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)
- jilkjlkj
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
Top Related