ABC | Volume 115, Nº1, Suplement, July 2020

Clinicoradiological Correlation Atik & Barbero-Marcial Pulmonary stenosis after Barbero-Marcial technique in truncus arteriosus Arq Bras Cardiol 2020; 115(1Suppl.1):37-39 23.6 x 17.6mm - distal: 21.0 x 17.6mm 4) Descending aorta: - proximal: 13.9 x 13.5mm - thoraco-abdominal transition: 11.4 x 9.6mm. 5) Pulmonary trunk: 17.1 x 13.6 mm (Z-score -2.27). 6) Right pulmonary artery: 16.3 x 13.0 mm (Z-score 0.35). 7) Left pulmonary artery: 11.7 x 10.1 mm (Z-score -0.96). 9) Left ventricle: - Ejection fraction: 49% - Indexed end-diastolic volume: 82.4 mL / m². Clinical Diagnosis: Truncus arteriosus Type I submitted to an early operation using the Barbero-Marcial technique, with severe and progressive pulmonary stenosis observed in adolescence, in an asymptomatic patient. Clinical reasoning: The evolution clinical elements were compatible with the diagnosis of progressive pulmonary stenosis since the correction of the basal defect, the Truncus arteriosus Type I. The absence of symptoms was expected in the presence of the insidious occurrence of the obstruction over time. The greatest progression of stenosis had occurred in the last three years, probably due to the greater calcification of the monocusp during this period. Differential diagnosis: Pulmonary valve injury after surgical correction can occur in any situation in which the pulmonary valve is previously repaired. Its diagnosis is simple, attained through the presence of a systolic murmur in the pulmonary area, plus right ventricular myocardial hypertrophy in imaging exams. Figure 2 – Angiotomography of the heart in four-cavity and cross-sectional views, highlighting myocardial hypertrophy of the right ventricle and the right ventricular outflow tract without dilation but with a clearly calcified monocusp valve (arrows). Abbreviations: PT: pulmonary trunk, RV: right ventricle, LV: left ventricle, RVOT: right ventricular outflow tract. Conduct: Considering the progression of the residual defect at the pulmonary valve level, with acquired characteristics such as myocardial hypertrophy and right ventricular dysfunction, the intervention approach in the obstructed region was easily assimilated. Given the adequate anatomy of the pulmonary valve region, with a diameter of 14 mm and without RV outflow tract dilation, it was considered pertinent to approach it using interventional cardiac catheterization. The use of a Melody prosthetic valve was the technique of choice, with the inconvenience of the possibility of occurrence of infectious endocarditis in a bovine jugular vein valve. The fact that the coronary arteries were well away from the right ventricular outflow tract favored the established assumption. Comments: The use of the Barbero-Marcial 1 technique for correction of the truncus arteriosus Type I, developed in 1989, is usually accompanied by pulmonary valve insufficiency due to the RV outflow tract dilation at the anastomosis with the pulmonary trunk, which is pulled towards it. It also accompanies the placement of a monocusp, which, analogously to what occurs after the correction of the Tetralogy of Fallot, also favors the subsequent evolution of progressive pulmonary regurgitation. These patients require correction of the residual defect and almost always by surgical intervention, due to the large dilation in the region, which makes it impossible to place an intravenous prosthesis. 38