Abstract
BackgroundRe-intervention after Ross procedure into the right ventricular outflow tract might be needed in patients in the long term. However, right ventricular outflow tract re-intervention indications are still unclear. Comprehensive assessment of total hemodynamics is needed.Case summaryA 42-year-old Japanese woman was referred to our hospital for moderately severe pulmonary regurgitation and severe tricuspid regurgitation after a Ross–Konno procedure. Thirteen years after surgery, she developed atrial fibrillation and atrial flutter and complained of dyspnea. Electrophysiological studies showed re-entry circuit around the low voltage area of the lateral wall on the right atrium. Four-dimensional flow magnetic resonance imaging revealed moderate pulmonary regurgitation, severe tricuspid regurgitation, and a dilated right ventricle. Flow energy loss in right ventricle calculated from four-dimensional flow magnetic resonance imaging was five times higher than in normal controls, suggesting an overload of the right-sided heart system. Her left ventricular ejection fraction was almost preserved. Moreover, the total left interventricular pressure difference, which shows diastolic function, revealed that her sucking force in left ventricle was preserved. After the comprehensive assessments, we performed right ventricular outflow tract reconstruction, tricuspid valve annuloplasty, and right-side Maze procedure. A permanent pacemaker with a single atrial lead was implanted 14 days postoperatively. She was discharged 27 days postoperatively. Echocardiography performed 3 months later showed that the size of the dilated right ventricle had significantly reduced.DiscussionA four-dimensional imaging tool can be useful in the decision of re-operation in patients with complex adult congenital heart disease. The optimal timing of surgery should be considered comprehensively.
Highlights
Introduction the long-term results of the Ross procedure have been improving with acceptable low mortality, it is common that a re-intervention of the right ventricular outflow tract (RVOT) might be needed in the long term, in addition to treating aortic valve or aortic root [1, 2]
Comprehensive assessments that included four-dimensional flow magnetic resonance imaging (MRI), electrophysiology studies, and sucking force of the left ventricle measured via echocardiography, that is, interventricular pressure difference (IVPD), were quite useful in the assessment of total hemodynamics and a successful surgical treatment was performed
We could not measure her flow energy loss (FEL) after the operation by MRI due to pacemaker implantation, echocardiography was performed 3 months later, which showed that the size of right ventricular end-systolic volume index (RVEDVI)/RVESVI had significantly reduced to 113.5/72.7 mL/m2
Summary
The Ross procedure is one of the standard surgical procedures for congenital aortic stenosis. Regarding the right ventricular deterioration, Shibata et al reported that FEL through the pulmonary valve after tetralogy of Fallot (TOF) repair was correlated with QRS duration prolongation in an electrocardiogram [8]. In our case, her FEL of the rightsided heart system calculated from four-dimensional flow MRI was very high due to the combination of. Surgical intervention of the tricuspid and pulmonary valve regurgitation increased the LV preload; the surgical indication should be carefully considered for each patient with an impaired LV function Her total and mid-to-apical IVPD showed that her sucking forces were preserved, suggesting a good tolerance against LV volume increase after re-operation. Electrical mapping before re-operation using Carto® mapping is useful to treat arrhythmia in patients with ACHD
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