Pulmonary Valve Replacement in Tetralogy of Fallot: Procedural Volume and Durability of Bioprosthetic Pulmonary Valves

Efficacy and safety of mechanical pulmonary valve replacement: a comprehensive systematic review and meta-analysis

BACKGROUND

Pulmonary valve replacement (PVR) is the most common valve replacement procedure for pulmonary valve dysfunction in congenital heart diseases (CHD). Despite the long-term need for anticoagulation and potential bleeding complications in mechanical PVR (MPVR), prosthetic dysfunction and reoperation might occur less frequently. The major guidelines on the CHD management have no recommendation on the valve type for the PVR. So, we systematically reviewed the latest literature on the efficacy and safety of MPVR with different etiologies.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered with PROSPERO (CRD42023425339). A systematic search was conducted in PubMed, Scopus, Web of Science, and Embase. The primary outcomes evaluated include all-cause mortality, reintervention for mechanical prostheses, valvular thrombosis, thromboembolic events, prosthetic valve dysfunction, major bleeding events, right ventricular failure, and infective endocarditis. A random-effects model was employed for the meta-analysis. The quality of the studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

The literature search was conducted up to June 12, 2023, and included 16 records in the qualitative synthesis, with 13 studies also included in the quantitative synthesis. Our systematic review indicates that the previously published patient-level analysis remains the most reliable evidence to date on MPVR, with 91%, 97%, and 95% 5-year freedom from valvular thrombosis, reintervention, and all-cause mortality, respectively. Our meta-analysis indicated low pooled incidence proportions of other outcomes as follows: Major bleeding (mean follow-up = 68.79 months, 16/336, 5% [95% CI 3-8]); Valvular dysfunction (mean follow-up = 68.89 months, 70/708, 10% [95% CI 8-12]); Thromboembolic events (mean follow-up = 78.28 months, 9/293, 3% [95% CI 2-6]); and Infectious endocarditis (mean follow-up = 42.03 months, 7/518, 1% [95% CI 1-3]).

CONCLUSIONS

Despite showing acceptable efficacy and safety in MPVR, there is still a significant knowledge gap in choosing the most appropriate prosthetic valve in patients undergoing PVR. High-quality research is warranted to resolve the existing gap in evidence.

Interventions for adult congenital heart disease

Advances in imaging diagnostics, surgical techniques and transcatheter interventions for paediatric patients with severe congenital heart disease (CHD) have substantially reduced mortality, thereby extending the lifespan of these individuals and increasing the number of adults with complex CHD. Transcatheter interventions have emerged as an alternative to traditional open-heart surgery to mitigate congenital defects. The evolution of techniques, the introduction of new devices and the growing experience of operators have enabled the treatment of patients with progressively more complex conditions. The general cardiology community might be less aware of contemporary interventions for adult CHD, their clinical indications and associated outcomes than interventional cardiologists and congenital heart specialists. In this Review, we provide a comprehensive evaluation of the available transcatheter interventions for adult patients with CHD.

Surgical pulmonary valve redo versus transcatheter pulmonary valve replacement for Tetralogy of Fallot patients

OBJECTIVES

To perform a systematic review to compare the efficacy and safety of transcatheter pulmonary valve replacement (TPVR) and surgical pulmonary valve replacement (SPVR) in managing pulmonary valve dysfunction in Tetralogy of Fallot (TOF) patients.

METHODS

This review investigates through three different databases for randomized control trials or observational studies evaluating TOF patients who underwent TPVR or SPVR until November 2024. The outcomes of interest were hemodynamic improvement, reduction in pulmonary regurgitation or stenosis, complications, quality of life, and long-term outcomes.

RESULTS

Four retrospective studies (1919 procedures) were analyzed. TPVR was non-inferior to SPVR, with a comparable safety profile. The durability of bioprosthetic valves was similar between TPVR and SPVR (HR: 0.97, 95% CI: 0.55-1.73; p = 0.93) and was influenced by patients' age at PVR (HR: 0.78 per 10 years from <1 year; 95% CI: 0.63-0.96; p = 0.02) and true inner valve diameter    .

CONCLUSIONS

TPVR is a safe and less-invasive alternative to SPVR with comparable efficacy in reducing pulmonary regurgitation. Complication rates are similar and valve durability is primarily age- and valve size-dependent. Although further research on long term outcomes is needed, TPVR may be integrated into routine practices, offering a viable alternative for high-risk TOF patients.

REGISTRATION

This systematic review was registered on the international prospective register of systematic reviews (PROSPERO; #CRD42024615871).