Pulmonary valve injury: Swan-Ganz or surgery.

Pulmonary artery catheter (PAC) is a commonly used monitor in cardiac surgery. Pulmonary valve injury from the balloon of the pulmonary artery catheter is exceedingly rare; its description by transesophageal echocardiography is nonexistent in the literature. A patient is reported who developed a flail anterior pulmonary leaflet several days after successful myectomy for hypertrophic cardiomyopathy. The temporal sequence of PAC use and four transesophageal echocardiography studies over 13 days, with the first three showing normal pulmonary valves, suggested pulmonary valve trauma, most likely from a Swan-Ganz catheter, as the etiology. Partial damage to the pulmonary valve from the original surgery may have predisposed the patient to further damage when the PAC was reintroduced in the intensive care unit.

Characterization of ultrastructural damage of valves cryopreserved under standard conditions.

Cryopreserved allograft valves are increasingly being used as valvular replacements. This study was conducted to characterize the ultrastructural damage on the allograft valves obtained by a current standard protocol of valve procurement, antibiotic exposure, and cryopreservation, as a basis for future studies on allograft valve preservation. Materials used were seven aortic and seven pulmonary fresh porcine valves, which were cryopreserved according to the requirements of the American and European Associations of Tissue Banks. The samples were randomly assigned into four groups: (1) fresh, untreated; (2) fresh, treated with antibiotics for 24 h.; (3) treated with antibiotics and exposed to dimethyl sulfoxide (without freezing); and (4) treated with antibiotics, exposed to dimethyl sulfoxide, and then cryopreserved and stored until the study. All tissue samples were processed simultaneously for routine light microscopy and transmission electron microscopy. Fresh-untreated, antibiotic-treated, and dimethyl sulfoxide-exposed valves showed adequate preservation of cellular components. However, after cryopreservation significant damage was observed in fibroblasts with signs of apoptotic cellular injury. Our observation suggests that apoptosis occurs during valve processing. This apoptotic process may be related to various factors, including chemical injury or hypoxia.

Echocardiographic detection of pulmonic valve rupture in a horse with right-sided heart failure.

Pulmonic valve rupture was determined to be the cause of severe right-sided heart failure in a 20-year-old Thoroughbred gelding. A flail in the intermediate pulmonic valve cusp was detected by 2-dimensional echocardiography. Significant pulmonic and tricuspid valvular regurgitation were confirmed by Doppler echocardiography. Despite treatment, the horse's condition deteriorated, and euthanasia was performed. At necropsy, a tear in the pulmonary artery extending into the right valve cusp and a tear at the base of the intermediate valve cusp were identified at the junction of the right and intermediate pulmonic valve cusps. Careful echocardiographic evaluation of the pulmonic valve is warranted for horses with right-sided heart failure, for which more common causes cannot be found.

Operative findings after percutaneous pulmonary balloon dilatation of the right ventricular outflow tract in tetralogy of Fallot.

Since 1983 percutaneous balloon dilatation of the right ventricular outflow tract has been performed as an alternative to surgical palliation in selected cases of tetralogy of Fallot at the Royal Liverpool Children's Hospital. From 31 December 1984 to 31 December 1988, 27 of these patients underwent subsequent surgical correction. Age at operation ranged from 7 to 58 months (median 2.7 years). The mean interval between balloon dilatation and correction was 15.6 months (range 3-39 months). Two patients had a systemic pulmonary shunt operation performed before dilatation and a further five required one afterwards. Overall 20 (74%) patients had some anatomical alteration as the result of balloon dilatation, while in seven (26%) there was no discernible change in the right ventricular outflow tract. There was no consistent relation between the ratio of balloon size to pulmonary annulus diameter and the morphological findings. Balloon dilatation may obviate the need for systemic-pulmonary shunt at the expense of some structural damage, particularly to the posterior cusp. The present data suggest that dilatation does not bring about growth of the annulus to such an extent that transannular patch is no longer needed at intracardiac repair.

Morphologic effects of percutaneous balloon pulmonary valvuloplasty.

Five patients with pulmonary valve stenosis and other cardiac anomalies had elective operative repair after percutaneous balloon pulmonary valvuloplasty. Four had reduction in pulmonary valve gradients from 67 +/- 9 mm Hg to 39 +/- 9 mm Hg (P less than .01), whereas one patient with a dysplastic pulmonary valve did not. Operative evaluation of the pulmonary valves revealed the morphologic effects of the balloon forces on the stenotic valves to be commissure splitting in one patient, cusp tear in one patient, and a combination of commissure splitting and cusp avulsion in two patients. There were no deaths. Patients with combined infundibular and pulmonary valve stenosis have a high potential for cusp avulsion due to fixation of the balloon in the infundibulum and retraction of the balloon into the ventricle during systole. Echocardiography, cardiac catheterization pressure gradients, and cineangiography should be used to assess infundibular stenosis and avoid percutaneous balloon angioplasty in patients who have combined pulmonary valve stenosis and infundibular pulmonary stenosis.

[Valve lesions of the right heart associated with use of indwelling pulmonary artery catheters (author's transl)]. / Klappenschäden des rechten Herzens nach Anwendung von Pulmonalarterienverweilkathetern.

Pulmonary artery chatheterisation by means of flow-directed balloon-tipped catheters has proved a valuable aid in assessing haemodynamic parameters of critically ill patients. Serious complications are reported to be uncommon. On postmortem examination of 8 patients, in whom flow-directed balloon-tipped catheters were employed, and whose catheters were dissected in situ, there were 5 instances of non-bacterial thrombotic endocarditis (NBTE) and 4 of focal valvular bleeding. This is a much more frequent incidence of valvular lesions than has been reported previously. The pathogensis of NBTE is briefly disicussed, and attention is drawn to potential long-term complications. We suppose that valvular diseases of the right side of the heart will gain in significance due to the increasing use of flow-directed balloon-tipped pulmonary artery catheters.

Complications of pulmonary artery catheterization in the care of critically ill patients. A prospective study.

In order to evaluate the incidence and the significance of complications resulting from the use of flow--directed, balloon--tipped catheters to monitor critically ill patients, we made a prospective study of 116 pulmonary artery catheterizations. Indications for catheterization included shock, pulmonary edema, or hemodynamic instability following surgery. Arrhythmias, including premature atrial or ventricular depolarizations, ventricular tachycardia, and transient right--bundle branch block occurred during 90 of the 116 insertion procedures, but were unassociated with morbidity or mortality. In two cases (1.7 percent) staphylococcal bacteremia probably originated from the catheter. In addition, the pulmonary artery catheter led to two cases (1.7 percent) of subclavian vein thrombosis. Postmortem examinations revealed perforations of the pulmonic valve in one case. We conclude that although significant complications may result from pulmonary arterial catheterization and monitoring of critically ill patients, the incidence is low.