Congenital Heart Surgeons' Society

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The Neo-aortic Valve That Would Not Stop Leaking
Christopher J. Knott-Craig.
Le Bonheur Children's Hospital, Memphis, TN, USA.

Objective(s): Significant neo-aortic valve regurgitation requiring intervention following successful Norwood operation is uncommon, and surgical options are limited.
Methods: A full-term infant with HLHS (AA/MA) underwent uncomplicated Norwood-Sano operation and later bidirectional Glenn anastomosis at age 7 months. Discharge echocardiogram documented trivial neo-aortic regurgitation. Four months later, following viral myocarditis, the patient developed severe neo-aortic valve and tricuspid valve regurgitation with well-preserved function and without arch obstruction.
Results: Patient underwent complex tricuspid and neo-aortic valve repair. The tricuspid valve was fully competent and the neo-aortic regurgitation downgraded to mild. Despite being extubated and clinically fine, within 4 days the neo-aortic regurgitation was again severe. The patient returned to operating room and the neo-aortic valve was again repaired, then replaced with a 17 mm aortic homograft as a root; the diminutive Damus was reimplanted with a patch augmentation. By echocardiogram, the homograft root also leaked 2-3/4. Reconstituting bypass the homograft root was opened and annular plication was done and bypass discontinued with good hemodynamics and excellent function. But with persistent moderate regurgitation. While closing the chest, the patient acutely decompensated; echocardiogram now demonstrated severe ventricular disfunction. The patient was converted to an LVAD using the aortic and right atrial cannulas. And the patient was listed for emergent transplant. A Melody valve was planned via a mini left anterior thoracotomy. While inflating the Melody valve, the aortic suture lines were disrupted and the patient exsanguinated within minutes.
Conclusions: The pursuit of excellence is fraught with disasters lurking around each corner.