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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
What is Wrong with the Right?
Case#: 24
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
60 yo male with a history of shortness of breath, dyspnea on exertion, and edema.

What is the diagnosis?
What is your recommendation?
Did the postop videos show that the lesion(s) was/were corrected?

What is loop#5?

Case Discussion/CME Questions
The patient has severe tricuspid regurgitation, severe pulmonary regurgitation, and moderate pulmonary stenosis. The right atrium and right ventricle is enlarged. The right ventricle is hypokinetic.

The hepatic vein Doppler profile shows reversal of the systolic wave. The tricuspid regurgitant jet was not very large so the diagnosis is by inference of the hepatic vein Doppler. The tricuspid vale exhibits a Type IIIb lestion - restriction due to right ventricular dilation. The CW Doppler profile indicates severe tricuspid regurgitation by profile density and the Vmax of the right ventricular inflow is near 120 cm/sec - indicating severe tricuspid regurgitation.

The pulmonary valve is restricted also - so what doesn't open normally doesn't close normally - and the pulmonary regurgitation is severe. The pulmonary regurgitant jet is wide and extends more than 2 cm into the RV. In one of the views the pulmonary regurgitation jet is very large and this also increases the tricuspid regurgitant jet. The CW Doppler profile of the pulmonary valve shows a gradient of 30+ mmHg and the pulmonary regurgitant jet is less than holodiastolic - indicating severe pulmonary regurgitation.

In one view the spleen is present and is enlarged as is the IVC and hepatic veins.

The recommendation is to replace the pulmonary valve with a bioprosthetic pericardial valve and to repair the tricuspid valve. Type IIIb lesions of the tricuspid valve are difficult to repair with a ring valvuloplasty only and on the post repair videos it appears that, while the tricuspid regurgitation is improved, it is still severe or moderate, at best. The hepatic vein profile is severely blunted or slightly reversed after the repair - which was an improvement.

Most pulmonary valve replacements occur from congenital heart disease and/or from a pulmonary valve autograft (Ross) procedure. The theory is that since the pulmonary circuit is under less stress/pressure than the left side, pericardial valves should last longer in the pulmonary valve position. Many of the studies are in younger patients.

Pulmonary valve failure risk factors are younger age, Tetralogy of Fallot repair, and the use of a homograft according to Zubari. Bovine pericardial valves were studied for short and medium term results in 73 patients and found that the mean pulmonary gradient was 19 mmHg. After 5 years, over 97% were free from reoperation and over 89% were free from moderate-severe or severe pulmonary regurgitation.

da Costa studied Ross procedure outcomes and notice that the pulmonary artery dilated after the pulmonary valve was replaced with cryopreserved allograft.. An aortic valve annulus > 25 mm was a risk factor for pulmonary artery dilation. Females and bicuspid aortic valves also tended to be associated with the risk of pulmonary artery dilation. About 5% of patients required reoperation for pulmonary artery dilation or RVOT allograft failure. Pulmonary artery dilation was associated with pulmonary regurgitation.

Fiore compared three biological valves in pulmonary valve replacement. Porcine, bovine pericardial and pulmonary homografts were used in 82 patients. Late pulmonary insufficiency was associated with the pulmonary homografts. The right ventricular diameter was reduced in the stented valves but not the allografts. Procine had less failures than the allografts, but, pericardial valves did the best, with about a 5% failure rate. A study by Morales found similar results as Fiore.

Loop #5 is showing an engorged liver and the inferior vena cava. The patient had venous congestion and the liver was enlarged and was scanned during a  transgastric interrogation.
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