Percutaneous pulmonary valve implantation for reconstruction of a patch‐repaired right ventricular outflow tract

Abstract

Percutaneous pulmonary valve implantation (PPVI) is nowadays an accepted treatment option to repair post-surgical conduit dysfunction of the right ventricular outflow tract (RVOT). In addition, many patients need a pulmonary valve to reconstruct a hemodynamically incompetent native or conduit free outflow tract. Based on our experience with percutaneous stent-valve placement in a cohort of 125 patients, we report here transvenous reconstruction of a conduit-free, patch repaired outflow tract by utilizing balloon-expandable stent-valves in 23 patients with a median age of 22 years (5-60 years). In 20 patients, the step-by-step procedure was performed uneventful with the aimed success. Severe RVOT dysfunction in term of a clinical relevant regurgitation could be changed to mild, as it was confirmed by follow-up color Doppler echocardiography. In a 5-year-old girl a Melody® valve was placed as a surgical-interventional hybrid approach. In one patient, the procedure was complicated by stent embolization during preparation of the RVOT for stent-valve implantation. Reposition of the embolized stent was nevertheless successful for finishing percutaneous valve-implantation. In one patient, surgical approach became necessary because of the inability to advance the balloon-mounted stent-valve through a pre-stented RVOT. Considering the current available balloon-expandable stent-valves, transvenous pulmonary valve implantation is feasible to treat even an incompetent conduit-free RVOT. However, preparation of the RVOT by pre-stenting, in most patients with more than two stents in telescope technique remains challenging. Reconstruction of RVOT by the current available valves is promising only for a carefully selected group of patients.

The standing of percutaneous pulmonary valve implantation compared to surgery in a non-preselected cohort with dysfunctional right ventricular outflow tract – Reasons for failure and contraindications

“…narrowest RVOT diameter > 22 mm on angiography) [22,23,27]. These patients usually are those after patch reconstruction of the RVOT or those with dilated native RVOTs and successful PPVI is the exception rather than the rule [19,20]. As most of the patients are assessed by a variable preselection process, the actual number of patients excluded by applying this process is unclear or not reported [10,28].…”

“…Considering the current available balloon-expandable stent-valves, transvenous pulmonary valve implantation is however feasible to treat even an incompetent conduit-free RVOT. Preparation of the RVOT by pre-stenting, in most patients with more than two stents in telescope technique remains challenging [15,20]. New valve designs such as the Medtronic Harmony 1 transcatheter pulmonary valve (TPV) are developed to be securely anchored in the oversized, dilated, and distorted RVOT [36,37].…”

“…In most of the reports presenting the results of PPVI, a careful preselection was performed for patients who ultimately were scheduled for PPVI [10][11][12][13]. Patients after patch reconstruction of the RVOT, or with dilated native RVOTs, have been successfully treated with PPVI technology, however they are the exception rather than the rule [19,20]. Conduits <16-mm diameter may also represent relatively poor candidates for PPVI [21].…”

A word of caution: diabolic behaviour of AndraStents®: inflation of supporting balloon leads to “diabolo”-misconfiguration of the stent

“…Other utilised large calibre stents are the semi-open cell designed MaxLD® (Ev3 Inc., Plymouth, Minnesota, United States of America) stent and the AndraStent® (Andramed, Reutlingen, Germany) as a mixed open-cell, closed-cell stent. [3][4][5] We report potentially fatal complications utilising AndraStents® for pre-stenting of the right ventricular outflow tract in six patients from five different institutions. A "diabolo"-shaped misconfiguration was observed, when the AndraStent® was expanded within the right ventricular outflow tract.…”

Management of balloon rupture during a percutaneous pulmonary valve implantation procedure

“…1 It is increasingly adopted also in patients with "native" right ventricle outflow tract. 2,3 In the latter, pre-stenting of the right ventricle outflow tract is more important before implanting the valve. 4 Here we report on a tricky situation that occurred during pre-stenting, and we describe how we successfully overcame it.…”