Tricuspid Valve Implantation in Fontan Patient

Circulation: Cardiovascular Interventions. 2011;4:112-3.
Images in Cardiology























History:
Tricuspid Atresia - type 1c
(Tricuspid atresia, Normally-related Great Arteries, VSD, no PS)

14 yrs: Fontan-Bjork Operation (RA-RV Hancock Prosthesis, Closure of ASD and VSD)

24 yrs: Obstruction of Hancock prosthesis. Therefore, replaced with 23 mm Aortic Homograft

38 yrs: Complete Heart Block - Dual Chamber pacemaker (RV lead via homograft)

45 yrs: PLE, failure of medical therapy, Severe TR

47 yrs: Melody Valve in Tricuspid position (inside Aortic Homograft). Resolution of PLE

14 mo follow-up: No recurrence of PLE.

Melody Valve in Branch PA in Tetralogy of Fallot with RV failure

Melody Valve Implantation Into the Branch Pulmonary Arteries for Treatment of Pulmonary Insufficiency in an Ovine Model of Right Ventricular Outflow Tract Dysfunction Following Tetralogy of Fallot Repair.

J. Daniel Robb, et al.

Circulation: Cardiovascular Interventions. 2011; 4: 80-87

Correspondence to Matthew J. Gillespie, MD, The Children's Hospital of Philadelphia, Room 6NE42, Main Building, 34th and Civic Center Blvd, Philadelphia, PA 19104. E-mail Gillespie@email.chop.edu

Background— Transannular patch (TAP) repair of tetralogy of Fallot often results in significant right ventricular outflow tract (RVOT) dilation and distortion. We hypothesized that insertion of Melody valves into the proximal right and left branch pulmonary arteries (PAs) would reduce pulmonary regurgitation fraction (PRF) in an ovine model of pulmonary insufficiency and dilated RVOT.

Methods and Results— Ten sheep underwent baseline cardiac catheterization, surgical pulmonary valvectomy, and TAP placement. A subset (n=5) had Melody valves (2 devices per animal) inserted into the proximal right and left PAs during the surgical procedure. Melody valves were placed distal to the right-upper-lobe (RUL) artery branch, leaving the RUL “unprotected.” Preoperative MRIs (n=5) were used to determine baseline RV ejection fraction (RVEF) and left ventricular (LV) EF. All surviving animals (n=9) underwent MRI and catheterization 6 weeks postsurgery.

Mean PRF was lower in the Melody valve group (15±6% versus 37±3%; P=0.014). The unprotected RUL was responsible for 64% of the PRF measured in the Melody valve group. In the non-Melody group, the RVEF was lower than baseline (P=0.003) and than in the Melody group (P=0.05). The LVEF was also lower in the non-Melody group versus baseline (P=0.004) and versus Melody (P=0.01).

Conclusions— Bilateral branch PA Melody valve implantation significantly reduced PRF and altered RV and LV function favorably in a model of TAP for tetralogy of Fallot. This novel intervention may offer potential benefit in treating patients with anatomically heterogeneous disease of the RVOT.

Cath Lab: Percutaneous Pulmonary Valve Implantation - Early and Late Functional Outcome

J Am Coll Cardiol, 2011; 57:724-731

Early Versus Late Functional Outcome After Successful Percutaneous Pulmonary Valve Implantation. Are the Acute Effects of Altered Right Ventricular Loading All We Can Expect?

Philipp Lurz, MD*,,,*, Johannes Nordmeyer, MD*,,, Alessandro Giardini, MD, PhD, Sachin Khambadkone, MD, Vivek Muthurangu, MD*, Silvia Schievano, PhD*, Jean-Benoit Thambo, MD,, Fiona Walker¶, Seamus Cullen¶, Graham Derrick, Andrew M. Taylor, MD*, and Philipp Bonhoeffer, MD*

Objectives: The purpose of this study was to assess the potential of late positive functional remodeling after percutaneous pulmonary valve implantation (PPVI) in right ventricular outflow tract dysfunction.

Background: PPVI has been shown to impact acutely on biventricular function and exercise performance, but the potential for further late functional remodeling remains unknown.
Methods: Sixty-five patients with sustained hemodynamic effects of PPVI at 1 year were included. Patients were divided into 2 subgroups based on pre-procedural predominant pulmonary stenosis (PS) (n = 35) or predominant pulmonary regurgitation (PR) (n = 30). Data from magnetic resonance imaging and cardiopulmonary exercise testing were compared at 3 time points: before PPVI, within 1 month (early) and at 12 months (late) after PPVI.

Results: There was a significant decrease in right ventricle end-diastolic volume early after PPVI in both subgroups of patients. Right ventricle ejection fraction improved early only in the PS group (51 ± 11% vs. 58 ± 11% and 51 ± 12% vs. 50 ± 11%, p < 0.001 for PS, p = 0.13 for PR). Late after intervention, there were no further changes in magnetic resonance parameters in either group (right ventricle ejection fraction, 58 ± 11% in the PS group and 52 ± 11% in the PR group, p = 1.00 and p = 0.13, respectively). In the PS group at cardiopulmonary exercise testing, there was a significant improvement in peak oxygen uptake early (24 ± 8 ml/kg/min vs. 27 ± 9 ml/kg/min, p = 0.008), with no further significant change late (27 ± 9 ml/kg/min, p = 1.00). In the PR group, no significant changes in peak oxygen uptake from early to late could be demonstrated (25 ± 8 ml/kg/min vs. 25 ± 8 ml/kg/min vs. 26 ± 9 ml/kg/min, p = 0.48).

Conclusions: In patients with a sustained hemodynamic result 1 year after PPVI, a prolonged phase of maintained cardiac function is observed. However, there is no evidence for further positive functional remodeling beyond the acute effects of PPVI

RVOT remodeling during Pulm. valve replacement

Circulation. 2010;122:S201-S208.
Randomized Trial of Pulmonary Valve Replacement With and Without Right Ventricular Remodeling Surgery


Tal Geva, MD; Kimberlee Gauvreau, ScD; Andrew J. Powell, MD; Frank Cecchin, MD; Jonathan Rhodes, MD; Judith Geva, MSW; Pedro del Nido, MD

Background—Although pulmonary valve replacement (PVR) is effective in reducing right ventricular (RV) volume overload in patients with chronic pulmonary regurgitation, persistent RV dysfunction and subsequent adverse clinical outcomes have been reported. This trial was conducted to investigate whether the addition of surgical RV remodeling with exclusion of scar tissue to PVR would result in improved RV function and laboratory and clinical parameters, as compared with PVR alone.

Methods and Results—Between February 2004 and October 2008, 64 patients who underwent RV outflow tract procedures in early childhood had more than or equal to moderate pulmonary regurgitation, and fulfilled defined criteria for PVR were randomly assigned to undergo either PVR alone (n=34) or PVR with surgical RV remodeling (n=30). No significant difference was observed in the primary outcome (change in RV ejection fraction, –2±7% in the PVR alone group and –1±7% in the PVR with RV remodeling group; P=0.38) or in any of the secondary outcomes at 6-month postoperative follow-up. Multivariable analysis of the entire cohort identified preoperative RV end-systolic volume index <90 mL/m2 and QRS duration <140 ms to be associated with optimal postoperative outcome (normal RV size and function), and RV ejection fraction <45% and QRS duration 160 ms to be associated with suboptimal postoperative outcome (RV dilatation and dysfunction).

Conclusion—The addition of surgical remodeling of the RV to PVR in patients with chronic pulmonary regurgitation did not result in a measurable early benefit. Referral to PVR based on QRS duration, RV end-systolic volume, or RV ejection fraction may be beneficial.