Pulmonary valve stenosis regurgitation treatment...

PULMONIC STENOSIS

Pulmonic stenosis; Etiology Pulmonic stenosis; Etiology

Odenwald T, EXP REV CARDIOVASC THER 2011Odenwald T, EXP REV CARDIOVASC THER 2011

‘…virtually all cases of pulmonary valve stenosis are congenital in origin’

Severity of the pulmonic stenosis; Severity of the pulmonic stenosis;

DefinitionDefinition

ACC/AHA Guidelines on Valvular Heart Disease, CIRCULATION 2008ACC/AHA Guidelines on Valvular Heart Disease, CIRCULATION 2008

• Severe pulmonic stenosis: Jet velocity

greater than 4 m per second or

maximum gradient greater than 60 mm

Hg

Pulmonic stenosis; Pulmonic stenosis;

Invasive therapeutical optionsInvasive therapeutical options

1. Balloon valvotomy (Guidelines)

2. Percutaneous pulmonic valve

replacement

3. Surgery (homografts, bioprosthetic/

mechanical valves, conduits)

Pulmonic stenosis; Natural history of Pulmonic stenosis; Natural history of

different subgroupsdifferent subgroups

Nadas et al CIRCULATION 1977, ONadas et al CIRCULATION 1977, O’’ Fallon et al CIRCULATION 1993Fallon et al CIRCULATION 1993

�N=564 (total), n=261 (medical), n=303 (surgery)

�22 years follow-up

�Gradients: a) trivial < 25, b) mild 25 to 49, c) moderate

50 to 79, d) severe> 80

�Medically treated group (trivial to moderate gradients)

•14% of patients gradient increase (children<2y and gradients

>40)

•14% significant gradient decrease

• < 20% required valvotomy

Pulmonic stenosis; Natural history of Pulmonic stenosis; Natural history of

different subgroupsdifferent subgroups

Nadas et al CIRCULATION 1977, ONadas et al CIRCULATION 1977, O’’ Fallon et al CIRCULATION 1993Fallon et al CIRCULATION 1993

�Surgery treated group (moderate to severe gradients)

• 1 death

• Insignificant gradient in 90%

• No recurrence of pulmonic stenosis

�Overall

• Pts with gradients < 25 → 96% free of cardiac

operation

Pulmonic stenosis; ValvotomyPulmonic stenosis; Valvotomy

Fawzy et al AM HEART J 2007Fawzy et al AM HEART J 2007

n=90, n=90, congenital pulmonary valve stenosis, congenital pulmonary valve stenosis, followfollow--up 17 years (mean 10 years)up 17 years (mean 10 years)

mmHgmmHg Pulmonic valve gradient

Pulmonic stenosis; Valvotomy vs SurgeryPulmonic stenosis; Valvotomy vs Surgery

Odenwald et al EXP REV CARDIOVASC THER 2011Odenwald et al EXP REV CARDIOVASC THER 2011

Valvotomy

�Mortality: 3-8%

� Successful reduction of the gradient in 80-90%

�10% restenosis rate in 10 years

Surgery

� Mortality: 0,33-4%

�10 years lifespan for bioprosthetic valves and conduits

� Need for reintervention

� Greater risk for PR and RV dilatation (transannular patch,

conduits)

Percutaneous pulmonary valve implantationPercutaneous pulmonary valve implantation

MELODY valve MELODY valve -- MedtronicMedtronic


A trileaflet bovine jugular vein sutured into a platinum–iridium balloon-expandable

stent


Edwards Lifesciences SAPIEN

Boone et al CCI 2010Boone et al CCI 2010

Three bovine pericardial leaflets hand-sewn to a tubular, slotted, stainless steel, stent

with fabric sealing cuff covering the lower portion of the stent


MELODY vs SAPIEN valveMELODY vs SAPIEN valve

Boone et al CCI 2010Boone et al CCI 2010


Factors to be taken into account Factors to be taken into account

• Size and distensibility of the RVOT/ pulmonary

trunk

• Morphology of the RVOT/pulmonary trunk

• The position of the coronary arteries



Selection criteria for MELODY valveSelection criteria for MELODY valve

Size and distensibilitySize and distensibility

Lurz et al Lurz et al Semin Thorac Cardiovasc Surg Pediatr Card Surg Ann 20092009


Selection criteria for MELODY valveSelection criteria for MELODY valve

Morphology of the RVOTMorphology of the RVOT

Not suitable for PPVI



CoronariesCoronaries’’ positionposition



MELODY MELODY -- Late resultsLate results

Lurz et al JACC 2011Lurz et al JACC 2011

n=35 PS, n=30 PR, MELODY valve, n=35 PS, n=30 PR, MELODY valve, followfollow--up 1 year up 1 year

1 month 1year

VO2 max improved

only in the PS group

the first month

from 24 to 27

ml/kg/min


SAPIEN SAPIEN -- Late resultsLate results

Kenny et al JACC 2011Kenny et al JACC 2011

n=36 dysfunctional RVn=36 dysfunctional RV--PA conduit (severe regurgitation), n=15 severe stenosis, SAPIEN PA conduit (severe regurgitation), n=15 severe stenosis, SAPIEN valve, valve,

followfollow--up 6 months up 6 months

Peak RV-PA gradient



McElhinney et al CIRCULATION 2010et al CIRCULATION 2010

n=136 dysfunctional RVOT conduit or prosthetic valves, n=17 withn=136 dysfunctional RVOT conduit or prosthetic valves, n=17 with Fallot+PS, n=2 PS, MELODY, Fallot+PS, n=2 PS, MELODY,

followfollow--up 2 yearsup 2 years

Peak RV-PA gradient

AHA/ACC GUIDELINESAHA/ACC GUIDELINES

PULMONIC STENOSIS PULMONIC STENOSIS

VALVOTOMYVALVOTOMY

1. In symptomatic adolescent and young adult patients who have:

- exertional dyspnea,

- angina, and

- syncope, or presyncope

an RV–to–pulmonary artery peak-to-peak gradient > 30mmHg (cath)

CLASS I, LEVEL OF EVIDENCE C

2. In asymptomatic adolescent and young adult patients with:

an RV–to–pulmonary artery peak-to-peak gradient > 40mmHg (cath)


AHA/ACC GUIDELINESAHA/ACC GUIDELINES

PULMONIC STENOSIS PULMONIC STENOSIS

VALVOTOMYVALVOTOMY

CLASS IIb, LEVEL OF EVIDENCE C

In asymptomatic adolescent and young adult patients with:

an RV–to–pulmonary artery peak-to-peak gradient 30-39 mmHg

(cath)


CLASS III, LEVEL OF EVIDENCE C

In asymptomatic adolescent and young adult patients with:

an RV–to–pulmonary artery peak-to-peak gradient < 30 mmHg (cath)

ESCARDIO GUIDELINESESCARDIO GUIDELINES

Intervention for right ventricular Intervention for right ventricular

outflow tract obstruction outflow tract obstruction

CLASS I, LEVEL OF EVIDENCE C

ESCARDIO Guidelines on Congenital Heart Disease, EUR HEART J 201ESCARDIO Guidelines on Congenital Heart Disease, EUR HEART J 20100



outflow tract obstruction outflow tract obstruction CLASS IIa, LEVEL OF EVIDENCE C




outflow tract obstruction outflow tract obstruction

•Catheter intervention is recommended for patients with valvular

PS with valves which are not dysplastic (balloon valvotomy) and

with peripheral PS (stent)

•Surgery is recommended for patients with subinfundibular or

infundibular PS and hypoplastic pulmonary annulus, with

dysplastic pulmonary valves (i.e. Noonan’s syndrome), and for

patients with severe PR, TR

•Surgery may be necessary in patients with peripheral PS,

anatomically not amenable for percutaneous therapy


PULMONIC REGURGITATION

Pulmonic regurgitation; EtiologyPulmonic regurgitation; Etiology

Fitzerald et al CARD CLIN 2011Fitzerald et al CARD CLIN 2011

1. Dilation of either the pulmonary valve annulus or the

pulmonary artery, secondary to:

i)pulmonary hypertension, ii) idiopathic pulmonary artery

dilation, iii) connective tissue disease

2. Congenital absence of a pulmonary valve leaflet may cause

regurgitation

3. Iatrogenic causes (pulmonary valve trauma related to

balloon valvuloplasty, pulmonary artery catheters, or surgical

repair of congenital heart disease)

Severity of the pulmonic regurgitation; Severity of the pulmonic regurgitation;

DefinitionDefinition


• Severe pulmonic regurgitation: Color jet

fills outflow tract; dense continuous wave

Doppler signal with a steep deceleration

slope

Pulmonic regurgitation;Pulmonic regurgitation;

Indications for invasive treatmentIndications for invasive treatment

• Patients with NYHA functional class II or III

symptoms and severe pulmonary regurgitation

• For asymptomatic patients, the indications based on

regurgitant fraction, RV end-diastolic or end-systolic

volume, RV ejection fraction and exercise capacity

remain unclear.


Pulmonic regurgitation; Pulmonic regurgitation;

Invasive therapeutical optionsInvasive therapeutical options

1. Percutaneous pulmonic valve replacement

2. Surgery (homografts, bioprosthetic/

mechanical valves)


MELODY MELODY –– Pulmonic regurgitationPulmonic regurgitation

Vezmar et al, JACC CARDIOVASC INTERV 2010Vezmar et al, JACC CARDIOVASC INTERV 2010

n=28, dysfunctional conduits or homografts, MELODY valve, n=28, dysfunctional conduits or homografts, MELODY valve, followfollow--up 3 yearsup 3 years



Lurz et al JACC 2011Lurz et al JACC 2011

n=35 PS, n=30 PR, MELODY valve, n=35 PS, n=30 PR, MELODY valve, followfollow--up 1 year up 1 year

1 month 1year

VO2 max improved

only in the PS group

the first month

from 24 to 27

ml/kg/min

ΕυχαριστώΕυχαριστώ πολύπολύ

Back up Back up

CONCLUSIONSCONCLUSIONS

GHZ

Perin E et al, Perin E et al, ACC Scientific Sessions 2012, Chicago, IL ACC Scientific Sessions 2012, Chicago, IL

Pulmonary valve stenosis regurgitation treatment...

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