Deciphering the mystery of the leaky pulmonary valve in a new era of interventional cardiology The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

Abstract

Deciphering the effect of pulmonary regurgitation on right ventricular (RV) function in patients after tetralogy of Fallot correction and deciding on timing for valve replacement seems like cracking the Da Vinci code. This question has become the Holy Grail of congenital cardiology in the 21st century. Every piece of information bringing us closer to an answer based on sound scientific data therefore is of great importance. The study by Coats et al. ,1 looking at the haemodynamic effect of percutaneous pulmonary valve implantation (PPVI) in patients with predominantly pulmonary regurgitation and RV volume overload, provides new insight into the physiological consequences of relieving chronic pulmonary regurgitation. The great advantage of this unique model is that it avoids the confounding effects of cardiopulmonary bypass and cardiac surgery. When prospectively studying their patients with detailed echocardiography, cardiac magnetic resonance imaging (MRI) and exercise testing, Coats et al. noted that 3 months after PPVI, RV end-diastolic volume decreased, and cardiac output at rest increased without a change in exercise capacity. Subjectively the patients felt better after the procedure, and New York Heart Association (NYHA) classification improved. When deciding on when to intervene for pulmonary regurgitation, different parameters such as symptoms, RV dilatation, RV function, and exercise capacity are generally taken into account.2–6 The decision is still subject to debate and largely dependent on centre preference and subjective medical judgement. Some centres advocate waiting until the patients are symptomatic, but there is no agreement on how to define these symptoms. Using RV dysfunction as a criterion is even more problematic as no good quantitative techniques are available for assessing RV function in the context of volume overload. During recent years, a lot of attention was focused on defining a … *Corresponding author. Tel: +32 16 343865; fax: +32 16 343981. E-mail address : luc.mertens{at}uzleuven.be