Timing of Pulmonary Valve Replacement: How Much Can the Right Ventricle Dilate Before it Looses Its Remodeling Potential?

Álvarez-Fuente, María; Garrido‐Lestache, Elvira; Fernández-Pineda, Luis; Romera, Blanca; Sanchez, Ingrid; Centella, Tomasa; Abelleira, César; Villagrá, Sandra; Tamariz, Rocío; Barrios, Elvira; Lamas, Maria-Jesús; Gómez, Ricardo; Cerro, María Jesús del

doi:10.1007/s00246-015-1320-4

Cited by 26 publications

(19 citation statements)

References 30 publications

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“…On the other hand, as with other investigators, we did not observe any relation between tissue Doppler velocities, TEI or TAPSE and the CMR findings of the right ventricle [3,9,12,18,19]. TEI is a reliable echocardiographic parameter showing ventricular function.…”

Section: Discussionsupporting

confidence: 81%

“…Improved late survival of these patients provide an ever-increasing number of patients who require regular follow-up for complications after initial correction. Pulmonary regurgitation acquired after operation for TOF causes a chronic volume overload for the right ventricle and frequently leads to progressive loss of function [2][3][4][5]. Pulmonary valve replacement has shown potential to improve right ventricular hemodynamics, yet the best timing is controversial [2-4, 6, 7].…”

Section: Introductionmentioning

confidence: 99%

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Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Ayabakan¹,

Tokel²,

Sarısoy³

2020

JICOA

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Aim: Although limited in assessing right ventricular (RV) function, echocardiography is widely used after correction for tetralogy of Fallot (TOF). The change in echocardiographic measurements of RV in asymptomatic patients after TOF repair over a long follow-up time is not explored yet. The variation in simple echocardiographic measurements during follow-up of our TOF patients are presented. The predictive value of those parameters in determining a future pulmonary valve replacement is sought. Method: Asymptomatic patients surviving the first year after correction for simple TOF from February 2007 to December 2019 at Başkent University, Istanbul Hospital are enrolled. Patients are followed annually with echocardiography including: RV area, volume, length, RV outflow tract (RVOT) diameter and gradient, tricuspid annulus diameter, tricuspid lateral annular tissue velocities, tricuspid annular plane systolic excursion, TEI index RV ejection fraction (EF) measurements. The change in the consecutive echocardiographic measurements during follow-up is analysed. Patients are evaluated with a cardiac magnetic resonance (CMR) imaging when deemed necessary and compared with echocardiographic measurements. Results: A total of 66 patients (54.5% males) are operated at age 14.4±9.3 months (78.8% with transannular patch). Twelve patients had pulmonary valve replacement (PVR) operation at an age 10.1±3.1 years. During follow-up of 7.2±4.3 years, tricuspid annulus diameter, RV area, RV inlet length, RV volume, RV volume index significantly increased (p=0.001 for all), whereas RV inlet length index, TEI and TEI z score decreased (p<0.0001 for all). When means are compared, tricuspid annulus (28.8mm vs 25.0mm; p=0.013), RV volume (72.2ml vs 52.2ml; p=0.042), RV inlet length index (77.9mm/m2 vs 60.2mm/m2 ; p=0.013), RVOT diameter (28.7 vs 23.0; p=0.007) are increased. RV EF is decreased (51.3% vs 60.5%; p=0.011) in those requiring PVR. Those with higher RV area index, RV volume index, tricuspid annulus diameter and tricuspid annular z score in their first echocardiography after the TOF repair, are more likely to have a PVR operation later on (p<0.05 for all). RV volume index ≥39ml/m2 predicts a PVR within 7 years with 100% sensitivity and 74% specificity. Tricuspid annular z score less than -0.43 seems to eliminate the possibility of having a PVR within 7 years with a sensitivity of 44% and specificity of 100%. Conclusion: Observing the sequential change in echocardiographic parameters like RV volume index, RV area index, tricuspid annulus z score is reliable in determining right ventricular function and can limit the costly CMR applications. Cut off values of RV volume index >39ml/m2 and tricuspid annulus z score ≥ - 0.43 after the initial TOF repair may determine patients with higher possibility of having early PVR and indicate a closer follow-up.

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Section: Discussionsupporting

confidence: 81%

Section: Introductionmentioning

confidence: 99%

Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Ayabakan¹,

Tokel²,

Sarısoy³

2020

JICOA

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“…[52] General agreement exists on the indication for PV implantation in asymptomatic patients in the presence of any of the following criteria, as judged by echocardiography and/or magnetic resonance imaging: (a) PV regurgitation >20%; (b) indexed end-diastolic right ventricular volume >120–150 ml m –2 BSA; or (c) indexed end-systolic right ventricular volume >80–90 ml m –2 BSA. [14,18,19,22,24,25] In our experience, all asymptomatic patients were matching all the accepted criteria of indication for PV implantation. The only two patients with indexed right ventricular end-diastolic volume < 150 ml m –2 BSA (respectively 130 and 142 ml m –2 BSA) were two of the four patients with associated right ventricular outflow tract obstruction.…”

Section: Discussionmentioning

confidence: 83%

Trifecta St. Jude medical® aortic valve in pulmonary position

Corno

Dawson

Bolger

et al. 2017

Nano Reviews & Experiments

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Introduction: To evaluate an aortic pericardial valve for pulmonary valve (PV) regurgitation after repair of congenital heart defects. Methods: From July 2012 to June 2016 71 patients, mean age 24 ± 13 years (four to years) underwent PV implantation of aortic pericardial valve, mean interval after previous repair = 21 ± 10 years (two to 47 years). Previous surgery at mean age 3.2 ± 7.2 years (one day to 49 years): tetralogy of Fallot repair in 83% (59/71), pulmonary valvotomy in 11% (8/71), relief of right ventricular outflow tract (RVOT) obstruction in 6% (4/71). Pre-operative echocardiography and MRI showed severe PV regurgitation in 97% (69/71), moderate in 3% (2/71) with associated RVOT obstruction. MRI and knowledge-based reconstruction 3D volumetry (KBR-3D-volumetry) showed mean PV regurgitation = 42 ± 9% (20–58%), mean indexed RV end-diastolic volume = 169 ± 33 (130–265) ml m–2 BSA and mean ejection fraction (EF) = 46 ± 8% (33–61%). Cardio-pulmonary exercise showed mean peak O2/uptake = 24 ± 8 ml kg–1 min–1 (14–45 ml kg–1 min–1), predicted max O2/uptake 66 ± 17% (26–97%). Pre-operative NYHA class was I in 17% (12/71) patients, II in 70% (50/71) and III in 13% (9/71). Results: Mean cardio-pulmonary bypass duration was 95 ± 30ʹ (38–190ʹ), mean aortic cross-clamp in 23% (16/71) 46 ± 31ʹ (8–95ʹ), with 77% (55/71) implantations without aortic cross-clamp. Size of implanted PV: 21 mm in seven patients, 23 mm in 33, 25 mm in 23, and 27 mm in eight. The z-score of the implanted PV was −0.16 ± 0.80 (−1.6 to 2.5), effective orifice area indexed (for BSA) of native PV was 1.5 ± 0.2 (1.2 to –2.1) vs. implanted PV 1.2 ± 0.3 (0.76 to –2.5) (p = ns). In 76% (54/71) patients surgical RV modelling was associated. Mean duration of mechanical ventilation was 6 ± 5 h (0–26 h), mean ICU stay 21 ± 11 h (12–64 h), mean hospital stay 6 ± 3 days (three to 19 days). In mean follow-up = 25 ± 14 months (six to 53 months) there were no early/late deaths, no need for cardiac intervention/re-operation, no valve-related complications, thrombosis or endocarditis. Last echocardiography showed absent PV regurgitation in 87.3% (62/71) patients, trivial/mild degree in 11.3% (8/71), moderate degree in 1.45% (1/71), mean max peak velocity through RVOT 1.6 ± 0.4 (1.0–2.4) m s–1. Mean indexed RV end-diastolic volume at MRI/KBR-3D-volumetry was 96 ± 20 (63–151) ml m–2 BSA, lower than pre-operatively (p < 0.001), and mean EF = 55 ± 4% (49–61%), higher than pre-operatively (p < 0.05). Almost all patients (99% = 70/71) remain in NYHA class I, 1.45% = 1/71 in class II. Conclusion: (a) Aortic pericardial valve is implantable in PV position with an easy and reproducible surgical technique; (b) valve size adequate for patient BSA can be implanted with simultaneous RV remodelling; (c) medium-term outcomes are good with maintained PV function, RV dimensions significantly reduced and EF significantly improved; (d) adequate valve size will allow later percutaneous valve-in-valve implantation.

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“…In asymptomatic patients the criteria for indications for PV implantation, and particularly the choice of the best timing, are less clearly defined ( 54 ). General agreement exists on the indication in asymptomatic patients in the presence of any of the following criteria, as judged by echocardiography and/or magnetic resonance imaging ( 13 , 17 , 18 , 21 , 23 , 24 ): PV regurgitation > 20% indexed end-diastolic right ventricular volume >120–150 ml/m 2 BSA indexed end-systolic right ventricular volume > 80–90 ml/m 2 BSA …”

Section: Timing Of Pulmonary Valve Implantationmentioning

confidence: 99%

Pulmonary Valve Regurgitation: Neither Interventional Nor Surgery Fits All

Corno

2018

Front. Pediatr.

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Introduction: PV implantation is indicated for severe PV regurgitation after surgery for congenital heart defects, but debates accompany the following issues: timing of PV implantation; choice of the approach, percutaneous interventional vs. surgical PV implantation, and choice of the most suitable valve.Timing of pulmonary valve implantation: The presence of symptoms is class I evidence indication for PV implantation. In asymptomatic patients indication is agreed for any of the following criteria: PV regurgitation > 20%, indexed end-diastolic right ventricular volume > 120–150 ml/m2 BSA, and indexed end-systolic right ventricular volume > 80–90 ml/m2 BSA.Choice of the approach: percutaneous interventional vs. surgical: The choice of the approach depends upon the morphology and the size of the right ventricular outflow tract, the morphology and the size of the pulmonary arteries, the presence of residual intra-cardiac defects and the presence of extremely dilated right ventricle.Choice of the most suitable valve for surgical implantation: Biological valves are first choice in most of the reported studies. A relatively large size of the biological prosthesis presents the advantage of avoiding a right ventricular outflow tract obstruction, and also of allowing for future percutaneous valve-in-valve implantation. Alternatively, biological valved conduits can be implanted between the right ventricle and pulmonary artery, particularly when a reconstruction of the main pulmonary artery and/or its branches is required.Hybrid options: combination of interventional and surgical: Many progresses extended the implantation of a PV with combined hybrid interventional and surgical approaches. Major efforts have been made to overcome the current limits of percutaneous PV implantation, namely the excessive size of a dilated right ventricular outflow tract and the absence of a cylindrical geometry of the right ventricular outflow tract as a suitable landing for a percutaneous PV implantation.Conclusion: Despite tremendous progress obtained with modern technologies, and the endless fantasy of researchers trying to explore new forms of treatment, it is too early to say that either the interventional or the surgical approach to implant a PV can fit all patients with good long-term results.

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Timing of Pulmonary Valve Replacement: How Much Can the Right Ventricle Dilate Before it Looses Its Remodeling Potential?

Cited by 26 publications

References 30 publications

Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Echocardiographic Follow-Up of Right Ventricular Function After Tetralogy of Fallot Operation

Trifecta St. Jude medical® aortic valve in pulmonary position

Pulmonary Valve Regurgitation: Neither Interventional Nor Surgery Fits All

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