Surgical Pulmonary Valve Replacement Research Articles

Surgical and transcatheter pulmonary valve replacement in patients with repaired tetralogy of Fallot: cardiac magnetic resonance imaging characteristics and morphology of right ventricular outflow tract.

Pulmonary valve replacement is recommended in patients with repaired tetralogy of Fallot based on cardiac magnetic resonance imaging (MRI) criteria. This procedure is performed by surgical or transcatheter approaches. We aimed to investigate the differences in preprocedural MRI characteristics (volume, function, strain) and morphology of the right ventricular outflow tract and branch pulmonary arteries in patients for whom surgical or transcatheter pulmonary valve replacementwas planned. Cardiac MRI of 166 patients with tetralogy of Fallot were analyzed. Of these, 36 patients for whompulmonary valve replacement was plannedwere included. Magnetic resonance imaging characteristics, right ventricular outflow tract morphology, branch pulmonary artery flow distribution and diameter were compared between surgical and transcatheter groups. Spearman correlation and Kruskal-Wallis tests were performed. Circumferential and radial MRI strain for the right ventricle were lower in thesurgical group (P=0.045and P=0.046, respectively). The diameter of the left pulmonary artery was significantly lower (P=0.021) and branch pulmonary artery flow and diameter ratio were higher (P=0.044and P = 0.002, respectively) in the transcatheter group. There was a significant correlation between right ventricular outflow tract morphology and right ventricular end-diastolic volume indexand global circumferential and radial MRI strain (P=0.046, P=0.046and P= 0.049, respectively). Preprocedural MRI strain, right-to-left pulmonary artery flow, diameter ratio and morphological features of the right ventricular outflow tract were significantly different betweenthe two groups. A transcatheter approach may be recommended for patients with branch pulmonary artery stenosis, since both pulmonary valve replacement and branch pulmonary artery stenting can be performed in the same session.

Biopsy-detected myocardial fibrosis predicts adverse cardiac events after pulmonary valve replacement in patients with repaired tetralogy of Fallot.

Risk factors associated with adverse cardiac events (cardiac AEs) after pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot are incompletely understood. In this study, we aimed to determine the relationship between histological myocardial fibrosis and cardiac AEs after PVR in patients with rTOF. We consecutively collected clinical, cardiac magnetic resonance, echocardiography and electrocardiogram data of 51 patients with rTOF who underwent surgical PVR. The right ventricular outflow tract tissue was collected during the PVR and the degree of histological myocardial fibrosis was determined by a tailor-made automated image analysis method of picrosirius red staining. The median follow-up time was 4.9 years, and 14 patients had cardiac AEs (a composite of heart failure admission and arrhythmia) during follow-up. The total analysis area of myocardial samples was 5782.18 mm2, and the median percentage of myocardial fibrosis was 20.6% (interquartile range 16.7-27.0%), which were significantly elevated in patients with cardiac AEs compared with patients without cardiac AEs (24.1% vs 19.7%, P = 0.007). Right ventricular ejection fraction and left ventricular end-systolic volume index were significantly associated with myocardial fibrosis in multivariable stepwise linear regression analysis (R2 = 0.238). Cox proportional hazards regression identified degree of myocardial fibrosis [hazard ratio 1.127; 95% confidence interval (CI) 1.047-1.213; P = 0.001] and age at PVR (hazard ratio 1.062; 95% CI 1.010-1.116; P = 0.019) were associated with increased risk of cardiac AEs. The incidence of adverse cardiac events was significantly increased when myocardial fibrosis >20.1% and age at PVR >18.2 years. Histological myocardial fibrosis was associated with biventricular systolic functions in rTOF. Higher myocardial fibrosis and older age at PVR are independent risk factors for the adverse cardiac events after PVR in patients with rTOF.

Over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement.

To determine the safety and feasibility of over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement. Transcatheter pulmonary valve placement is an alternative to surgical pulmonary valve replacement. Traditionally, it was thought to be unsafe to expand a conduit to >110% of its original size. This retrospective cohort study from two centers includes patients with right ventricle to pulmonary artery conduits with attempted transcatheter pulmonary valve placement from 2010 to 2017. Demographic, procedural, echocardiographic and follow-up data, and complications were evaluated in control and overdilation (to >110% original conduit size) groups. One hundred and seventy-two patients (51 overdilation and 121 control) had attempted transcatheter pulmonary valve placement (98% successful). The overdilation group was younger (11.2 versus 16.7 years, p < 0.001) with smaller conduits (15 versus 22 mm, p < 0.001); however, the final valve size was not significantly different (19.7 versus 20.2 mm, p = 0.2). Baseline peak echocardiographic gradient was no different (51.8 versus 55.6 mmHg, p = 0.3). Procedural complications were more frequent in overdilation (18%) than control (7%) groups (most successfully addressed during the procedure). One patient from each group required urgent surgical intervention, with no procedural mortality. Follow-up echocardiographic peak gradients were similar (24.1 versus 26 mmHg, p = 0.5). Over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement can be performed successfully. Procedural complications are more frequent with conduit overdilation, but there was no difference in the rate of life-threatening complications. There was no difference in valve function at most recent follow-up, and no difference in rate of reintervention. The long-term outcomes of transcatheter pulmonary valve placement with conduit over-expansion requires further study.

Outcomes of Treatment for Infective Endocarditis Following Transcatheter Pulmonary Valve Replacement.

Recipients of transcatheter pulmonary valve replacement (TPVR) have shown increased risk of infective endocarditis (IE). Little is known about the outcomes of different management strategies, particularly surgery, for IE after TPVR. We queried the Pediatric Health Information System database for cases of IE after TPVR performed from 2010-2020. We described patient demographics, hospital courses, admission complications, and treatment outcomes based on therapy offered, surgical or medical only. We compared outcomes of initial therapy. Data are expressed as median or percent. Sixty-nine cases of IE were identified, accounting for 98 related hospital admissions; 29% of patients recorded IE-related readmissions. Of those readmitted after initial medical therapy only, 33% had relapse IE. Rates of surgery were 22% during initial admission and 36% overall. Likelihood of surgical intervention increased with each subsequent admission. Renal and respiratory failure were more common in those given initial surgery. Mortality rate was 4.3% overall and 8% in the surgical cohort. Initial medical therapy may result in relapses/readmissions and possible delay of surgical therapy, which appears to be most effective for treatment of IE. For those treated only medically, a more aggressive course of therapy may be more likely to prevent relapse. Mortality following surgical therapy for IE after TPVR appears higher than reported for surgical pulmonary valve replacement generally.

Transcatheter pulmonary valve replacement in congenital heart diseases.

Surgical repair of a variety of congenital heart diseases involves repair of the right ventricular outflow tract (RVOT) with valved or non-valved conduit to connect the right ventricle (RV) to the pulmonary artery (PA) or just patch enlargement of the native RVOT. With time, this RV-PA conduit will degenerate with deterioration of function, either causing pulmonary stenosis or pulmonary regurgitation. This RVOT dysfunction may result in RV dilation, RV dysfunction, and eventual RV failure and arrhythmias. Multiple surgical pulmonary valve replacement (PVR) is often required throughout the patient's lifetime. Patients are subjected to increased risks with each additional cardiac operation. Transcatheter PVR (TPVR) has been developed over the past two decades as a valuable non-surgical alternative to restore the RVOT and RV function, and hence reduce patients' lifetime risks related to surgery. This article will discuss the long-term results of TPVR which are demonstrated to be comparable to surgical results and the latest development of large pulmonary valves which will allow TPVR to be performed on native or larger RVOT.

Abstract 14051: QRS Duration After Pulmonary Valve Replacement in Adults With Repaired Tetralogy of Fallot: Prediction of Ventricular Arrhythmias and Correlation With Right Ventricular Size

Background: Tetralogy of Fallot (ToF) patients face complications such as heart failure and ventricular arrhythmias (VA) after early repair which may be mitigated by pulmonary valve replacement (PVR). Prior studies have shown significant decreases in QRS duration and right ventricular (RV) size following PVR. We aimed to determine whether QRS duration reduction independently identifies patients at lower risk of VA and/or correlates with a decrease of RV size on cardiac magnetic resonance imaging (CMR) with long-term follow-up. Methods: We retrospectively identified patients ≥18 years old with repaired ToF who underwent surgical or transcatheter PVR, respectively, at our tertiary care center. Demographics, imaging, and ECGs (pre-PVR, 30 days to 1-year post-PVR, and closest to follow up CMR) were collected. Patients with ventricularly paced rhythm were excluded. The composite primary outcome was defined as sustained VT, ICD shock for sustained VT or inducible VT on EP study. Results: During the study period, 85 patients were included (median follow-up 3.6 years; median age 34 years; 51% females, 68% surgical PVR and median LVEF 56%). The primary outcome was observed in 8 (9.6%) patients. QRS duration decreased by 5 ms (pre-PVR mean 154±28 ms to 149±28ms post-PVR; p=0.0001). Increased age at PVR (OR 1.1 per year), QRS≥180ms post-PVR, no reduction in QRS after PVR (ΔQRS ≤ 0ms), and a history of VT were significantly associated with the composite outcome. (Table) The change in QRS was linearly correlated with the change in RVEDVi (R = 0.66; p=0.002). Conclusion: In conclusion, adults with repaired ToF experience a reduction in QRS duration post-PVR. This change correlates with the change in the RV size post-operatively. A QRS ≥180ms post-PVR, no reduction in QRS, increased age at repair, and a history of VT independently predict the occurrence of VT post-PVR. Patients with these risk factors may warrant closer monitoring and/or ICD consideration.

Right ventricular outflow tract landing zone perimeter / circularised diameter - new imaging standards in pulmonary valve replacement reporting.

Right ventricular outflow tract intervention spans transcatheter, surgical, or hybrid pulmonary valve replacement methodologies. Standardised pre-procedure workup includes cardiac MRI to identify an intended valve site (landing zone). Our institutional practice includes measurement of the right ventricular outflow tract perimeter (circumference) of this site in end-systole. Our primary aim was to compare patients by their perimeter values to the palliative interventions performed (transcatheter versus surgical/hybrid methodologies). Retrospective review of patients undergoing pulmonary valve replacement from January 2017 to 2021. We performed perimeter measurements at the intended valve site on advanced imaging; the outcomes of interventions were outlined via descriptive and statistical analyses. A total of 37 patients underwent pulmonary valve replacement that met study criteria - 21 transcatheter, 7 surgical, and 9 hybrid. Median age at intervention was 26 years (range 8-70). The mean end-systolic perimeter of the transcatheter cohort was 88.9 ± 8.7 mm and in the surgical/hybrid cohort measured 106.6 ± 7.5 mm. For the transcatheter cohort, the median "circularised" diameter derived from the perimeter measurement (divided by π) was 27.7 mm (range 24.3-32.4). Notably, this correlated (r = 0.93, p < 0.01) with the median diameter of the narrowest region during actual transcatheter right ventricular outflow tract balloon sizing (lateral imaging) of 27.1 mm (range 23.2-30.1). Right ventricular outflow tract perimeter measurement to determine circularised diameter is useful in planning pulmonary valve replacement in terms of candidacy of transcatheter versus the need for a surgical/hybrid approach. The circularised diameter correlates with transcatheter right ventricular outflow tract balloon sizing.

Predictors of long term tricuspid regurgitation after pulmonary valve replacement: a single center study on the cohort of significant preoperative tricuspid regurgitation

Abstract Background Almost one-third of repaired tetralogy of Fallot (TOF) and pulmonary stenosis (PS) patients referred for pulmonary valve replacement (PVR) have at least moderate tricuspid regurgitation (TR). Predictors of long term TR in this population are not well defined and the role of Tricuspid Annuloplasty (TA) in addition to PVR in this setting is controversial. Purpose Patients with preoperative severe TR or moderate TR with dilated tricuspid annulus (&amp;gt;40mm) undergo TA at the time of PVR as per protocol in our instititution. The aim of this observational study was to evaluate the long term results of this approach and to identify predictors of significant TR at the end of follow-up. Material and methods We retrospectively reviewed 35 repaired TOF and PS patients who underwent surgical PVR with (n=17, group 1) or without (n=18, group 2) TA in a single tertiary hospital between June-2009 and June-2021. Pre- and postoperative echocardiographic and cardiac magnetic resonance data were assessed for TR severity and right ventricle size and systolic function. Baseline and clinical follow up data were collected. Uni- and multivariable tests were used to analyze predictors of at least moderate TR after PVR. Results Mean age at PVR and baseline image parameters were comparable between groups, except for TR grade (p 0.006), tricuspid annulus size (p 0.018) and right ventricle outflow tract diameter (p 0.04) which were greater in group 1. TA did not confer and increased risk of surgical and peroperative complications. Intensive care unit (p 0.94) and total hospital admission days (p 0.59) did not differ among groups. At one year, TR grade significantly improved regardless of TA. At the end of follow-up (5.29±2.9 years), the degree of TR increased in both groups with no differences between groups (p 0.38) (see table 1). In univariable analysis, two independent predictors of at least moderate TR at end of follow-up were identified; mixed TR mechanism (OR 12.5, p 0.006) and severe preoperative TR grade (OR 10.21, p 0.003). Mixed TR mechanism (OR 15.78, p 0.01) and a right ventricle ejection fraction below 45% (OR 1.47, p 0.01) were identified as risk factors of significant TR in multivariable analysis (see Table 2). Conclusions TA seems a reasonable approach at the time of PVR in patients with severe TR or moderate TR with dilated annulus. Mixed TR mechanism and a worse right ventricular function have been identified as independent predictors factors of long term significant postoperative TR in our study cohort. Funding Acknowledgement Type of funding sources: None.

Early Concerning Outcomes for the Edwards Inspiris Resilia Bioprosthesis in the Pulmonary Position

BackgroundThe Inspiris Resilia (Edwards Lifesciences LLC) bioprosthesis has gained widespread use in the aortic position; however no robust data are available about its use in the pulmonary position. MethodsWe reviewed our outcomes for the Inspiris Resilia in the pulmonary position between August 2019 and October 2021. ResultsTwenty-seven patients (15 female patients [56%]; mean age, 22.26 ± 14.99 years) were included. The most common original pathology was tetralogy of Fallot (13 patients, 48%). Five patients (18.5%) had prior transcatheter interventions. The mean right ventricular end-diastolic volume index was 164.25 ± 45.1 mL/m2. Sternotomy or repeat sternotomy was the most common approach (21 patients, 77.8%). The standard technique for pulmonary valve replacement was used in 22 patients (81.5%), whereas the prosthesis was implanted as a conduit in the remaining 5 (18.5%). Trivial to mild prosthetic regurgitation was present in 6 patients (22.2%) at the time of discharge. There was no early mortality. Follow-up was complete in all patients (mean, 16 ± 8 months), with no late mortality or late reoperations. New prosthetic regurgitation developed in 13 patients (48%), all of whom underwent replacement with the standard surgical technique. No regurgitation occurred in the conduit cases. This progressed to moderate regurgitation in 6 patients (22%) and severe in 3 (11%). Three patients (11%) underwent transcatheter valve-in-valve after their surgical pulmonary valve replacement. ConclusionsThe early data regarding the Inspiris Resilia bioprosthesis use in the pulmonary position is concerning. The prosthesis design may not be suitable for low-pressure circulation, or modification of its implantation technique may be needed.

Outcomes of Transcatheter Pulmonary Valve Replacement and Surgical Pulmonary Valve Replacement: A Cohort Analysis.

Transcatheter pulmonary valve replacement (TPVR) has become an alternative to surgical pulmonary valve placement (SPVR) for patients after tetralogy of Fallot repair. This study compared the outcomes of TPVR with those of SPVR. We reviewed data from patients who underwent pulmonary valve replacement with a median of 2 years of follow-up. Between 2010 and 2021, 215 patients underwent pulmonary valve replacement (72 TPVR and 143 SPVR). The median size of the right ventricular end-diastolic volume index in the TPVR group was 165 mL/m2 (IQR, 136-190) and 184 mL/m2 (IQR, 163-230) in the SPVR group (P = .001). The median value of the maximum landing zone at the right ventricular outflow tract (RVOT) in patients with native RVOT was 26 mm (IQR, 24-28) in the 43 patients in the TPVR group and 31 mm (IQR, 28-34) in the 101 patients in the SPVR group (P < .001). The median size of the pulmonary valve implant for the native RVOT in the TPVR group was 29.0 mm (IQR, 26.0-29.0) and 24.0 mm (IQR, 24.0-24.0) in the SPVR group (P < .001). There were no deaths in the TPVR group and 8 deaths in the SPVR group (P = .041). Major complications and the length of hospitalization were lower in the TPVR group (P = .001). After 2 years, the mean decrease in QRS duration was 5 milliseconds (IQR, 1-14) in the TPVR group and 1 millisecond (IQR, -4 to 10) in the SPVR group (P = .006). TPVR allows for larger implants, resulting in lower mortality, shorter hospital stays, and fewer major cardiac events. SPVR may be preferable in patients with larger (>30 mm) native RVOT and in those who require concomitant surgical procedures.

Statistical primer: an introduction to the application of linear mixed-effects models in cardiothoracic surgery outcomes research-a case study using homograft pulmonary valve replacement data.

Summary OBJECTIVESThe emergence of big cardio-thoracic surgery datasets that include not only short-term and long-term discrete outcomes but also repeated measurements over time offers the opportunity to apply more advanced modelling of outcomes. This article presents a detailed introduction to developing and interpreting linear mixed-effects models for repeated measurements in the setting of cardiothoracic surgery outcomes research.METHODSA retrospective dataset containing serial echocardiographic measurements in patients undergoing surgical pulmonary valve replacement from 1986 to 2017 in Erasmus MC was used to illustrate the steps of developing a linear mixed-effects model for clinician researchers.RESULTSEssential aspects of constructing the model are illustrated with the dataset including theories of linear mixed-effects models, missing values, collinearity, interaction, nonlinearity, model specification, results interpretation and assumptions evaluation. A comparison between linear regression models and linear mixed-effects models is done to elaborate on the strengths of linear mixed-effects models. An R script is provided for the implementation of the linear mixed-effects model.CONCLUSIONSLinear mixed-effects models can provide evolutional details of repeated measurements and give more valid estimates compared to linear regression models in the setting of cardio-thoracic surgery outcomes research.

Single-Center Experience of Hybrid Pulmonary Valve Replacement Using Left Anterior Thoracotomy With Pulmonary Artery Plication in Patients With Large Right Ventricular Outflow Tract.

Background Until recently, a large right ventricle outflow tract interfered with the feasibility of standard transcatheter pulmonary valve replacement (PVR). We are describing our experience using a hybrid approach for PVR using a left anterior thoracotomy approach to allow for plication of the main pulmonary artery followed by a transcatheter PVR using a Sapien S3 valve. Methods and Results This is a single-center, retrospective review of patients who were evaluated to be appropriate for a hybrid PVR approach. The patients' demographics, procedure details, and follow-up data were collected. Between May 2018 and April 2021, a total of 11 patients presented for hybrid transcatheter PVR. The median age and weight were 24 years (interquartile range, 19-43 years) and 81.8 kg (interquartile range, 69-91 kg), respectively. Nine out of 11 patients received a transcatheter PVR after main pulmonary artery plication. There were no procedurally related deaths. One major complication was encountered in which the valve was malpositioned requiring successful surgical PVR. Minor complications included acute kidney injury (n=1) and a broken rib (n=1). The median length of stay was 4 days (interquartile range, 2-4 days), with median follow-up of 7 months (interquartile range, 3-18 months). A well-functioning pulmonary valve was observed in all patients at the last follow-up. Conclusions A hybrid approach using left anterior thoracotomy with pulmonary artery plication followed by transcatheter Sapien S3 PVR provides a less-invasive option for patients with an enlarged right ventricular outflow tract. Preliminary results demonstrated this to be a safe option with good short-term outcomes.

Infective endocarditis after transcatheter approach versus surgical pulmonary valve replacement: A meta-analysis.

Background In this meta-analysis, we aimed to assess the risk of infective endocarditis in transcatheter versus surgical pulmonary valve replacement patients. Methods We systematically searched PubMed, Cochrane, EMBASE, Scopus, and Web of Science for the studies that reported the event rate of infective endocarditis in both transcatheter and surgical pulmonary valve replacement between December 2012 and December 2021. Random-effects model was used in the meta-analysis. Results Fifteen comparison groups with 4,706 patients were included. The mean follow-up was 38.5±3.7 months. Patients with transcatheter pulmonary valve replacement had a higher risk of infective endocarditis than patients receiving surgically replaced valves (OR 2.68, 95% CI: 1.83-3.93, p<0.00001). The calculated absolute risk difference was 0.03 (95% CI: 0.01-0.05), indicating that if 1,000 patients received a surgical valve replacement, 30 cases of infective endocarditis would be prevented. A meta-regression of follow-up time on the incidence of infective endocarditis was not statistically significant (p=0.753). Conclusion Although transcatheter pulmonary valve replacement is a feasible alternative to surgical replacement in severe right ventricular outflow tract dysfunction, the higher incidence of infective endocarditis in transcatheter replacement remains a significant concern. Regarding this analysis, surgical treatment of right ventricular outflow tract dysfunction is still a viable option in patients with prohibitive risk.

Infective endocarditis after the transcatheter method compared to surgical pulmonary valve replacement: A meta-analysis study- What is meta analysis?

Infective endocarditis after the transcatheter method compared to surgical pulmonary valve replacement: A meta-analysis study- What is meta analysis?

Pediatric Surgical Pulmonary Valve Replacement Outcomes After Implementation of a Clinical Pathway.

Standardization of perioperative care can reduce resource utilization while improving patient outcomes. We sought to describe our outcomes after the implementation of a perioperative clinical pathway for pediatric patients undergoing elective surgical pulmonary valve replacement and compare these results to previously published national benchmarks. A retrospective single-center descriptive study was conducted of all pediatric patients who underwent surgical pulmonary valve replacement from 2017 through 2020, after the implementation of a clinical pathway. Outcomes included hospital length of stay and 30-day reintervention, readmission, and mortality. Thirty-three patients (55% female, median age 11 [7, 13] years, 32 [23, 44] kg) were included in the study. Most common diagnosis and indication for surgery was Tetralogy of Fallot (61%) with pulmonary valve insufficiency (88%). All patients had prior cardiac surgery. Median hospital length of stay was 2 [2, 2] days, and longest length of stay was three days. There were no 30-day readmissions, reinterventions, or mortalities. Median follow-up time was 19 [9, 31] months. Formalization of a perioperative surgical pulmonary valve replacement clinical pathway can safely promote short hospital length of stay without any short-term readmissions or reinterventions, especially when compared with previously published benchmarks. Such formalization enables the dissemination of best practices to other institutions to reduce hospital length of stay and limit costs.

Clinical outcomes of pulmonary valve replacement surgery in pediatrics: a single-center experience long-term study

Introduction: Heart valve disease in pediatricsis an increasing global concern, especially in developing countries. This study aims to determine the clinical outcomes of pulmonary valve replacement (PVR) surgery in pediatrics. Methods: The authors retrospectively identified all pediatrics undergoing PVR surgery at Imam Reza hospital (Mashhad, Iran) between 2000 and 2020. Their medical records were reviewed for demographic characteristics, clinical data (intra-operative and postoperative), and follow-up results. Echocardiography and electrocardiography were performedonall patients before the surgery and periodically after the surgery. Results: Among 50 pediatrics undergoing surgical PVR, 38 (76%) were female and others were male (14%), with a mean age of 10.39±5.31 years. The leading cause of PVR was the Tetralogy of Fallot. There was a significant relationship between age at the time of surgery and the size of the pulmonary valve(P=0.02).There were also statistically significant differences between QTc intervals before and after surgery (P=0.001). Further more, there was a significant correlation between QTc intervals before and after surgery and the ageof pediatrics at the time of surgery (P=0.01, r=-0.6).There was also a statistically significant relationship between the ICU stay (P=0.01) and the weaning time of the mechanical ventilation (P=0.03). Conclusion: It is recommended that this procedure ispostponed as much as possible to decrease postoperative life-threatening events in pediatrics.In addition, if this surgery is conducted with good surgical and nursing management, it can be safe with low complications among other cardiac valve procedures.

Surgical pulmonary valve replacement at a tertiary adult congenital heart centre in the current era

BackgroundSurgical pulmonary valve replacement (PVR) is the standard cardiac operation in adult patients with congenital heart disease (ACHD). We report recent experience at a large tertiary centre and examine the impact of prosthesis type on outcomes. MethodsAll surgical PVRs performed at our tertiary centre between January 2003 and December 2018 were included. ResultsThe study population included 490 patients (197 women; mean age 29.9 ± 13 years). The types of valves used were Homograft 179 (37%), Perimount 152 (31%), Mosaic 120 (24%), Hancock 31 (6%), and others 5 (1%). Seven (1.4%) early deaths occurred within 30 days after surgery. The survival rates at 1, 5, 10, and 15 years of follow-up were 98.3%, 97.7%, 96.8%, and 95.4%, respectively, whereas freedom from re-intervention was 99.8%, 96.6%, 90.2%, and 81.0%, respectively. During a mean follow-up of 6.5 ± 4.3 years, 27 (5.5%) patients required re-intervention. The type of valve used in these 27 patients during index operation showed no discernible difference in the probability of re-intervention; however, Mosaic valves required earlier re-intervention compared to Perimount valves. ConclusionOur data show no discernible difference in reoperation rates between the different types of prostheses used. On-going surveillance of patients after PVR and further research in developing a life-long prosthesis are clearly warranted.

Pulmonary Valve Replacement in Repaired Tetralogy of Fallot: Midterm Impact on Biventricular Response and Adverse Clinical Outcomes.

Background:Pulmonary regurgitation (PR), though well tolerated for short term in patients with repaired tetralogy of Fallot (rTOF), could lead to right ventricular (RV) dysfunction, arrhythmias, and sudden cardiac death. Pulmonary valve replacement (PVR), considered as the gold-standard treatment for PR, is performed to mitigate these late effects. In this study, we aimed to evaluate the midterm outcomes and predictors of adverse clinical outcomes (ACO).MethodsFrom May 2014 to December 2017, 42 patients with rTOF undergoing surgical or transcatheter PVR in our department were retrospectively included. Cardiovascular magnetic resonance was performed before PVR (pre-PVR), early after PVR (early post-PVR), and midterm after PVR (midterm post-PVR). Medical history and individual data were collected from medical records. ACO included all-cause death, new-onset arrhythmia, prosthetic valve failure, and repeat PVR.ResultsThe median follow-up duration was 4.7 years. PVR was performed at a median age of 21.6 years. There was no early or late death. Freedom from ACO at 3 and 5 years was 88.1 ± 5% and 58.2 ± 9%, respectively. RV end-diastolic volume index (RVEDVI) and end-systolic volume index (RVESVI) significantly reduced early after PVR and further decreased by midterm follow-up (pre-PVR vs. early post-PVR vs. midterm post-PVR: RVEDVI, 155.2 ± 34.7 vs. 103.8 ± 31.2 vs. 95.1 ± 28.6 ml/m2, p < 0.001; RVESVI, 102.9 ± 28.5 vs. 65.4 ± 28.2 vs. 57.7 ± 23.4 ml/m2, p < 0.001). Multivariable analysis revealed that the occurrence of ACO was significantly increased in patients with lower left ventricular end-systolic volume index.ConclusionsA significant reduction of RV volume occurred early after PVR, followed by a further improvement of biventricular function by midterm follow-up. The midterm freedom from ACO was favorable.

PO-704-06 CLINICAL PREDICTORS OF INDUCIBLE VENTRICULAR ARRHYTHMIAS AND ABLATION EFFECTIVENESS IN TETRALOGY OF FALLOT PATIENTS UNDERGOING PERCUTANEOUS PULMONARY VALVE REPLACEMENT

Peri-operative electrophysiology study (EPS) in patients with tetralogy of Fallot (TOF) undergoing surgical pulmonary valve replacement (PVR) can predict subsequent ventricular arrhythmias (VAs) and intraoperative cryoablation can reduce post-operative VAs. Percutaneous PVR (PPVR) may cover critical anatomic isthmuses that limit future catheter ablation. The clinical predictors of inducible VAs and effects of catheter ablation in patients undergoing PPVR are not known. Explore the clinical predictors and effect of ablation on inducible VAs in TOF patients undergoing PPVR. Patients >25 yrs with TOF who underwent peri-PPVR EPS were identified. Demographics, cardiac imaging, and procedural characteristics were reviewed. Clinical and procedural characteristics were compared between patients with and without inducible VAs. Catheter ablation was performed in patients with inducible VAs. Sixteen patients were identified of which 7 (44%) had inducible VAs. Implanted valves/stents included Sapien™ (11), Melody™ (3), Alterra™ (2) and Harmony™ (1). Arrhythmias included monomorphic VT (4; 57%) and VF (3; 43%). Predictors of inducibility were infundibular resection at initial repair (p=0.04), severe RV dysfunction (p=0.03), and the presence of slowly conducting anatomic isthmuses (SCAIs) (p=0.02). Having only moderate RV dysfunction was protective (p=0.04). All inducible patients underwent ablation with 4 (56%) remaining inducible and having an ICD placed. Having monomorphic VT was predictive of being non-inducible following ablation (p=0.02). No sustained VAs were detected in follow-up (median 9.4 (5-13 mo)). Predictors of inducible VAs in TOF patients undergoing PPVR include prior infundibular resection, severe RV dysfunction, and SCAIs. Targeting SCAIs with ablation may prevent inducible monomorphic VT though percutaneous valves may cover critical isthmuses.

Endocarditis in Bovine Vein Grafts in the Pulmonary Position Placed Surgically & Percutaneously.

Background: Infective endocarditis (IE) is one of the major complications following pulmonary valve replacement (PVR). This analysis hopes to evaluate the incidence, outcomes and possible risk factors of IE associated with trans-catheter and surgical placement of a bovine jugular vein (BJV) graft in the pulmonary position. Methods: In this single-center retrospective study, all records of trans-catheter and surgical PVR from 3/2010 to 12/2019 were reviewed. IE was defined as positive blood cultures, with vegetations seen on echocardiography or sudden increase in peak gradient across the valve or vegetations confirmed at time of valve replacement. Poor dental hygiene:1.dental procedures without S.B.E prophylaxis AND/OR 2.one or more dental cavities, caries, dental abscess. Results: 165 patients had PVR with BJV:107 trans-catheter and 63 surgical. 7%(12/170) of PVRs developed IE(catheter:n = 10, surgery:n = 2) at a median time from valve placement of 38 months. The incidence of IE in the catheter group:3-per-100patient-years and in surgical group:1-per-100patient-years. Multivariate cox regression showed that poor dental hygiene was significantly associated with IE [HR(95% CI):16.9(4.35-66.2)](p value <.001). Kaplan-Meier curves showed a significant difference in freedom from IE between patients with poor and appropriate dental hygiene (p value<.001). Conclusions: There is a 7% incidence of IE with the use of BJV grafts in the pulmonary position at mid-term follow-up. Though the rate in catheter placed BJV seems 3x higher than surgically placed ones, their cohorts are quite different making this comparison flawed. Poor dental hygiene is a strong predictor for post-operative IE and offers a significant opportunity for lowering the rate of infective endocarditis.