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1/10. Thrombolysis of prosthetic tricuspid valve thrombosis with human recombinant tissue plasminogen activator in an adolescent.

    Prosthetic heart valve thrombosis is associated with a high mortality. Traditionally, thrombectomy or valve replacement is performed. Thrombolysis offers a promising alternative to surgery. Usually, streptokinase and urokinase are the preferred agents for thrombolysis; however, human recombinant tissue plasminogen activator (rt-PA) is increasingly used. thrombosis of prosthetic valves in children and adolescents is rare and experience of thrombolysis for obstructed valves is limited. We report the successful lysis of a thrombosed prosthetic tricuspid valve in an adolescent using rt-PA. The outcome of our patient supports the assumption that rt-PA represents an adequate therapeutic option for thrombolysis of obstructed prosthetic heart valves in children and adolescents.
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2/10. Fetal diagnosis of lethal dysfunction of the right heart in three siblings.

    A woman, having already delivered one child, underwent fetal echocardiography during three subsequent pregnancies. All three showed enlargement and poor function of the right-sided chambers. The first was still-born, the second died as a neonate, while the third pregnancy was terminated. Pathological examination revealed the same findings in each fetus, possibly representing a variation of Uhl's anomaly, or alternatively a hitherto unrecognised cardiomyopathic process.
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3/10. Beating-heart valvular surgery: a possible alternative for patients with severely compromised ventricular function.

    Cardioplegic arrest of the severely compromised ventricle may make weaning from cardiopulmonary bypass problematic. We report a novel approach to myocardial protection in a patient requiring multi-valve surgery who had an ejection fraction of 15%. Warm oxygenated blood was infused continuously both antegrade and retrograde during aortic valve replacement and mitral and tricuspid valve repair. Adequacy of perfusion was confirmed by the absence of electrocardiographic changes. Clinical improvement suggests that this strategy of myocardial protection warrants further investigation.
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4/10. Arterial switch operation after Mustard procedures in adult patients with transposition of the great arteries: is it time to revise our strategy?

    BACKGROUND: After the Mustard or Senning procedure, adults with transposition of the great arteries may have right ventricular failure and require consideration of new therapies. A 2-stage arterial switch operation (ASO) may be performed as an alternative to heart transplantation. This procedure is relatively successful in children, but little is known about the 2-stage ASO in adults. We report our experience in adults undergoing pulmonary arterial banding as the first stage of a planned 2-stage arterial switch procedure after a failed Mustard operation. methods AND RESULTS: Three adult patients with systemic right ventricular failure late after Mustard procedures embarked, through pulmonary artery banding, on a course toward a 2-stage arterial switch at the Toronto General Hospital. Baseline clinical characteristics as well as preoperative hemodynamics were reviewed. Immediate perioperative and postoperative events, hemodynamic measurements, and clinical outcomes were also recorded. Two patients were banded acutely such that their morphologic left ventricular to right ventricular (LV/RV) systolic pressure ratios were >0.65 after the initial banding procedure. The subpulmonary left ventricle failed in both cases. In contrast, the third patient had a more gradual approach to pulmonary artery banding (PAB), with an initial LV/RV pressure ratio of 0.5, which eventually led to a successful conversion to an arterial switch procedure. CONCLUSIONS: Our evidence suggests that in adult patients expected to undergo a 2-stage arterial switch procedure after a failed Mustard operation, acute PAB achieving near-systemic subpulmonary LV pressure leads rapidly to ventricular failure and failure of this treatment strategy. A more gradual approach to PAB may be required to achieve a successful outcome.
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5/10. Presystolic tricuspid valve closure: an alternative mechanism of diastolic sound genesis.

    We describe a previously unrecognised cause of an added diastolic heart sound. The patient had first-degree heart block and diastolic tricuspid regurgitation, leading to presystolic closure of the tricuspid valve and the production of a loud diastolic sound. Unlike previously described mechanisms for diastolic sounds, this sound was generated by the sudden acceleration of retrograde AV flow in late diastole.
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6/10. Repair of flail anterior leaflets of tricuspid and mitral valves by cusp remodeling.

    We present an alternative approach to extensive rupture of the chordae tendineae leading to flail anterior leaflets. Resection of the affected cusp segment, suture of the cut edges, and extensive plication of the segment of annulus devoid of leaflets abolished massive regurgitation while maintaining an adequate valve orifice.
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7/10. "Balloon valvulotomy" of congenital pulmonary valve stenosis with tricuspid valve insufficiency.

    The rare congenital anomaly of pulmonary valve stenosis and massive tricuspid valve insufficiency with intact ventricular septum is a lethal condition without reported survival after attempted treatment. In a neonate suffering from this syndrome, the pulmonary valve stenosis was relieved by rupturing the fused valve with a balloon catheter introduced transvenously. The desperate condition of the patient quickly improved after this procedure, with subsequent disappearance of the tricuspid valve incompetence. Balloon rupturing of fused valves at angiography may represent a therapeutic alternative in cases in which surgical valvulotomy is associated with a high mortality.
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8/10. Unstented semilunar homograft replacement of tricuspid valve in Ebstein's malformation.

    Tricuspid valve pathology in Ebstein's malformation requires replacement when it is not possible to repair or reconstruct this valve. In smaller children, in whom the right-sided atrioventricular valve is severely dysplastic and right ventricular volume is prohibitive, prosthetic replacement is not always possible. We report here on 3 patients who underwent stentless semilunar homograft replacement (top-hat procedure) of tricuspid valve for Ebstein's anomaly with good short-term outcome. This provides an attractive alternative in the management of a certain difficult subset of patients, avoids long term anticoagulation and probably is more durable.
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9/10. Bidirectional shunt through a residual atrial septal defect after percutaneous transvenous mitral commissurotomy.

    A residual atrial septal defect with bidirectional shunt was detected by transesophageal echocardiography in a 28-year-old man 3 years after percutaneous transluminal mitral commissurotomy (PTMC) with the antegrade transseptal technique. He had had severe mitral stenosis, pulmonary hypertension, and tricuspid regurgitation before the procedure. The result of PTMC was suboptimal, the pulmonary hypertension regressed only partially, and the tricuspid regurgitation remained severe. These factors contributed to the bidirectional shunt. A bidirectional shunt is known to be associated with systemic desaturation and a higher risk of paradoxical embolization and brain abscess. When PTMC is considered in patients with pulmonary hypertension and tricuspid regurgitation, a retrograde left ventricular approach with or without transseptal puncture can avoid the atrial septotomy, decrease the incidence of significant shunt, and should be a rational alternative.
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10/10. Multiple cardiac procedures after heart transplantation: a case report.

    We report on a 56-year-old patient who underwent coronary artery bypass grafting, tricuspid valve replacement, and pacemaker implantation within 49 months after heart transplantation. This case readily demonstrates that multiple cardiac procedures can be safely performed after heart transplantation and may thus serve as an alternative to retransplantation.
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