Abstract
To the Editors: A 63-yr-old female underwent aortic and mitral valve replacement surgery (ATS 18 and 29 mm, respectively; ATS Medical, Inc., Minneapolis, MN, USA) for aortic stenosis and mitral incompetence in August 2009. Pre-operatively, she was in New York Heart Association class III and exhibited comorbid hypertension, obstructive sleep apnoea (managed with night-time continuous positive airway pressure), obesity (body mass index of 42 kg·m−2) and hypercholesterolaemia. Pre-operative right and left heart catheter investigation demonstrated a normal left ventricular ejection fraction, mean aortic valve gradient of 42 mmHg (normal 0–10 mmHg), valve opening area of 0.7 cm2 (normal >2 cm2), mean pulmonary arterial pressure of 48 mmHg (normal 12–16 mmHg), pulmonary vascular resistance of 225 dyn·s·cm−5 (normal 100–200 dyn·s·cm−5), pulmonary capillary wedge pressure of 34 mmHg and cardiac output of 4.97 L·min−1. Her medication included an angiotensin-converting enzyme inhibitor, diuretics and aspirin. Her post-operative course was complicated by a sternal wound infection, mediastinitis, pneumonia and renal failure requiring continuous high-flow haemodiafiltration. On the 14th post-operative day, she developed right heart failure (central venous pressure (CVP) of 25 mmHg, mean arterial pressure ( P a) of 60 mmHg and severely impaired right ventricular function …
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