Percutaneous Pulmonary Valve Implantation

Abstract

Percutaneous pulmonary valve implantation (PPVI) is recognized as a feasible and low risk alternative to surgery to treat dysfunctional right ventricular outflow tract (RVOT) in usually pluri-operated patients. Evolving technology allowed to develop different kind of prosthesis and to go from an initial treatment exclusively of stenotic conduit to an actual approach extended also to wide native RVOT. The Melody transcatheter pulmonary valve (TPV) and the Edwards Sapien valve are nowadays the most commonly implanted prostheses. However, other devices have been developed to treat large RVOT (i.e., the Venus p-valve, the Medtronic Harmony TPV, the Alterra Adaptive Prestent, and the Pulsta valve). Indications for PPVI are the same as for surgical interventions on pulmonary valve, with limits related to the maximum diameter of the available percutaneous prosthesis. Therefore, an accurate preoperative evaluation is of paramount importance to select patients who could benefit from this procedure. The overall periprocedural mortality incidence is around 1.4%, while freedom from RVOT reintervention ranges from 100% at 4 months to 70% at 70 months, according to the different published studies.

Pulmonary percutaneous valve implantation in large native right ventricular outflow tract with 32 mm Myval transcatheter heart valve

“…8 Until now, if balloon waist or complete RVOT occlusion are not reached with a 30 mm balloon completely inflated, PPVI cannot be performed, and unfortunately, the patient may require to undergo surgery. 1 Earlier, Sapien3 valve provided the possibility of oversizing up to 31 mm, 9 still there are clinical settings that require a larger valve. The recent development of a self-expandable (SE) system PPVI namely Pulsta TPV (Taewoong Medical, South Korea) and Venus p-valve (Venus MedTech, Shanghai, China) aimed to resolve the unmet clinical need for larger valve-stent for stable valve position.…”

“…Additionally, Myval THV delivery system allows flexion of the distal catheter system which facilitates trauma-free negotiation across the RVOT, that added to the use of the 65-cm-long DrySeal™ sheath (WL Gore and Associates, US) leads to faster and safer valve implantation reducing the potential procedural complications. 1,14 Furthermore, because of the elastic properties of the central PA and the elliptical shape of the RVOT, a BE-THV could be more appropriate than SE-THV to predict the desired target diameter, when the final RVOT shape after deployment is circular (Figure 3). 15…”

“…This resulted in a shift from exclusivity of initial treatment with PPVI of patients with dysfunctional conduits to an approach that extended PPVI to patients with large native right ventricular outflow tract (RVOT). 1 Nevertheless, it is still challenging for structural interventionists to perform PPVI in patients with large native RVOT lesions and hemodynamically significant pulmonary regurgitation (PR), since in most of the patients the native RVOT is large and distensible for stable balloon-expandable valve positioning. 2 We report our experience of initial in vitro bench testing to evaluate the possibility of oversizing the newer-generation tri-leaflet balloon-expandable (BE) Myval™ THV (Meril Life Sciences Pvt.…”

Coronary Artery Anomalies and Their Impact on the Feasibility of Percutaneous Pulmonary Valve Implantation

“…Following repair of congenital heart defects a significant number of patients are left with long-term impairment of pulmonary valve function. To avoid the sequelae of longterm pulmonary regurgitation and/or residual pulmonary stenosis on right ventricular function PPVI has become the preferred treatment option for many of these patients [2][3][4]. Excellent results have been reported both with the Melody™ and with the SAPIEN valves [4,12,13].…”

“…Percutaneous pulmonary valve implantation (PPVI) has found widespread acceptance in the postoperative revalvulation of the dysfunctional right ventricular outflow tract [1][2][3][4]. Major limitations for this procedure are coronary artery branches located in close proximity to the expected landing zone of the pulmonary valve resulting in the potential risk for coronary compression caused by radial tension from the balloon-expandable stent.…”