A calcified, eroded, and thrombosed Mustard: recurrent embolic strokes in a patient with dextro-transpostion of the great arteries corrected by atrial switch—case report

Figures

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  Figure 1. Schematic representation of the Mustard procedure. 1a. Superior venous baffle. 1b. Inferior venous baffle. 2. Pulmonary venous atrium. 3. Subaortic right ventricle. 4. Systemic tricuspid valve. 5. Subpulmonary left ventricle. Illustration taken from http://www.chd-diagrams.com. Illustrations are licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License by the New Media Center of the University of Basel.

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  Figure 2. Echocardiographic findings overtime. (A) Transoesophageal echocardiography performed at the time of the second stroke (8 months after the first stroke). The patient was on edoxaban 60 mg daily and was switched to acenocoumarol (target international normalized ratio 2.5–3.5). (B) Transoesophageal echocardiography performed 3 weeks after (A). The patient was admitted to the hospital, and acenocoumarol (target international normalized ratio 2.5–3.5) was switched to intravenous heparin and aspirin 100 mg daily. (C) Transoesophageal echocardiography performed 2 weeks after (B). The patient discharged on acenocoumarol (target international normalized ratio 2.5–3.5) and aspirin 100 mg daily. (D) Transoesophageal echocardiography performed 4 months after (C). The patient was on acenocoumarol (target international normalized ratio 2.5–3.5) and aspirin 100 mg daily. Green star: floaty thrombus on the pulmonary venous side of the polytetrafluorethylene patch. Red star: pulmonary venous outflow redirecting the blood flow from the pulmonary veins to the tricuspid valve. Yellow star: calcified and thrombotic systemic venous side of the polytetrafluorethylene patch. The ejection fraction of the…

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  Figure 3. The re-do Mustard procedure: (A) Canulations; (B) Right atriotomy showing the systemic venous side of the polytetrafluoroethylene patch; (C) Surgical construction and suturing of the new polytetrafluoroethylene patch. Yellow star: calcified and thrombotic systemic venous side of the polytetrafluorethylene patch. Ao, aorta (cannulated); IVCc, inferior vena cava cannulation; ICV, inferior vena cava; IVCl, inferior vena cava leg of the systemic venous baffle; sRV, systemic right ventricle; SVCc, superior vena cava cannulation; SVCl, superior vena cava leg of the systemic venous baffle.

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  Figure 4. (A) Macroscopic and (B) microscopic findings from the resected polytetrafluorethylene patch. Green star: eroded, calcified and thrombotic side of the pulmonary venous return of the pericardial patch. Note the external insulation of an extracted pacemaker lead (arrow). Yellow star: calcified and thrombotic side of the systemic venous return. MICRO1: calcified pericardial patch at the fractured area. Note the site of the external insulation pacemaker lead (upper right, arrow) and the thrombotic material on the systemic venous (upper middle) and pulmonary venous return (bottom right) sides of the patch. Stain: haematoxylin–eosin; original magnification: 10×; scale bar: 2 mm. MICRO2: Detailed view of the thrombotic material on the systemic venous return side of the patch. Stain: haematoxylin–eosin; original magnification: 40×; scale bar: 0.5 mm.