Trifecta St. Jude medical® aortic valve in pulmonary position

Durability of Pulmonary Valve Replacement with Large Diameter Stented Porcine Bioprostheses

There is limited information about durability of large diameter porcine bioprostheses implanted for pulmonary valve replacement (PVR). We studied patients who underwent surgical PVR from 2002-2019 with a stented porcine bioprosthetic valve (BPV) with a labeled size ≥27 mm. The primary outcome was freedom from reintervention. During the study period, 203 patients underwent PVR using a porcine BPV ≥27 mm, 94% of whom received a Mosaic valve (Medtronic Inc., Minneapolis, MN). Twenty patients underwent reintervention from 3.4-12.0 years after PVR: 5 surgical and 15 transcatheter PVR procedures. The indication for reintervention was regurgitation in 13 patients, stenosis in 2, mixed disease in 4, and endocarditis in 1. Estimated freedom from reintervention was 97±1% at 5 years and 82±4% at 10 years, and freedom from prosthesis dysfunction (moderate or severe regurgitation and/or a maximum Doppler gradient ≥50 mm Hg) over time was 91±2% at 5 years and 74±4% at 10 years. Younger age and smaller true valve diameter were associated with shorter freedom from reintervention, but valve oversizing was not. The durability of large stented porcine bioprostheses in the pulmonary position is generally excellent, particularly in adolescents and adults, similar to various other types of BPV. In the current study, relative valve size was not associated with valve longevity, although the low event-rate in this population was a limiting factor.

Percutaneous pulmonary valve implantation in a dysfunctional Trifecta® bioprothesis after high-pressure balloon fracturing

A percutaneous pulmonary valve-in-valve (PPVIV) implantation in small surgical tissue valves may be limited due to the valve's initial diameter. Fracturing of the valve's integrity by high-pressure balloons may enhance the diameter and facilitate subsequent PPVIV with a large valve. To the best of our knowledge, the Trifecta® valve seemed not to be accessible for fracturing. We report a case of successful 19-mm Trifecta valve fracturing, followed by PPVIV using a 26-mm Edwards SAPIEN 3 valve in pulmonary position. By repetitively using a high-pressure balloon 5 mm larger than the labeled valve size, we were able to fracture the valve's integrity and implant a 26-mm valve thereafter. Therefore, Trifecta valve appears to be suitable for valve ring fracturing and subsequent PPVIV in certain patients.

Pulmonary Valve Regurgitation: Neither Interventional Nor Surgery Fits All

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.