Transcatheter Pulmonary Valve Replacement: Current State of Art
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Purpose of Review
The past couple of decades have brought tremendous advances to the field of pediatric and adult congenital heart disease (CHD). Percutaneous valve interventions are now a cornerstone of not just the congenital cardiologist treating patients with congenital heart disease, but also—and numerically more importantly—for adult interventional cardiologists treating patients with acquired heart valve disease. Transcatheter pulmonary valve replacement (tPVR) is one of the most exciting recent developments in the treatment of CHD and has evolved to become an attractive alternative to surgery in patients with right ventricular outflow tract (RVOT) dysfunction. This review aims to summarize (1) the current state of the art for tPVR, (2) the expanding indications, and (3) the technological obstacles to optimizing tPVR.
Since its introduction in 2000, more than ten thousands tPVR procedures have been performed worldwide. Although the indications for tPVR have been adapted earlier from those accepted for surgical intervention, they remain incompletely defined. The new imaging modalities give better assessment of cardiac anatomy and function and determine candidacy for the procedure. The procedure has been shown to be feasible and safe when performed in patients who received pulmonary conduit and or bioprosthetic valves between the right ventricle and the pulmonary artery. Fewer selected patients post trans-annular patch repair for tetralogy of Fallot may also be candidates for this technology. Size restrictions of the currently available valves limit deployment in the majority of patients post trans-annular patch repair. Newer valves and techniques are being developed that may help such patients.
Refinements and further developments of this procedure hold promise for the extension of this technology to other patient populations.
KeywordsCongenital heart disease Tetralogy of Fallot Pulmonary stenosis Pulmonary regurgitation Right ventricular outflow tract dysfunction Transcatheter pulmonary valve replacement
Compliance with Ethical Standards
Conflict of Interest
Wail Alkashkari and Amani Alsubei declare that they have no conflict of interest.
Ziyad M. Hijazi is a consultant for Venus Medtech.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance
- 14.Fernandes FP, Manlhiot C, Roche SL, Grosse-Wortmann L, Slorach C, McCrindle BW, et al. Impaired left ventricular myocardial mechanics and their relation to pulmonary regurgitation, right ventricular enlargement and exercise capacity in asymptomatic children after repair of tetralogy of Fallot. J Am Soc Echocardiogr. 2012;25(5):494–503.PubMedCrossRefGoogle Scholar
- 21.Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Developed in collaboration with the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(23):e143–263.PubMedCrossRefGoogle Scholar
- 25.Berman DP, McElhinney DB, Vincent JA, Hellenbrand WE, Zahn EM. Feasibility and short-term outcomes of percutaneous transcatheter pulmonary valve replacement in small (<30 kg) children with dysfunctional right ventricular outflow tract conduits. Circ Cardiovasc Interv. 2014;7:142–8.PubMedCrossRefGoogle Scholar
- 27.Kenny D, Hijazi ZM, Kar S, Rhodes J, Mullen M, Makkar R, et al. Percutaneous implantation of the Edwards SAPIEN transcatheter heart valve for conduit failure in the pulmonary position: early phase 1 results from an international multicenter clinical trial. J Am Coll Cardiol. 2011;58:2248–56.PubMedCrossRefGoogle Scholar
- 29.AlkashkariW, Cao QL, Kavinsky CJ, Hijazi ZM. Percutaneous pulmonary valve implantation for RVOT Defect. Cardiac Intervention Today. September/October 2010.Google Scholar
- 30.AlBugami S, Althobaiti MW, Alrahemi J, Alsaiedi AJ, AlKashkari W. Coronary intervention of an anomalous left main coronary artery arising from the right sinus of valsalva presented as acute coronary syndrome. J Cardiol Curr Res. 2016;5(6):00184.Google Scholar
- 34.McElhinney DB, Cheatham JP, Jones TK, Lock JE, Vincent JA, Zahn EM, et al. Stent fracture, valve dysfunction, and right ventricular outflow tract reintervention after transcatheter pulmonary valve implantation: patient related and procedural risk factors in the US Melody Valve Trial. Circ Cardiovasc Interv. 2011;4:602–14.PubMedCrossRefGoogle Scholar
- 36.McElhinney DB, Benson LN, Eicken A, Kreutzer J, Padera RF, Zahn EM. Infective endocarditis after transcatheter pulmonary valve replacement using the Melody valve: combined results of 3 prospective North American and European studies. Circ Cardiovasc Interv. 2013;6(3):292–300.PubMedCrossRefGoogle Scholar
- 38.• Cheatham JP, Hellenbrand WE, Zahn EM, Jones TK, Berman DP, Vincent JA, et al. Clinical and hemodynamic outcomes up to 7 years after transcatheter pulmonary valve replacement in the US melody valve investigational device exemption trial. Circulation. 2015;131:1960–70. This study prove that tPVR with the Melody valve provided good hemodynamic and clinical outcomes up to 7 years after implantation Stent fracture was the most common cause of valve dysfunction.PubMedCrossRefGoogle Scholar
- 44.Gatlin SW, Kim DW, Mahle WT. Cost analysis of percutaneous pulmonary valve replacement. Am J Cardiol. 2011;108(4):572–4. 574Google Scholar
- 45.Raikou M, McGuire A, Lurz P, Bonhoeffer P, Wegmueller Y. An assessment of the cost of percutaneous pulmonary valve implantation (PPVI) versus surgical pulmonary valve replacement (PVR) in patients with right ventricular outflow tract dysfunction. J Med Econ. 2011;14(1):4752.PubMedCrossRefGoogle Scholar
- 52.Malekzadeh-Milani S, Ladouceur M, Patel M, Boughenou FM, Iserin L, Bonnet D, et al. Incidence and predictors of melody(R) valve endocarditis: a prospective study. Arch Cardiovasc Dis. 2015;108:97–106.Google Scholar
- 56.Schievano S, Coats L, Migliavacca F, Norman W, Frigiola A, Deanfield J, et al. Variations in right ventricular outflow tract morphology following repair of congenital heart disease: implications for percutaneous pulmonary valve implantation. J Cardiovas Magn Reson. 2007;9:687–95.CrossRefGoogle Scholar
- 60.Schievano S, Taylor AM, Capelli C, Coats L, Walker F, Lurz P, et al. First-in-man implantation of a novel percutaneous valve: a new approach to medical device development. Eur Secur. 2010;5:745–50.Google Scholar
- 61.Benson LN. One year outcomes from the early feasibility study of the Harmony transcatheter pulmonary valve. Presented at TCT, 2016.Google Scholar
- 63.Promphan W, Prachasilchai P, Siripornpitak S, Qureshi SA, Layangool T. Percutaneous pulmonary valve implantation with the Venus P-valve: clinical experience and early results. Cardiol Young. 2015;19:1–13.Google Scholar
- 66.Kim GB, Kwon BS, Lim HG. First in human experience of a new self-expandable percutaneous pulmonary valve implantation using knitted nitinol-wire and tri-leaflet porcine pericardial valve in the native right ventricular outflow tract. Catheter Cardiovasc Interv. 2017;89(5):906–9.PubMedCrossRefGoogle Scholar
- 70.Wilhelm C, Swinning J, Sisk M, Holzer R. Melody valve implantation using a double-balloon “flower-blossom” technique. Cong Cardiol Today. 2014;8:1–8.Google Scholar
- 76.•• Tretter JT, Friedberg MK, Wald RM, McElhinney DB. Defining and refining indications for transcatheter pulmonary valve replacement in patients with repaired tetralogy of Fallot: contributions from anatomical and functional imaging. Int J Cardiol. 2016;221:916–25. This article provide other indices that can refine the timing of tPVR, such as indices of myocardial wall strain, tissue velocities, diastology, and ventricular response to exercise.PubMedCrossRefGoogle Scholar