascending aorta, aneurysmal dilatation of the aortic root and ascending aorta is possible in the later stages of the disease [2, 3]. Yacoub’s technique for VSD closure [6] can safely be considered in such cases, without concerns about tension on the suture line, because of the redundancy of tissues in the ventricular aspect. To the best of our knowledge, this is the first case ever reported in the literature: performance of a modified Bentall’s procedure incorporating Yacoub’s technique of VSD Closure as a part of the primary operation in a case of Laubry-Pezzi syndrome [2] and probably the first case to combine a modified Bentall’s procedure, VSD closure without a patch, and PDA closure.
References 1. Laubry C, Pezzi C. Trait e des maladies cong enitales du coeur. Paris: JB Bailliere; 1921. Quoted by Labury C, Routier D, Soulie P. Les souffles de la maladie de Roger. Rev Med Paris 1933;50:439–448. 2. Martınez-Quintana E, Rodrıguez-Gonzalez F, L opezGude MJ. Laubry-Pezzi syndrome with aortic root dilatation treated with a Bentall and De Bono procedure. World J Pediat Congenit Heart Surg 2013;4:299–301. 3. Sakakibara S, Konno S. Congenital aneurysm of the sinus de Valsalva associated with ventricular septal defect: anatomical aspects. Am Heart J 1968;75:595–603. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Isolated tricuspid valve repairs are performed in adults most commonly as a result of infective endocarditis, traumatic injury, rheumatic involvement, and ischemia. The use of neochordae made from polytetrafluoroethylene, being widespread in mitral valve operations, is gaining ground in tricuspid valve repair. We report a very rare case that describes isolated tricuspid valve repair using neochordae after resection of a right ventricular tumor involving the tricuspid valve. The tumor isolated was metastatic teratoma in a patient with growing teratoma syndrome. We further describe our technique of tricuspid neochord implantation and the rationale behind the repair. (Ann Thorac Surg 2014;98:1447–9) Ó 2014 by The Society of Thoracic Surgeons
W
e present a case of an adult patient with a diagnosis of growing teratoma syndrome, which involved the right ventricle and the tricuspid valve. For the excision of the tumor, tendinous chords of the anterior leaflet had to be excised. The tricuspid valve was repaired with artificial polytetrafluoroethylene (PTFE) neochordae. Few reports have been published presenting the above repair technique for the tricuspid valve, but in this report this technique is being used after tumor resection. A 25-year-old patient received a diagnosis of growing teratoma syndrome after neoadjuvant chemotherapy, left orchidectomy, and excision of a para-aortic lymph nodal mass and an inferior vena caval mass. During the operation, a transesophageal echocardiography (TEE) probe was deployed to identify the proximal limit of the inferior vena caval tumor extension. This scan revealed a pedunculated mobile mass of unknown origin in the right ventricle. Cardiac magnetic resonance imaging (CMR) and transthoracic echocardiography (TTE) elucidated the possible causes in the postoperative period. TTE revealed a Accepted for publication Dec 9, 2013. Address correspondence to Dr Roubelakis, Department of Cardiothoracic Surgery, Southampton University Hospital, Tremona Road, Southampton, SO16 6YD, United Kingdom; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.057
FEATURE ARTICLES
Department of Cardiothoracic Surgery, Southampton University Hospitals NHS Foundation Trust, Southampton, United Kingdom
1448
CASE REPORT ROUBELAKIS ET AL TRICUSPID VALVE REPAIR USING NEOCHORDS
mobile, polypoid mass in the right ventricle with trivial tricuspid regurgitation. CMR demonstrated several pedunculated structures arising from the trabecular chordae of the tricuspid valve situated near the base of the right ventricular outflow tract (Fig 1). These structures were not typical of a thrombus but were suggestive of vegetations or a tumor. Biomarkers including a-fetoprotein, b-human chorionic gonadotropin, total leucocyte count, and C-reactive protein were all within normal limits. After discussion at the multidisciplinary team meeting, the patient was referred for excision of the right ventricular mass. The procedure was performed by use of a standard bypass circuit with bicaval venous return and ascending aortic return. The heart was arrested with antegrade intermittent cold-blood cardioplegia. After the right atrial incision, the tumor mass was identified entangling the chords of the septal leaflet of the tricuspid valve. It had not infiltrated into them, and we were able to unsnarl the tumor from the septal leaflet chords. The tumor had, however, seeded onto the primary chordae of the anterior leaflet of the tricuspid valve. After complete and careful excision of the tumor en bloc with the involved cords (Fig 2), a sample was sent for frozen section examination, which confirmed the presence of metastatic teratoma. The rest of the right ventricular cavity was inspected and was found to be free of disease. After the resection, the tricuspid valve was severely insufficient. It was therefore decided to repair the valve FEATURE ARTICLES Fig 1. Cardiac magnetic resonance image showing the tumor at the base of the right ventricular outflow tract (arrow).
Ann Thorac Surg 2014;98:1447–9
Fig 2. Surgical specimen showing the tumor en bloc with the associated tendinous chord.
with two 4-0 PTFE neochordae. Both ends of a PTFE suture were passed through the fibrous tip of the anterior papillary muscle over a PTFE pledget. This decision was made depending on the origin of the native cords, which were excised. Subsequently, both ends were passed from the ventricular side, 3 mm away from the free edge of the unsupported part of the tricuspid anterior leaflet. One of the two free ends was passed again from the ventricular side through the leaflet (Fig 3). This procedure was repeated for the second neochord. These neochordae were adjusted to length after distending the right ventricle with cold saline to a length that allowed the free edge to remain in the plane of the annulus before it was tied down. Given that the patient had no evidence of functional disease of the tricuspid valve, it was decided that there was no need for a supporting annuloplasty. The competence of the valve was checked, and the operation was completed in a standard manner. With the patient on
Fig 3. Schematic reproduction of the tricuspid valve repair. The attachments of the artificial chords to the anterior tricuspid leaflet and to the papillary muscle are demonstrated.
the operating table, transoesophageal echocardiography confirmed complete removal of the tumor and a competent tricuspid valve. A formal histology report identified the tumor as a mature cystic teratoma with the presence of reactive fibrous tissue. There was no evidence of high-grade germ cell tumor. The patient was discharged on the fifth postoperative day. Postoperative TTE and CMR showed a competent tricuspid valve with no residual disease. He has been followed up thoroughly by the oncologists at intervals of 3 to 4 months with computed tomography of the chest, abdomen and pelvis; TTE, and serum tumor markers, and he remains well on follow-up after 2 year. Transthoracic echocardiography on follow-up revealed only mild tricuspid regurgitation, with no further evidence of tumor recurrence.
Comment Growing teratoma syndrome is characterized by recurring solitary enlarging masses of germ cell tumors after successful treatment with chemotherapy and surgical excision leading to complete eradication of viable malignant cells and normalization of serum tumor markers [1]. These tumors are refractory to further chemotherapy and histologically are mature teratomas with absence of malignancy. This patient’s tumor markers were normal, and the histology of all resected tissue had no evidence of malignancy; therefore, there was no indication for adjuvant chemotherapy. The presence of tumors in the heart could herald distal embolization, obstruction, valve dysfunction, and arrhythmias after growth. Surgical excision would therefore prevent symptoms and deterioration of the patient’s condition. Resection is usually both diagnostic and curative, with an overall 5-year survival of 89% [2]. We have not found reviews in the current literature regarding growing teratoma syndrome that reported any intracardiac presentation [3]. In this case, the TTE and CMR proved invaluable modalities for the diagnosis and management of this tumor. Differential diagnosis should include the presence of intraventricular thrombus and the possibility of infective endocarditis. We base the resection of such tumors on oncologic principles and therefore prefer to resect involved native tissue. One has to bear in mind that the exact histologic diagnosis is not known while the resection is being performed. In this case we had to sacrifice a few native primary cords to the anterior tricuspid leaflet, rendering it severely regurgitant. Severe tricuspid regurgitation is associated with a poor prognosis. Reconstruction of this valve was not possible by conventional techniques of bicuspidization and DeVega or Carpentier annuloplasty; hence, we decided to use artificial neochordae, a technique with which we are well familiar because of our experience with mitral procedures. [4]. Isolated tricuspid valve repair with neochordae made from PTFE has been presented in the past in cases involving mainly infective endocarditis [5], trauma [6], and myocardial infarction [7]. However, repair Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
CASE REPORT DELIUS ET AL COMPLICATION OF THREE-PATCH REPAIR OF SVAS
1449
of the tricuspid valve after tumor excision and replacement of the affected native tendinous chords has not yet been reported, to our knowledge. Thinner grades of PTFE retain a natural level of flexibility after complete tissue incorporation [8]. Because a large tensile stress was not anticipated in this patient, we chose to use 4-0 PTFE cords. In the setting of a functionally normal tricuspid valve with a nondilated annulus, we do not believe that a securing annuloplasty would have added any benefit to the patient; in fact, it avoided the risk of postoperative conduction abnormalities and the possibility of injury to adjacent structures. To summarize, we report a tricuspid valve repair after a rare intracardiac tumor excision, which was performed with the use of PTFE artificial neochordae implantation without the use of annuloplasty, with an excellent outcome.
References 1. Afifi HY, Bosl GJ, Burt ME. Mediastinal growing teratoma syndrome. Ann Thorac Surg 1997;64:359–62. 2. Spiess PE, Kassouf W, Brown GA, et al. Surgical management of growing teratoma syndrome: the M. D. Anderson Cancer Center Experience. J Urol 2007;177:1330–4. 3. Seabra D, Faria E, Machado R, Quarteiro R, Teod osio R, Bianco M. The unusual and potentially fatal growing teratoma syndrome. Appl Cancer Res 2008;28:161–4. 4. Moorjani N, Viola N, Janusauskas V, Livesey S. Adjusting the length of artificial polytetrafluoroethylene chordae in mitral valve repair by a single loop technique. J Thorac Cardiovasc Surg 2009;138:1441–2. 5. Garcia-Rinaldi R. Tricuspid anterior leaflet replacement with autologous pericardium and polytetrafluoroethylene chordae, followed by edge-to-edge repair. Tex Heart Inst J 2007;34:310–2. 6. Hachiro Y, Sugimoto S, Takagi N, Osawa H, Morishita K, Abe T. Native valve salvage for post-traumatic tricuspid regurgitation. J Heart Valve Dis 2001;10:276–8. 7. Dandekar U, Sachithanandan A, Kalkat M, Ridley P, Satur CMR. Isolated severe ischemic tricuspid regurgitation: successful surgical repair. J Heart Valve Dis 2007;16:331–2. 8. Vetter HO, Burack JH, Factor SM, Frater RWM. Replacement of chordate tendineae of the mitral valve using the new expanded PTFE suture in sheep. In: Bodnar E, Yacoub M (eds). Biologic and Bioprosthetic Valves. New York: York Medical Books, 1986. p. 772–84.
An Unusual Complication of Three-Patch Repair of Supravalvar Aortic Stenosis Ralph E. Delius, MD, Henry L. Walters, III, MD, and Igor Bondarenko, MD Department of Cardiovascular Surgery, Children’s Hospital of Michigan, Detroit, Michigan
Three-patch repair of supravalvar aortic stenosis is a widely accepted surgical approach for this congenital Accepted for publication Nov 25, 2013. Address correspondence to Dr Delius, Department of Cardiovascular Surgery, Children’s Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.11.076
FEATURE ARTICLES
Ann Thorac Surg 2014;98:1449–51
