Shabana Shahanavaz1, Jeremy D Asnes2, Jochen Grohmann3, Athar M Qureshi4, Jonathan J Rome5, Daniel Tanase6, Matthew A Crystal7, Larry A Latson8, Brian H Morray9, William Hellenbrand2, David T Balzer1, Marc Gewillig10, Jon C Love11, Farhouch Berdjis12, Matthew J Gillespie5, Doff B McElhinney13. 1. Division of Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, MO (S.S., D.T.B.). 2. Yale University, New Haven, CT (J.D.A., W.H.). 3. Department of Congenital Heart Defects and Pediatric Cardiology, Heart Center, University of Freiburg, Germany (J.G.). 4. The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston (A.M.Q.). 5. The Children's Hospital of Philadelphia, PA (J.J.R., M.J.G.). 6. Department of Paediatric Cardiology and Congenital Heart Defects, German Heart Centre, Munich (D.T.). 7. Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY (M.A.C.). 8. Department of Cardiology, Joe DiMaggio Children's Hospital, Hollywood, FL (L.A.L.). 9. Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington School of Medicine (B.H.M.). 10. Department of Pediatric Cardiology, University Hospitals Leuven, Belgium (M.G.). 11. Division of Pediatric Cardiology, University of New Mexico, Albuquerque (J.C.L.). 12. Children's Hospital of Orange County, CA (F.B.). 13. Departments of Pediatrics and Cardiothoracic Surgery, Lucile Packard Children's Hospital Heart Center, Stanford University School of Medicine, Palo Alto, CA (D.B.M.).
Abstract
BACKGROUND: Percutaneous transcatheter pulmonary valve replacement (TPVR) has good clinical and hemodynamic outcomes in treating dysfunctional bioprosthetic valves (BPV) in the pulmonary position. Valve-in-valve therapy can further decrease the inner diameter (ID), potentially resulting in patient-prosthesis mismatch in patients with smaller BPVs. METHODS AND RESULTS: To evaluate feasibility and outcomes of intentional BPV fracture to enlarge the pulmonary valve orifice with TPVR, 37 patients from 13 centers who underwent TPVR with intended BPV fracture were evaluated. A control cohort (n=70) who underwent valve-in-valve TPVR without attempted fracture was evaluated. BPV was successfully fractured in 28 patients and stretched in 5 while fracture was unsuccessful in 4. A Melody valve was implanted in 25 patients with fractured/stretched frame and a Sapien (XT 3) valve in 8. Among patients whose BPV was fractured/stretched, the final ID was a median of 2 mm larger (0-6.5 mm) than the valve's true ID. The narrowest diameter after TPVR in controls was a median of 2 mm smaller ( P<0.001) than true ID. Right ventricular outflow tract gradient decreased from median 40 to 8 mm Hg in the fracture group. Cases with fracture/stretching were matched 1:1 (weight, true ID) to controls. Post-TPVR peak gradient was lower but not significant (8.3±5.2 versus 11.8±9.2 mm Hg; P=0.070). There were no fracture-related adverse events. CONCLUSIONS: Preliminary experience shows intentional fracture of BPV frame can be useful for achieving larger ID and better hemodynamics after valve-in-valve TPVR.
BACKGROUND: Percutaneous transcatheter pulmonary valve replacement (TPVR) has good clinical and hemodynamic outcomes in treating dysfunctional bioprosthetic valves (BPV) in the pulmonary position. Valve-in-valve therapy can further decrease the inner diameter (ID), potentially resulting in patient-prosthesis mismatch in patients with smaller BPVs. METHODS AND RESULTS: To evaluate feasibility and outcomes of intentional BPVfracture to enlarge the pulmonary valve orifice with TPVR, 37 patients from 13 centers who underwent TPVR with intended BPVfracture were evaluated. A control cohort (n=70) who underwent valve-in-valve TPVR without attempted fracture was evaluated. BPV was successfully fractured in 28 patients and stretched in 5 while fracture was unsuccessful in 4. A Melody valve was implanted in 25 patients with fractured/stretched frame and a Sapien (XT 3) valve in 8. Among patients whose BPV was fractured/stretched, the final ID was a median of 2 mm larger (0-6.5 mm) than the valve's true ID. The narrowest diameter after TPVR in controls was a median of 2 mm smaller ( P<0.001) than true ID. Right ventricular outflow tract gradient decreased from median 40 to 8 mm Hg in the fracture group. Cases with fracture/stretching were matched 1:1 (weight, true ID) to controls. Post-TPVR peak gradient was lower but not significant (8.3±5.2 versus 11.8±9.2 mm Hg; P=0.070). There were no fracture-related adverse events. CONCLUSIONS: Preliminary experience shows intentional fracture of BPV frame can be useful for achieving larger ID and better hemodynamics after valve-in-valve TPVR.
Entities:
Keywords:
hemodynamics; prostheses and implants; pulmonary valve; stents; tetralogy of Fallot
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