TRANSCATHETER VALVE IMPLANTATION IN

THE RIGHT HEART

Dr Aphrodite Tzifa, MD(Res), FRCPCH

Director, Paediatric and GUCH Cardiologist,

Mitera Children's Hospital, Athens, Greece

September 10, 2003

FAILURE OF RIGHT HEART VALVES

CONGENITAL

S/P Tetralogy of Fallot repair with conduit stenosis

S/P Fallot / pulmonary atresia repair with conduit

stensois

Truncus arteriosus / Conduit obstruction

TGA post switch with PS etc.

STRUCTURAL

Stenosis of TV bioprosthetic valve

Stensosis of PV bioprosthetic valve

TRANSCATHETER ALTERNATIVE of PVR

HIGH RISK PATIENTS

Multi-operated patients

Skoliosis or other skeletal anomalies

Lung hypoplasia or other significant respiratory problems

Syndromes

Other predisposing factors for a complicated post-op

course

Criteria for re-intervention

Συμπτωματικοί ασθενείς / peak VO2 < 60%

Ασυμπτωματικοί ασθενείς με 2 ή > από τα παρακάτω κριτήρια

Progressive volumetric changes on MRI

RVEDv > 160ml/kg/m2 or RV/LV EDV>2

RV ESv> 80ml/kg/m2

RV EF< 47%

LV EF< 55%

QRS> 140ms

Arrhythmias (1/3 to ½ of deaths in adult ToFs are sudden and 100% of those with sudden death had > moderate PR)

TRANSCATHETER PPVI

COURSE OF APPROVAL FOR TRANSCATHETER

VALVE IMPLANTATION

Patient clinical details letter with justification against

surgery

Supporting documents:

Cardiac MRI

Cardiac cath

Exercise testing with MVO2

24hr tape

IMPLANTATION IN THE RIGHT HEART

1. MELODY VALVE (requires a conduit or

bioprosthetic valve)

2. EDWARDS VALVE (26mm, 29mm XT): (requires

a conduit or bioprosthetic valve)

3. VENOUS P VALVE

Melody valve

Valved segment of bovine jugular vein sewn within a

balloon-expandable stent.

Used in patients with operated congenital heart disease

with pulmonary regurgitation, RVOT obstruction or both

> 8500 implants worldwide !

Edwards valve

700 valve implantations

worldwide

Available in 23-29mm

Diameters

Short stent. Landing zone with

prestenting is vital

Venous P valve

Nitinol self expandable

multi-level support frame

Integrated trileaflet porcine

pericardial tissue valve

On clinical trial: Europe, Asia

Can be implanted in native RVOT with transannular patch

Available up to 32mm diameter

PPVI IN THE PULMONARY POSITION

US MELODY VALVE TRIAL

Tetralogy of Fallot 65 (48)

Pulmonary atresia 40

Pulmonary stenosis 19

Absent pulmonary valve 5

Atrioventricular canal 1

Ross operation 28 (21)

TGA 15 (11)

Truncus arteriosus 14 (10)

Double-outlet right ventricle 8 (6)

Valvar pulmonary stenosis 3 (2)

Other 2 (1)

McElhinney et al. Short- and Medium-Term

Outcomes After Transcatheter Pulmonary

Valve Placement in the Expanded Multicenter

US Melody Valve Trial. Circulation 2011

Approved Melody use (INSIDE RV-PA conduits)

Approved Melody use (pulmonary homograft)

Off label Melody use (in native RVOT with or without

pericardial, bovine or PTFE transannular patch)

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PV preimplantation assessment

PV preimplantation assessment

PV preimplantation assessment

Criteria for re-intervention – Other factors

Available access

Size of RVOT

Shape of RVOT

Location / angulations / underlying diagnosis

Not too big ……. Not too small….

RVOT shape

Location – Relationships with neighboring

structures – co-existing problems

Assessment of RVOT relationship with coronaries

Test occlusion of RVOT with simultaneous

coronary angiogram

Test occlusion of RVOT with LCA occlusion

Cardiac catheterisation

Cardiac catheterisation

Prestenting: 1. CP stents , 2. Intrastents EV3,

Genesis stents

Stenting long conduit stenosis

Short landing zone - risky for Melody

Large RVOT – Venous P valve

Pulmonary BD during pre-assessment

IMPLANTATION IN THE

TRICUSPID POSITION

Transcatheter replacement of TV with Melody or

Edwards valve

Replacement within bioprosthetic valves

Indicated for severe TS or TR or mixed disease

Patients with ascites / peripheral oedemas

SOB

Good functional result

Resolution of ascites

NYHA II-III to I-II

Melody in TV (previous Edwards Perimount 25mm)

Melody in tricuspid valve (Edwards 25mm)

Tzifa et al Eurointervention

2013

Edwards in TV

Transcatheter Tricuspid Valve-in-Valve Implantation for the

Treatment of Dysfunctional Surgical Bioprosthetic Valves:

An International, Multicenter Registry Study

152 patients: 150/152 technically successful

22 deaths at F/U (5 within 30d)

77% were NYHA I-II at F/U (functional improvement)

Mc Elhinney et al. Circulation 2016

Endocarditis

SBE occurring in 4-16% of the population as compared to 2%

in the surgical group

Heart 2015: “Infective endocarditis of a transcatheter

pulmonary valve in comparison with surgical implants”:

Melody vs Contegra vs Homografts

7.5% of Melodies, 20% of Contegra, 2.4 % of homografts

present with SBE and when vegetations cause obstructions

the mortality is very high

M Gewillig. Heart 2015

Conclusions

Transcatheter valve therapy for patients with congenital

heart disease has revolutionised their management

Timely recognition will pick-up the patients with significant

RVOT stenosis or regurgitation before the onset of right heart failure

Key to the success is the patient preparation and the availability of a

specialist team consisting of Radiologists, Cardiologists, Anaesthetists

and Surgeons with expertise in the management of congenital patients

Thank you

atzifa@mitera.gr