Pulmonary Valve Incompetence Research Articles

Surgical ablation of ventricular tachycardia in patients with repaired tetralogy of Fallot†.

Life expectancy of patients with repaired tetralogy of Fallot is normal until adulthood, when it becomes burdened by major complications such as cardiac arrhythmias and heart failure. Ventricular tachycardia (VT), associated with electrical conduction abnormalities in anatomical isthmuses, is the most common complication and is refractory to medical therapy. The arrhythmogenic sources can be surgically ablated during reoperations for pulmonary valve incompetence. The purpose of our study is to evaluate the safety and effectiveness of surgical radiofrequency ablation during PVR and its long-term impact on the occurrence of cardiac events. A total of 118 patients with repaired tetralogy of Fallot underwent reoperation for pulmonary valve regurgitation in IRCCS-Policlinico San Donato between January 2002 and February 2016. Twenty patients with risk factors for ventricular arrhythmia underwent EP testing and were found positive. The mean QRS duration was 178 ms. Right ventricular dysfunction was present in all the patients, and 20% had associated tricuspid regurgitation. The cohort (N = 20), with positive EP study, underwent pulmonary valve replacement and concomitant intraoperative ventricular surgical radiofrequency ablation, targeting the slow conducting isthmuses identified during preoperative electroanatomical mapping. All patients were reviewed at 1 month, 3 months and 6 months with clinical evaluation, echocardiography, ECG and implantable cardioverter-defibrillator interrogation. At 6 months, a postoperative electrophysiological study was performed in all patients, and a cardioverter defibrillator was implanted as primary preventive measure in patients with residual inducible VT. Pulmonary valve replacement and surgical ventricular radiofrequency ablation were performed in all cases. One patient died while on V-V extracorporeal membrane oxygenation (ECMO) due to respiratory failure. There was no late mortality. Follow-up was complete with a median of 6.5 years. During the postoperative EPS study, inducible VT was found in 15.7% of patients who received an implantable cardioverter-defibrillator, whereas VT could no longer be induced in the remaining patients. No procedure-related complication was observed, and freedom from ventricular arrhythmia was 94% and 89.5% at 1 year and 5 years, respectively. Pulmonary regurgitation and right ventricular dysfunction correlate with VT and SCD, but valve replacement alone does not reduce the risk of ventricular tachyarrhythmias. Intraoperative ventricular ablation during reoperation for pulmonary regurgitation prevents the occurrence of ventricular arrhythmias in the early and medium term. Accordingly, this technique may be proposed as a safe associated procedure in selected patients.

What to Expect When You’re Expecting: A Rare Case of Sub–Pulmonary Valve Bacillus Endocarditis in a Pregnant Intravenous Drug User

We report the case of a 33-year-old pregnant female intravenous drug user who presented to our institution with a 2-week history of fevers and generalised lethargy. The patient had multiple blood cultures positive for bacillus species. Given the absence of a localising infective source, and an initial transthoracic echocardiogram that was unremarkable, the patient underwent transoesophageal echocardiography (TOE). Transoesophageal echocardiography showed a large vegetation arising from the ventriculo-arterial junction in the right ventricular outflow tract proximal to, but not involving, the pulmonary valve. There was no evidence of pulmonary valve incompetence, right ventricular outflow tract obstruction or acute right heart strain. The patient was commenced on intravenous benzylpenicillin and convalescent TOE showed resolution of the vegetative mass. Sub–pulmonary valve bacillus endocarditis has not previously been described. Isolated pulmonary valve endocarditis in itself is rare, with fewer than 90 cases of pulmonary valve endocarditis being previously reported, and only 45 reported cases in structurally normal hearts. The infrequency of pulmonary valve endocarditis is assumed to be caused by the low pressure gradients within the right heart, the low prevalence of congenital malformations, the lower oxygen content of venous blood, and the differences in covering and vascularisation of the right heart endothelium. This case highlights the importance of TOE, especially in the diagnosis of pulmonary valve endocarditis. In addition to the standard short-axis 30-degree mid-oesophageal view of the pulmonary valve on TOE, we recommend imaging of the right ventricular outflow tract in a 120-degree transoesophageal view and in a 90-degree trans-gastric view.

Sleep-Disordered Breathing in Patients with Pulmonary Valve Incompetence Complicating Congenital Heart Disease

Long standing pulmonary regurgitation results in deleterious effects on right heart size and function with late consequences of right heart volume overload including ventricular dilatation, propensity to arrhythmia and right heart failure. As sleep disordered breathing may predispose to elevations in pulmonary vascular resistance and associated negative effects on right ventricular function, we sought to assess this in patients with underlying congenital heart disease. We performed a pilot study to evaluate the incidence of sleep-disordered breathing in a patient population with a history of long standing pulmonary valve incompetence in patients with congenital heart disease using overnight oximetry. Patients with a background of tetralogy of Fallot repair or residual pulmonary incompetence following previous pulmonary valve intervention for congenital pulmonary stenosis were included. Twenty-two patients underwent overnight oximetry. The mean age of the cohort was 34.3 ± 15.2 years with no patients observed to have severe underlying pulmonary hypertension. Abnormal overnight oximetry was seen in 13/22 patients (59.1%) with 2/22 (9.1%) patients considered to have severe abnormalities. An important proportion of patients with a background of pulmonary incompetence complicating congenital heart disease are prone to the development of sleep-disordered breathing as assessed by overnight oximetry. Further study into the prevalence and mechanisms of sleep-disordered breathing in a larger cohort are warranted.

Aiming to Preserve Pulmonary Valve Function in Tetralogy of Fallot Repair: Comparing a New Approach to Traditional Management.

Pulmonary valve (PV) incompetence following transannular patch (TAP) repair of tetralogy of Fallot (TOF) results in long-term morbidity and mortality. Valve-sparing repairs have recently gained recognition; however, they may be associated with residual pulmonary stenosis (PS) in patients with small PV z scores. We sought to determine whether a repair that increases the PV annulus and augments the valve leaflet with a biomaterial would result in annular growth and in longer duration of valve competence compared with TAP. Eighty patients (median age 136days, range 4-350) who underwent surgical repair of TOF between 2010 and 2014 were included in the study. Patients were divided into three groups based on the PV intervention: balloon dilation/valvotomy (n=29), valve-sparing transannular repair (VSTAR) (n=19) and TAP (n=32). Intraoperative, early postoperative and midterm follow-up echocardiographic data (median 19months, range 1-59) were obtained. The primary outcomes were the presence and severity of pulmonary regurgitation and/or PS. Compared with TAP, VSTAR patients demonstrated significantly less severe PR with 100% freedom of severe PR immediately post-op (vs. 0% in TAP), 60% at 6months and 20% at 20months. There were no differences in PS between VSTAR and TAP at follow-up. A subgroup analysis of the VSTAR group was performed. PV z scores were calculated and fit to a random effects model. Patient data fit the model closely, predicting a reproducible increase in valve annulus size over time. With better short-term and comparable midterm results, VSTAR may be appropriate for TOF repair in patients with small PV that would conventionally require a TAP.

Variability of Pulmonary Regurgitation in Proportion to Pulmonary Vascular Resistance in a Porcine Model of Total Resection of the Pulmonary Valve: Implications for Early- and Long-Term Postoperative Management of Right Ventricular Outflow Tract Reconstruction With Resulting Pulmonary Valve Incompetence.

Pulmonary regurgitation (PR) is a major concern after right ventricular (RV) outflow tract surgery. We assessed the impact of physiological changes in pulmonary vasculature on hemodynamic severity of PR and RV function and their potential clinical implications for postoperative management using a porcine model with severe PR. Eight porcine models of acute PR were established by means of resection of pulmonary valve on cardiopulmonary bypass. After separation from bypass and stabilization, blood flow in the main pulmonary artery was measured by a pulsed Doppler flowmeter, and RV systolic function was assessed on the basis of RV segment shortening (RVSS), which was analyzed by sonomicrometry. In the acute PR model, we verified the impact of pulmonary vascular resistance (Rp) on pulmonary regurgitant fraction (PRF) and RV function. Pulmonary vascular resistance was changed by manipulating the level of PaCo 2 and by inhalation of nitric oxide (NO). After bypass, the mean PRF was 40% ± 5%, and there was a deterioration of RV function. Under each ventilation condition (high CO2, low CO2, and NO 20 ppm), Rp was 836 ± 207 dyne × s × cm(-5), 499 ± 125 dyne × s × cm(-5), and 340 ± 102 dyne × s × cm(-5), respectively, and PRF was 60% ± 10%, 37% ± 5%, and 24% ± 4%, respectively, under each condition. They also showed a positive correlation in all animals. Cardiac output and RVSS were decreased by hypercapnia, while they were significantly improved after NO inhalation. This study indicates that low Rp after right ventricular outflow tract reconstruction (RVOTR) resulting in acute PR is advantageous in reducing the severity of PR and RV volume load. These findings may have clinical implications for early and long-term postoperative management of patients subjected to RVOTR with resulting pulmonary valve incompetence.

Mid-Term Results of Balloon Pulmonary Valvuloplasty in Children at Queen Alia Heart Institute

Objective: To evaluate the mid-term results of balloon pulmonary valvuloplasty (BPV) in children. Design: Prospective study. Settings: Pediatric Cardiology Department of Queen Alia Heart (QAHI), Jordan. Methods: One hundred and thirty-two patients with a median age of 3 years (range 1 day to 16 years), underwent (BPV) between January 1999 and January 2006. We evaluated our patients with regard to peak pressure gradient across the right ventricular outflow tract before and after BPV. Thereafter we followed them at the Outpatient Clinic regarding the peak instantaneous gradient pressure, the pulmonary valve incompetence, right ventricular function based on echocardiographic findings, and the need for repeat BPV. Results: There was significant reduction in the peak to peak gradient from 93.5 ± 32.3 mmHg to 26.1 ± 9.6 mmHg (p < 0.001). Echo-Doppler data showed that residual peak instantaneous gradient dropped from 26.1 ± 9. 6 to 19 ± 6 mmHg; (p < 0.001) on follow-up for 6 years. Mild to moderarte pulmonary valve regurgitation was noticed in 34 patients (27.8%) at one year and in 43 patients (38%) at mid term follow-up, but non had right ventricular dilatation or paradoxical interventricular septal motion. Conclusions: The results of mid-term follow up after balloon dilatation of the pulmonary valve are encouraging. The degree of pulmonary regurgitation is increasing with time. Longer term follow-up studies should be undertaken to evaluate the significance of residual pulmonary regurgitation.

Modification of the Damus-Kaye-Stansel Procedure

The Damus-Kaye-Stansel procedure and its modifications have been performed to relieve systemic outflow tract obstruction in patients with a functional single ventricle. However, distortion of the pulmonary valve and sinus in the original procedure may cause pulmonary valve incompetence to develop, and prosthetic material is frequently required due to the size discrepancy between the newly reconstructed proximal great artery stump and the ascending aorta in recent modifications. We performed the Damus-Kaye-Stansel procedure with some technical modifications to overcome these concerns in 2 children and observed a competent pulmonary valve and a patent Damus-Kaye-Stansel pathway at the latest follow-up.

Secondary Repair of Incompetent Pulmonary Valves

Secondary repair of the pulmonary valve after right ventricular outflow tract (RVOT) reconstruction is infrequently reported. This article describes possible techniques of secondary pulmonary valve repair and reports follow-up results. Secondary pulmonary valve repairs in 7 patients (5 children and 2 adults) in our institution were reviewed. All patients presented with a severe pulmonary valve regurgitation associated with RV dilatation and dysfunction after primary RVOT reconstruction. The surgical techniques varied in our series, but secondary repair of the incompetent pulmonary valve was possible in all patients. Follow-up was complete, with a mean follow-up of 4.1 +/- 2.7 years. There were no operative or late deaths in our group. All valves were repaired successfully, with a mean regurgitation grade of 1.28 +/- 0.5 postoperatively. The mean transvalvular gradient was 20 +/- 4.1 mm Hg for children and 22.5 +/- 3.5 mm Hg for adults, and no significant increase of pulmonary valve regurgitation occurred during follow-up. The mean RV dilatation index (RVDI) decreased significantly from 0.85 +/- 0.25 to 0.6 +/- 0.2 for children and from 1.4 +/- 0.01 to 0.9 +/- 0.05 for adults. Our results showed functional recovery of the right ventricle after reoperation, with RVDI recovering to almost normal values in children. No significant regurgitation of the secondarily reconstructed pulmonary valve was observed during the 4-year follow-up period. Secondary repair for pulmonary valve incompetence after RVOT procedures might be a valuable alternative to conduit replacement.

Abstract 2611: Transcatheter Valve Insertion A Model Of Enlarged Right Ventricular Outflow Tracts

Background: Transcatheter pulmonary valve insertion has recently emerged as an alternative to surgery. To extend the indications to patients with large right ventricular outflow tract (RVOT), we previously developed an intravascular device that reduces the diameter of the main pulmonary artery (MPA) allowing the insertion of available valved stents. We report its use in a model of animals with enlarged RVOT and pulmonary valve incompetence (PVI). Methods and Results: 33 sheep were included. They first underwent surgical MPA enlargement. We then intended to implant percutaneously a reducer followed by the insertion of a valve. Three animals died during interstage. The remaining were sacrificed acutely (group 1, n=6), after a mean follow-up of 1 (group 2, n=12) and 2 months (group 3, n=12). Animals from chronic groups were equally divided into 2 subgroups according to the difference between diameters of the device inserted and MPA (A: < 5-mm, B: ≥ 5-mm). Reducers were inserted successfully (n=30). One embolized after its insertion (Group 3A). A valved stent could be implanted in all animals but one which experienced a balloon ruptured during its inflation leading to incomplete expansion and death of the animal. Six animals had pulmonary regurgitation after valve insertion. Five of them (Group A, n=5; Group B, n=1) had downsizing of the reducer. Conclusion: Pulmonary valve insertion is possible through a transcatheter technique using a PA reducer. Oversizing of this device reduces the risk of embolisation and paraprosthetic leak.

Severe Pulmonary Valve Incompetence Late After Debanding: Repair by Bicuspidization

We report a simple valve repair for severe pulmonary incompetence in a 25-year-old patient. The patient had been operated on twice before for ventricular septal defect and coarctation of the aorta. The first operation consisted of pulmonary artery banding and coarctectomy and end-to-end anastomosis at 4 months, followed by debanding and transinfundibular ventricular septal defect closure at 6 years of age. Massive pulmonary incompetence was due to destruction of one valve cusp with the right ventricular outflow tract and pulmonary artery dilated secondarily. Repair consisted of pulmonary valve bicuspidization and right ventricular remodelling.

Right Ventricular Outflow Tract Reconstruction With Contegra Monocuspid Transannular Patch in Tetralogy of Fallot

Pediatric diminutive right ventricular outflow tract (RVOT) reconstruction with homografts or porcine xenografts remains challenging because of limited availability, early degeneration, tissue ingrowth, and child growth. The objective of this study was to assess whether Contegra valved bovine conduit, implanted as monocuspid transannular patch, might be an interesting alternative to overcome these problems. We reconstructed the RVOT of 12 patients with tetralogy of Fallot, by the use of a Contegra conduit, tailored as a monocuspid valved transannular patch. The patients were 4 females and 8 males, with a mean age of 12.8 +/- 15.1 months and a mean weight of 7.2 +/- 1.9 kg. The mean pulmonary artery annulus size was 8.2 +/- 1.6 mm. The Contegra tissue was suitable for suturing and for reconstruction of even severely hypoplasic RVOT. We did not observe any sign of conduit or valve degeneration during the follow-up of 28.1 +/- 17.1 months. There were no early or late deaths, and no device-related adverse events. A peak transvalvular gradient of 36.5 +/- 4.7 mm Hg was measured by echocardiography in 4 patients postoperatively, and it decreased during the follow-up to 20 +/- 7.6 mm Hg. Pulmonary valve incompetence was grade 3 in 2 patients and grade 4 in 2 patients. The Contegra monocuspid transannular patch is widely applicable to RVOT reconstruction with satisfactory midterm results, particularly in patients with small pulmonary annulus. Its main advantage is to reduce the potential risk of supravalvular stenosis due to the narrowing at the distal suture line, as demonstrated when used as conduits, especially in the smaller sizes.

Surgical Treatment of Absent Pulmonary Valve Syndrome Associated With Bronchial Obstruction

Absent pulmonary valve syndrome (APVS) is a relatively rare anomaly that is usually associated with a ventricular septal defect and a restrictive pulmonary annulus with severe pulmonary regurgitation. The to-and-fro flow across the right ventricular outflow tract produces enormously dilated and pulsatile pulmonary arteries (PAs) that cause severe respiratory distress and tracheomalacia by compression of the trachea and primary bronchi. This retrospective study summarizes our 20-year experience of surgical treatment in patients with APVS. Between 1984 and 2005, 20 patients underwent repair of APVS using a valved conduit (n = 9), transannular patch (TAP) insertion alone (n = 5), or TAP with monocusp valve (n = 6) with PA reduction arterioplasty. Median age was 7 months (range, 6 days to 9 years). There were one perioperative and two late deaths. All deaths were related to airway complications. Survival was 90% at 1 year and 85% at 10 and 15 years. In a multivariate analysis only preoperative ventilator dependency was associated with a worse outcome (p = 0.02). Follow-up was available in 18 operative survivors (mean follow-up, 7.3 +/- 5.2 years). Six patients (33%) underwent reoperation for pulmonary valve incompetence and right ventricular dysfunction. Three patients (17%) had episodic bronchospasm of mild to moderate severity that were responsive to sympathomimetic bronchodilators. Morbidity associated with perioperative respiratory complications and ventilator dependency due to underlying tracheobronchomalacia is an important problem in patients with APVS. These infants may require multiple hospitalizations for recurrent respiratory infections secondary to their tracheobronchomalacia. Complete repair with a valved conduit and reduction pulmonary arterioplasty at the onset of symptoms and a definitive diagnosis is our procedure of choice for infants with APVS. With this approach, the airway can be optimized to give the best patient outcome.

Simultaneous Enlargement of the Pulmonary Annulus and the Pulmonary Cusp with Autologous Pericardium in Right Ventricular Outflow Tract Reconstruction

Surgical repair of obstructive lesions of the right ventricular outflow tract (RVOT) commonly creates pulmonary valve incompetence, which continues to stimulate research for the optimal materials and surgical techniques to reconstruct RVOT. In this study, we present the early results with simultaneous enlargement of the pulmonary annulus and the pulmonary cusp with a transannular patch of autologous pericardium in RVOT reconstruction. From January 2003 to December 2005, the surgical technique of simultaneous enlargement of the pulmonary annulus and the pulmonary cusp was used in 32 patients who had complex congenital heart anomalies with pulmonary artery hypoplasia. The functional status of the patients was followed up in the cardiologic clinic of our institute. The motion of the newly constructed valve and the degree of pulmonary insufficiency were evaluated by echocardiography before discharge and at 2-6 months, 12 months, and 36 months postoperatively. Early death occurred in one patient (3.1%). Postoperative complications occurred in six patients but they recovered uneventfully. During the follow-up, 28 of 31 operative survivors were in New York Heart Association functional class I without medication and the other three were in class II. Seventeen patients had no or trivial pulmonary regurgitation; mild regurgitation was present in 12 patients, and moderate regurgitation was seen in 2 patients. None of these patients needed reoperation and echocardiography showed good motion of the reconstructed valve. The surgical technique of simultaneous enlargement of the pulmonary annulus and the pulmonary cusp with a transannular patch of autologous pericardium is a safe, reliable, and effective way for RVOT reconstruction. Satisfactory early results have been achieved; however, long-term follow-up is necessary to determine the true value of this technique.

Repair of symptomatic neoaortic aneurysm after third-stage palliation for hypoplastic left heart syndrome

Repair of symptomatic neoaortic aneurysm after third-stage palliation for hypoplastic left heart syndrome

Balloon Valvuloplasty in a Cat with Pulmonic Stenosis

Journal of Veterinary Internal MedicineVolume 17, Issue 6 p. 928-930 Open Access Balloon Valvuloplasty in a Cat with Pulmonic Stenosis Michael Stafford Johnson, Corresponding Author Michael Stafford Johnson the Veterinary Cardiorespiratory Centre, Kenilworth, War-wickshire, UK. MVB, MRCVS, CERT SAM, CERT VC, MACVS (Canine Medicine), 43 Waverley Road, Ken-ilworth, Warwickshire, CV8 1JL, UK; e-mail: m[email protected]Search for more papers by this authorMike Martin, Mike Martin the Veterinary Cardiorespiratory Centre, Kenilworth, War-wickshire, UK.Search for more papers by this author Michael Stafford Johnson, Corresponding Author Michael Stafford Johnson the Veterinary Cardiorespiratory Centre, Kenilworth, War-wickshire, UK. MVB, MRCVS, CERT SAM, CERT VC, MACVS (Canine Medicine), 43 Waverley Road, Ken-ilworth, Warwickshire, CV8 1JL, UK; e-mail: [email protected]Search for more papers by this authorMike Martin, Mike Martin the Veterinary Cardiorespiratory Centre, Kenilworth, War-wickshire, UK.Search for more papers by this author First published: 28 June 2008 https://doi.org/10.1111/j.1939-1676.2003.tb02535.xCitations: 9AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL References 1 Kienle RD. Congenital pulmonic stenosis. In: MD Kittleson, RD Kienle, ed. Small Animal Cardiovascular Medicine. St Louis , MO : Mosby; 1998: 248– 260. 2 Buchanan JW, Anderson JH, White RI. The 1st balloon valvu-loplasty: An historical note. J Vet Intern Med 2002; 16: 116– 117. 3 Rao PS. Long-term follow-up results after balloon dilatation of pulmonic stenosis, aortic stenosis and coarctation of the aorta: A review. Prog Cardiovasc Dis 1999; 42: 59– 74. 4 Ewey DM, Pion PD, Hird DW. Survival in treated and untreated dogs with congenital pulmonic stenosis. J Vet Intern Med 1992; 6: 114 (ACVIM abstracts). 5 Boon JA. Pulmonic stenosis. In: JA Boon, ed. Manual of Veterinary Echocardiography, 1st ed. Baltimore , MD : Williams and Wil-kins; 1998: 397– 404. 6 Orton EC, Bruecker KA, Mc Cracken TO. An open patch-graft technique for correction of pulmonic stenosis in the dog. Vet Surg 1990; 19: 148– 154. 7 Hunt GB, Pearson MRB, Bellenger CR, Malik R. Use of a modified patch-graft technique and valvulectomy for correction of severe pulmonic stenosis in dogs: Eight consecutive cases. 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Balloon valvuloplasty in 30 dogs with pulmonic stenosis: Effect of valve morphology and annular size in initial and 1-year outcome. J Vet Intern Med 2001; 15: 553– 558. 19 Ristic JME, Marin CJ, Baines EA, Herrtage ME. Congenital pulmonic stenosis a retrospective study of 24 cases seen between 1990–1990. J Vet Cardiol 2001; 3: 13– 19. Citing Literature Volume17, Issue6November 2003Pages 928-930 ReferencesRelatedInformation

One hundred pulmonary valve replacements in children after relief of right ventricular outflow tract obstruction

Background. Surgical repair of obstructive lesions of the right ventricular outflow tract (RVOT) in children commonly creates pulmonary valve incompetence that may eventually require pulmonary valve replacement (PVR). We reviewed our experience with PVR late after RVOT reconstruction. Methods. We performed 100 PVRs in 93 children 1.1 months to 22.4 years (median 8) after RVOT reconstruction. Children with right ventricular to pulmonary artery conduits and primary PVRs were excluded. Age at PVR was 4.5 months to 27.9 years (median 9.5 years). Initial diagnosis was tetralogy of Fallot and variants, 62; critical pulmonary stenosis, 15; pulmonary atresia with intact ventricular septum, 7; and others, 9. Eleven patients had a redo PVR. A total of 62 PVRs were homografts; 38 were porcine valves. Results. There was one early death. On follow-up of 5 months to 12.4 years (mean 4.9 years) there were no late deaths although 1 child underwent cardiac transplantation. Actuarial freedom from redo PVR at 8 years was 100% for porcine valves but 70% for homograft valves ( p = 0.17). For children younger than 3 years at PVR, freedom from reoperation was 76% at 1 year and 39% at 8 years compared with freedom from redo PVR at 8 years of 100% for children older than 3 years. On latest echocardiogram 97% of porcine valves had mild or no pulmonary regurgitation compared with 72% of homograft valves. Conclusions. PVR after RVOT reconstruction can be performed with low risk. Porcine valves may be superior to homograft valves although this advantage may be due to older age at time of PVR.

Transcatheter implantation of a bovine valve in pulmonary position: a lamb study.

Pulmonary regurgitation can lead to severe right ventricular dysfunction, which is a delicate postoperative problem in the long-term follow-up of patients who had surgery for congenital heart diseases. Clinical conditions of patients suffering from pulmonary valve incompetence are improved by valve replacement with a prosthetic valve. To date, the surgical approach is the only option to replace a pulmonary valve. We report the first experience of percutaneous pulmonary valve implantation. A fresh bovine jugular vein containing a native valve was sutured into a vascular stent and then cross-linked with a 0.6% glutaraldehyde solution for 36 hours. After being hand-crimped onto a balloon catheter, the device was inserted percutaneously according to standard stent-placing techniques. The valved stent was finally deployed in the position of the native pulmonary valve of the lamb. Hemodynamic evaluation was carried out before and 2 months after implantation. Anatomic evaluation was finally performed. Percutaneous pulmonary valve replacement was successful in 5 lambs. No complications were noted. Early and late angiographic and hemodynamic studies confirmed a good position of the stents with a competent valve at the end of the protocol. One stent was slightly stenotic, with macroscopically visible calcifications. Nonsurgical implantation of pulmonary valves is possible in the lamb. This new technique is similar to standard stent implantation. Thus, it should be feasible in humans, in whom it will lead to a significant reduction of reoperations in patients in need of pulmonary valve replacement.

Significant pulmonary valve incompetence following oversize balloon pulmonary valveplasty in small infants: A long-term follow-up study.

Oversized dilatation balloons are recommended for relief of valvar pulmonic stenosis in infants and children during cardiac catheterization. Little information exists about the long-term outcome of this practice. Six of 107 consecutive patients undergoing balloon pulmonary valveplasty developed increasing pulmonary valve incompetence during follow-up periods of 0.5-10 years (mean, 7.2 years). Secondary right ventricular dilatation prompted insertion of a bioprosthetic pulmonary valve in one patient 6.8 years after intervention; valve replacement is pending in two additional patients, 4.3 and 10 years after intervention, respectively; and the three remaining subjects are thought likely to require valve replacement during childhood. The six reported subjects differ from the pulmonary valveplasty group as a whole in that they are younger (median age, 3 days vs. 11 months), had a higher degree of obstruction (right/left ventricular systolic pressure ratio prior to valveplasty 1.28 vs. 0.92), and underwent dilatation with relatively oversized balloons (balloon diameter to pulmonary valve annulus ratio 1.44 vs. 1.08). The balloon diameter to valve annulus ratio did not exceed 1.5 in any subject. Caution is advised in the use of oversized dilatation balloons in neonates or young infants with severe or critical pulmonic stenosis. Long-term consequences of substantial pulmonary valve incompetence outweigh, in our opinion, the limited gradient relief achieved with smaller balloons, sometimes requiring a second dilatation of the valve at an older age and larger size. Cathet. Cardiovasc. Intervent. 48:61-65, 1999.

Significant pulmonary valve incompetence following oversize balloon pulmonary valveplasty in small infants: A long‐term follow‐up study

Significant pulmonary valve incompetence following oversize balloon pulmonary valveplasty in small infants: A long‐term follow‐up study

Resultados a longo prazo da reconstrução da via de saída do ventrículo direito com monocúspide porcina

O beneficio hemodinâmico e funcionamento tardio das monocuspides implantada na via de saida do ventriculo direito sao pontos que continuam controversos na literatura. Com o objetivo de se estudar o comportamento tardio de uma monocuspide porcina montada em remendo de pericardio bovino, 45 pacientes selecionados, portadores de diversos tipos de cardiopatia congenita operados entre junho de 1989 e abril de 1996, foram acompanhados ate dezembro de 1996. A idade variou de 2 semanas a 18 anos (media 4,8 ± 4,7 anos). Ocorreram 5 obitos hospitalares, diretamente relacionados a condicao clinica pre-operatoria e a complexidade da doenca. Com 3 pacientes nao tendo sido encontrados para acompanhamento, 37 foram seguidos por um periodo que variou de 6 a 90 meses (media 4,8 ± 19,0 meses). Nao houve mortalidade tardia. Dois pacientes foram reoperados, sendo o primeiro apos 24 meses devido a insuficiencia pulmonar grave em crianca portadora de sindrome da valva pulmonar ausente e o segundo apos 23 meses devido a estenose pulmonar infundibular residual. A reoperacao, os enxertos mostravam-se bem conservados e sem sinais de calcificacao, o que foi confirmado pelos estudos histologicos das pecas retiradas. O segundo paciente recebeu uma nova monocuspide. Os demais 35 pacientes encontram-se assintomaticos. Trinta e seis pacientes tem sido avaliados periodicamente, atraves de ecocardiogramas seriados. A monocuspide permanece movel e funcionante em todos os casos, sem sinais de calcificacao, estenose ou dilatacao. O gradiente sistolico medio de pico atraves da via de saida do ventriculo direito tem sido de 19,0 ± 5,8 mmHg. Regurgitacao pulmonar esta ausente em (33%) 12 pacientes, e leve em 15 (42%) e moderada em 9 (25%). Em conclusao, a monocuspide porcina apresenta excelente desempenho hemodinâmico a longo prazo, sem evidencias de estenose tardia. Apresenta-se funcional e sincronica com o ciclo cardiaco ate 7 anos apos o implante.