287 Extension of indications for percutaneous pulmonary valve implantation in native right ventricle outflow tract: should all patients be considered?

Abstract

Patient selection for percutaneous pulmonary valve insertion PPVI is widely accepted, being limited to patients having a right ventricle to pulmonary artery conduit. Little data has been reported regarding PPVI on patients having a native RVOT. We present our data regarding percutaneous PPVI in native RVOT and discuss the specific requirements to make this technique safe and durable. We review patients included over the last 12 months in the prospective study (REVALV) for patients undergoing RVOT intervention for severe stenosis and/or insufficiency. Only valved stent on native RVOT group is analyzed here. 10 patients were included. We perform MRI, balloon calibration and angiography of the RVOT to all patients in order to define the RVOT morphology, and to establish a personalized technique for each patient in order to implant a valved stent on the native RVOT. All patients undergoing valved stent implantation are previously pre-stented with a bare metal stent according to present recommendations. Initial dimensions for these patients were on the upper limit for the established criteria. 2 had a diameter above 24 mm. Decision for implanting valved stent was taken based on the fact that pre-stenting reduces RVOT diameter acchieving 22 mm, and giving the native outflow track the stability to prevent valved-stent fractures. For one patient, left pulmonary branch was stented down to the pulmonary trunk in order to have an appropriate diameter for valved-stenting. Pulmonary valve was placed successfully in all cases. All but one had been pre-stented at same procedure than valvulation. Of those, one freshly implanted bare metal stent dislodged to the right pulmonary artery when tenting to place the delivery system for the percutaneous valve. Two extra bare metal stents were implanted in order to cover the branch to the trunk, and finally valved stent was placed with no further problems. Percutaneous pulmonary valve implantation can be performed on patients having native RVOT with success. Pre-stenting should be performed in a previous intervention in order to ensure stabilization of the bare metal stent and to avoid dislodgements. MRI, angiography and balloon calibration are not discriminating criteria for discarding candidates if personalized techniques are established for each patient. Pulmonary branches can be used as anchors for PPVI.