Thorax: first published as 10.1136/thx.21.4.337 on 1 July 1966. Downloaded from
Thorax (1966), 21, 337.
Homograft replacement of the pulmonary valve
DENIS N. FULLER, PAUL MARCHAND, MONTY M. ZION, AND SAUL ZWI From Johannesburg General Hospital and University of the Witwatersrand
Pulmonary incompetence is a common sequel of In January 1959 open pulmonary valvotomy was pulmonary valvotomy, but many authors believe performed under cardiopulmonary bypass using the that the haemodynamic consequences of this disc oxygenator. The heart was arrested with potas- regurgitation are well tolerated (Talbert, Morrow, sium citrate. The pulmonary artery was opened and a cone-shaped pulmonary valve was encountered. No Collins, and Gilbert, 1963). In this paper we commissures were identifiable. The diaphragm was report a patient who had severe pulmonary incom- cut, converting it into a bicuspid valve with an esti- petence after valvotomy and who failed to main- mated orifice diameter of 2-5 cm. A small patent tain her initial clinical improvement. Because of foramen ovale was closed by direct suture. the severe leak it was considered reasonable to Convalescence was uneventful. correct the incompetence surgically. A homograft Examination three weeks after operation revealed pulmonary valve was used, and we are unaware no cyanosis, and the systemic arterial pulse was col- of any previous report of its use in man, though lapsing in character. The blood-pressure was 120/60 mm. Hg. Jugular venous pressure was raised to the Ross, Cooper, and Brockenbrough (1961) de- angle of the jaw due to tricuspid incompetence. The scribed the experimental replacement of the liver was not palpable. No adventitious sounds were pulmonary valve with a tricuspid semilunar audible in the lungs. On palpation of the precordium prosthesis in dogs. a systolic thrill under the left clavicle and a right ventricular left parasternal heave were felt. The first http://thorax.bmj.com/ heart sound was loud. The pulmonary component of CASE REPORT the second sound could not be heard. There was a coarse pulmonary ejection murmur (grade 4/6), A 9-year-old white girl was seen in 1958. There was stopping short of the second sound, and a rough pul- a history of sweating and listlessness during infancy. monary diastolic murmur. After the age of 1 year she began to tire easily, and The patient was seen again at the age of 15 years at the age of 4 years cyanosis of the lips and nails in February 1964. She had remained well and been was noted. She was breathless on moderate exertion. able to swim and play tennis until about a month
She was undersized for her age and weighed 53 lb. previously, when she had begun to feel continually on September 30, 2021 by guest. Protected copyright. (24 kg.). Central and peripheral cyanosis was present. tired. She was now a well-developed adolescent. There The pulse was regular and the blood-pressure was was no cyanosis or respiratory distress. Prominent 104/70 mm. Hg. There was a left parasternal heave 'a' waves were noted in the jugular venous pulsa- of right ventricular hypertrophy, but no thrill could be tions. The marked left parasternal heave due to right felt. On auscultation a loud coarse pulmonary ejection ventricular enlargement persisted. There was a grade systolic murmur with a single second sound was 2/6 pulmonary ejection systolic murmur and a grade heard. Femoral pulses were present. The liver was 2/4 rough diastolic murmur of pulmonary incom- not palpable. petence commencing 0-08 sec. after aortic valve Radiographs showed an increase in the transverse closure (Fig. 3). diameter of the heart with a cardiothoracic ratio of 55% and a prominent pulmonary artery segment. The TABLE I right ventricle and right atrium were enlarged. The lung fields were under-vascularized (Fig. 1). CARDIAC CATHETERIZATION 1958 The electrocardiogram (Fig. 2) showed right ven- Pressure 02 tricular hypertrophy and strain. Site (mm. Hg) Saturation Cardiac catheterization was done under basal Systolic Diastolic (oximeter) narcosis with rectal barbiturate and using local Right pulmonary capillary| 5 3 96 anaesthetic. The salient findings are listed in Table I. Main pulmonary artery 15 8 35 The diagnosis was 'valvular pulmonic stenosis with Right ventricle 185 0-15 Right atrium a 11 (mean =6) intact ventricular septum; small right-to-left shunt, Brachial artery 75 55 86 probably via a patent foramen ovale'. 337 Thorax: first published as 10.1136/thx.21.4.337 on 1 July 1966. Downloaded from
338 Denis N. Fuller, Paul Marchand, Monty M. Zion, and Saul Zwi http://thorax.bmj.com/ FIG. 1. Postero-anterior chest radiograph 1958. on September 30, 2021 by guest. Protected copyright.
V6 XT tS V4R T x, .+I - - r w T 1 r r tTTTT- o x r a
.. X ___W .,, x _ = 1- x, T-- T I_ _ _ w:xl _ - T I T I
-tt- s TS - - _.+= y+^ _1ll' r Ttt14 1 T4t,r I; 10t11t!111r * X r T r r I s T X T7 7T-TT7 IT i Ii T X r r 1 T FIG. 2. Electrocardiogram 1958. The chest leads are at half sensitivity. l!T-XELT i ' w . T _ r. 1 1 . - * ., r _z_ T : T I^ l S T _ * - *1l_ Thorax: first published as 10.1136/thx.21.4.337 on 1 July 1966. Downloaded from
Homograft replacement of the pulmonary valve 339
A A_
-.]L-- x
AL
Jr------v
MIL I 9 X JL X -IL __X MML_ ------Ar
--AL I-
X IL --y w N L7K X MEL-- -IL JL___ N N IL JL X N JL-----AL
___JL_ X W Jr ___X_ -X MK_ XX -X -AL -X __JF_
FIG. 3. Phonocardiogram 1964. Recorded at pulmonary area (logarithmic tracing). SM, systolic murmur; A2, aortic component of second heart sound; DM, diastolic murmur. http://thorax.bmj.com/ on September 30, 2021 by guest. Protected copyright.
FIG. 4. Postero-anterior chest radiograph 1964. Thorax: first published as 10.1136/thx.21.4.337 on 1 July 1966. Downloaded from
340 Denis N. Fuller, Paul Marchand, Monty M. Zion, and Saul Zwi
I II III AVR AVL AVF
VI V2 V3 V4 Vs V6 V4R ...... I. 1......
. http://thorax.bmj.com/
n . . . . .I . ti 1 1:1:i 1 -t t m 1 im.WNWHERH
FIG. 5. Electrocardiogram 1964.
Cardiac radiographs showed persistent enlargement pressure tracing in the main pulmonary artery top with marked prominence of the pulmonary artery resemble that in the right ventricle. The end-diastolic segment and enlargement of the right ventricle and pressure in the right ventricle and the right atrial right atrium (Fig. 4). The pulmonary vascularity was pressure were raised. The arterial oxygen saturation on September 30, 2021 by guest. Protected copyright. within normal limits. of 89% is at the lower limit of normal for this An electrocardiogram showed right ventricular altitude (5,760 feet) (1,755 m.). hypertrophy and strain (Fig. 5). In August 1965 she was admitted to hospital for Cardiac catheterization was done under sedation observation and further assessment. Her symptoms, and local anaesthesia. The salient findings are shown physical findings, electrocardiogram, and radiographs in Table II. The gradient across the pulmonary valve were unchanged. had been eliminated by the pulmonary valvotomy, but The severe degree of pulmonary incompetence was free pulmonary incompetence was present causing the considered to be partly responsible for her symptoms and it was felt that restoration of pulmonary valve TABLE II competence was a reasonable approach to the prob- lem. CARDIAC CATHETERIZATTON 1964 On 2 September 1965 a homograft pulmonary valve Pressure 02 was inserted at the pulmonary valve site under cardio- Site (mm. Hg) Saturation pulmonary bypass. Systolic Diastolic (oximeter) The approach was through a vertical sternal- splitting incision. Pericardial adhesions were divided Main pulmonary artery 35 5 72 Right ventricle 35 0-10 72 without difficulty. The external diameter of the base Right atrium a= 12 v= 10 71 of the pulmonary artery measured 4-3 cm. The main -(mean-8) Brachial artery 125 75 89 pulmonary artery was opened longitudinally, the incision extending from the valve ring to the arterial Cardiac output 4-7 1. 'min. (measured by dye dilution technique). bifurcation. In view of the large size of the vessel Thorax: first published as 10.1136/thx.21.4.337 on 1 July 1966. Downloaded from
Homograft replacement of the pulmonary valve 341 excellent exposure was provided. It was possible to homograft were then sewn to the remnants of the identify three blunt commissures, but the remnants bases of the host's cusps with continuous 5-0 silk of the cusps were thickened and -retracted, forming sutures. These remnants were not always clearly narrow ledges which could not possibly approximate. identifiable, and in parts the suturing had to be made They were excised at their bases. A freeze-dried pul- directly to the pulmonary artery endothelium along monary valve homograft taken from a youth who an estimated curve. On completion the graft sat had been killed accidentally three months previously snugly in its bed and the cusps were free and mobile. was rehydrated with a saline solution containing The artery was then repaired. penicillin and streptomycin. The stretched diameter Throughout the 70 minutes' bypass the heart re- of the reconstituted homograft, measured with a mained in sinus rhythm and no difficulties were Tubbs dilator, was 4-2 cm. and the internal stretched experienced when coming off the pump. diameter of the host's pulmonary arterial ring using Pressures recorded by direct needle puncture of the the same instrument was 3-8 cm. The arterial wall of pulmonary artery before bypass showed a close the homograft had been cut about 2 mm. clear of resemblance to ventricular pressure curves (Fig. 6A). the cusp bases and commissures, and below the cusps After replacement of the pulmonary valve the pul- as much muscle as possible had been removed up to monary artery pressure tracing (Fig. 6B) revealed and following the curve of the cusp bases. normal features but with a Venturi effect in early The insertion of the homograft in this position was systole. There was a peak systolic gradient of 10 mm. technically easier than the equivalent replacement of Hg across the homograft valve. an aortic valve because of the large size of both the Convalescence was rapid and free of complica- host's artery and the homograft. Three 4-0 silk tions. anchoring sutures were placed precisely below the Clinical examination three weeks after operation site of the host's commissures. These were then revealed persistence of the prominent "a" waves in brought through the base of the homograft in the the jugular venous pulsations and of the right ven- same relative positions and were tied. The commis- tricular enlargement. On auscultation (Fig. 7) there sural pillars of the homograft were then fixed with was a grade 3/6 pulmonary ejection systolic murmur, mattress sutures passed through the pulmonary artery and both aortic and pulmonary components of the wall at the precise situation of the commissural rem- second heart sound were clearly audible. Movement nants and were tied externally over teflon pledgets. of the components of this sound with respiration The fringes of pulmonary artery left attached to the was normal. http://thorax.bmj.com/
nm.Hg *S 4 A__4 M -i-t_q _- _ _ & ., .p_ .,. ,.d_ _ __4
- - __ -4---; FFWEz1 v -t 1 Z i 3 I 4 7 q- i zF.' r ..5j ;.I tsetr*rne- ---1'-''''-'----!- i- --!----,-t-7,---1' ---!-----Tb
tat--- !--u-tz ----t-- -+u-^- '------+---l*i ----t-----;-----'! l. .-.-l t- on September 30, 2021 by guest. Protected copyright. 7 ._._...E_ t ' f_ So_{ t--tS .. 4<. .t ; {_4_ *}-tt -St. ....4.x-S_ 1| 4*z-tv-i_... 45--+*IJ-_-4_ -+ R- *_ i| 'j| t t: X > @---t---t @-t.---B-9---b' @-t*-tt . -tt>-m-. ' t +o: 111 ;A j S|_ {8-83 .i I t4t}t.^.. 1 .-I _.1 ..___tI - !._i 20 - l"t HE----l------*w------+-----|+|--^-^|-l---w-r--t.-*n °-,wEe7 , . W -i ^ 12,-' , . *, i |.W | .*_._ 4- . A:.sl |..tD|. , _ .e |l .t+ t_ ,, _ t ."-...- t 9W i .rr,t - §- u t-em4= s | . " 1 ^ S 1-- S_ 4 _*_-| A <-t ^ I5 4 -* + I-- t'-- | t | 1
342 Denis N. Fuller, Paul Marchand, Monty M. Zion, and Saul Zwi
of a pulmonary valve homograft is reported. The technique of the operation is described. The operation was not difficult, particularly as coronary artery perfusion was not required. The pulmonary valve homograft was not particularly flimsy, and it held sutures without difficulty. Clinical evidence to date suggests competence of the pulmonary valve. The clinical and haemodynamic response will be fully assessed one year after operation.
FIG. 7. Phonocardiogram September 1965, three weeks We wish to express our thanks to Dr. H. Pretorius after surgery, recorded at pulmonary area (logarithmic for permission to reproduce the electrocardiogram in tracing). SM, systolic murmur; A, aortic, and P, pulmonary Fig. 2, and to Mr. A. Shevitz for his assistance with component ofthe second heart sound. all the reproductions.
The electrocardiogram and radiographs were un- changed. REFERENCES SUMMARY AND CONCLUSIONS Ross, J., Jr., Cooper, T., and Brockenbrough, E. C. (1961). Experi- mental replacement of the pulmonic valve with a tricuspid semilunar prosthesis. J. thorac. cardiovase. Surg., 42, 371. A case of pulmonary incompetence following Talbert, J. L., Morrow, A. G., Collins, N. P., and Gilbert, J. W. (1963). The incidence and significance of pulmonic regurgitation after pulmonary valvotomy with treatment by insertion pulmonary valvulotomy. Anier. Heart J., 65, 590. http://thorax.bmj.com/ on September 30, 2021 by guest. Protected copyright.