RESUMO
BACKGROUND: Pulmonary valve regurgitation is a significant long-term complication in patients with tetralogy of Fallot (TOF). OBJECTIVE: This study aims to investigate the effects of pulmonary valve implantation (PVI) on the anatomy and function of the right ventricle (RV) and the long-term evolution of the implanted prosthesis in the pulmonary position. METHODS: A single-center retrospective cohort analysis was performed in 56 consecutive patients with TOF who underwent PVI. The study included patients of both sexes, aged ≥ 12 years, and involved assessing clinical and surgical data, pre- and post-operative cardiovascular magnetic resonance imaging, and echocardiogram data more than 1 year after PVI. RESULTS: After PVI, there was a significant decrease in RV end-systolic volume indexed by body surface area (BSA), from 89 mL/BSA to 69 mL/BSA (p < 0.001) and indexed RV end-diastolic volume, from 157 mL/BSA to 116 mL/BSA (p < 0.001). Moreover, there was an increase in corrected RV ejection fraction [ RVEFC = net pulmonary flow (pulmonary forward flow - regurgitant flow) / R V end-diastolic volume ] from 23% to 35% (p < 0.001) and left ventricular ejection fraction from 58% to 60% (p = 0.008). However, a progressive increase in the peak pulmonary valve gradient was observed over time, with 25% of patients experiencing a gradient exceeding 60 mmHg. Smaller prostheses (sizes 19 to 23) were associated with a 4.3-fold higher risk of a gradient > 60 mmHg compared to larger prostheses (sizes 25 to 27; p = 0.029; confidence interval: 1.18 to 17.8). CONCLUSION: As expected, PVI demonstrated improvements in RV volumes and function. Long-term follow-up and surveillance are crucial for assessing the durability of the prosthesis and detecting potential complications. Proper sizing of prostheses is essential for improved prosthesis longevity.
Assuntos
Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar , Valva Pulmonar , Tetralogia de Fallot , Humanos , Tetralogia de Fallot/cirurgia , Tetralogia de Fallot/fisiopatologia , Tetralogia de Fallot/diagnóstico por imagem , Masculino , Feminino , Estudos Retrospectivos , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/etiologia , Valva Pulmonar/cirurgia , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Resultado do Tratamento , Adulto , Adolescente , Adulto Jovem , Fatores de Tempo , Criança , Ecocardiografia , Função Ventricular Direita/fisiologia , Volume Sistólico/fisiologia , Ventrículos do Coração/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Imageamento por Ressonância Magnética , Período Pós-OperatórioRESUMO
BACKGROUND: There are limited data about the impact of timing of pulmonary valve replacement (PVR) on right heart reverse remodeling in patients with pulmonary regurgitation following intervention for isolated pulmonary valve stenosis (PS). This study compared differences in postprocedural right heart reverse remodeling after early versus late PVR (defined as PVR before versus after attainment of the conservative consensus criteria proposed by Bokma et al, 2018) in patients with prior intervention for PS, using patients with tetralogy of Fallot as the reference group. METHOD AND RESULTS: Right atrial reservoir strain and right ventricular free wall strain was measured at baseline, 1 and 3 years after PVR. There were 114 patients with PS (early PVR, 87 [76%]; late PVR, 27 [24%]) and 291 patients with tetralogy of Fallot (early PVR, 197 [67%]; late PVR, 96 [33%]). The PS group had greater improvement in right atrial reservoir strain at 1 year (12%±4% versus 8%±4%; P<0.001) and 3 years (15%±6% versus 9%±6%; P<0.001), and a greater improvement in right ventricular free wall strain at 1 year (12%±4% versus 7%±3%, P=0.008) and 3-years (16%±6% versus 12%±5%; P=0.01) after PVR compared with the tetralogy of Fallot group. There was no difference in right heart reverse remodeling between patients who underwent early versus later PVR within the PS group. In contrast, late PVR was associated with less right heart reverse remodeling within the tetralogy of Fallot group. CONCLUSIONS: These data suggest that patients with palliated PS presenting pulmonary regurgitation have a more benign clinical course, and hence delaying PVR in this population may be appropriate.
Assuntos
Implante de Prótese de Valva Cardíaca , Estenose da Valva Pulmonar , Valva Pulmonar , Tetralogia de Fallot , Função Ventricular Direita , Remodelação Ventricular , Humanos , Tetralogia de Fallot/cirurgia , Tetralogia de Fallot/fisiopatologia , Tetralogia de Fallot/complicações , Estenose da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/fisiopatologia , Estenose da Valva Pulmonar/complicações , Masculino , Feminino , Função Ventricular Direita/fisiologia , Valva Pulmonar/cirurgia , Valva Pulmonar/fisiopatologia , Adulto , Insuficiência da Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/etiologia , Resultado do Tratamento , Adulto Jovem , Fatores de Tempo , Estudos Retrospectivos , AdolescenteRESUMO
OBJECTIVES: The potential risk of autograft dilatation and homograft stenosis after the Ross procedure mandates lifelong follow-up. This retrospective cohort study aimed to determine long-term outcome of the Ross procedure, investigating autograft and homograft failure patterns leading to reintervention. METHODS: All adults who underwent the Ross procedure between 1991 and 2018 at the University Hospitals Leuven were included, with follow-up data collected retrospectively. Autograft implantation was performed using the full root replacement technique. The primary end-point was long-term survival. Secondary end-points were survival free from any reintervention, autograft or homograft reintervention-free survival, and evolution of autograft diameter, homograft gradient and aortic regurgitation grade over time. RESULTS: A total of 173 adult patients (66% male) with a median age of 32 years (range 18-58 years) were included. External support at both the annulus and sinotubular junction was used in 38.7% (67/173). Median follow-up duration was 11.1 years (IQR, 6.4-15.9; 2065 patient-years) with 95% follow-up completeness. There was one (0.6%) perioperative death. Kaplan-Meier estimate for 15-year survival was 91.1% and Ross-related reintervention-free survival was 75.7% (autograft: 83.5%, homograft: 85%). Regression analyses demonstrated progressive neoaortic root dilatation (0.56 mm/year) and increase in homograft gradient (0.72 mmHg/year). CONCLUSIONS: The Ross procedure has the potential to offer excellent long-term survival and reintervention-free survival. These long-term data further confirm that the Ross procedure is a suitable option in young adults with aortic valve disease which should be considered on an individual basis.
Assuntos
Valva Aórtica , Humanos , Adulto , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Adulto Jovem , Adolescente , Seguimentos , Valva Aórtica/cirurgia , Resultado do Tratamento , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Implante de Prótese de Valva Cardíaca/mortalidade , Reoperação/estatística & dados numéricos , Insuficiência da Valva Aórtica/cirurgia , Valva Pulmonar/transplante , Valva Pulmonar/cirurgia , Autoenxertos , Valvopatia Aórtica/cirurgiaRESUMO
INTRODUCTION: Pulmonary regurgitation (PR) remains a common sequela in patients following surgically corrected TOF, and may lead to progressive right ventricle dilatation and dysfunction. The conventional approach of redo-sternotomy for pulmonary valve replacement (PVR) is associated with increased operative time as well as risks of bleeding and injury to the heart and great vessels. Thus, left anterior mini-thoracotomy has become an alternative approach in eliminating the risks of redo-sternotomy in these patients. This series aimed to determine the outcomes of minimally invasive pulmonary valve replacement after surgical TOF correction. METHODS: A retrospective analysis was conducted on 24 patients with severe PR post-surgical TOF correction who underwent left anterior mini-thoracotomy PVR in Penang General Hospital from January 2021 to January 2023. RESULTS: The median age was 23.5 years (I.Q.range 17.6-36.3), with a male:female ratio of 1:4. Majority of patients had mild to moderate symptoms prior to surgery and 19 patients (79.1%) were on regular diuretics medication. All patients had severe free-flow PR with evidence of right ventricular dilatation and dysfunction. Magnetic Resonance Imaging and computed tomography of pulmonary artery were performed prior to surgery. Minimally invasive PVR was performed on all patients via left upper anterior mini-thoracotomy and femoral-femoral bypass without cardioplegic arrest. The operative time and cardiopulmonary bypass time were 208 (I.Q.range 172-324) and 98.6 minutes(I.Q.range 87.4-152.4) respectively. The time to wean off inotropes postoperatively was 6.2 hours (I.Q.range1.4-14.8), and no postoperative arrhythmia and chest re-exploration were reported. Most patients stayed in Intensive Care Unit (ICU) for 10.8 hours (I.Q.range 8.4-36.5), and the total hospital stay was 4.2 days (I.Q.range 3.4-7.6). 2 patients (11.1%) required blood transfusion postoperative. There was no paravalvular leak and no mortality during the follow-up period of up to 28 months. CONCLUSION: Minimally invasive PVR after surgical correction of TOF is a safe alternative to the conventional redo-sternotomy approach in patients with favorable anatomy. This approach is able to reduce the risks associated with redo-sternotomy, particularly bleeding and injury to mediastinal structures, with the additional benefit of expedited recovery and hospital discharge. Our series has shown a safe and efficient approach in these patients with favorable outcomes.
Assuntos
Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Pulmonar , Tetralogia de Fallot , Toracotomia , Humanos , Masculino , Feminino , Tetralogia de Fallot/cirurgia , Estudos Retrospectivos , Adulto , Toracotomia/métodos , Adolescente , Implante de Prótese de Valva Cardíaca/métodos , Adulto Jovem , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/etiologia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Valva Pulmonar/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The Alterra adaptive prestent is a novel self-expanding device designed to provide a landing zone for the 29 mm SAPIEN 3 valve to treat pulmonary regurgitation in patients with a right ventricular outflow tract that is too large for a balloon expandable valve alone. The mechanism of fixation for the Alterra prestent is radial force from the self-expanding stent frame, combined with a unique set of flared "tines" that protrude from both ends of the stent. AIMS, METHODS, AND RESULTS: In this report, we describe 6 patients who underwent uncomplicated transcatheter pulmonary valve replacement with an Alterra adaptive prestent and SAPIEN 3 valve and had surveillance chest computed tomography (CT) scans performed 1 day to 21 months after implant. In each patient, the CT scan demonstrated extravascular extension of a portion of the Alterra prestent, without clinical sequelae, but with extension into the ascending aorta in 1 patient and contact with the ascending aorta, left pulmonary vein, or left atrial appendage in 3 others. CONCLUSIONS: Surveillance CT imaging shows that the Alterra prestent can perforate the pulmonary artery and/or right ventricle. Although no sequelae were seen in these patients, prestent perforation has the potential to be clinically important. Implanters should be aware of this finding and its potential implications. As experience with the Alterra prestent grows, it will be important to further define the risk factors, incidence, and implications of this phenomenon.
Assuntos
Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Valor Preditivo dos Testes , Desenho de Prótese , Humanos , Masculino , Feminino , Resultado do Tratamento , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/efeitos adversos , Fatores de Tempo , Adulto , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/efeitos adversos , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/cirurgia , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/etiologia , Adulto Jovem , Angiografia por Tomografia Computadorizada , Adolescente , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/fisiopatologia , Tomografia Computadorizada por Raios XAssuntos
Valvuloplastia com Balão , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Desenho de Prótese , Valva Pulmonar , Humanos , Resultado do Tratamento , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/efeitos adversos , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/cirurgia , Valva Pulmonar/fisiopatologia , Masculino , Estenose da Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/fisiopatologia , Feminino , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/etiologiaAssuntos
Implante de Prótese de Valva Cardíaca , Valva Pulmonar , Tetralogia de Fallot , Humanos , Tetralogia de Fallot/cirurgia , Tetralogia de Fallot/complicações , Tetralogia de Fallot/fisiopatologia , Masculino , Valva Pulmonar/cirurgia , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/cirurgia , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Valor Preditivo dos Testes , Adolescente , Adulto Jovem , Adulto , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/diagnóstico , Imagem Cinética por Ressonância Magnética , Criança , Resultado do TratamentoRESUMO
BACKGROUND: Studies of transcatheter pulmonary valve replacement (TPVR) with the Melody valve have demonstrated good clinical and hemodynamic outcomes. Our study analyzes the midterm clinical and hemodynamic outcomes for patients who underwent Melody valve implantation in Southeast Asia. METHODS: Patients with circumferential conduits or bioprosthetic valves and experiencing post-operative right ventricular outflow tract (RVOT) dysfunction were recruited for Melody TPVR. RESULTS: Our cohort (n = 14) was evenly divided between pediatric and adult patients. The median age was 19 years (8-38 years), a male-to-female ratio of 6:1 with a median follow-up period of 48 months (16-79 months), and the smallest patient was an 8-year-old boy weighing 18 kg. All TPVR procedures were uneventful and successful with no immediate mortality or conduit rupture. The primary implant indication was combined stenosis and regurgitation. The average conduit diameter was 21 ± 2.3 mm. Concomitant pre-stenting was done in 71.4% of the patients without Melody valve stent fractures (MSFs). Implanted valve size included 22-mm (64.3%), 20-mm (14.3%), and 18-mm (21.4%). After TPVR, the mean gradient across the RVOT was significantly reduced from 41 mmHg (10-48 mmHg) to 16 mmHg (6-35 mmHg) at discharge, p < 0.01. Late follow-up infective endocarditis (IE) was diagnosed in 2 patients (14.3%). Overall freedom from IE was 86% at 79 months follow-up. Three patients (21.4%) developed progressive RVOT gradients. CONCLUSION: For patients in Southeast Asia with RVOT dysfunction, Melody TPVR outcomes are similar to those reported for patients in the US in terms of hemodynamic and clinical improvements. A pre-stenting strategy was adopted and no MSFs were observed. Post-implantation residual stenosis and progressive stenosis of the RVOT require long term monitoring and reintervention. Lastly, IE remained a concern despite vigorous prevention and peri-procedural bacterial endocarditis prophylaxis.
Assuntos
Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Hemodinâmica , Desenho de Prótese , Valva Pulmonar , Recuperação de Função Fisiológica , Humanos , Masculino , Criança , Feminino , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/efeitos adversos , Adolescente , Valva Pulmonar/cirurgia , Valva Pulmonar/fisiopatologia , Valva Pulmonar/diagnóstico por imagem , Resultado do Tratamento , Adulto Jovem , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/efeitos adversos , Fatores de Tempo , Adulto , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Bioprótese , Estenose da Valva Pulmonar/cirurgia , Estenose da Valva Pulmonar/fisiopatologia , Estenose da Valva Pulmonar/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Sudeste AsiáticoAssuntos
Próteses Valvulares Cardíacas , Trombose , Humanos , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/fisiopatologia , Resultado do Tratamento , Falha de Prótese , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/cirurgia , Valva Pulmonar/fisiopatologia , Desenho de Prótese , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/efeitos adversos , Masculino , Inflamação/fisiopatologia , FemininoRESUMO
Over the last 2 decades, experience with transcatheter pulmonary valve replacement (TPVR) has grown significantly and has become an effective and reliable way of treating pulmonary valve regurgitation, right ventricular outflow (RVOT) obstruction, and dysfunctional bioprosthetic valves and conduits. With the introduction of self-expanding valves and prestents, dilated native RVOT can be addressed with the transcatheter approach. In this article, the authors review the current practices, technical challenges, and outcomes of TPVR.
Assuntos
Cateterismo Cardíaco , Cardiopatias Congênitas , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar , Valva Pulmonar , Humanos , Cateterismo Cardíaco/métodos , Implante de Prótese de Valva Cardíaca/métodos , Valva Pulmonar/cirurgia , Cardiopatias Congênitas/cirurgia , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/diagnóstico , Obstrução do Fluxo Ventricular Externo/cirurgia , Desenho de Prótese , BiopróteseRESUMO
In the Ross procedure, a patient's pulmonary valve is transplanted in the aortic position. Despite advantages of this surgery, reoperation is still needed in many cases due to excessive dilatation of the pulmonary autograft. To further understand the failure mechanisms, we propose a multiscale model predicting adaptive processes in the autograft at the cell and tissue scale. The cell-scale model consists of a network model, that includes important signaling pathways and relations between relevant transcription factors and their target genes. The resulting gene activity leads to changes in the mechanical properties of the tissue, modeled as a constrained mixture of collagen, elastin and smooth muscle. The multiscale model is calibrated with findings from experiments in which seven sheep underwent the Ross procedure. The model is then validated against a different set of sheep experiments, for which a qualitative agreement between model and experiment is found. Model outcomes at the cell scale, including the activity of genes and transcription factors, also match experimentally obtained transcriptomics data.
Assuntos
Valva Pulmonar , Valva Pulmonar/cirurgia , Valva Pulmonar/transplante , Animais , Ovinos , Autoenxertos , Transdução de Sinais , Modelos Cardiovasculares , Simulação por Computador , Humanos , Valva Aórtica/cirurgia , Valva Aórtica/patologiaRESUMO
Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. Palliative procedures, either surgical or transcatheter, aim to improve oxygen saturation, affording definitive procedures at a later stage. Transcatheter interventions have been used before and after surgical palliative or definitive repair in children and adults. This review aims to provide an overview of the different catheter-based interventions for TOF across all age groups, with an emphasis on palliative interventions, such as patent arterial duct stenting, right ventricular outflow tract stenting, or balloon pulmonary valvuloplasty in infants and children and transcatheter pulmonary valve replacement in adults with repaired TOF, including the available options for a large, dilated native right ventricular outflow tract.
Assuntos
Valvuloplastia com Balão , Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Cuidados Paliativos , Stents , Tetralogia de Fallot , Humanos , Tetralogia de Fallot/cirurgia , Tetralogia de Fallot/diagnóstico por imagem , Tetralogia de Fallot/fisiopatologia , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/efeitos adversos , Lactente , Resultado do Tratamento , Fatores Etários , Pré-Escolar , Criança , Adulto , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/efeitos adversos , Adolescente , Recém-Nascido , Adulto Jovem , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Fatores de Risco , Feminino , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/cirurgia , Valva Pulmonar/fisiopatologia , Masculino , Hemodinâmica , Pessoa de Meia-Idade , Recuperação de Função FisiológicaRESUMO
Partial heart transplantation (PHT) is a novel surgical approach that involves transplantation of only the part of the heart containing a valve. The rationale for this approach is to deliver growing heart valve implants that reduce the need for future re-operations in children. However, prior to clinical application of this approach, it was important to assess it in a preclinical model. To investigate PHT short-term outcomes and safety, we performed PHT in a piglet model. Yorkshire piglets (n = 14) were used for PHT of the pulmonary valve. Donor and recipient pairs were matched based on blood types. The piglets underwent PHT at an average age of 44 days (range 34-53). Post-operatively, the piglets were monitored for a period of two months. Of the 7 recipient piglets, one mortality occurred secondary to anesthesia complications while undergoing a routine echocardiogram on post-operative day 19. All piglets had appropriate weight gain and laboratory findings throughout the post-operative period indicating a general state of good health and rehabilitation after undergoing PHT. We conclude that PHT has good short-term survival in the swine model. PHT appears to be safe for clinical application.
Assuntos
Transplante de Coração , Animais , Transplante de Coração/métodos , Transplante de Coração/efeitos adversos , Suínos , Valva Pulmonar/cirurgia , Modelos Animais , Modelos Animais de DoençasRESUMO
OBJECTIVE: In young patients, aortic valve disease is often treated by placement of a pulmonary autograft (PA) which adapts to its new environment through growth and remodeling. To better understand the hemodynamic forces acting on the highly distensible PA in the acute phase after surgery, we developed a fluid-structure interaction (FSI) framework and comprehensively compared hemodynamics and wall shear-stress (WSS) metrics with a computational fluid dynamic (CFD) simulation. METHODS: The FSI framework couples a prestressed non-linear hyperelastic arterial tissue model with a fluid model using the in-house coupling code CoCoNuT. Geometry, material parameters and boundary conditions are based on in-vivo measurements. Hemodynamics, time-averaged WSS (TAWSS), oscillatory shear index (OSI) and topological shear variation index (TSVI) are evaluated qualitatively and quantitatively for 3 different sheeps. RESULTS: Despite systolic-to-diastolic volumetric changes of the PA in the order of 20 %, the point-by-point correlation of TAWSS and OSI obtained through CFD and FSI remains high (r > 0.9, p < 0.01) for TAWSS and (r > 0.8, p < 0.01) for OSI). Instantaneous WSS divergence patterns qualitatively preserve similarities, but large deformations of the PA leads to a decrease of the correlation between FSI and CFD resolved TSVI (r < 0.7, p < 0.01). Moderate co-localization between FSI and CFD is observed for low thresholds of TAWSS and high thresholds of OSI and TSVI. CONCLUSION: FSI might be warranted if we were to use the TSVI as a mechano-biological driver for growth and remodeling of PA due to varying intra-vascular flow structures and near wall hemodynamics because of the large expansion of the PA.
Assuntos
Hemodinâmica , Modelos Cardiovasculares , Artéria Pulmonar , Hemodinâmica/fisiologia , Artéria Pulmonar/fisiologia , Artéria Pulmonar/fisiopatologia , Hidrodinâmica , Animais , Humanos , Simulação por Computador , Valva Pulmonar/cirurgia , Valva Pulmonar/fisiologia , Autoenxertos , Estresse MecânicoRESUMO
Introduction: The pulmonic valve-sparing technique (PVS) is an emerging approach of right ventricular outflow tract reconstruction in tetralogy of Fallot (TOF) correction aimed at reducing the incidence of pulmonic regurgitation (PR) and the need for subsequent reintervention. This study aims to compare the long-term occurrence of moderate to severe PR/stenosis (PR/PS) between three different approaches. Patients and Methods: We conducted a retrospective cohort study involving 173 patients who underwent TOF correction at Chiang Mai University hospital between January 2006 and December 2016. The patients were divided into three groups: transannular patch (TAP; n = 88, 50.9%), monocusp insertion (MCI; n = 40, 23.1%), and PVS (n = 45, 26%). The study assessed freedom from moderate to severe PR/PS. Results: The median overall follow-up time was 79.8 months (interquartile range: 50.7-115.5 months. The PVS exhibited larger PV Z-score (-2.6 ± 2.3 mm, P < .001), with predominantly tricuspid morphology (64.4%). The PVS had significantly shorter median ventilator time, intensive care unit stay, hospital stay, and longer median follow-up time. Postoperative moderate-severe PR was lower in the PVS group (P < .001), with no significant difference in PS (P = .356) and complications among the groups. Freedom from moderate-severe PR/PS was longer in the MCI group (2.8, 0.2-42.3 months vs 30.9, 0.2-50.9 months, respectively). Multivariable analysis showed TAP and MCI had a higher risk of developing moderate-severe PR (hazard ratio [HR] 2.51; 95% confidence interval [CI] 1.23-5.13 vs HR 1.41; 95%CI 0.59-3.38) but lower risk of moderate-severe PS (HR 0.14; 95%CI 0.02-0.9 vs HR 0.39; 95%CI 0.05-3.19). Conclusion: Pulmonic valve-sparing reconstruction showed promise in preventing late moderate-severe PR in patients with favorable PV anatomy. However, it should be noted that this technique is associated with a higher incidence of PS.
Assuntos
Insuficiência da Valva Pulmonar , Valva Pulmonar , Tetralogia de Fallot , Humanos , Estudos Retrospectivos , Tetralogia de Fallot/cirurgia , Feminino , Masculino , Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Pré-Escolar , Lactente , Seguimentos , Resultado do Tratamento , Criança , Fatores de Tempo , Obstrução do Fluxo Ventricular Externo/cirurgia , Ventrículos do Coração/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaAssuntos
Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Valva Pulmonar , Trombose , Humanos , Trombose/etiologia , Trombose/diagnóstico por imagem , Trombose/diagnóstico , Implante de Prótese de Valva Cardíaca/efeitos adversos , Valva Pulmonar/cirurgia , Valva Pulmonar/diagnóstico por imagem , Cateterismo Cardíaco/efeitos adversos , Masculino , Feminino , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/fisiopatologia , Ecocardiografia Transesofagiana , Próteses Valvulares Cardíacas/efeitos adversos , Resultado do TratamentoRESUMO
Transcatheter pulmonary valve implantation (TPVI) is indicated for use in the management of failing pulmonary valves in humans. We report here the long-term follow-up of the first documented transcatheter pulmonary valve implanted in a client-owned dog. A one-year-old Beagle dog with severe congenital type A valvular pulmonic stenosis first underwent percutaneous balloon pulmonary valvuloplasty, leading two years later to severe pulmonary regurgitation. A TPVI using a Melody™ bioprosthetic valve was then successfully performed, with normalization of the right heart cavities. Repeated two- and three-dimensional transthoracic echocardiographic examinations combined with Doppler modes confirmed the appropriate position and function of the valve for four years. Mitral myxomatous valvular degeneration led to refractory left-sided congestive heart failure, and the dog was humanely euthanized. After postmortem examination, X-ray imaging and histopathological evaluation of the stent and the valve were performed. Ex-vivo imaging of the implanted valve using a Faxitron® Path radiography system and microscopic evaluation of the implanted stent and bioprosthetic leaflets did not show any relevant leaflet or stent alterations. This case provides a proof of concept in interventional veterinary cardiology, showing that TPVI can be performed in dogs with subsequent long-term maintaining normal pulmonary valve function.
Assuntos
Doenças do Cão , Implante de Prótese de Valva Cardíaca , Estenose da Valva Pulmonar , Valva Pulmonar , Animais , Cães , Doenças do Cão/cirurgia , Doenças do Cão/diagnóstico por imagem , Doenças do Cão/patologia , Estenose da Valva Pulmonar/veterinária , Estenose da Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/patologia , Implante de Prótese de Valva Cardíaca/veterinária , Implante de Prótese de Valva Cardíaca/instrumentação , Ecocardiografia Tridimensional/veterinária , Insuficiência da Valva Pulmonar/veterinária , Insuficiência da Valva Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Ecocardiografia/veterinária , Bioprótese/veterinária , Masculino , Próteses Valvulares Cardíacas/veterinária , FemininoRESUMO
BACKGROUND: In patients with tetralogy of Fallot (ToF) or ToF-like anatomy, factors possibly impacting the longevity of biological valves in the pulmonary position were investigated. METHOD: Between 1997 and 2017, 79 consecutive hospital survivors with a median age of 8.7 years (range: 0.2-56.1 years; interquartile range [IQR]: 14.8 years) with ToF or ToF-like anatomy underwent surgical implantation of Contegra (n = 34), Hancock (n = 23), Perimount (n = 9), pulmonary homograft (n = 9), and miscellaneous (n = 4) conduits. The median internal graft diameter was 19 mm (range: 11-29 mm; IQR: 8 mm) which refers to a median z-score of 0.6 standard deviation (SD) (range: -1.8 to 4.0 SD; IQR: 2.1 SD). RESULTS: The median time of follow-up was 9.4 years (range: 1.1-18.8 years; IQR: 6.0 years). Thirty-nine patients (49%) underwent surgical (n = 32) or interventional (n = 7) pulmonary valve re-replacement. Univariate Cox regression revealed patient age (p = 0.018), body surface area (p = 0.004), internal valve diameter (p = 0.005), and prosthesis z-score (p = 0.018) to impact valve longevity. Multivariate Cox regression analysis, however, did not show any significant effect (likely related to multicollinearity). Subgroup analysis showed that valve-revised patients have a higher average z-score (p = 0.003) and younger average age (p = 0.007). CONCLUSION: A decreased longevity of biological valves in the pulmonary position is related to younger age, lower valve diameter, and higher z-score. Because valve size (diameter and z-score) can be predicted by age, patient age is the crucial parameter influencing graft longevity.