Outcomes of Venus P-valve for dysfunctional right ventricular outflow tracts from Indian Venus P-valve database

Simplified approach to Venus-P pulmonary valve implantation in a patient with complex cardiac anatomy: a simple solution for a difficult anatomy

This report describes a 41-year-old female with left isomerism, interrupted inferior caval vein with azygos continuation, dextrocardia, and repaired tetralogy of Fallot, who underwent percutaneous pulmonary valve implantation using the Venus P-valve system. Due to anatomical constraints, left jugular venous access was utilised. A Venus P-valve (30 by 25 mm) was successfully implanted in the right ventricular outflow tract using a simplified, one-curve trajectory directly on its delivery system without a delivery sheath. Contrast injections during valve implantation were not possible, and the pre-implanted duct occluder was our anatomical landmarks. This case highlights the adaptability of the Venus P-valve and the importance of individualised procedural strategies in addressing anatomical challenges and achieving optimal outcomes.

Image-Derived Modeling to Assess Coronary Proximity in Patients Undergoing Transcatheter Pulmonary Valve Replacement With Self-Expanding Valves

BACKGROUND

The potential for coronary artery compression (CC) during transcatheter pulmonary valve replacement (TPVR) using self-expanding valves (SEV) is not fully understood, yet anecdotal reports suggest that this risk exists.

AIMS AND METHODS

We performed a retrospective cohort study of patients evaluated for SEV-TPVR to evaluate the relationship between the right ventricular outflow tract (RVOT) and coronary arteries (CA). CT-derived segmentations of the RVOT and CA were created using machine learning. A 2D map of the distance between the RVOT surface and CA, in systole and diastole, was created. In the subset of patients with post-procedural CTA, the distance before and after TPVR was measured.

RESULTS

Forty-two individuals underwent screening for SEV-TPVR, of which 83% (n = 35) had SEV implanted (Harmony = 24; Alterra = 11). Median age was 22.9 years (range 12-60) and 76% had tetralogy of Fallot (TOF). There was no significant change in the distance between the RVOT and LCA between diastole and systole (p = 0.31), yet the RVOT area nearest to the LCA displaced proximally by 11 mm (IQR: 5.6-19.9) in systole. In 8 patients with pre- and post-TPVR CTA, no statistically significant differences were observed in the RVOT-to-LCA relation after intervention. The distance to the LCA was smaller in pulmonary stenosis/atresia patients than those with TOF (median distance 1.2 and 2.1 mm, respectively; p = 0.185).

CONCLUSION

The RVOT area in closest proximity to LCA is dynamic and should be considered when planning TPVR. Special attention should be given to patients with a diagnosis of pulmonary stenosis/atresia.

Percutaneous self-expandable valve implantation in patients with stented pulmonary arteries: case examples

CHDs affecting the right ventricular outflow tract often require repeated surgical or transcatheter interventions due to pulmonary insufficiency or stenosis. This study presents percutaneous implantation of large self-expanding valves in patients with complex right ventricular outflow tract anatomy after prior pulmonary branch stenting.

A 3D Statistical Shape Model of the Right Ventricular Outflow Tract in Pulmonary Valve Replacement Patients Post-Surgical Repair

Assessment of the right ventricular outflow tract and pulmonary arteries (RVOT) for percutaneous pulmonary valve implantation (PPVI) uses discrete measurements (diameters and lengths) from medical images. This multi-centre study identified the 3D RVOT shape features prevalent in patients late after surgical repair of congenital heart disease (CHD). A 3D RVOT statistical shape model (SSM) was computed from 81 retrospectively selected CHD patients (14.7 ± 6.8 years) who required pulmonary valve replacement late after surgical repair. A principal component analysis identified prevalent shape features (modes) within the population which were compared with standard geometric measurements (diameter, length and surface area) and between sub-groups of diagnosis, RVOT type and dysfunction. Shape mode 1 and 2 represented RVOT size and curvature and tapering and length, respectively. Shape modes 3-5 related to branch pulmonary artery calibre, conical vs. bulbous RVOTs and RVOT curvature, respectively. Tetralogy of Fallot, transannular patch type and regurgitant RVOTs were larger and straighter while conduit and stenotic types were longer and more cylindrical than other subgroups. This SSM analysed the main 3D shape features present in a population of RVOTs, exploiting the wide 3D anatomical information provided by routine imaging. This morphological information may have implications for PPVI patient selection and device design.

Transcatheter pulmonary valve implantation with custom-made 35-mm Myval™ transcatheter heart valve

Transcatheter pulmonary valve implantation (TPVI) is the standard of care in patients with repaired tetralogy of Fallot (rTOF) presenting with right ventricular outflow tract (RVOT) dysfunction. However, the feasibility of TPVI is limited by the high cost and nonavailability of larger-sized valves for dilated native RVOT of rTOF patients. We report the first successful TPVI with a custom-made 35 mm balloon-expandable valve (Myval™) in a 30-year-old rTOF patient with severe pulmonary regurgitation and RV dysfunction.

Transcatheter Pulmonary Valve in Congenital Heart Disease

Over the last 2 decades, experience with transcatheter pulmonary valve replacement (TPVR) has grown significantly and has become an effective and reliable way of treating pulmonary valve regurgitation, right ventricular outflow (RVOT) obstruction, and dysfunctional bioprosthetic valves and conduits. With the introduction of self-expanding valves and prestents, dilated native RVOT can be addressed with the transcatheter approach. In this article, the authors review the current practices, technical challenges, and outcomes of TPVR.

Holography-guided procedural planning for modifying Venus P-valve implantation technique in patients with left pulmonary artery stents: a case-series

Background

Venus P-valve™ (Venus Medtech, Hangzhou, China) is a self-expandable bioprosthetic valve that can be transcatheter-implanted in native right ventricular outflow tract (RVOT) patients. Valve implantation is technically challenging. Due to the implantation technique, left pulmonary artery (LPA) stents represent a relative contraindication to Venus P-valve. In this case series, we describe our experience in implanting Venus P-valve in patients with previous LPA stents and the use of holographic models to facilitate procedural planning.

Methods and results

From January to October 2023, 17 patients were scheduled for Venus P-Valve implantation. 16/17 (94%) patients were successfully implanted. 3/16 (18.7%) patients underwent Venus P-valve implantation with LPA stents. All patients underwent pre-operative CT scan. CT data set were employed to create three-dimensional (3D) holographic models (Artiness, Milan, Italy) of the entire heart, which were useful to plan valve implantation with a modified technique. Procedural success rate was 100%. No procedural complications occurred. All three patients presented good haemodynamic and angiographic results at discharge and follow-up visits.

Conclusion

This case-series underscores the feasibility of Venus P-valve implantation in patients with previous LPA stents. The use of holographic models facilitated procedural planning in these challenging anatomical scenarios.

Transcatheter-Based Interventions for Tetralogy of Fallot Across All Age Groups

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. Palliative procedures, either surgical or transcatheter, aim to improve oxygen saturation, affording definitive procedures at a later stage. Transcatheter interventions have been used before and after surgical palliative or definitive repair in children and adults. This review aims to provide an overview of the different catheter-based interventions for TOF across all age groups, with an emphasis on palliative interventions, such as patent arterial duct stenting, right ventricular outflow tract stenting, or balloon pulmonary valvuloplasty in infants and children and transcatheter pulmonary valve replacement in adults with repaired TOF, including the available options for a large, dilated native right ventricular outflow tract.

[The PULSTA valve in native right ventricular outflow tract: initial experience in 3 Spanish hospitals]

Introduction and objectives

Surgery for congenital heart defects with right ventricular outflow tract (RVOT) stenosis often results in significant pulmonary regurgitation, requiring pulmonary valve replacement in the long term. Despite the development of balloon-expandable prostheses, the native RVOT frequently dilates beyond the maximum diameters allowed for these valves. To allow percutaneous pulmonary valve implantation (PPVI) in these patients, clinical trials have been initiated with self-expanding prostheses, including the PULSTA valve. The aim of this study was to report the initial experience with this valve at three Spanish hospitals.

Methods

Descriptive study presenting the results of PPVI with the PULSTA prosthesis in patients with native RVOT and pulmonary regurgitation.

Results

We included 10 patients with a mean age of 15 ± 2.8 years. The implantation was successful in all patients, with no major complications occurring during the procedure. The mean length of follow-up was 18 [range, 2-35] months. In 8 patients, cardiac magnetic resonance was performed at 6 months, revealing a reduction in mean end-diastolic volume (131.7 ± 31.7 mL/m2 vs 100.3 ± 28.9 mL/m2) and end-systolic volume (68 ± 20.8 mL/m2 vs 57 ± 18.5 mL/m2).

Conclusions

The PULSTA prosthesis offers a safe, feasible, and effective alternative for PPVI in patients with native dilated RVOT. Due to the limited available follow-up data, further studies are needed to assess its long-term safety and durability.

Standardized Bench Test Evaluation of Biomechanical Characteristics of Stents Used in Right Ventricular Outflow Tract Revalvulation

PURPOSE

Pre-stenting of the right ventricular outflow tract (RVOT) is commonly performed before percutaneous pulmonary valve implantation (PPVI), to relieve obstruction, prevent valved stent fractures, and provide a landing zone. This study aimed to evaluate the biomechanical characteristics of the stents currently used to perform pre-stenting of the RVOT.

METHODS

We assessed five commercially available stents: Cheatham-Platinum Stent ("CP Stent"), AndraStent XL, AndraStent XXL, Optimus XL, and Optimus XXL. Following stent deployment at nominal pressure, radial and longitudinal elastic recoils and radial resistance were measured. The bending stiffness of the stents crimped onto the balloons was also evaluated.

RESULTS

Three samples were tested for each stent. Our study showed no significant difference between the stent platforms in terms of radial elastic recoil, which was relatively low (< 10%). The longitudinal elastic recoil was also low for all the devices (< 5%). Significant differences were observed in radial resistance (P < 0.001). CP Stent and AndraStent XL exhibited the highest radial resistances. The bending stiffnesses of the stents crimped on their balloons were significantly different (P < 0.00001). Optimus XL and XXL were more flexible than the other stents.

CONCLUSION

This study highlights the significant differences between the stents currently used in RVOT pre-stenting. Stents with good radial resistance are preferred, especially for calcified vessels, and flexibility is crucial for tortuous vessels. We proposed an algorithm for selecting the most suitable stent according to the need for radial force and flexibility, which will help inform clinicians considering RVOT revalvulation.

Current status of transcatheter intervention for complex right ventricular outflow tract abnormalities

Various transcatheter interventions for the right ventricular outflow tract (RVOT) have been introduced and developed in recent decades. Transcatheter pulmonary valve perforation was first introduced in the 1990s. Radiofrequency wire perforation has been the approach of choice for membranous pulmonary atresia in newborns, with high success rates, although complication rates remain relatively common. Stenting of the RVOT is a novel palliative treatment that may improve hemodynamics in neonatal patients with reduced pulmonary blood flow and RVOT obstruction. Whether this option is superior to other surgical palliative strategies or early primary repair of tetralogy of Fallot remains unclear. Transcatheter pulmonary valve replacement has been one of the biggest innovations in the last two decades. With the success of the Melody and SAPIEN valves, this technique has evolved into the gold standard therapy for RVOT abnormalities with excellent procedural safety and efficacy. Challenges remain in managing the wide heterogeneity of postoperative lesions seen in RVOT, and various technical modifications, such as pre-stenting, valve ring modification, or development of self-expanding systems, have been made. Recent large studies have revealed outcomes comparable to those of surgery, with less morbidity. Further experience and multicenter studies and registries to compare the outcomes of various strategies are necessary, with the ultimate goal of a single-step, minimally invasive approach offering the best longer-term anatomical and physiological results.

CMR and Percutaneous Treatment of Pulmonary Regurgitation: Outreach the Search for the Best Candidate

Performance of cardiovascular magnetic resonance (CMR) in the planning phase of percutaneous pulmonary valve implantation (PPVI) is needed for the accurate delineation of the right ventricular outflow tract (RVOT), coronary anatomy and the quantification of right ventricular (RV) volume overload in patients with significant pulmonary regurgitation (PR). This helps to find the correct timings for the intervention and prevention of PPVI-related complications such as coronary artery compression, device embolization and stent fractures. A defined CMR study protocol should be set for all PPVI candidates to reduce acquisition times and acquire essential sequences that are determinants for PPVI success. For correct RVOT sizing, contrast-free whole-heart sequences, preferably at end-systole, should be adopted in the pediatric population thanks to their high reproducibility and concordance with invasive angiographic data. When CMR is not feasible or contraindicated, cardiac computed tomography (CCT) may be performed for high-resolution cardiac imaging and eventually the acquisition of complementary functional data. The aim of this review is to underline the role of CMR and advanced multimodality imaging in the context of pre-procedural planning of PPVI concerning its current and potential future applications.

Ten Years of Percutaneous Pulmonary Valve Implantation in Australia and New Zealand

OBJECTIVE

This study sought to investigate the characteristics, morbidity (including the rate of infective endocarditis and valve replacement) and mortality of individuals undergoing percutaneous pulmonary valve implantation in Australia and New Zealand since the procedure has been performed.

BACKGROUND

The outcomes of percutaneous pulmonary valve implantation in Australia and New Zealand have not been evaluated. Recent international data, including patients from New Zealand, suggests the rate of infective endocarditis is not insignificant.

METHODS

A retrospective multi-site cohort study was undertaken via medical record review at the centres where percutaneous pulmonary valve implantation has been performed. All procedures performed from 2009-March 2018 were included. Individuals were identified from local institution databases. Data was collected and analysed including demographics, details at the time of intervention, haemodynamic outcome, post procedure morbidity and mortality. Multi-site ethics approval was obtained.

RESULTS

One hundred and seventy-nine (179) patients attended the cardiac catheter laboratory for planned percutaneous pulmonary valve implantation. Of these patients, 172 underwent successful implantation. Tetralogy of Fallot and pulmonary atresia were the most common diagnoses. The median age at procedure was 19 years (range 3-60 yrs). There was a significant improvement in the acute haemodynamics in patients undergoing percutaneous pulmonary valve implantation for stenosis. Seven (7) patients (3.9%) experienced a major procedural/early post procedure complication (death, conversion to open procedure, cardiac arrest), including two deaths. The annualised rates of infective endocarditis and valve replacement were 4.6% and 3.8% respectively. There was one death related to infective endocarditis in follow-up.

CONCLUSIONS

Percutaneous pulmonary valve replacement is a relatively safe method of rehabilitating the right ventricular outflow tract.

First hybrid implantations of novel Salus-Valves in patients with severe pulmonary regurgitation: A case series

With the increasing age of patients after right ventricular outflow tract (RVOT) reconstruction, progressive pulmonary valve (PV) dysfunction can result in different degrees of right heart insufficiency, and PV replacement is frequently needed during follow-up. The traditional redo thoracotomy is difficult and associated with higher risks when compared to transcatheter implantations. Herein, we report the advantages and describe the outcomes of the first hybrid implantations of the novel Salus-Valves (Balance Medical, Beijing, China) from the sub-xiphoid approach in five patients (mean age of 22.6 years) with severe pulmonary regurgitation (PR) after RVOT reconstruction.

Transcatheter Device Therapy and the Integration of Advanced Imaging in Congenital Heart Disease

Transcatheter device intervention is now offered as first line therapy for many congenital heart defects (CHD) which were traditionally treated with cardiac surgery. While off-label use of devices is common and appropriate, a growing number of devices are now specifically designed and approved for use in CHD. Advanced imaging is now an integral part of interventional procedures including pre-procedure planning, intra-procedural guidance, and post-procedure monitoring. There is robust societal and industrial support for research and development of CHD-specific devices, and the regulatory framework at the national and international level is patient friendly. It is against this backdrop that we review transcatheter implantable devices for CHD, the role and integration of advanced imaging, and explore the current regulatory framework for device approval.