Valve Replacement In Children Research Articles

Long-term outcomes following mitral valve replacement in children at heart center Leipzig: a 20-year analysis

BackgroundAlthough mitral valve repair is the preferred surgical strategy in children with mitral valve disease, there are cases of irreparable severe dysplastic valves that require mitral valve replacement. The aim of this study is to analyze long-term outcomes following mitral valve replacement in children in a tertiary referral center.MethodsA total of 41 consecutive patients underwent mitral valve replacement between February 2001 and February 2021. The study data was prospectively collected and retrospectively analyzed. Primary outcomes were in-hospital mortality, long-term survival, and long-term freedom from reoperation.ResultsMedian age at operation was 23 months (IQR 5–93), median weight was 11.3 kg (IQR 4.8–19.4 kg). One (2.4%) patient died within the first 30 postoperative days. In-hospital mortality was 4.9%. Four (9.8%) patients required re-exploration for bleeding, and 2 (4.9%) patients needed extracorporeal life support. Median follow-up was 11 years (IQR 11 months − 16 years). Long-term freedom from re-operation after 1, 5, 10 and 15 years was 97.1%, 93.7%, 61.8% and 42.5%, respectively. Long-term survival after 1, 5, 10 and 15 years was 89.9%, 87%, 87% and 80.8%, respectively.ConclusionIf MV repair is not feasible, MV replacement offers a good surgical alternative for pediatric patients with MV disease. It provides good early- and long-term outcomes.

Mitral valve replacement in children: balancing durability and risk with mechanical and bioprosthetic valves.

To investigate if there is still a place for bioprosthetic mitral valve replacement in children by comparing the prosthetic durability and transplant-free survival after bioprosthetic and mechanical mitral valve replacement. We reviewed all mitral valve replacements in children between 1981 and 2020. Bioprosthetic mitral valve replacement cases were individually matched to mechanical mitral valve replacement cases. The incidence rate of a 2nd replacement was calculated using the cumulative incidence function that considered death or transplantation as a competing risk. The median age at implantation was 3.6 years (interquartile range 0.8-7.9) for the bioprosthetic valve cohort (n = 28) and 3 years (interquartile range 1.3-7.8) for the mechanical valve cohort (n = 28). Seven years after bioprosthetic mitral valve replacement, the cumulative incidence of death or transplantation was 17.9% [95% confidence interval (CI) 6.3-34.1] and the cumulative incidence of a 2nd replacement was 63.6% (95% CI 39.9-80.1). Seven years after mechanical mitral valve replacement, the cumulative incidence of death or transplantation was 28.6% (95% CI 13.3-46) and the cumulative incidence of a 2nd replacement was 10.7% (95% CI 2.6-25.5). Fifteen years after mechanical mitral valve replacement, the cumulative incidence of death or transplantation was 33.6% (95% CI 16.2-52.1) and the cumulative incidence of a 2nd replacement was 41.1% (95% CI 18.4-62.7). The cumulative incidence curves for bioprosthetic and mechanical mitral valve replacement were statistically different for a 2nd valve replacement (P < 0.001) but not for death or transplantation (P = 0.33). There is no difference in transplant-free survival after bioprosthetic and mechanical mitral valve replacement in children. The lifespan of bioprosthetic mitral valves remains limited in children because of structural valve failure due to calcification. After 15 years, 40% of mechanical valves were replaced, primarily because of patient-prosthesis mismatch related to somatic growth.

Our 7-year experience supporting the Ross autograft with the novel technique of Personalized External Aortic Root Support

ObjectiveThe Ross operation is a widely accepted option for aortic valve replacement in children, and evidence shows its excellent results in terms of hemodynamics and durability. However, indications are still limited due to the fact that it is a technically demanding procedure, only performed by specialized surgeons. On top of that, and despite numerous techniques being applied, autograft dilatation remains a key disadvantage, which can lead to graft failure. In recent years, the ExoVasc Personalized External Aortic Root Support (PEARS) has proven to be a safe and effective option to prevent aortic root dilatation in various aortopathies and is a technique that lends itself to support the pulmonary autograft in the Ross operation. MethodsDuring the past 7 years, we have used the ExoVasc PEARS graft, manufactured from the patients' pulmonary artery measurements from computed tomography scan data, to support the pulmonary autograft in the Ross operation. This graft (manufactured by Exstent Ltd, UK) is implanted at the same time as the autograft. We have reviewed all the patients who underwent this surgery, including demographic data, aorta measurements, operative data, and follow-up assessment consisting of periodic echocardiograms and magnetic resonance imaging scans. ResultsFifty patients were included in the study. Mean age at the time of the operation was 29.84 years, the youngest patient was 9 years-old. Nineteen patients (38%) had previous sternotomies; 11 of them having had a previous aortic valve replacement. Seventy-two percent of patients had initially a bicuspid aortic valve. Mean diameter of the ascending aorta was 3.83 cm. Forty-four percent of patients required a concomitant reduction aortoplasty due to mismatch sizes between the ascending aorta and the autograft. Mean bypass and crossclamp times were 200.66 and 151.14 minutes, respectively. Median length of stay was 6 days. Mean follow-up was 16.88 months. Two patients required subsequent aortic valve replacement (1 had rheumatic valve disease and the other had iatrogenic damage in his autograft valve leaflet). Ascending aorta dimensions remain stable when compared with immediate postoperative studies. There were no deaths. ConclusionsThe ExoVasc PEARS graft has proven to be an excellent support in the Ross operation to prevent the autograft failure related to autograft dilatation that can offer several advantages compared with other existing techniques. With this type of support, we believe the Ross indications can be expanded to multiple clinical scenarios, given the good long-term results this operation offers in terms of durability, life expectancy, and hemodynamics.

Outcomes after Mechanical Aortic Valve Replacement in Children with Congenital Heart Disease.

The optimal choice of valve substitute for aortic valve replacement (AVR) in pediatric patients remains a matter of debate. This study investigated the outcomes following AVR using mechanical prostheses in children. Forty-four patients younger than 15 years who underwent mechanical AVR from March 1990 through March 2023 were included. The outcomes of interest were death or transplantation, hemorrhagic or thromboembolic events, and reoperation after mechanical AVR. Adverse events included any death, transplant, aortic valve reoperation, and major thromboembolic or hemorrhagic event. The median age and weight at AVR were 139 months and 32 kg, respectively. The median follow-up duration was 56 months. The most commonly used valve size was 21 mm (14 [31.8%]). There were 2 in-hospital deaths, 1 in-hospital transplant, and 1 late death. The overall survival rates at 1 and 10 years post-AVR were 92.9% and 90.0%, respectively. Aortic valve reoperation was required in 4 patients at a median of 70 months post-AVR. No major hemorrhagic or thromboembolic events occurred. The 5- and 10-year adverse event-free survival rates were 81.8% and 72.2%, respectively. In univariable analysis, younger age, longer cardiopulmonary bypass time, and smaller valve size were associated with adverse events. The cut-off values for age and prosthetic valve size to minimize the risk of adverse events were 71 months and 20 mm, respectively. Mechanical AVR could be performed safely in children. Younger age, longer cardiopulmonary bypass time and smaller valve size were associated with adverse events. Thromboembolic or hemorrhagic complications might rarely occur.

PR and QRS interval changes after transcatheter pulmonary valve replacement in children

BackgroundChanges in PR intervals after transcatheter pulmonary valve replacement (TCPVR) have not been thoroughly evaluated in children. This study evaluated the changes in PR and QRS intervals six months after TCPVR in children with congenital heart disease.ResultsThis study included 41 patients who underwent TCPVR from 2010 to 2022. ECG of patients was reviewed before and six months after TCPVR, and the PR and QRS intervals were reported. Right ventricular systolic pressure (RVSP) was retrieved indirectly from echocardiography and compared pre- and 6-months after TPVR. The median age was 13 years (25th–75th percentiles: 11–16), and 61% were males. The preoperative diagnosis was tetralogy of Fallot (n = 29, 71%), transposition of great vessels (n = 4, 10%), common arterial trunk (n = 3, 7%), pulmonary valve stenosis (n = 3, 7%) and pulmonary atresia (n = 2, 5%). The Melody valve was used in 30 patients, and Edwards Sapien was used in 11 patients. RVSP was significantly reduced six months after the procedure (pre-RVSP 40 (30–55) mmHg vs. post-RVSP 25 (20–35) mmHg; P < 0.001). The PR interval was 142 (132–174) msec before TPVR and 146 (132–168) msec post-TCPVR (P = 0.442). Post-TPVR PR was positively related to the pre-PR (β: 0.79 (0.66–0.93), P < 0.001) and inversely related to the right ventricular outflow tract size (− 1.48 (− 2.76 to − 0.21), P = 0.023). The pre-TPVR QRS was 130 (102–146) msec, and the post-TPVR QRS was 136 (106–144) msec (P = 0.668).ConclusionsIn children undergoing TCPVR, the PR and QRS intervals did not change significantly during a 6-month follow-up.

On-demand heart valve manufacturing using focused rotary jet spinning

On-demand heart valve manufacturing using focused rotary jet spinning

Congenital mitral valve defects in pediatric population: a narrative review of surgical repair

Background and Objective: Congenital mitral valve malformations (CMVM) are rare and heterogeneous. The functional classification includes mitral regurgitation, stenosis, and combined lesions. Surgical strategies of CMVM remain challenging in the pediatric population due to various malformations, growth potential, the requirement of long-term anticoagulation, and the necessity of avoiding or delaying valve replacement. Surgical techniques for CMVM must be individually tailored for patients to achieve a proper valve function rather than “normal” anatomy. Compared with mitral repair, mitral valve replacement (MVR) is a less common procedure in children due to high mortality and morbidity rates. Options for cardiac valve replacement in children are limited to prostheses sizes that do not accommodate somatic growth, especially for neonates and infants. The need for lifelong anticoagulation may lead to adverse long-term pregnancy outcomes for female patients, limiting the application of MVR. This review aims to provide a comprehensive analysis of the current surgical techniques and developments for treating mitral valve (MV) regurgitation and stenosis and the outcome of various surgical strategies.

Modified atrioventricular valve replacement in children

One major challenge of atrioventricular valve replacement in children is the small size of the native valve annulus. In addition, in cases of atrioventricular septal defect, the atrioventricular node (AVN) shifts to a different location, making this condition difficult to treat. This report describes a technique that uses a trapezoid-shaped patch to separate the implanted valve suture-line from the AVN, which allows surgeons to implant larger valves while simultaneously preventing injury to the AVN.

Outcomes Following Aortic Valve Replacement in Children With Conotruncal Anomalies.

Conotruncal anomalies can develop aortopathy and/or aortic valve (AV) disease and AV replacement (AVR) is occasionally needed. We report long-term results and examine factors affecting survival following AVR in this group. We queried the Pediatric Cardiac Care Consortium (PCCC, US database for interventions for congenital heart diseases) to identify patients with repaired conotruncal anomalies and AVR. Long-term outcomes were provided by the PCCC, the US National Death Index, and Organ Procurement and Transplantation Network. Competing risks analysis examined outcomes following AVR (death/transplantation, reoperation) and multivariable regression analysis assessed significant factors. One hundred six children with repaired conotruncal anomalies underwent AVR (1982-2003). Underlying anomaly was truncus (n = 40), d-transposition (n = 22), type-B interrupted arch (n = 16), double-outlet right ventricle (n = 12), pulmonary atresia with ventricular septal defect (n = 9), tetralogy of Fallot (n = 6), corrected transposition (n = 1). 18 (17%) had prior aortic valvuloplasty (surgical = 12, percutaneous = 6). Median age at AVR was 6.9 years (interquartile range = 2.5-12.4). AV pathophysiology was regurgitation (n = 83, 78%), stenosis (n = 9, 9%), and mixed (n = 14, 15%). AVR type was mechanical (n = 72, 68%), homograft (n = 21, 20%), and Ross (n = 13, 12%). Operative mortality was 13(12%). Infant age at AVR was risk factor (odds ratio = 55, 95% confidence interval [CI] = 6-539, P = .0006). On competing risks analysis, five years after AVR, 6% died or received transplantation, 20% had reoperation. Twenty-five years transplant-free survival was 53%. Factors associated with death after hospital discharge included mitral surgery (hazards ratio [HR] = 11, 95% CI = 3-39, P = .0002), underlying defect (HR = 2, 95% CI = 1-5, P = .446). Twenty years transplant-free survival in conotruncal anomalies group was inferior to matched children undergoing AVR for congenital non-conotruncal disease (61% vs 82%, P = .0012). Long-term survival following AVR in children with conotruncal anomalies is inferior to that of isolated congenital AV disease and is linked to an underlying cardiac defect. Although valve type was not associated with survival, infant age was a risk factor for operative mortality. Continuous attrition and high reoperation warrant vigilant monitoring.

Comments of results after surgical replacement of mechanical mitral and aortic valve in children at Hanoi Heart Hospital

Objective: Assessment of early results after surgical treatment of mechanical mitral valve and aortic valve replacement in children at Hanoi Heart Hospital from 2004 to June 2019.&#x0D; Methods: Analysis and evaluation based on data collected from patients undergoing surgery and from the results of follow-up examination.&#x0D; Results: The total number of patients was 50, in which 34 cases of simple mechanical mitral valve replacement, 16 cases of simple mechanical aortic valve replacement. Average age of surgery: 7.58 ± 6.01 years (The lowest age is 7 months, the highest is 15 years). Male: 29 patients (58%), female: 21 patients (42%). Ultrasound before discharge and after 3 months, we found similar results: mean EF: mechanical mitral valve: 56.28 ± 10.67 %; Aortic valve: 54.72 ± 9.66% .Mean pressure : Mitral valve: 3.18 ± 1.25; Aortic valve: 12.12 ± 3.25 mmHg. INR index: mitral valve : 2.58 ± 1.20; Aortic valve: 2.34 ± 0.92. Complications of valve replacement: 2 cases of mitral valve replacement after surgery 3 years and 4 years; There was 1 case of aortic valve 5 years after surgery. Death immediately after surgery: mitral valve: 2 cases (5.88%); aortic valve: 1 case (6.25%); Late death: After 2 years, there was 1 case of death after mitral valve replacement; After 4 years, there was 1 case of death after aortic valve replacement.&#x0D; Conclusion: The results of heart valve replacement surgery in children are positive. It is necessary to have better equipment and experience in open heart surgery in low-birth-weight children in order to operate the disease as early and effectively as possible, in which the treatment of complications of heart failure and post-operative coagulopathy should be considered important.

Surgical techniques for aortic valve xenotransplantation

BackgroundHeart valve replacement in neonates and infants is one of the remaining unsolved problems in cardiac surgery because conventional valve prostheses do not grow with the children. Similarly, heart valve replacement in children and young adults with contraindications to anticoagulation remains an unsolved problem because mechanical valves are thrombogenic and bioprosthetic valves are prone to early degeneration. Therefore, there is an urgent clinical need for growing heart valve replacements that are durable without the need for anticoagulation.MethodsA human cadaver model was used to develop surgical techniques for aortic valve xenotransplantation.ResultsAortic valve xenotransplantation is technically feasible. Subcoronary implantation of the valve avoids the need for a root replacement.ConclusionAortic valve xenotransplantation is promising because the development of GTKO.hCD46.hTBM transgenic pigs has brought xenotransplantation within clinical reach.

Abstract 10390: Transcatheter and Surgical Aortic Valve Replacement in Children with Congenital Heart Disease: An Institutional Experience

Introduction: Surgical approaches have historically been the mainstay for aortic valve replacement in children and adults, while transcatheter approaches have been increasingly utilized in adults with rare use in children. We hypothesized that short-term outcomes for native aortic valve replacement are comparable between the surgical (SAVR) or transcatheter (TAVR) approach in children. Methods: Patients &lt; 21 years who had native SAVR or TAVR between January 2010 to April 2020 at our institution were included. Analysis focused on short-term outcomes for ages 10-21. SAVR and TAVR were compared using a composite outcome score (stroke within 6 months, readmission within 30 days, death). Pre- and post-procedural characteristics were compared using chi-squared test or Wilcox rank sum test as appropriate. Results: Of 77 patients included, 46 were 10-21 yrs (30 SAVR, 16 TAVR). Mean follow-up was 3.7 yrs for the SAVR group and 1.7 yrs for the TAVR group. There was no significant difference in the composite score between groups (3 SAVR, 2 TAVR; p = 1). Patients in the SAVR group were more likely to have undergone concomitant surgical intervention (e.g., Konno procedure, mitral valve repair/replacement, etc.) and have longer hospital stays (Table 1). Death in the SAVR group was secondary to patient non-compliance with recommended medications and follow-up, resulting in severe aortic stenosis with cardiogenic shock and respiratory failure. Death in the TAVR group was secondary to endocarditis of the valve and associated stroke, which converted from ischemic to hemorrhagic following surgical intervention. Conclusion: Our study suggests similar short-term outcomes for TAVR and SAVR in children and young adults &gt; 10 years of age. Long-term studies are essential in the pediatric population to fully explore the option of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement.

Multicentre comparative analysis of long-term outcomes after aortic valve replacement in children

ObjectiveThe ideal valve substitute for surgical intervention of congenital aortic valve disease in children remains unclear. Data on outcomes beyond 10–15 years after valve replacement are limited but important for...

Mitral valve replacement in infants and younger children

Data on mitral valve replacement (MVR) in young children is still limited. Our objective was to evaluate MVR in children below 5 years and identify factors affecting the outcomes. This retrospective study included 29 patients who had MVR from 2002 to 2020. We grouped the patients into two groups according to their age: age ≤ 24 months (n = 18) and > 24 months (n = 11). Primary cardiac diagnoses were Shone complex (n = 7; 24%), isolated congenital mitral valve abnormality (n = 11; 38%), and complete atrioventricular septal defect (n = 3; 10%). The median age was 19 month (25th–75th percentile: 11–32) and 59% were females (n = 17). The hemodynamic lesions were mitral regurgitation in 66%, mitral stenosis in 10%, and combined mitral stenosis and regurgitation in 24% of the patients. St. Jude mitral valve was the most common valve implanted (n = 19, 66%), followed by CarboMedics in 21% of the patients (n = 6). The mitral valve was implanted in the supra-annular position in 6 cases (21%). Preoperative and operative data were comparable between both groups. There was no association between valve size and position with postoperative heart block (P > 0.99, for both). The median follow-up duration was 19.4 months (8.6–102.5). Nine patients had mitral valve reoperation, six had MVR, and three had clot removal from the mitral valve. There was no effect for age group on reoperation (SHR 0.89 (95% CI 0.27–2.87), P = 0.84). Valve size significantly affected reoperation (SHR 0.39 (95% CI 0.18–0.87), P = 0.02). The supra-annular position was associated with an increased risk of reoperation (SHR 3.1 (95% CI 1.003–9.4), P = 0.049). There was no difference in survival according to the age (Log-rank P = 0.57) or valve size (Log-rank P = 0.66). Mitral valve replacement in children is associated with low morbidity and mortality. The risk of reoperation could be affected by the valve size and position rather than the age.

What Factors Should Be Considered to Improve Outcome of Mechanical Mitral Valve Replacement in Children?

To identify risk factors for pediatric mechanical mitral valve replacement (mMVR) to improve management in this challenging population. From 1993 to 2019, 93 children underwent 119 mMVR operations (median age, 8.8 years [interquartile range [IQR]: 2.1-13.3], 54.6% females) at our institution. Twenty-six (21.8%) patients underwent mMVR at ≤2 years and 93 (78.2%) patients underwent mMVR at >2 years. Median follow-up duration was 7.6 years [IQR: 3.2-12.4]. Early mortality was 9.7%, but decreased with time and was 0% in the most recent era (13.9% from 1993 to 2000, 7.3% from 2001 to 2010, 0% from 2011 to 2019, P = .04). It was higher in patients ≤2 years compared to patients >2 years (26.9% vs 2.2%, P < .01). On multivariable analysis for mitral valve reoperation, valve size <23 mm was significant with a hazard ratio of 5.38 (4.87-19.47, P = .01);. Perioperative stroke occurred in 1% and permanent pacemaker was necessary in 12%. Freedom from mitral valve reoperation was higher in patients >2 years and those with a prosthesis ≥23 mm. Median time to reoperation was 7 years (IQR: 4.5-9.1) in patients >2 years and 3.5 years (IQR: 0.6-7.1) in patients ≤2 years (P = .0511), but was similar between prosthesis sizes (P = .6). During follow-up period (median 7.6 years [IQR: 3.2-12.4], stroke occurred in 10%, prosthetic valve thrombosis requiring reoperation in 4%, endocarditis in 3%, and bleeding in 1%. Early and late outcomes of mMVR in children are improved when performed at age >2 years and with prosthesis size ≥23 mm. These factors should be considered in the timing of mMVR.

Acute and Short-Term Outcomes of Percutaneous Transcatheter Mitral Valve Replacement in Children.

[Figure: see text].

Debate - Replacement of the Mitral Valve Under One Year of Age: Mechanical Valves Should Be Used.

This article reviews the literature, focusing on publications from the third millennium and the results of mitral valve replacement in children younger than 1 year of age. Special consideration has been given to neonatal and infant valve replacement to provide insights into valve choice and technique. Mitral valve replacement is an important topic because it carries the highest mortality and poorer long-term prognosis than any other valve replacement in children.

Ross Operation in Neonates: A Meta-analysis

The Ross operation is the preferred treatment for aortic valve replacement in children. However previous studies indicate that outcomes in neonates are poor. This meta-analysis examines the pooled outcomes of the Ross operation in neonates. Four major databases (PubMed/MEDLINE, EMBASE, Scopus, and ScienceDirect) were searched from inception until May 1, 2020 for studies describing outcomes of the Ross operation in neonates. The primary outcome was early mortality, and secondary outcomes were late mortality and mechanical support. Random-effects models were used to account for possible heterogeneity between studies, and continuity corrections were used to include zero total event trials. Eighteen studies comprising outcomes data on 181 neonates were included in the analysis. Meta-analysis showed a pooled early mortality rate of 24% (95% confidence interval, 12%-38%; I2= 52%, P for heterogeneity= .01). Meta-regression analysis showed that more recently published studies reported significantly worse early mortality (P= .03). The pooled incidence of postoperative mechanical support was 15% (95% confidence interval, 5%-28%; I2= 28%, P for heterogeneity= .22). No evidence of publication bias was found according to Egger's test (bias coefficient= 0.21, P= .57). The neonatal Ross operation carries a high early mortality rate. The treatment of unrepairable aortic valves in neonates remains an unsolved problem in congenital cardiac surgery.

Abstract 17193: Acute and Short-Term Outcomes of Percutaneous Transcatheter Mitral Valve Replacement in Children

Introduction: Despite the improvement of surgical techniques for mitral valve (MV) repair in children, mitral valve replacement (MVR) is sometimes still necessary. MVR and redo-MVR continue to be burdened by early postoperative mortality and long-term morbidity with only about 75% of these patients being alive or transplant-free 10 years after the initial MVR. Although trans-femoral mitral valve replacement (TMVR) is a well-established intervention in high surgical risk adults, only a few pediatric Valve-in-Valve (ViV) case reports have been published. Hypothesis: We hypothesized that trans-venous transcatheter mitral valve replacement is feasible, safe, and effective in pediatric patients. Methods: Retrospective analysis of pediatric patients who underwent TMVR at Boston Children's Hospital between October 2018 and May 2020 Results: 7 consecutive high surgical risk pediatric patients (median age 9 years, range 8-15) underwent TMVR (6 as ViV, 1 in a native MV). Each patient previously underwent multiple MV surgeries or MVR (median 4, range 2-5) and was highly symptomatic (Ross functional class 3 or 4). The indication for TMVR was mitral stenosis in 5 patients, regurgitation in 1, and mixed disease in 1. TMVR was successful in each patient, effectively reduced the left atrium hypertension (p=0.018), and was carried out without significant complications. Conclusion: Trans-venous trans-catheter mitral valve replacement is an attractive alternative to MVR in high surgical risk patients. In this small series, TMVR was acutely effective and safe, with very encouraging early results.

Current Treatment Options for Catheter-Based Pulmonary Valve Replacement in Children

For decades, surgical replacement of the pulmonary valve has been the gold standard. The last 10 years have seen significant progress in improvement in the technology and techniques around percutaneous pulmonary valve Percutaneous pulmonary valve replacement (PPVR). This has allowed us to expand the range of patients who can be treated with percutaneous techniques. This review serves as an update for referring cardiologists. Several studies have demonstrated similar clinical outcomes comparing surgical and percutaneous valve replacement, noting the decreased recovery time and morbidity after PPVR. Along with the overall periprocedural advantages of PPVR, newer devices now allow pulmonary valve replacement in patients with surgically placed conduits and in patients with dilated native right ventricular outflow tracts (RVOT). PPVR is now also performed in smaller patients thanks to newly available techniques and technology. Imaging technology to guide these procedures has also evolved allowing such complex interventions to be performed with minimal radiation and contrast use in the catheterization laboratory. knowledge of technological advancements in PPVR will allow referring cardiologists and patients to make informed decisions about pulmonary valve replacement in each individual case. Technology will continue to evolve and hopefully provide many more surgical and percutaneous options to care for the congenital heart disease population.