First Per-ventricular Insertion Of Melody Valve-in-valve In The Neo-aortic Position In A Single Ventricle
Raghav Murthy, Howaida El-Said, John Lamberti.
Rady Children's Hospital, San Diego, CA, USA.
OBJECTIVE: We describe the first reported case of per-ventricular insertion of a Melody Valve, in a failing previously implanted bioprosthetic valve in the neo-aortic position of a patient with hypoplastic left heart syndrome.
METHODS: A 3 kg baby boy with a diagnosis of HLHS (mitral stenosis, aortic stenosis) and a quadricuspid pulmonary valve underwent Norwood with modified BT shunt(3.5 mm) in April 2013. Following discharge, his course was complicated by multiple admissions for poor ventricular function, neo-aortic regurgitation and failure to thrive. Cardiac catheterization and stenting of the mBT shunt, ballooning of stenotic pulmonary veins and dilation of coarctation was performed. At 5 months of age (4.9kg) A 21 mm mitraflow bioprosthetic valve was implanted in the neo-aortic position using a modified Konno technique. At 1 year of age (7.3kgs) the child underwent repair of the tricuspid valve for moderate insufficiency, shunt up sizing to 5 mm and sutureless repair of left lower pulmonary vein stenosis. Secondary to progressive decline in ventricular function and severe prosthetic valve stenosis, he was evaluated and declined for cardiac transplantation. At age 2 years (9.2 kgs) he underwent per-ventricular placement of a Melody Valve, as a valve-in-valve, into the bioprosthesis. Post-operative course required a Nissen, gastrostomy tube and a tracheostomy. He suffered a cardiac arrest at age 2.5 years and was not deemed to be an ECMO candidate and passed away. Autopsy revealed a severely hypertrophied ventricle and a compressed melody valve stent secondary to chest compressions.
RESULTS: Successful implant of the melody valve-in-valve per-ventricularly with survival for 5 months.
CONCLUSIONS: Per-ventricular placement of the Melody Valve is a treatment option for management of failing bioprostehtic valves in the neo-aortic position in patients who are poor surgical candidates.
LEGEND: Picture shows the pre-operative echo with severe prosthetic valve stenosis, cardiac catheterization images during per-ventricular implant of the Melody valve-in-valve and the heart at autopsy. The melody valve and leaflets are intact and functional with compression of the stent from CPR.
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