Revista Argentina de Cardiología ISSN: 0034-7000 ISSN: 1850-3748 [email protected] Sociedad Argentina de Cardiología Argentina

Vaccarino, Guillermo; Kreutzer, Cristian; Killinger, Daniel; Chiostri, Benjamín; Gil, Christian; Bastianelli, Gustavo Reconstruction with Autologous Revista Argentina de Cardiología, vol. 86, no. 1, 2018, -February, pp. 50-51 Sociedad Argentina de Cardiología Argentina

DOI: https://doi.org/10.7775/rac.es.v86.i1.11479

Available in: https://www.redalyc.org/articulo.oa?id=305362535011

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Aortic Valve Reconstruction with Autologous developed template designed to cut the pericardium Pericardium into the three future aortic cusps which were sutured with 5/0 running Prolene stitches. The new valve re- This is the case of a 15-year old patient with history of constructed with autologous pericardium presented a rheumatic fever at the age of 8 years, who in the first coaptation zone >1 cm with no evidence of prolapse. control visit to a cardiologist presented trivial aortic Once the valve was reconstructed, the aortotomy was regurgitation with a normal aortic valve and one year closed. After aortic-cross clamp removal and CPB dis- later evolved with fast progression of the aortic regur- continuation, intraoperative transesophageal echo- gitation. During the last 6 months, the patient devel- cardiography showed that the new tricuspid aortic oped impaired functional capacity due to exercise-in- valve, reconstructed with autologous pericardium, duced dyspnea and was referred to the cardiovascular had an adequate surface of coaptation with no signs of surgeon by the attending cardiologist. valve regurgitation (Figure 2). Color-Doppler echocardiography showed a dys- Aortic valve replacement with biologic or me- plastic aortic valve, with thickened cusps, right and chanical valve prosthesis is the conventional surgical left commissural fusion and lack of coaptation, result- treatment of aortic valve disease, as well as the indi- ing in severe aortic regurgitation. The jet width was cation of transaortic valve implant for a rapidly grow- > 70% of the left ventricular outflow tract and the ing group of patients. However, the challenge in the left was severely dilated (LVDD 60 mm) with discussion focuses on the child-adolescent or young preserved systolic function and reverse flow in the de- population. The advantage of bioprostheses in aortic scending . position is that they do not require patient anticoagu- The patient underwent aortic valve reconstruction lation; however, the structural damage and the need with autologous pericardium. for early reoperation make this approach unsuitable The procedure was performed using the tradition- for the young population. On the contrary, mechani- al technique: complete sternotomy, cardiopulmonary cal valve prostheses require lifelong anticoagu- bypass (CPB), cannulation of the ascending aorta, ve- lation therapy and international series have reported nous drainage in the right and antegrade HTK an incidence of major complications of 1-2%. cardioplegia. There are many techniques of aortic valve recon- The full length of the anterior pericardium was struction currently available, depending on the mor- harvested using harmonic scalpel to free pericadial phology of the diseased valve, as commissurotomy, attachments. The harvested pericardium was then cusp resuspension, plication of cusp free edge, an- treated with a 0.6% glutaraldehyde solution for 10 nuloplasty, decalcification, or cusp enlargement with min (Figure 1A). pericardium, among others. Aortic valve preservation After aortotomy, the native bicuspid aortic valve techniques, as the Yacoub or Tirone David procedures, (fibrotic, with commissural fusion and retraction) was are other possible options that can be used depending resected, preserving the aortic annulus and the com- on the characteristics of the valve. The Ross proce- missures. The distance between each commissure was dure is a very good option in the young population due then measured using a gauging apparatus specifically to its excellent hemodynamic profile and because the developed for this technique and the size of each cusp patients do not need anticoagulation therapy. Howev- was individually determined (Figure 1B). er, the procedure requires a highly experienced surgi- These parameters were then transferred to a self- cal team and the pulmonary autograft may result in calcification, dilatation or dysfunction after 10 years.

Fig. 1. A. Intraoperative image of gutaraldehyde-treated autol- ogous pericardium. B. Gauging apparatus to measure intercom- Fig. 2. Transesophageal echocardiography shows adequate cusp missural distance. coaptation without aortic regurgitation. 50 ARGENTINE JOURNAL OF CARDIOLOGY / VOL 86 Nº 1 / FEBRUARY 2018

The use of autologous pericardium is possible due dium: a stentless readily available cheap valve? Eur J Cardiothorac to the biological stabilization with glutaraldehyde. Surg. 2005;28:200-5.http://doi.org/dzt7s7 3. Ozaki S, Kawase I,Yamashita H, Uchida S, Nozawa Y, Takatoh M, This technique has been used for more than 30 years et al. A total of 404 cases of aortic valve reconstruction with glutar- and many authors have developed different surgical aldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg approaches for partial or complete valve reconstruc- 2014;147:301-6.http://doi.org/cmjb 4. Ozaki S, Kawase I, Yamashita H, Uchida S, Nozawa Y, Takatoh M, tion. Carpenter et al. have reported that preservation et al. Reconstruction of Bicuspid Aortic Valve With Autologous Peri- with glutaraldehyde prevents calcification of aortic cardium. Circulation Journal, 2014;78:1144-51.http://doi.org/f528gr and prostheses. (1) 5. Kawase I, Ozaki S, Yamashita H, Uchida S, Nozawa Y, Matsuyama Duran et al. presented their 16-year experience T, et al. Aortic valve reconstruction with autologous pericardium for dialysis patients. Interact CardioVasc Thorac Surg 2013;16:738-42. with reconstruction of the aortic valve with autolo- http://doi.org/f4wzs2 gous pericardium treated with 0.5% buffered glu- 6. Lansac E, Di Centa I, Sleilaty G, Lejeune S, Berrebi A, Zacek P, et taraldehyde solution for 10 min. They used plastic al. Remodeling root repair with an external aortic ring annuloplasty. measurement instruments to gauge and cast the peri- J Thorac Cardiovasc Surg. 2017;153:1033-42.http://doi.org/gbhjhs cardium to reconstruct the new aortic cusps. (2) Based on these initial experiences, Ozaki et al. de- veloped a new technique for aortic valve reconstruc- Severe Pulmonary Stenosis as Vascular tion with autologous pericardium which constitutes Manifestation of Von Recklinghausen Disease an attractive therapeutic option for some scenarios. in Adults The results presented are particularly encouraging in over 400 cases undergoing this technique, without Neurofibromatosis type 1 (NF1), also known as Von conversions to prosthetic valve replacement and no Recklinghausen disease, is the most common neuro- in-hospital cardiovascular mortality. (3) This tech- cutaneous syndrome estimated to occur in approxi- nique has also been used in patients with unicuspid, mately 1 out of every 3,300 infants. Despite the most bicuspid or tetracuspid aortic valves. (4) frequent clinical manifestations are café au lait spots The main benefit of the procedure was the excel- and cutaneous neurofibromas, the presence of multi- lent hemodynamic results at early and mid-term due system involvement may lead to diverse clinical mani- to the characteristics of the new valve (19.8±10.2 festations. (1, 2) mmHg 1 week after surgery and 13.8±3.7 mmHg 3.5 The cardiovascular manifestations include systemic years after surgery) with good quality of life without hypertension and hypertension, ste- need for anticoagulation. (3) This characteristic has nosis of the renal artery, congenital heart defects, hy- significant relevance in dialysis patients due to dialy- pertrophic cardiomyopathy and less frequently pheo- sis-related complications. (5) chromocytoma. In the National Neurofibromatosis In agreement with Osaki et al., we did not perform Foundation International Database, among 2,322 pa- internal or external aortic ring annuloplasty because tients with definite NF1, 2.3% presented cardiovascular our patients had normal aortic annulus. It is debat- abnormalities. Class II flow defects are the most com- able whether this will have any impact on long-term mon defects in the great vessels, and include pulmonary outcome, as Lansac et al. have described. (6) The long- valve stenosis, pulmonary subvalvular stenosis and co- term results will be available in the future. arctation of the aorta. (3, 4) The diagnosis is commonly made during childhood and in young adults. (3-5) Conflicts of interest We present a 71 year-old female patient who None declared. sought medical care due to class II-III dyspnea. At (See authors’ conflicts of interest forms on the website/Sup- physical examination, an intense systolic murmur was plementary material). heard at the pulmonic area accompanied by thrill. A particularly striking feature was the presence of large, Guillermo Vaccarino, Cristian Kreutzer, soft, brownish-colored tumors on the face and trunk Daniel Killinger, Benjamín Chiostri, (Figure 1). Christian Gil, Gustavo Bastianelli Two-dimensional echocardiography and Doppler Hospital Universitario Austral, Pilar, Buenos Aires, Argentina. [email protected] ultrasound demonstrated the presence of severe pul- monary valve stenosis with a 100 mmHg gradient, mild subvalvular gradient in end-systole and mild Rev Argent Cardiol 2018;86:49-50. http://dx.doi.org/10.7775/rac.v86. dilation of the right chambers. Such findings corre- i1.11479 lated with those seen at cardiac magnetic resonance imaging, providing key information about the absence REFERENCES of other heart defects associated with the underlying 1. Chachques JC, Vasseur B, Perier P, Balansa J, Chauvaud S, Car- disease (Figure 2). pentier A. A rapid method to stabilize biological materials for cardio- The biopsy of a skin lesion showed well-circum- vascular surgery. Annals New York Academy Sciences 1988; 529:184- scribed lesions composed of spindle-shaped cells with 6.http://doi.org/fnbpmr 2. Al Halees Z, Al Shahid M, Al Sanei A, Sallehuddin A, Duran C. myxoid collagenized stroma, a typical finding of the Up to 16 years follow-up of aortic valve reconstruction with pericar- disease. (5)