The potential impact of percutaneous pulmonary valve stent implantation on right ventricular outflow tract re-intervention

Abstract

Objective: To assess the impact of a percutaneous technique for pulmonary valve implantation on the conventional surgical valve/conduit approach to right ventricular outflow tract re-intervention. Methods: We have retrospectively reviewed our results following surgical or percutaneous re-intervention to the right ventricular outflow tract in both paediatric and adult groups. Between November 1998 and March 2004, 94 patients underwent surgical re-intervention to the right ventricular outflow tract. Percutaneous pulmonary valve implantation was introduced in October 2002 and 35 procedures were performed to March 2004. The median age was 26 years (6-65 years) in the surgical group and 16 years (9-39 years) in the percutaneous group. Tetralogy of Fallot was the commonest original diagnosis (64.9 and 62.9%, respectively). The predominant indication for re-intervention in the surgical group was pulmonary regurgitation (64.9%) compared to the percutaneous group in which it was homograft/conduit stenosis or a mixed lesion (68.6%). Results: There has been one (1.1%) early death reported in the surgical series and none in the percutaneous group. In the surgical group 9 (9.6%) experienced a procedural complication whilst 3 (8.5%) of those undergoing a percutaneous valve experienced a significant procedural event necessitating urgent surgery. Important early morbidity was 8 (8.5%) in the surgical group and 2 (5.7%) in the percutaneous group. Freedom from re-operation at 1 year was 100% in the surgical group and 86.1% in the percutaneous group due to late restenosis. Median hospital stay in the surgical group was 7 (4-114) days and 2 (2-22) days in the percutaneous group. Conclusions: Preliminary data suggests that percutaneous pulmonary valve implantation provides a promising additional and complementary approach to a successful surgical programme. Both approaches are safe with acceptable levels of morbidity and low mortality. With current technology the aneurysmal outflow tract remains a problem for the percutaneous approach. Follow-up remains too short, at present, to prove longevity of the percutaneous conduit. q

Risk Stratification, Systematic Classification, and Anticipatory Management Strategies for Stent Fracture After Percutaneous Pulmonary Valve Implantation

“…The valved stents were implanted in patients with RVOT obstruction, with or without pulmonary regurgitation, that occurred as a late consequence of previous surgery. 4,5 In the vast majority, the valves were implanted into dysfunctional conduits that connected the right ventricle to the pulmonary artery. 4,5 Before this, stenotic conduits have been treated by bare stent implantation by our team and others, 6 -8 whereas regurgitation often required reoperation.…”

Right ventricular outfl ow tract revalvulation using the Melody Valve: The next frontier

“…Overall, early complications were rare during percutaneous procedures, occurring in less than 8.5% of implantations. (8,16,17) This compares favorably to surgical series where early complications have been described in up to 9.6% of patients. (18) Follow-up results for outcome are now short to mid-term.…”

“…(8,16,17) This compares favorably to surgical series where early complications have been described in up to 9.6% of patients. (18) Follow-up results for outcome are now short to mid-term. The most common complication has been stent fractures which occurred in 5% to 30% of cases.…”

“…Major procedural complications included dislodgement of the valve, coronary compression, rupture of homograft and haemothorax due to pulmonary artery perforations. (7,(13)(14)(15)(16)(17)(18) Dislodgement of the device occurred mostly during the initial development phase and could be related to operator inexperience as well as the early learning curve. It is now extremely rare, especially with pre-stenting.…”

Transcatheter Pulmonary Valve Replacement: The Venus P valve-Current Status

“…The availability of these minimally invasive and effective therapies may allow for earlier treatment of right ventricular outflow tract (RVOT) dysfunction before the onset of irreversible ventricular remodeling and dysfunction. Moreover, transcatheter options can reduce the need for multiple surgical interventions over a patient's lifetime, thereby minimizing the morbidity of this growing patient popu-lation [9]. tPVR is categorized as a class II American Heart Association recommendation for conduits with moderate-to-severe stenosis or regurgitation, provided the patient meets inclusion and exclusion criteria for the available valves [10].…”