Management of severe tricuspid valve regurgitation due to ruptured papillary muscle in a patient with mediastinitis early after heart transplant

OBJECTIVE: Even though severe tricuspid regurgitation is not uncommon after cardiac transplantation, primary severe tricuspid regurgitation is rare. We present such a case with additional complexities. METHODS: The patient was 44-year-old man with a HeartWare durable left ventricular assist device (Heartware Inc) who received a temporary right ventricular assist device (RVAD) with a ProtekDuo cannula (LivaNova Inc USA) for refractory ventricular fibrillation and underwent a heart transplant as United Network for Organ Sharing Status 1, in the presence of partially compensated cardiogenic shock, renal failure. Given complex re-operative surgery in a volume-overloaded patient with unknown pulmonary vascular resistance, an RVAD cannula was preserved and re- inserted during cardiac transplant. Postoperatively he required hemodialysis, had severe primary tricuspid regurgitation discovered after RVAD removal and developed Enterobacter mediastinitis. He underwent complex tricuspid valve repair for flail tricuspid leaflet due to ruptured papillary muscle likely due to RVAD cannula injury, after multiple mediastinal washouts and was followed by delayed chest reconstruction. RESULTS: The patient is doing well, 6 months after discharge to home, asymptomatic, without re-admissions, on renal recovery path, with no tricuspid regurgitation and good biventricular function. CONCLUSIONS: Replacing the tricuspid valve in presence of hemodialysis catheter, immunosuppression and mediastinitis could be high risk for endocarditis. Even though we have short-term follow-up, tricuspid valve repair can be an effective way of managing primary severe regurgitation especially when there is a desire or need to avoid valve replacement

The effect of a large proximal haemodialysis arterio-venous fistula on weaning off cardiopulmonary bypass: case report

An increasing number of renal dialysis-dependent patients with Arterio-Venous fistulae are undergoing cardiac surgery

Imaging modalities for retrieval of a migrated coil from the left ventricle, after pulmonary arterio-venous malformation embolisation

We present a case of a 62-year-old lady who was a known case of hereditary haemorrhagic telangectasia (Rendu-Osler-Weber syndrome) and had pulmonary arteriovenous malformations (AVMs). She had multiple embolisations of pulmonary AVMs. During the last embolisation therapy, one of the coils migrated into the heart. This could not be located by transoesophageal echocardiography, however, was identified in the left ventricle by computerised tomogram scan. It was removed successfully using cardiopulmonary bypass