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 Table of Contents  
INTERESTING CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 132-133

The Utility of Three-Dimensional Echocardiography in the Assessment of Pulmonary Valve Function in a Novel “Hand-Made” Pulmonary Valve Conduit


1 Department of Pediatric Cardiology, R. K. Hospital, Thanjavur, Tamil Nadu, India
2 Department of Cardiovascular and Thoracic Surgery, GKNM Hospital, Coimbatore, Tamil Nadu, India

Date of Submission18-Oct-2021
Date of Acceptance21-Dec-2021
Date of Web Publication14-Mar-2022

Correspondence Address:
Dr. Mani Ram Krishna
Dr. R. K. Hospital for Women and Children, No 7, V.O.C. Nagar, Thanjavur - 613 007, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_58_21

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  Abstract 

The right ventricle to pulmonary artery valved conduit is a key component of surgeries to rehabilitate the right ventricular outflow tract in children with congenital heart disease. Evaluation of the conduit valve function forms a key part of follow-up evaluation of these children. We report the utility of three-dimensional transthoracic echocardiography to evaluate the conduit valve function in these children.

Keywords: Pulmonary valve echocardiography, three-dimensional transthoracic echocardiography, trileaflet pulmonary valve conduit


How to cite this article:
Krishna MR, Raju V. The Utility of Three-Dimensional Echocardiography in the Assessment of Pulmonary Valve Function in a Novel “Hand-Made” Pulmonary Valve Conduit. J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:132-3

How to cite this URL:
Krishna MR, Raju V. The Utility of Three-Dimensional Echocardiography in the Assessment of Pulmonary Valve Function in a Novel “Hand-Made” Pulmonary Valve Conduit. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2022 Oct 3];6:132-3. Available from: https://jiaecho.org/text.asp?2022/6/2/132/339673


  Introduction Top


The right ventricle to pulmonary artery conduit remains the Achilles heel for the pediatric cardiac surgeon. We recently published our initial experience with a “hand-fashioned” tri-leaflet pericardial valve conduit fashioned using the Ozaki templates, which have been designed for aortic neocuspidization.[1] We then utilized three-dimensional transthoracic echocardiography (TTE) to assess the function of the valve in 2 of our patients on follow-up.


  Case Reports Top


Case 1

A 4-year-old girl with pulmonary atresia and ventricular septal defect, who had initially been palliated with a systemic to pulmonary artery shunt, underwent a complete repair with a “hand-fashioned” tri-leaflet valved conduit. Her surgical recovery was uneventful. When we reviewed her in the outpatient clinic 7 months after surgery, there were no clinical concerns. On two-dimensional imaging from a modified para-sternal short-axis view, the conduit valve leaflets were shown to function normally [Video 1]. There was no significant pulmonary outflow obstruction with the gradient <15 mm Hg or valve incompetence on color Doppler imaging. Three-dimensional evaluation of the conduit valve was obtained using both x-plane imaging and electrocardiogram gated full volume datasets. The full volume datasets were then cropped from both the ventricular and pulmonary arterial aspects to visualize the valve leaflets in the short axis. The mobility of the individual leaflets was found to be satisfactory with good coaptation between the leaflets [Figure 1]a and [Figure 1]b and [Video 2].
Figure 1: (a and b) Three-dimensional echocardiogram image from Case 1 of the three pulmonary valve leaflets in diastole (a arrows) and early systole (b arrows) viewed from the pulmonary arterial aspect

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Video 1: Two-dimensional echocardiogram from case 1 in the modified para-sternal short-axis demonstrating normal motility of the valve and apposition of the leaflets in diastole[Additional file 1]

Video 2: Three-dimensional echocardiogram of the conduit valve from case 1 viewed from the pulmonary arterial aspect demonstrating normal motility of the individual leaflets and no region of nonapposition of the leaflets in diastole[Additional file 2]

Case 2

A 4-year-old girl with atrioventricular septal defect and pulmonary atresia had previously been palliated with bilateral superior cavo-pulmonary anastomosis. She underwent a complete repair with a “hand-fashioned” valved conduit and reattachment of her right superior caval vein to the right atrial appendage. She presented 6 months later with a headache and peri-orbital puffiness. There was obstruction of the right superior caval vein at its attachment to the atrial appendage. When the conduit valve was imaged in the modified para-sternal short axis, there was no significant outflow obstruction with the gradient of only 16 mm Hg. On X-plane imaging, there appeared to be restriction of mobility of one of the leaflets and mild pulmonary incompetence [Video 3]. Three-dimensional evaluation was performed by obtaining electrocardiogram gated full volume datasets. This showed restriction of mobility of one of the leaflets resulting in a small zone of noncoaptation [Figure 2[ and [Video 4].
Figure 2: Three-dimensional echocardiogram image from case 2 demonstrating the three pulmonary valve leaflets in diastole viewed from the pulmonary arterial aspect demonstrating a small zone of noncoaptation (green arrow)

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Video 3: X-plane imaging of the conduit from case 2 suggesting limited mobility of one of the leaflets[Additional file 3]

Video 4: Three-dimensional echocardiogram of the conduit valve from case 2 viewed from the pulmonary arterial aspect demonstrating limited motility of one of the leaflets resulting in a zone of noncoapation[Additional file 4]

Comprehensive evaluation of the pulmonary valve function by trans-thoracic echocardiography is limited by its retro-sternal position and proximity to the left upper lobe of the lung.[2] A short-axis image of the pulmonary valve may be obtained in young children by an experienced operator but becomes progressively difficult with age. Hence, cardiologists and echocardiographers increasingly use three-dimensional echocardiography to evaluate the pulmonary valve anatomy.[3] Despite the established utility of three-dimensional echocardiography in the assessment of the cardiac valves, it has not been widely used in interrogating the pulmonary valve. The adequacy of the three-dimensional dataset often depends on the quality of the two-dimensional images and the limiting factors mentioned for two-dimensional imaging may potentially hinder three-dimensional evaluation. Our initial experience suggests that three-dimensional echocardiography may be a promising tool in assessing the pulmonary valve function in the right ventricle to pulmonary artery conduits.

Informed consent

Informed consent was obtained from the parents of the neonate who was involved in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients' parents have given their consent for their images and other clinical information to be reported in the journal. The patients' parents understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raju V, Padmanabhan C, Baird CW. Alternative uses of the Ozaki technique: Aortic valved conduit in a Bentall operation and right ventricle-to-pulmonary artery conduit. World J Pediatr Congenit Heart Surg 2021;12:406-10.  Back to cited text no. 1
    
2.
Saremi F, Gera A, Ho SY, Hijazi ZM, Sánchez-Quintana D. CT and MR imaging of the pulmonary valve. Radiographics 2014;34:51-71.  Back to cited text no. 2
    
3.
Anwar AM, Soliman O, van den Bosch AE, McGhie JS, Geleijnse ML, ten Cate FJ, et al. Assessment of pulmonary valve and right ventricular outflow tract with real-time three-dimensional echocardiography. Int J Cardiovasc Imaging 2007;23:167-75.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

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