日本小児循環器学会雑誌 Pediatric Cardiology and Cardiac Surgery

A 32-year-old American man visited our outpatient clinic for a chief complaint of exertional dyspnea. His medical history was remarkable for the diagnosis of d-TGA, Rastelli operation, right ventricular outflow tract (RVOT) reimplantation of the conduit twice, and plastic surgery for a thoracic deformity. Because of the progression of RVOT stenosis, a Melody valve was implanted when he was 24 years old and living in New York. On physical examination, harsh systolic ejection murmur of Levine 3/VI at his third left sternal border was audible. Chest X-ray demonstrated three metal plates bridging his bilateral thorax. Echocardiography revealed paradoxical movement of the interventricular septum, flattened left ventricular cavity, and 55–60 mmHg pressure gradient due by tricuspid regurgitation. The stenotic site of his RVOT was not apparent because of the artifact. The plasma hANP and BNP levels were 54.1 and 54.7 pg/ml, respectively. Because of his past medical history of multiple cardiovascular and thoracic surgeries, surgical reconstruction of his stenotic RVOT was assessed to be too risky. A Melody valve-in-valve implantation was performed in Los Angeles, California, and he returned to our hospital 1 month later. His quality of life has significantly improved, and his heart murmur changed to a soft murmur. During the procedure, the stent fracture was confirmed to be responsible for RVOT restenosis, although the frontal view chest X-ray failed to reveal it. Approval is awaited for clinical use of the Melody valve in Japan.