Rescue surgery following percutaneous pulmonary valve implantation☆☆☆

Abstract

Objective: Percutaneous pulmonary valve insertion (PPVI) is an evolving alternative to surgical pulmonary valve insertion. The aim of this study is to review the acute complications of PPVI requiring emergency rescue surgery. Patients and methods: Between 09/2000 and 01/2007, 152 patients (pts), received a PPVI. Patient's charts were reviewed in retrospect. Results: Emergency rescue surgery (ERS) took place in 6 pts (3.9%). Indications for ERS were: homograft rupture two pts, dislodgment of the stented valve in a dilated right ventricular outflow tract two pts, occlusion of the right pulmonary artery one pt and compression of the left main coronary artery one pt. Cardiopulmonary bypass was established through repeat sternotomy incision with femorofemoral cannulation in 2/6 pts. The stented valve was removed in five and replaced with a homograft in three and a valved conduit in two pts. One ruptured homograft was repaired leaving the stented valve in situ. All patients survived, one sustained mild neurological impairment. Conclusion: Although some of the acute complications of PPVI were probably related to a learning curve (4 among the first 50 pts and 2 among the last 102 patients) the need for ERS is unlikely to be completely abolished. This experience highlights the importance of close collaboration between cardiologists and surgeons in these evolving technologies. Highly skilled and responsive surgical back up is necessary to support the introduction and to sustain institutional programmes such as PPVI. #

Coronary compression caused by stenting a right pulmonary artery conduit

“…Low pressure ballooning delineates the waist to accurately and safely position a stent [6]. High pressure ballooning in combination with coronary or other angiography allows assessment of the possible effects of stent expansion to threatened structures [5,7]. This is currently routinely carried out before implantation of percutaneous pulmonary valves.…”

“…Percutaneous pulmonary valve implantation will further increase the number of conduits being stented [3]. Compression of a coronary artery has been reported as a rare and potential life-threatening complication of stents in the main pulmonary artery [4,5]. This case report describes fatal myocardial infarction due to extrinsic compression of the left main coronary artery because of stent implantation in a stenosed right pulmonary artery conduit.…”

Risk of Coronary Artery Compression Among Patients Referred for Transcatheter Pulmonary Valve Implantation

“…Despite the recognized risk of CA compression in this patient population, there have been several documented cases of CA compression after stent or valve implantation, often with catastrophic consequences. 5,[8][9][10] This highlights the importance of recognizing the numerous technical considerations that go into proper assessment of CA anatomy in every patient.…”

“…Potential CA compression from an RVOT stent, with or without a valve, was first recognized in 2006. 7 At least 4 cases of CA compression after Melody valve implantation have been described in literature, 5,[8][9][10] and the authors are aware of ≥3 others that have occurred. In addition, there have been documented cases of CA compression following stent deployment in the main or right pulmonary artery (PA).…”

Angioplasty of Obstructed Homograft Conduits in the Right Ventricular Outflow Tract With Ultra-Noncompliant Balloons

“…Angioplasty and bare metal stent placement have become important components of conduit preparation for a TPV 7 ; however, the potential for conduit disruption is an important concern that is not well understood. 8,9 Effective balloon dilation of obstructed conduits with conventional balloons has been shown to be limited because of inability to resolve waists at rated burst pressures, balloon rupture by calcified conduits, and rupture before waist resolution at or above rated burst pressures. 5,6,10 Placement of balloon expandable stents is reportedly superior to simple conduit angioplasty in terms of reducing obstruction and prolonging conduit lifespan.…”