Outcomes After Transcatheter Reintervention for Dysfunction of a Previously Implanted Transcatheter Pulmonary Valve

Interventional Treatment of Acute Right Ventricular Outflow Tract Infectious Endocarditis: A Bridge to Surgical or Percutaneous Pulmonary Valve Replacement

BACKGROUND

Infective endocarditis (IE) poses significant risks following percutaneous pulmonary valve implantation (PPVI) or surgical replacement (PVR).

AIMS

This study evaluates the effectiveness of emergency percutaneous treatment in stabilizing patients with severe right ventricular dysfunction or obstructive cardiac shock, allowing for delayed surgical or percutaneous valve replacement.

METHODS

This retrospective study examines 16 patients (age 19.9 [15.1-43.3] years) with right-sided IE treated with primary percutaneous intervention. Data collected included cardiac diagnosis, valve types, pathogens identified, procedural details, and outcomes.

RESULTS

Underlying diagnoses included aortic valve stenosis post-Ross surgery (43%), repaired tetralogy of Fallot (25%), common arterial trunk (18%), and repaired double outlet right ventricle (14%). Valve types varied, with Contegra Ven-Pro (56%) and Melody-valve (25%) being the most common. Diagnosis of IE occurred 66.5 (28.3-87.4) months postlast intervention/surgery, with emergency percutaneous treatment performed 2 (1-17) days postdiagnosis. Clinical presentations included obstructive cardiac shock (50%) and septic shock (25%). Preintervention RVOT velocity was 4.4 (4.2-5) m/s, with severely reduced RV function in 68%. Interventions included balloon dilatation, uncovered or covered stent implantation, and Melody valve implantation. Immediate resolution of RVOT obstruction was achieved in all patients, with significant reductions in RV systolic pressures (mean reduction 42.0 (30.2-50.0) mmHg) and improved RV function. No periprocedural deaths occurred, but one complication was noted. Follow-up included surgical repair (68%) and PPVI (18%). Mortality included one IE relapse and one surgical death.

CONCLUSIONS

Emergency percutaneous interventions can stabilize patients with RVOT obstruction due to IE, enabling delayed surgical or percutaneous interventions.

Early-term results of percutaneous pulmonary valve implantation (valve-in-valve) in dysfunctional bioprosthetic valves in pulmonary position

Background

This study aimed to assess the outcomes of valve-in-valve implantation within previously placed bioprosthetic valves.

Methods

This single-center retrospective study included patients who underwent percutaneous valve-in-valve procedures between July 2014 and September 2023. These patients had previously received pulmonary bioprosthetic valves via surgical or transcatheter methods.

Results

The study included 20 patients (13 males, 7 females; mean age: 20.4±7.1 years; range, 10.8 to 35.8 years). Preprocedural assessment revealed stenotic dysfunction in 12 patients, regurgitant dysfunction in two patients, and a combination of both in six patients. Following implantation, there was a notable improvement in invasive measurements; systolic right ventricular pressure decreased from 64.0±24.5 mmHg to 31.3±6.7 mmHg (p<0.001), right ventricular outflow tract gradient from 44.0±23.2 mmHg to 7.6±5.8 mmHg (p<0.001), and echocardiographic pulmonary regurgitation grade from 2.1±1.2 to 0.2±0.4 (p<0.001). The median time between initial bioprosthetic pulmonary valve placement and valve-in-valve procedure was 8.2 years (IQR, 6.2 to 9.9 years). The median follow-up duration was 24.8 months (IQR, 8.3 to 40.2 months). Only one patient required a repeat PPVI procedure 10 years after the valve-in-valve procedure, while no other patients required reintervention during the follow-up period.

Conclusion

Valve-in-valve implantation within previously placed bioprosthetic valves is a feasible and safe approach, offering symptom relief and eliminating the need for further surgical interventions.

Over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement

OBJECTIVES

To determine the safety and feasibility of over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement.

BACKGROUND

Transcatheter pulmonary valve placement is an alternative to surgical pulmonary valve replacement. Traditionally, it was thought to be unsafe to expand a conduit to >110% of its original size.

METHODS

This retrospective cohort study from two centers includes patients with right ventricle to pulmonary artery conduits with attempted transcatheter pulmonary valve placement from 2010 to 2017. Demographic, procedural, echocardiographic and follow-up data, and complications were evaluated in control and overdilation (to >110% original conduit size) groups.

RESULTS

One hundred and seventy-two patients (51 overdilation and 121 control) had attempted transcatheter pulmonary valve placement (98% successful). The overdilation group was younger (11.2 versus 16.7 years, p < 0.001) with smaller conduits (15 versus 22 mm, p < 0.001); however, the final valve size was not significantly different (19.7 versus 20.2 mm, p = 0.2). Baseline peak echocardiographic gradient was no different (51.8 versus 55.6 mmHg, p = 0.3). Procedural complications were more frequent in overdilation (18%) than control (7%) groups (most successfully addressed during the procedure). One patient from each group required urgent surgical intervention, with no procedural mortality. Follow-up echocardiographic peak gradients were similar (24.1 versus 26 mmHg, p = 0.5).

CONCLUSIONS

Over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement can be performed successfully. Procedural complications are more frequent with conduit overdilation, but there was no difference in the rate of life-threatening complications. There was no difference in valve function at most recent follow-up, and no difference in rate of reintervention. The long-term outcomes of transcatheter pulmonary valve placement with conduit over-expansion requires further study.

Long-term outcomes of transcatheter pulmonary valve implantation with melody and SAPIEN valves

BACKGROUND

Transcatheter pulmonary valve implantation (TPVI) is effective for treating right ventricle outflow tract (RVOT) dysfunction. Factors associated with long-term valve durability remain to be investigated.

METHODS

Consecutive patients successfully treated by TPVI with Melody valves (n = 32) and SAPIEN valves (n = 182) between 2008 and 2020 at a single tertiary centre were included prospectively and monitored.

RESULTS

The 214 patients had a median age of 28 years (range, 10-81). The RVOT was a patched native pulmonary artery in 96 (44.8%) patients. Median follow-up was 2.8 years (range, 3 months-11.4 years). Secondary pulmonary valve replacement (sPVR) was performed in 23 cases (10.7%), due to stenosis (n = 22, 95.7%) or severe regurgitation (n = 1, 4.3%), yielding an incidence of 7.6/100 patient-years with melody valves and 1.3/100 patient-years with SAPIEN valves (P = 0.06). The 5- and 10-year sPVR-freedom rates were 78.1% and 50.4% with Melody vs. 94.3% and 82.2% with SAPIEN, respectively (P = 0.06). The incidence of infective endocarditis (IE) was 5.5/100 patient-years with Melody and 0.2/100 patient-years with SAPIEN (P < 0.0001). Factors associated with sPVR by univariate analysis were RV obstruction before TPVI (P = 0.04), transpulmonary maximal velocity > 2.7 m/s after TPVI (p = 0.0005), valve diameter ≤ 22 mm (P < 0.003), IE (P < 0.0001), and age < 25 years at TPVI (P = 0.04). By multivariate analysis adjusted for IE occurrence, transpulmonary maximal velocity remained associated with sPVR.

CONCLUSIONS

TPVI is effective for treating RVOT dysfunction. Incidence of sPVR is higher in patients with residual RV obstruction or IE. IE add a substantial risk of TPVI graft failure and is mainly linked to the Melody valve.

SOCIAL MEDIA ABSTRACT

Transcatheter pulmonary valve implantation is effective for treating right ventricular outflow tract dysfunction in patients with congenital heart diseases. Incidence of secondary valve replacement is higher in patients with residual obstruction or infective endocarditis.

Reintervention and Survival After Transcatheter Pulmonary Valve Replacement

BACKGROUND

Transcatheter pulmonary valve (TPV) replacement (TPVR) has become the standard therapy for postoperative pulmonary outflow tract dysfunction in patients with a prosthetic conduit/valve, but there is limited information about risk factors for death or reintervention after this procedure.

OBJECTIVES

This study sought to evaluate mid- and long-term outcomes after TPVR in a large multicenter cohort.

METHODS

International registry focused on time-related outcomes after TPVR.

RESULTS

Investigators submitted data for 2,476 patients who underwent TPVR and were followed up for 8,475 patient-years. A total of 95 patients died after TPVR, most commonly from heart failure (n = 24). The cumulative incidence of death was 8.9% (95% CI: 6.9%-11.5%) 8 years after TPVR. On multivariable analysis, age at TPVR (HR: 1.04 per year; 95% CI: 1.03-1.06 per year; P < 0.001), a prosthetic valve in other positions (HR: 2.1; 95% CI: 1.2-3.7; P = 0.014), and an existing transvenous pacemaker/implantable cardioverter-defibrillator (HR: 2.1; 95% CI: 1.3-3.4; P = 0.004) were associated with death. A total of 258 patients underwent TPV reintervention. At 8 years, the cumulative incidence of any TPV reintervention was 25.1% (95% CI: 21.8%-28.5%) and of surgical TPV reintervention was 14.4% (95% CI: 11.9%-17.2%). Risk factors for surgical reintervention included age (0.95 per year [95% CI: 0.93-0.97 per year]; P < 0.001), prior endocarditis (2.5 [95% CI: 1.4-4.3]; P = 0.001), TPVR into a stented bioprosthetic valve (1.7 [95% CI: 1.2-2.5]; P = 0.007), and postimplant gradient (1.4 per 10 mm Hg [95% CI: 1.2-1.7 per 10 mm Hg]: P < 0.001).

CONCLUSIONS

These findings support the conclusion that survival and freedom from reintervention or surgery after TPVR are generally comparable to outcomes of surgical conduit/valve replacement across a wide age range.

Prevention and management of endocarditis after transcatheter pulmonary valve replacement: current status and future prospects

Introduction: Transcatheter pulmonary valve replacement (TPVR) has become an important tool in the management of congenital heart disease with abnormalities of the right ventricular outflow tract. Endocarditis is one of the most serious adverse long-term outcomes and among the leading causes of death in patients with congenital heart disease and after (TPVR).Areas covered: This review discusses the current state knowledge about the risk factors for and outcomes of endocarditis after transcatheter pulmonary valve replacement in patients with congenital and acquired heart disease. It also addresses practical measures for mitigating endocarditis risk, as well as diagnosing and managing endocarditis when it does occur.Expert opinion: With increasing understanding of the risk factors for and management and outcomes of endocarditis in patients who have undergone TPVR, we continue to learn how to utilize TPVR most effectively in this complex population of patients.