Percutaneous pulmonary valve implantation

Percutaneous pulmonary valve implantation

Percutaneous pulmonary valve implantation has the elite distinction that it was first percutaneous intervention for a regurgitant lesion in humans [1]. Bonhoeffer P et al described the development of a system for percutaneous stent implantation combined with valve replacement for right ventricle to pulmonary artery prosthetic conduit with valve dysfunction [2]. They used it in a 12 year old boy with stenosis and regurgitation of a prosthetic conduit from right ventricle to pulmonary artery. Percutaneous implantation of bovine jugular valve in the conduit was achieved successfully in 2000. Echo, angio and hemodynamic assessment showed no residual regurgitation and partial relief of conduit stenosis. There were no complications and patient was in good physical condition at one month follow up.

A report of 58 patients with a mean age of 16 years was published in 2005 [3]. Majority had variants of tetralogy of Fallot or transposition of great arteries with ventricular sepal defect and pulmonary stenosis. They had undergone right ventricular outflow tract reconstruction in infancy with valved conduit and presented in later life for reintervention for pulmonary regurgitation and stenosis. There was significant fall in right ventricular pressure, right ventricular outflow tract gradient and pulmonary regurgitation. There was no mortality in the series.

Data on 155 patients was published in 2008 [4]. Follow up was up to 83.7 months. Freedom from reoperation was 70% at 70 months. Freedom from transcatheter reintervention was 73% at 70 months. Survival at 83 months was 96.9%. First series of 50 patients and patients with a residual gradient more than 25 mm Hg were associated with higher risk of reoperations. 

A review on percutaneous pulmonary valve implantation in 2015 opined that it is a safe and effective procedure [5]. The procedure has the potential to improve symptoms, functional capacity and biventricular hemodynamics. Limitation noted was that eligibility for the procedure was in less than one fourth of the patients with right ventricular outflow tract dysfunction. The Melody valve crimped over a balloon-in-balloon catheter was delivered through a 22F long sheathed balloon catheter. 18 mm device could be expanded up to 22 mm.

Coronary compression by the implanted valve is a rare but significant problem with percutaneous pulmonary valve implantation. Balloon coronary test has been used to check for the likelihood of coronary compression. But it is not foolproof and could have high false positive rate [6].

When a short valve is needed, manual shortening of the Melody device has been used and is known as “Folded Melody Valve” technique. It has been shown to be a safe technique with favourable outcomes up to 6.5 years after implantation, in a retrospective study of 49 patients [7].

References

  1. Khambadkone S. Percutaneous pulmonary valve implantation. Ann Pediatr Cardiol. 2012 Jan;5(1):53-60. 
  2. Bonhoeffer P, Boudjemline Y, Saliba Z, Merckx J, Aggoun Y, Bonnet D, Acar P, Le Bidois J, Sidi D, Kachaner J. Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction. Lancet. 2000 Oct 21;356(9239):1403-5. 
  3. Khambadkone S, Coats L, Taylor A, Boudjemline Y, Derrick G, Tsang V, Cooper J, Muthurangu V, Hegde SR, Razavi RS, Pellerin D, Deanfield J, Bonhoeffer P. Percutaneous pulmonary valve implantation in humans: results in 59 consecutive patients. Circulation. 2005 Aug 23;112(8):1189-97.
  4. Lurz P, Coats L, Khambadkone S, Nordmeyer J, Boudjemline Y, Schievano S, Muthurangu V, Lee TY, Parenzan G, Derrick G, Cullen S, Walker F, Tsang V, Deanfield J, Taylor AM, Bonhoeffer P. Percutaneous pulmonary valve implantation: impact of evolving technology and learning curve on clinical outcome. Circulation. 2008 Apr 15;117(15):1964-72. 
  5. Ansari MM, Cardoso R, Garcia D, Sandhu S, Horlick E, Brinster D, Martucci G, Piazza N. Percutaneous Pulmonary Valve Implantation: Present Status and Evolving Future. J Am Coll Cardiol. 2015 Nov 17;66(20):2246-2255. 
  6. Morgan GJ, Rodriguez SA, Leahy R, Zablah JE. Coronary compression testing by balloon interrogation during pulmonary valve implantation: room for doubt? Cardiol Young. 2021 Feb 10:1-7.
  7. Jalal Z, Valdeolmillos E, Malekzadeh-Milani S, Eicken A, Georgiev S, Hofbeck M, Sieverding L, Gewillig M, Ovaert C, Bouvaist H, Pillois X, Thambo JB, Boudjemline Y. Mid-Term Outcomes Following Percutaneous Pulmonary Valve Implantation Using the “Folded Melody Valve” Technique. Circ Cardiovasc Interv. 2021 Apr;14(4):e009707.