Case report
A 77-year-old woman underwent mitral valve replacement (MVR) and tricuspid annuloplasty (TAP) for severe mitral valve stenosis and severe tricuspid regurgitation complicated with pulmonary hypertension and atrial fibrillation. Atrial fibrillation was not corrected because of severe dilation of both atria and disappearance of the f-wave on the electrocardiogram. Mitral annular calcification at the posteromedial site was debrided using an ultrasound aspirator. A bioprosthesis and a rigid prosthetic ring were used for the MVR and TAP, respectively. The patient was discharged without adverse events. Three months after the operation, the patient suddenly complained of shortness of breath on exertion and severe peripheral edema. A new harsh pansystolic murmur was auscultated at the 4th left sternal border. Although there was an interventricular shunt on the transthoracic echocardiogram, transesophageal echocardiography revealed that the jet was not an interventricular shunt but from the LV to the RA (Fig.1). The bioprosthetic valve functioned normally and no paravalvular leakage was detected. After intensive medical treatment for congestive heart failure, the LV-RA communication was repaired. A defect, 6mm in diameter, was located just cephalad to the anterosepatal commissure of the tricuspid valve. The lower margin of the defect was bordered by the annulus of the tricuspid valve (Fig.2). The anterior edge of the rigid prosthetic ring was detached to achieve single stitch width. Close inspection of the tricuspid valve revealed no interventricular communication. 15mm of the anterior edge of the rigid prosthetic ring was resected, because that part of the ring interfered with defect repair. The defect was closed using a xenopericardial patch with five pledget mattress sutures. The inferior part of the patch was fixed using two mattress sutures, that were anchored to the interventricular septum and then passed through the annulus of the tricuspid valve to avoid the conduction system. No intracardiac shunt was detected on transesophageal echocardiography after repair. The patient recovered uneventfully and has been doing well with no signs of congestive heart failure after discharge.