Images in Cardiovascular Medicine Surgically Constructed Double-Outlet Right Ventricle Alexander C. Egbe, MD, MPH; Heidi M. Connolly, MD, FACC; Muhammad Y. Qureshi, MBBS; Hartzell V. Schaff, MD, FACC
A
32-year-old woman with a history of fibrosing mediastinitis attributable to histoplasmosis presented to Mayo Clinic with occlusion of her right pulmonary artery. She underwent bypass of the occluded pulmonary artery with a 26-mm CryoLife homograft conduit from the right ventricle to the right pulmonary artery. Her postoperative course was uncomplicated, and postoperative cardiac MRI showed a patent right ventricle (RV) to right pulmonary artery homograft conduit, normal perfusion of the lobar branches of the right pulmonary artery, and normal pulmonary venous return (Figure 1). The patient did well after surgery and had an uncomplicated pregnancy 2 years later. Fifteen years postoperatively, she presented with exertional dyspnea and signs of right heart failure. Chest computed tomography angiogram showed calcification and severe stenosis of the RV–right pulmonary artery conduit (Figure 2). Attempted dilatation of the conduit was unsuccessful. The patient’s clinical condition deteriorated with the development of oliguric acute kidney injury and progressive right heart failure refractory to inotropic support and diuresis. She was transferred to the Mayo Clinic for repeat surgical intervention. At operation, the RV–right pulmonary artery conduit was replaced with a composite graft constructed with an 18-mm distal graft and a 24-mm proximal graft containing a 21-mm
porcine bioprosthesis; also, a DeVega tricuspid annuloplasty was performed. A postoperative chest computed tomography angiogram performed showed a patent RV–right pulmonary artery conduit and an incidental pulmonary embolus located in the left pulmonary artery branches to the lingula (Figures 3 and 4, Movie I in the online-only Data Supplement). The patient was started on systemic anticoagulation and was dismissed home 9 days after surgery. To our knowledge, this is the first case of surgically constructed double-outflow reconstruction of the RV with each of the outlets supplying a separate branch of the pulmonary artery. The only similar report in the literature is a patient with tetralogy of Fallot with severe RV outflow tract obstruction requiring placement of RV–main pulmonary artery conduit to augment blood flow around the stenotic native pulmonary valve.1
Disclosures None.
References 1. Vaidyanathan KR, Sankar MN, Cherian KM. Double barrel reconstruction of the right ventricular outflow tract. J Card Surg. 2010;25:235. doi: 10.1111/j.1540-8191.2009.00963.x.
From Division of Cardiovascular Diseases (A.C.E., H.M.C.), Division of Pediatric Cardiology (M.Y.Q.), and Division of Cardiovascular Surgery (H.V.S.), Mayo Clinic, Rochester, MN. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA. 115.019312/-/DC1. Correspondence to Hartzell V. Schaff, MD, Division of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail [email protected] (Circulation. 2016;133:765-767. DOI: 10.1161/CIRCULATIONAHA.115.019312.) © 2016 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.115.019312
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766 Circulation February 23, 2016
Figure 1. A, Computed tomography angiogram performed before the first surgical intervention, showing severe calcification (arrow) in the area of the right pulmonary artery. B, Three-dimensional reconstructed image of MRI after initial surgery (insertion of conduit from right ventricle to right pulmonary artery). The artifact from the sternal wires precludes assessment of ventricular end of the conduit. A indicates anterior; LPA, left pulmonary artery; MPA, main pulmonary artery; P, posterior; and RPA, right pulmonary artery.
Figure 2. Computed tomography angiogram after 15 years of the initial surgery showing calcification of the conduit with significant stenosis at the ventricular and the arterial ends, in maximum-intensity projection in near-axial plane (A) and 3-dimensional reconstructed image (B). A indicates anterior; F, feet; H, head; LPA, left pulmonary artery; MPA, main pulmonary artery; P, posterior; and RPA, right pulmonary artery
Figure 3. Three-dimensional reconstruction of computed tomography angiogram after revision of the conduit from right ventricle to right pulmonary artery showing 2 outlets from the right ventricle: the native pulmonary valve and main pulmonary artery supplying blood to the left pulmonary artery and the valved conduit supplying blood to the right pulmonary artery. F indicates feet; H, head; L, left; LPA, left pulmonary artery; MPA, main pulmonary artery; R, right; and RV, right ventricle.
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Egbe et al Double-Outlet Right Ventricle 767
Figure 4. Computed tomography angiogram showing small pulmonary embolism (arrow) in the left lower and lingular branches of pulmonary artery. A indicates anterior; and P, posterior.
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Surgically Constructed Double-Outlet Right Ventricle Alexander C. Egbe, Heidi M. Connolly, Muhammad Y. Qureshi and Hartzell V. Schaff Circulation. 2016;133:765-767 doi: 10.1161/CIRCULATIONAHA.115.019312 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2016 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/133/8/765
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A
32-year-old woman with a history of fibrosing mediastinitis attributable to histoplasmosis presented to Mayo Clinic with occlusion of her right pulmonary artery. She underwent bypass of the occluded pulmonary artery with a 26-mm CryoLife homograft conduit from the right ventricle to the right pulmonary artery. Her postoperative course was uncomplicated, and postoperative cardiac MRI showed a patent right ventricle (RV) to right pulmonary artery homograft conduit, normal perfusion of the lobar branches of the right pulmonary artery, and normal pulmonary venous return (Figure 1). The patient did well after surgery and had an uncomplicated pregnancy 2 years later. Fifteen years postoperatively, she presented with exertional dyspnea and signs of right heart failure. Chest computed tomography angiogram showed calcification and severe stenosis of the RV–right pulmonary artery conduit (Figure 2). Attempted dilatation of the conduit was unsuccessful. The patient’s clinical condition deteriorated with the development of oliguric acute kidney injury and progressive right heart failure refractory to inotropic support and diuresis. She was transferred to the Mayo Clinic for repeat surgical intervention. At operation, the RV–right pulmonary artery conduit was replaced with a composite graft constructed with an 18-mm distal graft and a 24-mm proximal graft containing a 21-mm
porcine bioprosthesis; also, a DeVega tricuspid annuloplasty was performed. A postoperative chest computed tomography angiogram performed showed a patent RV–right pulmonary artery conduit and an incidental pulmonary embolus located in the left pulmonary artery branches to the lingula (Figures 3 and 4, Movie I in the online-only Data Supplement). The patient was started on systemic anticoagulation and was dismissed home 9 days after surgery. To our knowledge, this is the first case of surgically constructed double-outflow reconstruction of the RV with each of the outlets supplying a separate branch of the pulmonary artery. The only similar report in the literature is a patient with tetralogy of Fallot with severe RV outflow tract obstruction requiring placement of RV–main pulmonary artery conduit to augment blood flow around the stenotic native pulmonary valve.1
Disclosures None.
References 1. Vaidyanathan KR, Sankar MN, Cherian KM. Double barrel reconstruction of the right ventricular outflow tract. J Card Surg. 2010;25:235. doi: 10.1111/j.1540-8191.2009.00963.x.
From Division of Cardiovascular Diseases (A.C.E., H.M.C.), Division of Pediatric Cardiology (M.Y.Q.), and Division of Cardiovascular Surgery (H.V.S.), Mayo Clinic, Rochester, MN. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA. 115.019312/-/DC1. Correspondence to Hartzell V. Schaff, MD, Division of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail [email protected] (Circulation. 2016;133:765-767. DOI: 10.1161/CIRCULATIONAHA.115.019312.) © 2016 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.115.019312
Downloaded from http://circ.ahajournals.org/ at765 CONS CALIFORNIA DIG LIB on March 5, 2016
766 Circulation February 23, 2016
Figure 1. A, Computed tomography angiogram performed before the first surgical intervention, showing severe calcification (arrow) in the area of the right pulmonary artery. B, Three-dimensional reconstructed image of MRI after initial surgery (insertion of conduit from right ventricle to right pulmonary artery). The artifact from the sternal wires precludes assessment of ventricular end of the conduit. A indicates anterior; LPA, left pulmonary artery; MPA, main pulmonary artery; P, posterior; and RPA, right pulmonary artery.
Figure 2. Computed tomography angiogram after 15 years of the initial surgery showing calcification of the conduit with significant stenosis at the ventricular and the arterial ends, in maximum-intensity projection in near-axial plane (A) and 3-dimensional reconstructed image (B). A indicates anterior; F, feet; H, head; LPA, left pulmonary artery; MPA, main pulmonary artery; P, posterior; and RPA, right pulmonary artery
Figure 3. Three-dimensional reconstruction of computed tomography angiogram after revision of the conduit from right ventricle to right pulmonary artery showing 2 outlets from the right ventricle: the native pulmonary valve and main pulmonary artery supplying blood to the left pulmonary artery and the valved conduit supplying blood to the right pulmonary artery. F indicates feet; H, head; L, left; LPA, left pulmonary artery; MPA, main pulmonary artery; R, right; and RV, right ventricle.
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 5, 2016
Egbe et al Double-Outlet Right Ventricle 767
Figure 4. Computed tomography angiogram showing small pulmonary embolism (arrow) in the left lower and lingular branches of pulmonary artery. A indicates anterior; and P, posterior.
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 5, 2016
Surgically Constructed Double-Outlet Right Ventricle Alexander C. Egbe, Heidi M. Connolly, Muhammad Y. Qureshi and Hartzell V. Schaff Circulation. 2016;133:765-767 doi: 10.1161/CIRCULATIONAHA.115.019312 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2016 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/133/8/765
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
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