Severe Stenosis of a Bovine Jugular Vein Graft in Pulmonary Position

Abstract

The bovine jugular vein graft (Contegra, Medtronic Inc, Minneapolis, Minn) has been successfully used as vascular conduit for valve reconstruction in the last few years, generally in the pediatric population. Complications after implantation include thrombosis at the level of the conduit valve (especially in infants), pseudoaneurysm, and stenosis at the level of the distal anastomosis. A 29-year-old man presented with symptoms and signs of right-sided heart failure (ie, exercise intolerance, dyspnea, jugular vein distention, hepatomegaly, ascites, ankle edema). Two and a half years previously, he had undergone Ross procedure because of severe aortic regurgitation caused by intravenous drug abuse–related Staphylococcus aureus endocarditis. The 22-mm bovine jugular vein graft was implanted in pulmonary position. Transthoracic echocardiography revealed a severely stenotic graft at the distal anastomosis to the pulmonary trunk whereas the valve itself appeared normal (Figure 1, A). The supravalvular tissue overgrowth detected was suggestive of massive neointimal hyperplasia. Doppler analysis documented a maximal instantaneous systolic gradient of 105 mm Hg and a mean systolic gradient of 63 mm Hg (Figure 1, B) and color Doppler imaging confirmed flow acceleration at the level of the distal graft anastomosis (Figure 1, C). The patient underwent percutaneous balloon angioplasty and stent implantation (34-mm 8Zig Stent, Numed, Cornwall, Ontario, Canada). Transthoracic echocardiography performed the day of the procedure showed a well-expanded stent with a constant diameter across the graft (Figure 2, A). Doppler echocardiography documented a maximal instantaneous systolic gradient of 37 mm Hg and a mean systolic gradient of 23 mm Hg (Figure 2, B). The diastolic pressure gradient before the atrial contraction wave detected before stenting (Figure 1, B) vanished, indicating lowered