Assuntos
Humanos , Adulto , Cardiopatias Congênitas/cirurgia , Cardiopatias Congênitas/terapia , Coartação Aórtica/diagnóstico , Coartação Aórtica/terapia , Estenose da Valva Aórtica/cirurgia , Arritmias Cardíacas , Insuficiência da Valva Pulmonar/terapia , Tetralogia de Fallot , Transposição dos Grandes Vasos , Morte Súbita Cardíaca , Anomalia de Ebstein/terapia , Bloqueio Atrioventricular/terapia , Comunicação Interatrial/terapia , Comunicação Interventricular/terapiaRESUMO
Transcatheter pulmonary valve placement is emerging as a standard therapy for dysfunctional right ventricular outflow tract conduits. The Melody transcatheter pulmonary valve is indicated for use in the management of pediatric and adult patients with right ventricular outflow tract conduits measuring at least 16 mm in diameter. This is the first reported case of placement in a patient with a left ventricular assist device. We outline the preprocedural evaluation process, the procedural methods, and the outcomes of a successful implantation in a complex patient. With a team-based approach including thoughtful preprocedural evaluation, and close monitoring, successful deployment of a transcatheter pulmonary valve is possible in complex patients in the setting of mechanical circulatory support.
Assuntos
Cateterismo Cardíaco/métodos , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Coração Auxiliar , Insuficiência da Valva Pulmonar/terapia , Valva Pulmonar/cirurgia , Adulto , Ecocardiografia Transesofagiana , Feminino , Fluoroscopia , Humanos , Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/diagnósticoRESUMO
BACKGROUND: In patients with Noonan syndrome (NS), cardiac disorders such as pulmonary valve stenosis (PS) or hypertrophic cardiomyopathy (HCM) are common. While some patients can develop heart failure associated with HCM, the long-term outcome of adult patients with NS is reported to be good. Fatal outcomes of heart failure in patients with NS but without HCM are rare. CASE PRESENTATION: We report a 25-year-old Japanese woman diagnosed with NS in adulthood. She exhibited short stature and minor facial dysmorphism and was diagnosed with PS at 1 year of age. After surgical valvuloplasty for PS at 6 years of age, her general condition became stable without specific medical treatment. She discontinued regular medical follow-up for PS. At 21 years of age, she developed acute decompensated heart failure, which was mainly right-sided heart failure due to severe pulmonary regurgitation (PR) and tricuspid regurgitation (TR). There was no evidence of HCM or PS recurrence. On the basis of the history of PS and characteristic physical features including short stature, webbed neck, and hypertelorism, she was clinically diagnosed with NS. At 25 years of age, she developed heart failure of both sides due to PR, TR and late-onset severe mitral stenosis (MS). The etiology of MS was uncertain. Owing to the patient's condition, surgical options were considered to be extremely high risk. She was treated with optimal medical treatment as well as the occasional abdominal cavity drainage for recurrent ascites; however, she died of decompensated heart failure at 27 years of age. CONCLUSIONS: We describe an adult patient with NS without HCM who died of heart failure caused by severe PR, TR and MS. Clinicians should recognize that ongoing or late-onset cardiac disorders can develop in patients with NS, and lead to fatal heart failure. Optimal medical follow-up to monitor cardiac function and early identification of heart failure are important.
Assuntos
Insuficiência Cardíaca/etiologia , Estenose da Valva Mitral/etiologia , Síndrome de Noonan/complicações , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Tricúspide/etiologia , Adulto , Ecocardiografia Doppler em Cores , Evolução Fatal , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Estenose da Valva Mitral/diagnóstico por imagem , Estenose da Valva Mitral/fisiopatologia , Estenose da Valva Mitral/terapia , Síndrome de Noonan/diagnóstico , Síndrome de Noonan/terapia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/terapia , Índice de Gravidade de Doença , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/terapiaRESUMO
Severe pulmonary regurgitation (PR) most commonly occurs as a sequelae of treatment of pulmonic stenosis or Tetralogy of Fallot with fewer cases of primary pulmonic valvular regurgitation. The amount of PR is influenced by valvular integrity, right ventricular (RV) size, and RV diastolic pressures. In chronic severe PR, the RV remodels to accommodate the regurgitant flow and RV stroke volume increases to maintain effective forward blood flow. Hemodynamic changes include a widened pulmonary artery (PA) pulse pressure and low PA diastolic pressures. As the amount of regurgitation increases, RV end diastolic pressure becomes elevated and systemic cardiac output is reduced, especially with exercise. "Ventricularization" of the PA pressure tracing, in which the contour of the PA pressure is similar to the contour of the RV pressure, is a specific but not sensitive finding in severe PR. © 2015 Wiley Periodicals, Inc.
Assuntos
Hemodinâmica , Artéria Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Valva Pulmonar/fisiopatologia , Adaptação Fisiológica , Idoso , Cateterismo de Swan-Ganz , Doença Crônica , Eletrocardiografia , Feminino , Humanos , Valor Preditivo dos Testes , Prognóstico , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/terapia , Fatores de Risco , Índice de Gravidade de Doença , Remodelação Vascular , Função Ventricular Direita , Remodelação VentricularRESUMO
Pulmonary valve replacement (PVR) is indicated in patients with significant pulmonary regurgitation (PR), stenosis (PS), or mixed pulmonary valve disease. While once an exclusively surgical procedure, many patients can undergo transcatheter PVR (TPVR) with excellent early outcomes (Haas et al. 2013, Clin. Res. Cardiol. Off. J. German Cardiac Soc. 102:119-128; Kenny et al. 2011, J. Am. Coll. Cardiol. 58:2248-2256; Cheatham et al. Circulation 2015, 131:1960-1970). The available transcatheter options continue to expand, but the majority of cases performed in the United States involve the use of FDA approved Melody valve (Medtronic; Minneapolis, MN) or the SAPIEN (Edwards Lifesciences; Irvine, CA) family of valves. The SAPIEN 3 valve (S3) recently received FDA approval for transcatheter aortic valve replacement. We report the first S3 implantation in the pulmonary position for treatment of chronic pulmonary regurgitation and progressive right ventricular dilation in an 18 year old male with repaired Tetralogy of Fallot. © 2016 Wiley Periodicals, Inc.
Assuntos
Cateterismo Cardíaco/instrumentação , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/terapia , Tetralogia de Fallot/cirurgia , Obstrução do Fluxo Ventricular Externo/terapia , Adolescente , Cateterismo Cardíaco/métodos , Doença Crônica , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Desenho de Prótese , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/etiologia , Índice de Gravidade de Doença , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/etiologiaRESUMO
Percutaneous pulmonary valve implantation has gradually become the first line strategy for re-intervention for right ventricular outflow tract dysfunction during long-term follow-up after congenital cardiac surgery in many centers. We describe a case of a patient with double outlet right ventricle (Fallot's type) with a doubly committed subarterial ventricular septal defect, where the unique anatomy precluded percutaneous pulmonary valve implantation. © 2016 Wiley Periodicals, Inc.
Assuntos
Anormalidades Múltiplas , Cateterismo Cardíaco , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Dupla Via de Saída do Ventrículo Direito/cirurgia , Comunicação Interventricular/complicações , Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Pulmonar/terapia , Valva Pulmonar , Obstrução do Fluxo Ventricular Externo/terapia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Aortografia , Valvuloplastia com Balão/efeitos adversos , Cateterismo Cardíaco/instrumentação , Pré-Escolar , Contraindicações , Dupla Via de Saída do Ventrículo Direito/complicações , Dupla Via de Saída do Ventrículo Direito/diagnóstico por imagem , Dupla Via de Saída do Ventrículo Direito/fisiopatologia , Feminino , Comunicação Interventricular/diagnóstico por imagem , Implante de Prótese de Valva Cardíaca/instrumentação , Hemodinâmica , Humanos , Valor Preditivo dos Testes , Valva Pulmonar/diagnóstico por imagem , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/fisiopatologia , Fatores de Risco , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/etiologia , Obstrução do Fluxo Ventricular Externo/fisiopatologiaRESUMO
O implante transcateter da valva pulmonar (ITVP) evoluiu significativamente desde sua introdução, no início dos anos 2000. Atualmente, esta técnica é uma opção segura e eficaz para o tratamento das disfunções valvares graves (estenose e/ou insuficiência) em biopróteses ou condutos cirúrgicos em posição pulmonar, em vários centros do mundo. No Brasil, os resultados iniciais com este procedimento em centros de referência foram similares àqueles observados na experiência global. O ITVP tem se demonstrado factível, seguro e eficaz em mãos treinadas na nossa realidade. Porém, antes da aplicação disseminada desta técnica em outros centros em nosso país, houve a necessidade de se estabelecerem alguns critérios para a seleção do paciente, a técnica de implante e o seguimento clínico, assim como para o treinamento e o credenciamento de novos operadores e centros. As orientações aqui descritas foram determinadas por um grupo de especialistas com experiência renomada em cardiopatias congênitas e ITVP, tendo sido encaminhadas ao Conselho Federal de Medicina (CFM). Representantes das diferentes sociedades médicas foram envolvidas na preparação deste documento, incluindo a Sociedade Brasileira de Cardiologia (SBC), a Sociedade Brasileira de Hemodinâmica e Cardiologia Invasiva (SBHCI) e a Sociedade Brasileira de Cirurgia Cardiovascular (SBCCV). Acreditamos que a rígida aderência às recomendações listadas neste documento oficial seja crucial para a segurança do paciente e para que ótimos resultados sejam alcançados imediatamente e a longo prazo. Uma vez consolidado em nosso meio, o ITVP abrirá caminho para a introdução de novas terapias valvares em cardiopatias congênitas
Transcatheter pulmonary valve implantation (TPVI) has evolved significantly since its introduction in the early 2000s. Currently, this technique is a safe and effective option for the treatment of severe valve dysfunction (stenosis and/or regurgitation) in bioprostheses or surgical conduits in pulmonary position, in several centers worldwide. In Brazil, the initial results with this procedure in reference centers were similar to those observed in the overall experience. TPVI was proven to be feasible, safe, and effective in trained hands in Brazil. However, prior to the widespread application of this technique to other centers in this country, it was necessary to establish some criteria for patient selection, implantation technique, and clinical follow-up, as well as for the training and accreditation of new interventionists and centers. The guidelines described here were determined by a group of experts with well-known experience in congenital heart disease and TPVI, and were referred to the Conselho Federal de Medicina (CFM, portuguese for Federal Council of Medicine). Representatives of the different medical societies were involved in the creation of this document, including the Sociedade Brasileira de Cardiologia (SBC, portuguese for Brazilian Society of Cardiology), the Sociedade Brasileira de Hemodinâmica e Cardiologia Invasiva (SBHCI, portuguese for Brazilian Society of Hemodynamics and Invasive Cardiology), and the Sociedade Brasileira de Cirurgia Cardiovascular (SBCCV, portuguese for Brazilian Society of Cardiovascular Surgery). The authors believe that strict adherence to the recommendations contained in this official document is crucial for patient safety and for optimal results to be achieved in both the short and long term. Once consolidated in Brazil, TPVI will open doors for the introduction of new valve therapies in congenital cardiopathies
Assuntos
Humanos , Masculino , Feminino , Próteses e Implantes , Valva Pulmonar , Brasil , Protocolos Clínicos/normas , Acreditação de Instituições de Saúde , Diretrizes para o Planejamento em Saúde , Artéria Pulmonar , Insuficiência da Valva Pulmonar/terapia , Estenose da Valva Pulmonar/terapia , Bioprótese , Ecocardiografia/métodos , Cateterismo Cardíaco/métodos , Cardiopatias Congênitas , Ventrículos do Coração/cirurgiaRESUMO
Transcatheter pulmonary valves are being used off-label to treat pulmonary insufficiency in patched right ventricular outflow tracts (RVOTs). We describe the first reported cases of patched RVOT rupture, during balloon sizing for percutaneous pulmonary valve implantation, in two patients with tetralogy of Fallot status post repair. Both RVOTs were too large for subsequent catheter-based intervention. The ruptures remained stable over time, and both patients were managed conservatively with follow-up imaging.
Assuntos
Valvuloplastia com Balão , Cateterismo Cardíaco/instrumentação , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/terapia , Valva Pulmonar , Tetralogia de Fallot/cirurgia , Obstrução do Fluxo Ventricular Externo/terapia , Adolescente , Cateterismo Cardíaco/métodos , Criança , Angiografia Coronária , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Lactente , Recém-Nascido , Masculino , Desenho de Prótese , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Tetralogia de Fallot/diagnóstico , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/etiologia , Obstrução do Fluxo Ventricular Externo/fisiopatologiaRESUMO
AIMS: Conduit rupture is a serious complication encountered during percutaneous pulmonary valve implantation (PPVI). We sought to evaluate the incidence and predictors of conduit rupture during right ventricular outflow tract (RVOT) transcatheter treatment. METHODS AND RESULTS: All consecutive patients who underwent transcatheter RVOT treatment from May 2008 to December 2011 were prospectively studied. Baseline demographics along with incidence, predictors and outcomes of conduit rupture with various transcatheter therapies were reviewed. Conduit rupture occurred in nine out of 99 patients (9.09%). All conduit ruptures occurred during balloon dilatation. Significant risk factors included heavy calcification (p<0.05, OR=16 [1.87-357]), and conduit type (homograft/others; p<0.05, OR=4.37 [1.1-17.8]). Other factors such as prolonged time interval between prior surgical RVOT repair and interventions, use of high-pressure balloons, balloon diameter, and overexpansion of conduit statistically failed to show any association. All patients were managed in the cardiac catheterisation laboratory. There were no delayed complications during a mean follow-up period of 2.3±0.95 years. CONCLUSIONS: Conduit rupture is a serious complication. Heavy calcification and homograft conduit were significant predictors. Immediate diagnosis with the use of targeted interventional therapies should be attempted before proceeding with PPVI.
Assuntos
Implante de Prótese Vascular/efeitos adversos , Prótese Vascular , Cateterismo Cardíaco/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Falha de Prótese , Insuficiência da Valva Pulmonar/terapia , Valva Pulmonar/fisiopatologia , Obstrução do Fluxo Ventricular Externo/terapia , Adolescente , Adulto , Aloenxertos , Valvuloplastia com Balão/efeitos adversos , Implante de Prótese Vascular/instrumentação , Cateterismo Cardíaco/instrumentação , Distribuição de Qui-Quadrado , Cineangiografia , Feminino , França , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Prospectivos , Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/diagnóstico , Obstrução do Fluxo Ventricular Externo/etiologia , Adulto JovemRESUMO
BACKGROUND: Transcatheter pulmonary valve replacement (tPVR) is an accepted therapy for treatment of dysfunctional right ventricular outflow tract (RVOT) conduits. At present, the majority of Fallot patients who undergo transannular patch (TAP) repair are not candidates for tPVR due to the large irregular nature of their RVOT. Herein, we describe a novel approach to assessing the RVOT in this group, which may then be used to design, test, and carry out hybrid RVOT modification and transcatheter valve implantation in this population. METHODS: A retrospective analysis of TAP patients who underwent 3D modeling of the RVOT which was then used to develop individualized hybrid procedures designed to modify the RVOT, thereby rendering patients suitable for transcatheter valve implantation. RESULTS: Eight consecutive patients underwent 3D RVOT modeling followed by hybrid implantation of a transcatheter valve via a perventricular approach. A landing zone stent was placed in all and four required additional intravascular geometric remodeling of the RVOT prior to valve implant. Transcatheter valves were successfully implanted in all. There were no instances of valve malposition, embolization, or death. There was one minor procedural complication. No patient had more than trivial pulmonary regurgitation at follow-up. CONCLUSIONS: Using a hybrid approach to remodel the RVOT in TAP patients supported by preprocedural 3D-model planning allows for successful tPVR implantation in this population. A larger cohort and longer follow-up will be needed to determine the ultimate utility of this approach.
Assuntos
Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Pulmonar/terapia , Valva Pulmonar , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Cateterismo Cardíaco/instrumentação , Criança , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Imageamento Tridimensional , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Modelos Anatômicos , Modelos Cardiovasculares , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Radiografia Intervencionista , Estudos Retrospectivos , Stents , Tetralogia de Fallot/diagnóstico , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto JovemRESUMO
The emergence of transcatheter valve technology over the last decade has made significant impact on the treatment of patients with valvular heart disease. There has been increasing experience with both native and valve-in-valve indications with promising results. We present the case of a young woman with congenital heart disease who underwent the Ross procedure for bicuspid aortic valve endocarditis with subsequent reoperation and surgical aortic valve replacement for neo-aortic root dilation who experienced worsening symptoms related to both pulmonary and aortic valve dysfunction. She was successfully treated with percutaneous pulmonary and aortic valve replacement with excellent early term technical results and marked improvement in symptoms.
Assuntos
Insuficiência da Valva Aórtica/terapia , Valva Aórtica/anormalidades , Cateterismo Cardíaco/métodos , Doenças das Valvas Cardíacas/cirurgia , Insuficiência da Valva Pulmonar/terapia , Stents , Adulto , Angiografia/métodos , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Doença da Válvula Aórtica Bicúspide , Procedimentos Cirúrgicos Cardíacos/métodos , Feminino , Seguimentos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/cirurgia , Doenças das Valvas Cardíacas/congênito , Doenças das Valvas Cardíacas/diagnóstico por imagem , Humanos , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Medição de Risco , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
Balloon angioplasty and stent placement in close proximity to the bifurcation of the branch pulmonary arteries can be challenging. Multiple approaches have been previously described, though none of these approaches both treats bilateral proximal branch pulmonary artery stenosis and provides an anchor for a transcatheter pulmonary valve replacement. We report a novel approach that involves serial stent placement and balloon dilation through the struts of the stent in each pulmonary artery, along with balloon expansion of the proximal portion of the stents to the diameter of the main pulmonary artery. In the two cases we describe, this strategy resulted in significant relief of branch pulmonary artery obstruction without compromising the anatomy of the main pulmonary artery segment. This technique can be an effective way to alleviate stenoses of the bilateral proximal branch pulmonary arteries and provides a landing zone for a future transcatheter pulmonary valve.
Assuntos
Angioplastia com Balão/métodos , Arteriopatias Oclusivas/terapia , Cateterismo Cardíaco/métodos , Artéria Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/terapia , Stents , Adolescente , Adulto , Angiografia/métodos , Arteriopatias Oclusivas/diagnóstico por imagem , Procedimentos Endovasculares/métodos , Seguimentos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Artéria Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Medição de Risco , Estudos de Amostragem , Tetralogia de Fallot/cirurgia , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/terapiaAssuntos
Cateterismo Cardíaco/métodos , Implante de Prótese de Valva Cardíaca/métodos , Síndrome do Carcinoide Maligno/complicações , Insuficiência da Valva Pulmonar/terapia , Valva Pulmonar , Insuficiência da Valva Tricúspide/cirurgia , Valva Tricúspide/cirurgia , Idoso , Valvuloplastia com Balão , Bioprótese , Cateterismo Cardíaco/instrumentação , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Síndrome do Carcinoide Maligno/diagnóstico , Desenho de Prótese , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Índice de Gravidade de Doença , Resultado do Tratamento , Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/fisiopatologiaRESUMO
Transcatheter therapies in structural heart disease have evolved tremendously over the past 15 years. Since the introduction of the first balloon-expandable valves for stenotic lesions with implantation in the pulmonic position in 2000, treatment for valvular heart disease in the outflow position has become more refined, with newer-generation devices, alternative techniques, and novel access approaches. Recent efforts into the inflow position and regurgitant lesions, with transcatheter repair and replacement technologies, have expanded our potential to treat a broader, more heterogeneous patient population. The evolution of multimodality imaging has paralleled these developments. Three- and 4-dimensional visualization and concomitant use of novel technologies, such as fusion imaging, have supported technical growth, from pre-procedural planning and intraprocedural guidance, to assessment of acute results and follow-up. A multimodality approach has allowed operators to overcome many limitations of each modality and facilitated integration of a multidisciplinary team for treatment of this complex patient population.
Assuntos
Doenças das Valvas Cardíacas/terapia , Insuficiência da Valva Aórtica/terapia , Cateterismo Cardíaco , Diagnóstico por Imagem , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/fisiopatologia , Próteses Valvulares Cardíacas , Humanos , Insuficiência da Valva Mitral/terapia , Insuficiência da Valva Pulmonar/terapia , Insuficiência da Valva Tricúspide/terapiaRESUMO
We describe a 29 mm Sapien XT valve implantation in a 10-year-old girl with repaired Tetralogy of Fallot, severe pulmonary regurgitation, and right ventricular dilatation, using the NovaFlex+ delivery system and the expandable introducer eSheath, without pre-stenting of the right ventricular outflow tract.
Assuntos
Cateterismo Cardíaco/métodos , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/terapia , Tetralogia de Fallot/cirurgia , Obstrução do Fluxo Ventricular Externo/cirurgia , Angiografia/métodos , Criança , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Desenho de Prótese , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/etiologia , Medição de Risco , Tetralogia de Fallot/complicações , Fatores de Tempo , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/complicações , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagemRESUMO
OBJECTIVES AND BACKGROUND: Patient-specific finite element (FE) simulations were used to assess different transcatheter valve devices and help select the most appropriate treatment strategy for a patient (17-year-old male) with borderline dimensions for Melody® percutaneous pulmonary valve implantation (PPVI). METHODS AND RESULTS: Patient-specific implantation site morphology was derived from cardiovascular magnetic resonance (CMR) images along with the implantation site mechanical behavior by coupling systolic/diastolic dimensions and the pressure gradient in a linear elastic model, and iterative tuning. In this way, the model accounted for the mechanical response not only of the arterial wall, but also of the surrounding tissue. Four stents (2 balloon-expandable including prestenting and 2 self-expandable) were virtually implanted and the stent final configuration, anchoring, migration forces, arterial wall stresses, paravalvular regurgitation, and device mechanical performance were evaluated. A Sapien29 device with prestenting was indicated as the optimal approach for this specific patient as it had a fully open valve, safe anchoring along the entire circumference, low risk of paravalvular leak, and arterial rupture. However, at the time of the PPVI procedure, after balloon sizing, device implantation was suspended due to perceived high risk of device embolization. CONCLUSIONS: FE analysis allows a comparison between different treatment scenarios to add information to the clinical decision making process. However, further studies are required to fully predict patient-specific response to stenting and therefore true clinical outcomes.
Assuntos
Cateterismo Cardíaco/métodos , Simulação por Computador , Análise de Elementos Finitos , Próteses Valvulares Cardíacas , Insuficiência da Valva Pulmonar/terapia , Adolescente , Tomada de Decisão Clínica , Seguimentos , Humanos , Imagem Cinética por Ressonância Magnética/métodos , Masculino , Modelos Cardiovasculares , Desenho de Prótese , Insuficiência da Valva Pulmonar/diagnóstico , Medição de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: The aim of the study was to evaluate the role of cardiopulmonary exercise testing (CPET) parameters in assessing exercise capacity improvement after percutaneous pulmonary valve implantation (PPVI). Additionally, it aimed to determine if there are any baseline characteristics influencing that change. METHODS AND RESULTS: The study comprised 32 patients (mean age 26 ± 9); 53% males; diagnosis: tetralogy of Fallot (n = 18), pulmonary atresia (n = 6), Ross procedure (n = 4), other (transposition of great arteries, pulmonary stenosis, double outlet right ventricle, common arterial trunk type II--n = 4) who underwent successful PPVI due to right ventricular out-flow tract dysfunction (predominant pulmonary regurgitation--n = 17, predominant pulmonary stenosis--n = 15). Treadmill CPET was performed before and a year after PPVI along with clinical evaluation, cardiac magnetic resonance and transthoracic echocardiography. Twelve months post successful PPVI (pulmonary valve competence restoration and pulmonary gradient reduction from 58.8 ± 47.1 to 26.6 ± 10.8 mm Hg) there was a significant decrease in the ventilatory equivalent for CO2 at peak exercise (EQCO2) (25.3 ± 3.3 to 24.3 ± 3.0, p = 0.04) and oxygen consumption at peak exercise (pVO2) (20.4 ± 5.0 to 22.6 ± 5.3 mL/kg/min, p = 0.04). Improved EQCO2 correlated with an increase in right and left ventricular ejection fraction (respectively R = -0.57, p = 0.002; R = -0.56, p = 0.002). In this study, no baseline factors that might affect improvement in exercise function were found. CONCLUSIONS: Successful PPVI leads to an improvement in exercise capacity and hemodynamic response to exercise. The correlation between the improvement in EQCO2 or peak VO2 and baseline characteristics was too weak to reliably identify the group of patients that will benefit from the procedure.
Assuntos
Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos , Tolerância ao Exercício , Cardiopatias Congênitas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Pulmonar/terapia , Estenose da Valva Pulmonar/terapia , Valva Pulmonar/fisiopatologia , Adolescente , Adulto , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ecocardiografia , Teste de Esforço , Feminino , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/fisiopatologia , Hemodinâmica , Humanos , Imageamento por Ressonância Magnética , Masculino , Consumo de Oxigênio , Seleção de Pacientes , Valor Preditivo dos Testes , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/etiologia , Insuficiência da Valva Pulmonar/fisiopatologia , Estenose da Valva Pulmonar/diagnóstico , Estenose da Valva Pulmonar/etiologia , Estenose da Valva Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Percutaneous pulmonary valve implantation (PPVI) is a safe, less invasive alternative to surgical valve replacement for the congenital heart disease patient with right ventricular (RV) outflow tract dysfunction. The aim of this study was to determine whether reverse RV remodeling after PPVI was persistent in the longer term and whether timing of PPVI influenced outcomes. METHODS AND RESULTS: Consecutive patients from the pediatric and adult congenital heart disease programs were enrolled. Cardiac MRI, echocardiography, metabolic exercise testing, chest radiography, and hemodynamics before intervention were compared with repeated follow-up measurements to assess changes over time. Fifty-one patients (including 23 patients <16 years old) were followed for a mean 4.5±1.9 (0.9-6.9) years after implantation, 59% of patients having available comparative cardiac MRI data. Freedom from any reintervention was 87% and 68% at 3 and 5 years, and freedom from surgery was 90% at 5 years. For every decade younger at implantation, there was an increase of 3.9%±1.0% in cardiac MRI left ventricular ejection fraction (P<0.001) and 2.4±0.9 mL/kg/min in maxVO2 (P=0.005) and a decrease of 0.7±0.2 cm in RV end-diastolic dimension (P<0.001) after intervention. Younger patients displayed an additional decline in the RV/left ventricular end-diastolic volume ratio (P=0.05) and trended toward improved RV ejection fraction in late follow-up (50%±7% versus 41%±12%, P=0.07). CONCLUSIONS: This is the largest series to show that PPVI at a younger age yields incremental improvements in RV size and maximum oxygen consumption. Early valve implantation is associated with better RV function and should be considered in management planning for this population.