spies_hijazi.qxp 10/10/08 9:32 am Page 62
Coronary Valve Replacement
Transcatheter Pulmonary Valve Implantation
a report by
Christian Spies
1
and Ziyad M Hijazi
2
1. Fellow, Interventional Cardiology, Rush University Medical Center; 2. Professor of Pediatrics and Internal Medicine, Rush University Medical Center,
and Director, Rush Center for Congenital and Structural Heart Disease
Unlike the left-sided semi-lunar valve, clinically significant acquired valves, including homografts, cloth tubes with a valve sewn inside or
pulmonary valve disease is rare. However, stenotic or regurgitant the more recent Contegra conduits (bovine jugular veins with a valve
pulmonary valve lesions are not uncommon following surgery for inside). However, even with successful operations there is no good
congenital heart defects, including tetralogy of Fallot, pulmonary atresia evidence that survival is better with these valves.
10,11
Some authors
and other surgical procedures requiring reconstruction of the right have suggested that perhaps valve replacement is performed too late,
ventricular outflow tract (RVOT).
1–4
Even with the use of valved conduits or which has raised the question of the appropriate timing for such
bioprosthetic valves – such as homografts, porcine valves or Contegra – operations.
12,13
Even with good myocardial protection, repeat
RVOT stenosis, regurgitation or a combination of both usually occurs five operations on an already compromised right ventricle may lead to
to 15 years following surgery. These valvular abnormalities may result in further deterioration in its function.
14
Therefore, the timing and
progressive right ventricular dilatation and dysfunction, leading to indications for pulmonary valve replacement in patients with repaired
arrhythmias and premature death.
2,4,5
complex congenital heart disease are controversial.
10,12
Commonly
accepted indications for pulmonary valve replacement are summarised
Pure native pulmonary valve stenosis can usually be successfully treated with in Table 1.
percutaneous balloon valvuloplasty.
6
However, stenotic lesions occurring in
surgically reconstructed RVOTs commonly do not respond well to simple For all of the reasons stated above, transcatheter implantation of the
balloon angioplasty; furthermore, they frequently present as a combined pulmonary valve appears to be an attractive option in high-risk patients.
stenosis–regurgitant lesion. These combined lesions have been successfully Bonhoeffer performed the first transcatheter valve replacement in
treated with stent placement across the pulmonary valve, overcoming the September 2000.
15
Since then, he and others have implanted the
stenosis but causing free pulmonary regurgitation.
7,8
Initially, severe Melody
®
valve (Medtronic, Minneapolis, MN, US) in over 500 patients
pulmonary regurgitation is tolerated well, but over time this may lead to (personal communication, William E Hellenbrand, 2008). With the
decreased exercise tolerance, right heart failure, arrhythmias and death.
8,9
recent advances in percutaneous aortic valve implantation, we have
tested the Edwards Sapien™ (Edwards Lifesciences, Irvine, CA, US)
Until recently, patients with severe pulmonary regurgitation were transcatheter heart valve (THV) for implantation in the pulmonic
treated with surgical pulmonary valve replacement using a variety of position as an alternative to the Melody valve.
The Melody Valve
Christian Spies is a Fellow in Interventional Cardiology
at Rush University Medical Center, Chicago. He is a
The Melody valve consists of a valve-containing bovine jugular vein
member of the American College of Cardiology (ACC), the sewn inside a balloon-expandable Cheatham platinum–iridium stent
Society for Cardiovascular Angiography and Interventions
(see Figure 1). The valve is delivered via a 22Fr system and can be
(SCAI) and the Society of Vascular Medicine (SVM). He
completed his training in cardiovascular medicine at Rush
expanded up to a diameter of 22mm.
16
It has been implanted in over
University Medical Center and his residency and internship
500 patients worldwide, with the largest series published to date
at the University of Hawaii. Prior to moving to the US, he
completed an internship in cardiothoracic and vascular
reporting outcome data of 155 patients.
17
The median age of the
surgery at the Medizinische Hochschule Hannover, following graduation from medical cohort was 21 years. Ninety-two per cent of the patients had a
school at the University of Hamburg in 1999.
previous right-ventricle-to-pulmonary-artery conduit of some sort. In
E:
cspies@queens.org the vast majority of patients the valve was implanted via the femoral
venous approach. Following implantation, the mean RVOT gradient
Ziyad M Hijazi is a Professor of Pediatrics and Internal
fell from 37 to 10mmHg (p<0.001), and no patients had more than
Medicine at Rush University Medical Center in Chicago
and Director of the Rush Center for Congenital and
mild pulmonary regurgitation on angiography at the conclusion of the
Structural Heart Disease. His main interest is in
procedure. Seven major complications occurred (4.5%), including
developing new technologies (balloons, devices, stents,
device dislodgement, homograft rupture and compression of the left
catheters, etc.) for the treatment of congenital and
structural heart disease. He has published extensively in
main coronary artery. During a median follow-up period of 28 months,
this field, with over 200 original papers, four books and
freedom from re-operation was 93% at 10 months and 84% at 50
hundreds of abstracts. He is President of the Society for
Cardiovascular Angiography and Interventions (SCAI). Dr Hijazi earned his MD from Jordan
months. Valvular competence was preserved during follow-up. Four
University, Amman in 1982, then completed a Masters in Public Heath at Yale University patients died (mortality at 83 months: 3.4%), two of whom initially
and a residency and fellowship at Yale New Haven Hospital.
presented with cardiogenic shock and died during the peri-procedural
E:
zhijazi@rush.edu period. The authors concluded that the Melody valve is an effective
treatment for RVOT dysfunction and that deployment is highly
62 © TOUCH BRIEFINGS 2008
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92