LAUSR

Introduction Right sided valvular regurgitation is a rare complication after heart transplantation, and can occur with hyperacute rejection or later from repeated endomyocardial biopsy. Early surgical intervention has been recommended when managing a tricuspid regurgitant valve post transplantation. We describe a case of severe tricuspid and pulmonic valve regurgitation after heart transplantation. Case Report A 39 yo male with D-TGA, post Mustard repair that progressed into end stage HF. He underwent uncomplicated orthotopic heart transplantation with bicaval anastomosis from a young donor with normal cardiac structures and function on TEE and visual survey. Intraoperative TEE showed moderate tricuspid and moderate pulmonic valve regurgitation. A PA catheter was thought to be contributing to the central regurgitant jet; the RV size and function were normal, the PA pressures were also normal. Post operatively patient developed progressive right heart failure syndrome with worsening regurgitation despite diuresis and removal of the PA catheter. Endomyocardial biopsy did not show any signs of rejection. Repeated TEE showed normal biventricular function, torrential TR with pan systolic flow reversal in the hepatic vein due to non coaptation of the leaflets. The pulmonic valve was also severely insufficient with a central regurgitant jet and holodiastolic flow reversal in the pulmonary arteries. The patient underwent a tricuspid repair with a 30mm tricuspid ring and pulmonic valve replacement with a 25 mm bovine valve on POD 10. Surgical endomyocardial biopsy had no evidence of rejection. His heart failure symptoms resolved and he was discharged 4 weeks post op. Summary We describe a novel case of a 39 yo orthotopic heart transplant recipient with acute post operative concomitant TR and PI with right heart failure requiring a tricuspid ring annuloplasty and pulmonic valve replacement. To date, there are no such reported complications after heart transplant. The incidence of isolated tricuspid valve regurgitation after heart transplant have decreased with the bicaval transplantation technique however not eliminated. Literature suggests that isolated moderate to severe tricuspid valve regurgitation should under a repair or replacement early post transplantation. Pulmonic valve insufficiency is extremely rare after heart transplant and management strategies are not well defined.