ABSTRACT
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.
Subject(s)
Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Pulmonary Valve Insufficiency , Pulmonary Valve , Tetralogy of Fallot , Humans , Tetralogy of Fallot/surgery , Tetralogy of Fallot/physiopathology , Tetralogy of Fallot/diagnostic imaging , Male , Female , Retrospective Studies , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/diagnostic imaging , Pulmonary Valve Insufficiency/etiology , Pulmonary Valve/surgery , Pulmonary Valve/diagnostic imaging , Pulmonary Valve/physiopathology , Treatment Outcome , Adult , Adolescent , Young Adult , Time Factors , Child , Echocardiography , Ventricular Function, Right/physiology , Stroke Volume/physiology , Heart Ventricles/physiopathology , Heart Ventricles/diagnostic imaging , Magnetic Resonance Imaging , Postoperative PeriodABSTRACT
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.
Subject(s)
Heart Valve Prosthesis Implantation , Pulmonary Valve Stenosis , Pulmonary Valve , Tetralogy of Fallot , Ventricular Function, Right , Ventricular Remodeling , Humans , Tetralogy of Fallot/surgery , Tetralogy of Fallot/physiopathology , Tetralogy of Fallot/complications , Pulmonary Valve Stenosis/surgery , Pulmonary Valve Stenosis/physiopathology , Pulmonary Valve Stenosis/complications , Male , Female , Ventricular Function, Right/physiology , Pulmonary Valve/surgery , Pulmonary Valve/physiopathology , Adult , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/etiology , Treatment Outcome , Young Adult , Time Factors , Retrospective Studies , AdolescentABSTRACT
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.
Subject(s)
Heart Valve Prosthesis Implantation , Pulmonary Valve Insufficiency , Tetralogy of Fallot , Thoracotomy , Humans , Male , Female , Tetralogy of Fallot/surgery , Retrospective Studies , Adult , Thoracotomy/methods , Adolescent , Heart Valve Prosthesis Implantation/methods , Young Adult , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/etiology , Minimally Invasive Surgical Procedures/methods , Pulmonary Valve/surgery , Treatment OutcomeABSTRACT
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.
Subject(s)
Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Predictive Value of Tests , Prosthesis Design , Humans , Male , Female , Treatment Outcome , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/adverse effects , Time Factors , Adult , Cardiac Catheterization/instrumentation , Cardiac Catheterization/adverse effects , Pulmonary Valve/diagnostic imaging , Pulmonary Valve/surgery , Pulmonary Valve/physiopathology , Pulmonary Valve Insufficiency/diagnostic imaging , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/etiology , Young Adult , Computed Tomography Angiography , Adolescent , Pulmonary Artery/diagnostic imaging , Pulmonary Artery/physiopathology , Tomography, X-Ray ComputedSubject(s)
Balloon Valvuloplasty , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Prosthesis Design , Pulmonary Valve , Humans , Treatment Outcome , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/adverse effects , Pulmonary Valve/diagnostic imaging , Pulmonary Valve/surgery , Pulmonary Valve/physiopathology , Male , Pulmonary Valve Stenosis/diagnostic imaging , Pulmonary Valve Stenosis/surgery , Pulmonary Valve Stenosis/physiopathology , Female , Pulmonary Valve Insufficiency/diagnostic imaging , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/etiologySubject(s)
Heart Valve Prosthesis Implantation , Pulmonary Valve , Tetralogy of Fallot , Humans , Tetralogy of Fallot/surgery , Tetralogy of Fallot/complications , Tetralogy of Fallot/physiopathology , Male , Pulmonary Valve/surgery , Pulmonary Valve/diagnostic imaging , Pulmonary Valve/physiopathology , Female , Heart Valve Prosthesis Implantation/adverse effects , Tachycardia, Ventricular/physiopathology , Tachycardia, Ventricular/surgery , Tachycardia, Ventricular/diagnosis , Tachycardia, Ventricular/etiology , Predictive Value of Tests , Adolescent , Young Adult , Adult , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/diagnostic imaging , Pulmonary Valve Insufficiency/etiology , Pulmonary Valve Insufficiency/diagnosis , Magnetic Resonance Imaging, Cine , Child , Treatment OutcomeABSTRACT
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.
Subject(s)
Cardiac Catheterization , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Hemodynamics , Prosthesis Design , Pulmonary Valve , Recovery of Function , Humans , Male , Child , Female , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/adverse effects , Adolescent , Pulmonary Valve/surgery , Pulmonary Valve/physiopathology , Pulmonary Valve/diagnostic imaging , Treatment Outcome , Young Adult , Cardiac Catheterization/instrumentation , Cardiac Catheterization/adverse effects , Time Factors , Adult , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/etiology , Pulmonary Valve Insufficiency/diagnostic imaging , Bioprosthesis , Pulmonary Valve Stenosis/surgery , Pulmonary Valve Stenosis/physiopathology , Pulmonary Valve Stenosis/diagnostic imaging , Retrospective Studies , Risk Factors , Asia, SoutheasternABSTRACT
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.
Subject(s)
Cardiac Catheterization , Heart Defects, Congenital , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Pulmonary Valve Insufficiency , Pulmonary Valve , Humans , Cardiac Catheterization/methods , Heart Valve Prosthesis Implantation/methods , Pulmonary Valve/surgery , Heart Defects, Congenital/surgery , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/diagnosis , Ventricular Outflow Obstruction/surgery , Prosthesis Design , BioprosthesisABSTRACT
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.
Subject(s)
Pulmonary Valve Insufficiency , Pulmonary Valve , Tetralogy of Fallot , Humans , Retrospective Studies , Tetralogy of Fallot/surgery , Female , Male , Pulmonary Valve/surgery , Pulmonary Valve Insufficiency/surgery , Plastic Surgery Procedures/methods , Cardiac Surgical Procedures/methods , Cardiac Surgical Procedures/adverse effects , Child, Preschool , Infant , Follow-Up Studies , Treatment Outcome , Child , Time Factors , Ventricular Outflow Obstruction/surgery , Heart Ventricles/surgery , Postoperative Complications/prevention & control , Postoperative Complications/epidemiology , Postoperative Complications/etiologySubject(s)
Cardiac Catheterization , Heart Valve Prosthesis Implantation , Pulmonary Valve , Thrombosis , Humans , Thrombosis/etiology , Thrombosis/diagnostic imaging , Thrombosis/diagnosis , Heart Valve Prosthesis Implantation/adverse effects , Pulmonary Valve/surgery , Pulmonary Valve/diagnostic imaging , Cardiac Catheterization/adverse effects , Male , Female , Pulmonary Valve Insufficiency/etiology , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/diagnostic imaging , Pulmonary Valve Insufficiency/physiopathology , Echocardiography, Transesophageal , Heart Valve Prosthesis/adverse effects , Treatment OutcomeABSTRACT
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.
Subject(s)
Dog Diseases , Heart Valve Prosthesis Implantation , Pulmonary Valve Stenosis , Pulmonary Valve , Animals , Dogs , Dog Diseases/surgery , Dog Diseases/diagnostic imaging , Dog Diseases/pathology , Pulmonary Valve Stenosis/veterinary , Pulmonary Valve Stenosis/diagnostic imaging , Pulmonary Valve Stenosis/surgery , Pulmonary Valve/surgery , Pulmonary Valve/diagnostic imaging , Pulmonary Valve/pathology , Heart Valve Prosthesis Implantation/veterinary , Heart Valve Prosthesis Implantation/instrumentation , Echocardiography, Three-Dimensional/veterinary , Pulmonary Valve Insufficiency/veterinary , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/diagnostic imaging , Echocardiography/veterinary , Bioprosthesis/veterinary , Male , Heart Valve Prosthesis/veterinary , FemaleABSTRACT
Repaired Tetralogy of Fallot (rTOF) patients suffer from pulmonary regurgitation and may require pulmonary valve replacement (PVR). Cardiac magnetic resonance imaging (cMRI) guides therapy, but conventional measurements do not quantify the intracardiac flow effects from pulmonary regurgitation or PVR. This study investigates intracardiac flow parameters of the right ventricle (RV) of rTOF by computational fluid dynamics (CFD). cMRI of rTOF patients and controls were retrospectively included. Feature-tracking captured RV endocardial contours from long-axis/short-axis cine. Ventricular motion was reconstructed via diffeomorphic mapping, serving as domain boundary for CFD simulations. Vorticity (1/s), viscous energy loss (ELoss, mJ/L) and turbulent kinetic energy (TKE, mJ/L) were quantified in RV outflow tract (RVOT) and RV inflow. These parameters were normalized against total RV kinetic energy (KE) and RV inflow vorticity to derive dimensionless metrics. Vorticity contours by Q-criterion were qualitatively compared. rTOF patients (n = 15) had mean regurgitant fraction 38 ± 12% and RV size 162 ± 35 mL/m2. Compared to controls (n = 12), rTOF had increased RVOT vorticity (142.6 ± 75.6/s vs. 40.4 ± 11.8/s, p < 0.0001), Eloss (55.6 ± 42.5 vs. 5.2 ± 4.4 mJ/L, p = 0.0004), and TKE (5.7 ± 5.9 vs. 0.84 ± 0.46 mJ/L, p = 0.0003). After PVR, there was decrease in normalized RVOT Eloss/TKE (p = 0.0009, p = 0.029) and increase in normalized tricuspid inflow vorticity/KE (p = 0.0136, p = 0.043), corresponding to reorganization of the "donut"-shaped tricuspid ring-vortex. The intracardiac flow in rTOF patients can be simulated to determine the impact of PVR and improve the clinical indications guided by cardiac imaging.
Subject(s)
Hemodynamics , Hydrodynamics , Magnetic Resonance Imaging, Cine , Models, Cardiovascular , Predictive Value of Tests , Pulmonary Valve Insufficiency , Tetralogy of Fallot , Ventricular Function, Right , Humans , Tetralogy of Fallot/surgery , Tetralogy of Fallot/physiopathology , Tetralogy of Fallot/diagnostic imaging , Female , Male , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/diagnostic imaging , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/etiology , Retrospective Studies , Kinetics , Adult , Young Adult , Blood Flow Velocity , Heart Ventricles/physiopathology , Heart Ventricles/diagnostic imaging , Patient-Specific Modeling , AdolescentABSTRACT
BACKGROUND: Anatomic selection for Harmony valve implant is determined with the aid of a screening report and perimeter plot (PP) that depicts the perimeter-derived radius along the right ventricular outflow tract (RVOT) and projects device oversizing. The PP provides an estimation of suitability for implant, but its sensitivity as a screening method is unknown. This study was performed to describe anatomic features and outcomes in patients who underwent Harmony TPV25 implant despite a PP that predicted inadequate oversizing. METHODS: We reviewed RVOT anatomic features and measurements in patients who underwent transcatheter pulmonary valve replacement with the Harmony TPV25 device despite a PP that predicted inadequate oversizing. RESULTS: This study included 22 patients. There were no unsuccessful implants or adverse valve-related events. Anatomic features varied, but all patients fit into 1 of 3 anatomic types characterized by differences in RVOT dimensions. Type 1 patients (n=9) had a long RVOT with a choke point and a wide main pulmonary artery. Type 2 patients (n=6) had a short RVOT that was pyramidal in shape, with no choke point, and extensive main pulmonary artery lengthening/expansion during systole. Type 3 patients (n=7) had a short, bulbous main pulmonary artery with a choke point and an open pulmonary artery bifurcation. CONCLUSIONS: Transcatheter pulmonary valve replacement with the Harmony valve is feasible in some patients whose PP fit analysis predicts inadequate oversizing. All cases in this series fit into 1 of 3 anatomic patterns, which are not identified in the screening report. Implanters must review cases individually to assess the feasibility of the implant.
Subject(s)
Cardiac Catheterization , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Prosthesis Design , Pulmonary Valve , Humans , Pulmonary Valve/surgery , Pulmonary Valve/diagnostic imaging , Pulmonary Valve/physiopathology , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/adverse effects , Cardiac Catheterization/instrumentation , Cardiac Catheterization/adverse effects , Treatment Outcome , Male , Female , Adolescent , Young Adult , Child , Adult , Retrospective Studies , Predictive Value of Tests , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/diagnostic imaging , Patient Selection , Clinical Decision-Making , Recovery of Function , HemodynamicsSubject(s)
Heart Valve Prosthesis Implantation , Pulmonary Valve Insufficiency , Pulmonary Valve , Tetralogy of Fallot , Ventricular Outflow Obstruction , Humans , Pulmonary Valve/surgery , Tetralogy of Fallot/surgery , Pulmonary Valve Insufficiency/surgery , Treatment Outcome , Heart Valve Prosthesis Implantation/methods , Ventricular Outflow Obstruction/surgeryABSTRACT
BACKGROUND: Percutaneous pulmonary valve implantation (PPVI) is a non-surgical treatment for right ventricular outflow tract (RVOT) dysfunction. During PPVI, a stented valve, delivered via catheter, replaces the dysfunctional pulmonary valve. Stent oversizing allows valve anchoring within the RVOT, but overexpansion can intrude on the surrounding structures. Potentially dangerous outcomes include aortic valve insufficiency (AVI) from aortic root (AR) distortion and myocardial ischemia from coronary artery (CA) compression. Currently, risks are evaluated via balloon angioplasty/sizing before stent deployment. Patient-specific finite element (FE) analysis frameworks can improve pre-procedural risk assessment, but current methods require hundreds of hours of high-performance computation. METHODS: We created a simplified method to simulate the procedure using patient-specific FE models for accurate, efficient pre-procedural PPVI (using balloon expandable valves) risk assessment. The methodology was tested by retrospectively evaluating the clinical outcome of 12 PPVI candidates. RESULTS: Of 12 patients (median age 14.5 years) with dysfunctional RVOT, 7 had native RVOT and 5 had RV-PA conduits. Seven patients had undergone successful RVOT stent/valve placement, three had significant AVI on balloon testing, one had left CA compression, and one had both AVI and left CA compression. A model-calculated change of more than 20% in lumen diameter of the AR or coronary arteries correctly predicted aortic valve sufficiency and/or CA compression in all the patients. CONCLUSION: Agreement between FE results and clinical outcomes is excellent. Additionally, these models run in 2-6 min on a desktop computer, demonstrating potential use of FE analysis for pre-procedural risk assessment of PPVI in a clinically relevant timeframe.
Subject(s)
Cardiac Catheterization , Finite Element Analysis , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Models, Cardiovascular , Patient-Specific Modeling , Prosthesis Design , Pulmonary Valve , Humans , Pulmonary Valve/physiopathology , Pulmonary Valve/surgery , Pulmonary Valve/diagnostic imaging , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/adverse effects , Risk Assessment , Adolescent , Treatment Outcome , Risk Factors , Male , Child , Retrospective Studies , Female , Cardiac Catheterization/adverse effects , Cardiac Catheterization/instrumentation , Young Adult , Predictive Value of Tests , Hemodynamics , Stents , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/diagnostic imaging , Pulmonary Valve Insufficiency/etiology , Ventricular Outflow Obstruction/physiopathology , Ventricular Outflow Obstruction/etiology , Ventricular Outflow Obstruction/diagnostic imaging , Clinical Decision-Making , AdultABSTRACT
BACKGROUND: Transcatheter pulmonary valve replacement (TPVR) with the self-expanding Harmony valve (Medtronic) is an emerging treatment for patients with native or surgically repaired right ventricular outflow tract (RVOT) pulmonary regurgitation (PR). Limited data are available since U.S. Food and Drug Administration approval in 2021. OBJECTIVES: In this study, the authors sought to evaluate the safety and short-term effectiveness of self-expanding TPVR in a real-world experience. METHODS: This was a multicenter registry study of consecutive patients with native RVOT PR who underwent TPVR through April 30, 2022, at 11 U.S. CENTERS: The primary outcome was a composite of hemodynamic dysfunction (PR greater than mild and RVOT mean gradient >30 mm Hg) and RVOT reintervention. RESULTS: A total of 243 patients underwent TPVR at a median age of 31 years (Q1-Q3: 19-45 years). Cardiac diagnoses were tetralogy of Fallot (71%), valvular pulmonary stenosis (21%), and other (8%). Acute technical success was achieved in all but 1 case. Procedural serious adverse events occurred in 4% of cases, with no device embolization or death. Hospital length of stay was 1 day in 86% of patients. Ventricular arrhythmia prompting treatment occurred in 19% of cases. At a median follow-up of 13 months (Q1-Q3: 8-19 months), 98% of patients had acceptable hemodynamic function. Estimated freedom from the composite clinical outcome was 99% at 1 year and 96% at 2 years. Freedom from TPVR-related endocarditis was 98% at 1 year. Five patients died from COVID-19 (n = 1), unknown causes (n = 2), and bloodstream infection (n = 2). CONCLUSIONS: In this large multicenter real-world experience, short-term clinical and hemodynamic outcomes of self-expanding TPVR therapy were excellent. Ongoing follow-up of this cohort will provide important insights into long-term outcomes.
Subject(s)
Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Pulmonary Valve Insufficiency , Pulmonary Valve , Humans , Adult , Pulmonary Valve/surgery , Heart Valve Prosthesis Implantation/adverse effects , Cardiac Catheterization/adverse effects , Treatment Outcome , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/etiology , Registries , Prosthesis Design , Retrospective StudiesABSTRACT
Right ventricular (RV) diastolic stiffness is an independent predictor of survival and is strongly associated with disease severity in patients with precapillary pulmonary hypertension (PH). Therefore, a fully validated echocardiographic method for assessing RV diastolic stiffness needs to be established. This study aimed to compare echocardiography-derived RV diastolic stiffness and invasively measured pressure-volume loop-derived RV diastolic stiffness in patients with precapillary PH. We studied 50 consecutive patients with suspected or confirmed precapillary PH who underwent cardiac catheterization, magnetic resonance imaging, and echocardiography within a 1-week interval. Single-beat RV pressure-volume analysis was performed to determine the gold standard for RV diastolic stiffness. Elevated RV end-diastolic pressure (RVEDP) was defined as RVEDP ≥ 8 mmHg. Using continuous-wave Doppler and M-mode echocardiography, an echocardiographic index of RV diastolic stiffness was calculated as the ratio of the atrial-systolic descent of the pulmonary artery-RV pressure gradient derived from pulmonary regurgitant velocity (PRPGDAC) to the tricuspid annular plane movement during atrial contraction (TAPMAC). PRPGDAC/TAPMAC showed significant correlation with ß (r = 0.54, p < 0.001) and RVEDP (r = 0.61, p < 0.001). A cut-off value of 0.74 mmHg/mm for PRPGDAC/TAPMAC showed 83% sensitivity and 93% specificity for identifying elevated RVEDP. Multivariate analyses indicated that PRPGDAC/TAPMAC was independently associated with disease severity in patients with precapillary PH, including substantial PH symptoms, stroke volume index, right atrial size, and pressure. PRPGDAC/TAPMAC, based on pulmonary regurgitation velocity waveform analysis, is useful for the noninvasive assessment of RV diastolic stiffness and is associated with prognostic risk factors in precapillary PH.
Subject(s)
Cardiac Catheterization , Diastole , Echocardiography, Doppler , Hypertension, Pulmonary , Predictive Value of Tests , Pulmonary Valve Insufficiency , Ventricular Function, Right , Ventricular Pressure , Humans , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/diagnostic imaging , Male , Female , Middle Aged , Reproducibility of Results , Aged , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/diagnostic imaging , Adult , Ventricular Dysfunction, Right/physiopathology , Ventricular Dysfunction, Right/diagnostic imaging , Ventricular Dysfunction, Right/etiology , Pulmonary Artery/physiopathology , Pulmonary Artery/diagnostic imaging , ROC Curve , Area Under Curve , Arterial Pressure , Severity of Illness IndexABSTRACT
Cardiac magnetic resonance imaging (CMR) often shows discrepancies between right ventricular outflow tract (RVOT) flow and left ventricular outflow tract flow in patients with late-stage repaired tetralogy of Fallot (rTOF), leading to potential errors in pulmonary regurgitation fraction (PRF) assessment. This study aimed to identify the conditions under which RVOT flow can be acutely evaluated using four-dimensional (4D) flow CMR. Twenty-seven consecutive patients with rTOF underwent both two-dimensional phase-contrast (2D PC) and 4D flow CMR between 2016 and 2018, excluding those with peripheral pulmonary artery stenosis, RVOT conduit replacement, unknown surgical method, and an aortic valve regurgitation greater than 20%. Seven healthy controls also underwent only 4D Flow CMR. All healthy controls and fifteen patients with rTOF showed laminar RVOT flow, while seven patients exhibited helical, and four patients exhibited vortical RVOT flow in 4D flow CMR visualization. Flow-volume concordance between the pulmonary artery and aortic flow was significantly lower in patients with rTOF and PRF > 40% in 2D PC CMR. This concordance rate in the suprapulmonary valve was high in both the TOF and control groups, comparing at five RVOT locations in 4D flow CMR. Regarding RVOT flow regurgitation in 4D flow, the whole bulk evaluation exhibited greater variation depending on the flow type compared to the whole pixel-wise evaluation. The study confirmed the flow volume at the upper section of the pulmonary valve as the most accurate correlate of aortic flow volume. Furthermore, the 4D flow CMR using the pixel-wise method demonstrated superior accuracy compared to the traditional bulk flow method.
Subject(s)
Magnetic Resonance Imaging, Cine , Tetralogy of Fallot , Humans , Tetralogy of Fallot/surgery , Tetralogy of Fallot/physiopathology , Male , Female , Adult , Magnetic Resonance Imaging, Cine/methods , Blood Flow Velocity/physiology , Adolescent , Cardiac Surgical Procedures/methods , Young Adult , Heart Ventricles/physiopathology , Heart Ventricles/diagnostic imaging , Ventricular Function, Right/physiology , Retrospective Studies , Pulmonary Valve Insufficiency/physiopathology , Pulmonary Valve Insufficiency/surgery , Pulmonary Valve Insufficiency/etiology , Pulmonary Valve Insufficiency/diagnosis , Pulmonary Valve Insufficiency/diagnostic imaging , Child , Ventricular Outflow Obstruction/physiopathology , Ventricular Outflow Obstruction/etiology , Ventricular Outflow Obstruction/surgery , Ventricular Outflow Obstruction/diagnostic imagingABSTRACT
BACKGROUND: Recently, improvements in the repair of tetralogy of Fallot have increased the need for reoperation in adulthood, and it's not rare that these reoperation candidates suffer from biventricular failure. However, there are no firm treatment guidelines, and each country, and even each facility, treats each case individually. CASE PRESENTATION: We report the successful staged treatment of pulmonary regurgitation and pacemaker-induced cardiomyopathy with biventricular failure in adulthood in a case of complete atrioventricular block after tetralogy of Fallot repair in childhood. We planned a staged therapeutic strategy with preoperative left ventricular volume reduction with medication, following surgical pulmonary valve replacement concomitant epicardial lead implantation on the lateral basal wall, placed just beneath the generator pocket through 3rd intercostal space. in addition to postoperative intervention with a defibrillator to adjust cardiac resynchronization therapy, resulted in improvement of symptoms. CONCLUSION: In a patient with biventricular failure after TOF repair, a staged treatment strategy involving medication, PVR, and CRT with a combination of epicardial and intravenous leads could be a useful treatment worth trying before heart transplantation.
Subject(s)
Cardiomyopathies , Pacemaker, Artificial , Pulmonary Valve Insufficiency , Tetralogy of Fallot , Humans , Cardiomyopathies/etiology , Cardiomyopathies/surgery , Heart Failure/surgery , Pacemaker, Artificial/adverse effects , Pulmonary Valve Insufficiency/surgery , Tetralogy of Fallot/surgery , Treatment Outcome , AdultABSTRACT
BACKGROUND: Pulsta valve is increasingly used for percutaneous pulmonary valve implantation (PPVI) in patients with a large native right ventricular outflow tract (RVOT). This study aims to elucidate the outcomes of Pulsta valve implantation within the native RVOT and assess its adaptability to various native main pulmonary artery (PA) anatomies. METHODS: A multicenter retrospective study included 182 patients with moderate to severe pulmonary regurgitation in the native RVOT who underwent PPVI with Pulsta valves® between February 2016 and August 2023 at five Korean and Taiwanese tertiary referral centers. RESULTS: Pulsta valve implantation was successful in 179 out of 182 patients (98.4%) with an average age of 26.7 ± 11.0 years. The median follow-up duration was 29 months. Baseline assessments revealed enlarged right ventricle (RV) volume (mean indexed RV end-diastolic volume: 163.1 (interquartile range, IQR: 152.0-180.3 mL/m²), which significantly decreased to 123.6(IQR: 106.6-137.5 mL/m2 after 1 year. The main PA types were classified as pyramidal (3.8%), straight (38.5%), reverse pyramidal (13.2%), convex (26.4%), and concave (18.1%) shapes. Pulsta valve placement was adapted, with distal main PA for pyramidal shapes and proximal or mid-PA for reverse pyramidal shapes. Two patients experienced Pulsta valve embolization to RV, requiring surgical removal, and one patient encountered valve migration to the distal main PA, necessitating surgical fixation. CONCLUSIONS: Customized valve insertion sites are pivotal in self-expandable PPVI considering diverse native RVOT shape. The rather soft and compact structure of the Pulsta valve has characteristics to are adaptable to diverse native RVOT geometries.