Abstract
One of the major obstacles preventing successful percutaneous pulmonary valve implantation (PPVI) is related to the close proximity of coronary artery branches to the expected landing zone. The aim of this study was to assess the frequency of coronary artery anomalies (CAAs) especially those associated with major coronary branches crossing the right ventricular outflow tract (RVOT) and to describe their relevance for the feasibility of percutaneous pulmonary valve implantation (PPVI). In our retrospective single-center study 90 patients were evaluated who underwent invasive testing for PPVI in our institution from 1/2010 to 1/2020. CAAs were identified in seven patients (8%) associated with major branches crossing the RVOT due to origin of the left anterior descending (LAD) or a single coronary artery from the right aortic sinus. In 5/7 patients with CAAs balloon testing of the RVOT and selective coronary angiographies revealed a sufficiently large landing zone distal to the coronary artery branch. While unfavorable RVOT dimensions prevented PPVI in one, PPVI was performed successfully in the remaining four patients. The relatively short landing zone required application of the “folded” melody technique in two patients. All patients are doing well (mean follow-up 3 years). CAAs associated with major coronary branches crossing the RVOT can be expected in about 8% of patients who are potential candidates for PPVI. Since the LAD crossed the RVOT below the plane of the pulmonary valve successful distal implantation of the valve was possible in 4/7 patients. Therefore these coronary anomalies should not be considered as primary contraindications for PPVI.
Highlights
Percutaneous pulmonary valve implantation (PPVI) has found widespread acceptance in the postoperative revalvulation of the dysfunctional right ventricular outflow tract [1,2,3,4]. Major limitations for this procedure are coronary artery branches located in close proximity to the expected landing zone of the pulmonary valve resulting in the potential risk for coronary compression caused by radial tension from the balloon-expandable stent
It should be noted that our cohort may be associated with some bias since some patients with unfavorably large right ventricular outflow tract (RVOT) diameters were referred for surgical intervention without invasive testing of the RVOT based on MRI findings
Abnormal coronary artery anatomy was demonstrated in 34/226 (15%) patients with tetralogy of Fallot who underwent catheterization and testing for intended percutaneous pulmonary valve implantation (PPVI) [7]. In this and in other studies coronary artery anomalies were associated with an increased risk of coronary artery compression during balloon interrogation of the RVOT [5, 7, 16]. Despite this statistically increased risk the results of our study show that successful PPVI is possible in the majority of patients exhibiting a major coronary artery branch crossing the RVOT
Summary
Percutaneous pulmonary valve implantation (PPVI) has found widespread acceptance in the postoperative revalvulation of the dysfunctional right ventricular outflow tract [1,2,3,4] Major limitations for this procedure are coronary artery branches located in close proximity to the expected landing zone of the pulmonary valve resulting in the potential risk for coronary compression caused by radial tension from the balloon-expandable stent. In patients with origin of the left anterior descending coronary artery (LAD) from the right aortic sinus the LAD crosses the right ventricular outflow tract (RVOT) in close proximity to a potential landing zone This coronary anomaly is not uncommon in patients with tetralogy of Fallot, who represent a major percentage of potential candidates for PPVI [7,8,9]. The aim of this study was to assess the frequency and relevance of CAA impacting the feasibility of PPVI based on retrospective evaluation of all patients who underwent invasive testing in our institution
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