Options for Pulmonary Valve Replacement

Options for Pulmonary
Valve Replacement
Emile Bacha, MD
Congenital and Pediatric Cardiac Surgery
Morgan Stanley Children’s Hospital of New York-Presbyterian
Columbia University Medical Center
No Conflict with regard to this
topic
Indications for Pulmonary Valve
Replacement (PVR)
• Chronic pulmonary regurgitation (PR) is an
important cause of morbidity and mortality late after
TOF repair
• Chronic pulmonary regurgitation (PR) is an
important cause of morbidity and mortality late after
TOF repair
• RV remodeling and other compensatory
mechanisms ultimately fail, leading to RV and LV
dysfunction and clinical deterioration*
* Geva T., et al. JACC 2004;43:1068-74
RV function - MRI
RV volumes, PV regurgitant fraction, Ejection Fraction, amount and location
of scar tissue (delayed enhancement)
Learning curve
Patients are getting referred earlier and in a better condition
PVR is now a very commonly performed operation
PVR is an operation that has a low operative mortality and a
good mid-term outcome
McKenzie D et al, JTCVS 2014
PVR is an operation that has a low operative mortality and a
good mid-term outcome
McKenzie D et al, JTCVS 2014
INDICATIONS FOR
PULMONARY
VALVE IMPLANTATION
Geva et al,
Circulation 2013
Geva T,
Circulation 2013
Pulmonary Valve Implantation: currently the most
commonly performed operations for adults with
congenital heart disease
Technical aspects
Technique of Pulmonary Valve Implantation
A common mistake:
Angulation of the prosthesis vis-à-vis the RVOT and PA
Types of conduits and prosthetic
valves
• MECHANICAL:
– pyrolytic carbon/graphite substrates (St Jude, Carbomedics)
– pure carbon (On-X)
• BIOLOGICAL:
– Human tissue: homografts (Cryolife, Lifenet, Alabama Tissue)
– Animal tissue (bovine or porcine):
• Valve (pig): Medtronic, St Jude
• Pericardium (cow, pig): Carpentier-Edwards, Sorin
• Jugular vein (cow): Contegra
• ARTIFICIAL HAND-SEWN
– PTFE 0.1mm
Advantage:
-Extreme longevity (decades)
-Thromboembolic events may
be less than previously thought
Disadvantages:
-Coumadin
-Rigid
-Percutaneous PA interventions
not possible
Biological valves/conduits
• Advantages:
– No need for anticoagulation
– Flexible
– Can be used in infected territory (homografts)
• Disadvantages:
– Poor longevity, especially in younger patients
Biological prosthesis
Medtronic Mosaic Aortic and Mitral Bioprosthesis
(Porcine valves)
Medtronic Freestyle aortic root (stentless)
(Porcine aortic valve)
Biological prosthesis
Carpentier-Edwards Perimount
(cow pericardium)
Contegra
bovine jugular vein with a tri-leaflet venous valve
Shelhigh valved conduits
Stentless porcine valve with pericardial extension
St Jude Toronto SPV (Stentless valves)
(aortic porcine valve)
Pulmonary Homograft
Hand-Sewn RVOT prostheses
•
•
•
•
Technically more difficult
May not be as reproducible as prostheses
May last longer
Adaptable to various RVOT geometries
Lee C et al, EJCTS 2013
How do you choose the right
valve?
How do you choose the right
valve?
• Baseline Anatomy
Truncus Arteriosus:
Completed Repair
Reconstruction of RVOT
with Homograft
Completed Ross procedure
How do you choose the right
valve?
• Baseline Anatomy
• Age of patient/expected longevity
• Size of patient
How do you choose the right
valve?
•
•
•
•
Baseline Anatomy
Age of patient/expected longevity
Size of patient
Sex
How do you choose the right
valve?
•
•
•
•
•
Baseline Anatomy
Age of patient/expected longevity
Size of patient
Sex
Sociocultural factors
Chen C et al, JTCVS 2012
Effect of age on structural Valve degeneration
Chen C et al, JTCVS 2012
Larger valves relative to BSA had higher probability of SVD
Chen C et al, JTCVS 2012
Lee C, et al, Cardiol in the Young 2012
At 10 years, roughly 80% will require a reintervention
Lee C, et al, Cardiol in the Young 2012
Is the percutaneous option
taking over?
Medtronic Melody Valve
Percutaneous pulmonary valve
• Currently only for RV-PA conduit patients
• Small human study (Medtronic) on device
implantation in native RVOT (s/p TAP)
Percutaneous pulmonary valve
• Percutaneous techniques will improve
freedom from surgical reintervention
Perimount
Mitroflow
Epic St Jude
Mosaic Medtronic
Freestyle
In conclusion
-Pulmonary Valve Implantation is now a commonly
performed congenital procedure
-Bioprosthetic tissue valves are the most commonly used
valves
-Valve degeneration over time remains an unsolved
problem, especially in young patients
-Hand-sewn PTFE may hold promise long term
-Percutaneous options help prolong prosthetic longevity