2025 FSA Podium and Poster Abstracts

Introduction/Background: Congenital anomalies of pulmonic valve (PV) are uncommon (0.76/1,000 live births for pulmonic stenosis (PS), scant literature on pulmonic insufficiency (PI)) and typically present in childhood with progressive PI, PS, and right ventricular outflow tract (RVOT) obstruction requiring surgical intervention. We present the rare case of an adult patient with a history of childhood PV repair, now with mild PS, severe PI, and pulmonary artery (PA) aneurysm. 

Case Report: A 59-year-old male with hypertension, diabetes, and repaired PS at 14-years-old presented with progressive dyspnea and fatigue. Preoperative transesophageal echocardiography (TEE) revealed severe PI, mild PS, and patent foramen ovale (PFO). Electrocardiogram revealed right bundle branch block. Chest contrast computed tomography (CT) demonstrated PA dilatation (3cm, Figure 1). 

Following preinduction radial arterial line, general anesthesia was induced without incident using etomidate, fentanyl, and rocuronium, employing central venous catheterization and TEE. Femoral artery sheath was placed prior to sternotomy given concern for potential iatrogenic PA aneurysm rupture. Following uneventful redo sternotomy and cardiac dissection, cardiopulmonary bypass was instituted with bicaval venous cannulas and distal ascending aorta arterial cannula.

Perioperative TEE revealed moderately dilated RV (end systolic area 21cm2) with mildly reduced function (fractional area change 33%), severe PI (Figure 2), mild PS, PA dilatation (2.99cm), and PFO (bidirectional flow) (Figure 3). Surgical findings confirmed unicuspid PV (extraordinarily rare variant, Figure 4), PA aneurysm, and PFO. 25mm Inspiris bioprosthetic valve was placed in pulmonary position. PA aneurysm was closed with bovine pericardial patch. PFO was closed with running suture. TEE confirmed well-seated bioprosthetic PV without perivalvular leak (acceptable mean gradient of 5mmHg), PFO closure, and PA aneurysm resolution. Patient was weaned from CPB with standard inotropic support and transferred to ICU without complications.

Discussion/Conclusion: Redo sternotomies carry intrinsic surgical risks including bleeding risk from existing right-sided surgical grafts/conduits and PA aneurysm due their anterior anatomic nature. Anticipation of potential (spontaneous or sternotomy) PA rupture or injury to the modified RVOT highlights the importance of pre-sternotomy invasive access if the patient needs to crash on pump. Intraoperative TEE assists surgical decision-making and verifies repair. 

Anesthetic considerations of PA aneurysm emphasize preventing sympathetic surges in blood pressure to avoid rupture while ensuring adequate coronary and cerebral perfusion pressures, requiring placement of a preinduction arterial line. Long standing PS complicates the clinical picture causing RV hypertrophy, RV dysfunction, tricuspid regurgitation, and right atrial enlargement. Long standing PI leads to RV dilatation and RV dysfunction. It is critical to avoid hypovolemia, increased contractility, and decreased systemic vascular resistance to decrease risk of RVOT obstruction in patients with RV dysfunction. This case highlights unique anesthetic and surgical challenges posed by reoperative right-sided cardiac surgery adults with rare congenital anomalies. 

Images:

Figure 1: PA Aneurysm

Figure 2: PI Jet

Figure 3: PFO 

Figure 4: 3D PV

References:

1. Zhao QM, et al. Prevalence of Congenital Heart Disease at Live Birth in China. J Pediatr. 2019;204:53-58.
2. Fathallah M, et al. Pulmonic Valve Disease: Review of Pathology and Current Treatment Options. Curr Cardiol Rep. 2017;19(11):108. Published 2017 Sep 16.