Pulmonic regurgitation treatment: Difference between revisions

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__NOTOC__
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{{Pulmonic regurgitation}}
{{Pulmonic regurgitation}}
{{CMG}}{{AE}} {{AKI}}, {{AA}}
{{CMG}}{{AE}} {{AKI}}, {{AA}}, {{JA}}


==Overview  ==
==Overview  ==
[[Treatment]] of [[pulmonic regurgitation]] (PR) may be divided into medical and surgical treatment. Medical management of [[PR]] may include use of [[diuretics]] among [[patients]] with [[RV dysfunction]]. [[ACE inhibitors]] and [[beta blockers]] may be used to reverse neurohormonal activation and improve [[symptoms]]. [[Antibiotic]] [[prophylaxis]] may be indicated in certain conditions such as [[patients]] with [[cyanotic heart disease]], [[prosthetic heart valves]], [[rheumatic heart disease]], and previously sustained [[bacterial endocarditis]]. Surgical management of [[PR]] may include [[pulmonary valve]] replacement (PVR). The major indications for PVR may include symptomatic [[patients]] with [[arrythmias]] or [[NYHA]] class higher than II, an [[ejection fraction]] of less than 40% when assessed with [[CMR]], patients with progressive right ventricular [[regurgitation]](right ventricular [[end-diastolic volume]] ≥160 mL/m2 or [[end-systolic volume]] ≥82 mL/m2 on CMR), moderate to severe [[tricuspid valve regurgitation]], resulting from annular dilatation, [[patients]] at risk of developing [[arrythmias]] and with prolonged [[QRS]] duration (total [[QRS]] duration ≥180 msec, or QRS duration increase >3.5 msec per year and severe [[PR]] among [[patients]] with another cardiac lesion that requires operative intervention. Timing of pulmonary [[valve replacement]] is not well defined. However timely intervention is advised before the onset of [[RV dysfunction]]. Among [[patients]] with [[arrhythmias]], intraoperative electrophysiological mapping with [[cryoablation]] during [[pulmonary valve]] replacement has demonstrated promising results.


Treatment of pulmonic regurgitation may be divided into medical and surgical treatment. Medical management of pulmonic regurgitation may include use of diuretics in patients with RV dysfunction. ACE inhibitors and B blockers may be used to reverse neurohormonal activation and improve symptoms. Antibiotic prophylaxis may be indicated in certain conditions such as patients with cyanotic heart disease, prosthetic heart valves, rheumatic heart disease, and patients previously having sustained bacterial endocarditis. Surgical management of pulmonic regurgitation may include replacement of pulmonary valve. The major indications for pulmonic valve replacement may include symptomatic patients with arrythmias or NYHA class higher than II, ejection Fraction of less than 40% when assessed with CMR, patients with progressive right ventricular regurgitation(right ventricular end- diastolic volume ≥160 mL/m2 or end-systolic volume ≥82 mL/m2 on CMR), moderate to severe tricuspid valve regurgitation, resulting from annular dilation, patients at risk of developing arrythmias and with prolonged QRS duration.(total QRS duration ≥180 msec, or QRS duration increase >3.5 msec per year and severe pulmonic regurgitation in a patient with another cardiac lesion that requires operative intervention. Follow up of patients with pulmonic regurgitation requires regular echocardiographic monitoring after PVR, oral anticoagulation in patients with mechanical or bioprosthetic valves and lifelong follow up to monitor pulmonary valve morphology and RV function.
==Treatment==
==Treatment==
Treatment of pulmonic regurgitation may be divided into medical and surgical treatment:
Treatment of [[pulmonic regurgitation]] (PR) may be divided into medical and surgical treatment:
===Medical Therapy===
==Medical Therapy==
*There are no specific medical measures for management of PR.
*There are no specific medical measures for the management of [[PR]].
*Diuretics are recommended in patients with RV dysfunction for maintenance of fluid balance.
*[[Diuretics]] are recommended in patients with [[RV dysfunction]] or [[PAH]] for maintenance of fluid balance.<ref>{{cite book | last = Fauci | first = Anthony | title = Harrison's principles of internal medicine | publisher = McGraw-Hill Medical | location = New York | year = 2008 | isbn = 978-0071466332 }}</ref>
*In patients with repaired [[Tetralogy of Fallot|tetralogy of fallot]], [[ACE inhibitor|ACE inhibitors]] or [[Beta blockers|beta-blockers]] are used to reverse the neuroharmonal activation and improve the symptoms.<ref name="pmid12093776">{{cite journal| author=Bolger AP, Sharma R, Li W, Leenarts M, Kalra PR, Kemp M et al.| title=Neurohormonal activation and the chronic heart failure syndrome in adults with congenital heart disease. | journal=Circulation | year= 2002 | volume= 106 | issue= 1 | pages= 92-9 | pmid=12093776 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12093776  }} </ref><ref name="pmid12354712">{{cite journal| author=Davos CH, Davlouros PA, Wensel R, Francis D, Davies LC, Kilner PJ et al.| title=Global impairment of cardiac autonomic nervous activity late after repair of tetralogy of Fallot. | journal=Circulation | year= 2002 | volume= 106 | issue= 12 Suppl 1 | pages= I69-75 | pmid=12354712 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12354712  }} </ref>
*Among [[patients]] with repaired [[Tetralogy of Fallot|tetralogy of fallot]], [[ACE inhibitor|ACE inhibitors]] or [[Beta blockers|beta-blockers]] are used to reverse the neuroharmonal activation and improve the symptoms.<ref name="pmid12093776">{{cite journal| author=Bolger AP, Sharma R, Li W, Leenarts M, Kalra PR, Kemp M et al.| title=Neurohormonal activation and the chronic heart failure syndrome in adults with congenital heart disease. | journal=Circulation | year= 2002 | volume= 106 | issue= 1 | pages= 92-9 | pmid=12093776 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12093776  }} </ref><ref name="pmid12354712">{{cite journal| author=Davos CH, Davlouros PA, Wensel R, Francis D, Davies LC, Kilner PJ et al.| title=Global impairment of cardiac autonomic nervous activity late after repair of tetralogy of Fallot. | journal=Circulation | year= 2002 | volume= 106 | issue= 12 Suppl 1 | pages= I69-75 | pmid=12354712 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12354712  }} </ref>
'''Antiobiotic prophylaxis'''
===Antiobiotic prophylaxis===


The American Heart Association Recommendations on Prevention of [[Bacterial Endocarditis]] indicate that antibiotic prophylaxis is not necessary for pulmonic regurgitation in those patients with otherwise structurally normal pulmonic valves, particularly if there is no [[diastolic murmur]]. It should be noted, though, that those patients with the following conditions may warrant antibiotic prophylaxis:
The [[American Heart Association]] Recommendations on Prevention of [[Bacterial Endocarditis]] indicate that [[antibiotic]] [[prophylaxis]] is not necessary for [[pulmonic regurgitation]] in those patients with otherwise structurally normal [[pulmonic valves]], particularly if there is no [[diastolic murmur]]. It should be noted, though, that those patients with the following conditions may warrant antibiotic prophylaxis:<ref name="pmid15201262">{{cite journal| author=Seiler C| title=Management and follow up of prosthetic heart valves. | journal=Heart | year= 2004 | volume= 90 | issue= 7 | pages= 818-24 | pmid=15201262 | doi=10.1136/hrt.2003.025049 | pmc=1768319 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15201262  }} </ref>


#Complex [[cyanotic heart disease]]
#Complex [[cyanotic heart disease]]
#[[Prosthetic heart valves]]
#[[Prosthetic heart valves]]
#Patients with congenital heart disease and pulmonic regurgitation
#Patients with [[congenital heart disease]] and [[PR]]
#Acquired pulmonic valve regurgitation as the result of [[rheumatic heart disease]]
#Acquired [[PR]] as the result of [[rheumatic heart disease]]
#Patients with complex cyanotic heart disease
#Patients with complex [[cyanotic heart disease]]
#In patients who have previously sustained [[bacterial endocarditis]]
#In patients who have previously sustained [[bacterial endocarditis]]


*Among [[patients]] with severe acute [[PR]] due to the large duct (such as in neonatal [[Ebstein's anomaly]] or post balloon dilation of [[pulmonary stenosis]] or [[perforation]] of valvar [[pulmonary atresia]])<ref name="pmid16169376">{{cite journal |vauthors=Wald RM, Adatia I, Van Arsdell GS, Hornberger LK |title=Relation of limiting ductal patency to survival in neonatal Ebstein's anomaly |journal=Am. J. Cardiol. |volume=96 |issue=6 |pages=851–6 |date=September 2005 |pmid=16169376 |doi=10.1016/j.amjcard.2005.05.035 |url=}}</ref><ref name="pmid17569817">{{cite journal |vauthors=Chaturvedi RR, Redington AN |title=Pulmonary regurgitation in congenital heart disease |journal=Heart |volume=93 |issue=7 |pages=880–9 |date=July 2007 |pmid=17569817 |pmc=1994453 |doi=10.1136/hrt.2005.075234 |url=}}</ref>:
** If [[TR]] accompanies the situation, a circular shunt may occur leading to poor systemic blood flow. The treatment involves stopping the [[prostaglandins]] and urgent duct ligation among unstable [[patients]].
**If [[tricuspid valve]] is competent, increasing [[ventilation]], [[oxygen]], and [[nitric oxide]] to cause pulmonary [[vasodilation|vasodilatation]] can reduce [[PR]].
===Heart failure therapy===
*General measures for the treatment of [[heart failure]] include<ref name="pmid15367531">{{cite journal |vauthors=Fox DJ, Khattar RS |title=Carcinoid heart disease: presentation, diagnosis, and management |journal=Heart |volume=90 |issue=10 |pages=1224–8 |date=October 2004 |pmid=15367531 |pmc=1768473 |doi=10.1136/hrt.2004.040329 |url=}}</ref>:
**Diet:  Salt and water restriction
**Monitoring: Weight and fluid balance monitoring
**Mobility: Mobility and [[compression stockings]] help prevent the development of [[DVT|deep venous thrombosis]] and leg [[edema]].
**[[Right heart failure]]: A combination of [[loop diuretics]] and [[digoxin]] (may help with [[RV|right ventricular]] contractility). Often, loop diuretics alone are enough to achieve sufficient fluid loss, but if additional diuresis is required, the judicious coadministration of a [[Thiazide diuretic]] may be administered with loop diuretics to achieve optimal fluid balance.
*To read more about the medical therapy utilized in heart failure, [[Congestive heart failure#Treatment|click here]].
===[[Carcinoid syndrome|Carcinoid heart disease]]<ref name="pmid15367531">{{cite journal |vauthors=Fox DJ, Khattar RS |title=Carcinoid heart disease: presentation, diagnosis, and management |journal=Heart |volume=90 |issue=10 |pages=1224–8 |date=October 2004 |pmid=15367531 |pmc=1768473 |doi=10.1136/hrt.2004.040329 |url=}}</ref><ref name="pmid9156122">{{cite journal |vauthors=Janmohamed S, Bloom SR |title=Carcinoid tumours |journal=Postgrad Med J |volume=73 |issue=858 |pages=207–14 |date=April 1997 |pmid=9156122 |pmc=2431281 |doi=10.1136/pgmj.73.858.207 |url=}}</ref>===
[[Subcutaneously]] administered [[octreotide]] in 2–4 divided doses (50–1500 μg/day) provides symptomatic and [[biochemical tests|biochemical]] benefit. [[Octreotide]] ([[somatostatin analog]]) binds to [[somatostatin receptors]], and reduces the [[vasoactive peptides]] that provoke [[carcinoid syndrome]]. Concomitant monitoring of [[BSL]] and [[blood glucose levels]] is required. [[Lanreotide]] (BIM23014, [[angiopeptin]] and [[somatuline]]) is a newer [[somatostatin analog]], has an advantage of less frequent administrations, and can be used as an alternative to octreotide.
==Surgical Therapy==
==Surgical Therapy==
====Indications for Surgery====
[[Pulmonary valve]] replacement (PVR) is one of the most common procedures performed among adults with [[congenital heart disease]], due to different [[diseases]] causing [[regurgitation]] or [[stenosis]]. [[Patients]] may undergo reoperations during their lifetime.<ref name="SaremiGera2014">{{cite journal|last1=Saremi|first1=Farhood|last2=Gera|first2=Atul|last3=Yen Ho|first3=S.|last4=Hijazi|first4=Ziyad M.|last5=Sánchez-Quintana|first5=Damián|title=CT and MR Imaging of the Pulmonary Valve|journal=RadioGraphics|volume=34|issue=1|year=2014|pages=51–71|issn=0271-5333|doi=10.1148/rg.341135026}}</ref>
Indications for Pulmonary Valve Replacement include:<ref name="pmid16638542">{{cite journal| author=Geva T| title=Indications and timing of pulmonary valve replacement after tetralogy of Fallot repair. | journal=Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu | year= 2006 | volume=  | issue=  | pages= 11-22 | pmid=16638542 | doi=10.1053/j.pcsu.2006.02.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638542  }}</ref>  
 
*Symptomatic patients with [[arrythmias]] or NYHA class higher than II
===Indications for Surgery===
*Ejection Fraction of less than 40% when assessed with CMR
Indications for [[pulmonary valve]] replacement (PVR) include:<ref name="pmid16638542">{{cite journal| author=Geva T| title=Indications and timing of pulmonary valve replacement after [[tetralogy of Fallot]] repair. | journal=Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu | year= 2006 | volume=  | issue=  | pages= 11-22 | pmid=16638542 | doi=10.1053/j.pcsu.2006.02.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638542  }}</ref><ref name="WarnesWilliams2008">{{cite journal|last1=Warnes|first1=Carole A.|last2=Williams|first2=Roberta G.|last3=Bashore|first3=Thomas M.|last4=Child|first4=John S.|last5=Connolly|first5=Heidi M.|last6=Dearani|first6=Joseph A.|last7=del Nido|first7=Pedro|last8=Fasules|first8=James W.|last9=Graham|first9=Thomas P.|last10=Hijazi|first10=Ziyad M.|last11=Hunt|first11=Sharon A.|last12=King|first12=Mary Etta|last13=Landzberg|first13=Michael J.|last14=Miner|first14=Pamela D.|last15=Radford|first15=Martha J.|last16=Walsh|first16=Edward P.|last17=Webb|first17=Gary D.|title=ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Executive Summary|journal=Circulation|volume=118|issue=23|year=2008|pages=2395–2451|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.190811}}</ref><ref name="pmid17569817">{{cite journal |vauthors=Chaturvedi RR, Redington AN |title=Pulmonary regurgitation in congenital heart disease |journal=Heart |volume=93 |issue=7 |pages=880–9 |date=July 2007 |pmid=17569817 |pmc=1994453 |doi=10.1136/hrt.2005.075234 |url=}}</ref><ref name="SaremiGera2014">{{cite journal|last1=Saremi|first1=Farhood|last2=Gera|first2=Atul|last3=Yen Ho|first3=S.|last4=Hijazi|first4=Ziyad M.|last5=Sánchez-Quintana|first5=Damián|title=CT and MR Imaging of the Pulmonary Valve|journal=RadioGraphics|volume=34|issue=1|year=2014|pages=51–71|issn=0271-5333|doi=10.1148/rg.341135026}}</ref>
*Patients with progressive right ventricular regurgitation(right ventricular end- diastolic volume ≥160 mL/m2 or end-systolic volume ≥82 mL/m2 on CMR)
*Symptomatic patients with [[arrythmias]] or [[NYHA]] class higher than II.
*Moderate to severe tricuspid valve regurgitation, resulting from annular dilation
*[[Ejection fraction]] of less than 40% when assessed with [[cardiac MRI]]. Both [[right ventricle|right]] and [[left ventricle|left ventricular]] dysfunction  serve as an indication.
*Patients at risk of developing arrythmias and with prolonged [[QRS duration|QRS duration.]](total QRS duration ≥180 msec, or QRS duration increase >3.5 msec per year)
*Patients with progressive right ventricular dysfunction (right ventricular [[end-diastolic volume]] ≥160 mL/m2 or [[end-systolic volume]] ≥82 mL/m2 on CMR).
*Severe pulmonic regurgitation in a patient with another cardiac lesion that requires operative intervention
*Moderate to severe [[tricuspid regurgitation]], resulting from [[annular dilation]].
====Timing Of Surgery====
*Patients at risk of developing [[arrythmias]] and with prolonged [[QRS duration|QRS duration.]](total [[QRS complex|QRS]] duration ≥180 msec, or QRS duration increase >3.5 msec per year).
*Timing of pulmonary valve replacement is not well defined as in aortic and mitral regurgitation. However timely intervention is advised before the onset of RV dysfunction.<ref name="pmid15757612">{{cite journal| author=Therrien J, Provost Y, Merchant N, Williams W, Colman J, Webb G| title=Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair. | journal=Am J Cardiol | year= 2005 | volume= 95 | issue= 6 | pages= 779-82 | pmid=15757612 | doi=10.1016/j.amjcard.2004.11.037 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15757612  }} </ref>
*Severe [[PR]] in a [[patient]] with another cardiac lesion (such as [[RVOT]] aneurysm) that requires operative intervention.
*According to ACC/AHA guidelines, PVR is reasonable among adults with the previous [[TOF]], severe [[PR]], and any of the following:
** Moderate to severe RV dysfunction/ enlargement
** Development of symptomatic or sustained [[atrial arrhythmia|artial]] and/or [[ventricular arrhythmias]]
** Moderate to severe [[TR]]
 
===Timing Of Surgery===
*Timing of pulmonary [[valve replacement]] is not well defined as in [[aortic]] and [[mitral regurgitation]]. However timely intervention is advised before the onset of [[RV dysfunction]].<ref name="pmid15757612">{{cite journal| author=Therrien J, Provost Y, Merchant N, Williams W, Colman J, Webb G| title=Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair. | journal=Am J Cardiol | year= 2005 | volume= 95 | issue= 6 | pages= 779-82 | pmid=15757612 | doi=10.1016/j.amjcard.2004.11.037 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15757612  }} </ref>
*[[Pulmonary valve]] should be replaced before [[right ventricle|RV]] [[Diastolic dysfunction diagnostic criteria|end-diastolic volume-index]] (EDVI) exceeds 163 mL/m2 or [[right ventricle|RV]] [[end-systolic volume]] index (ESVI) exceeds 80 mL/m2. [[RV]] ESVI is the major factor to be considered.<ref name="LeeKim2012">{{cite journal|last1=Lee|first1=Cheul|last2=Kim|first2=Yang Min|last3=Lee|first3=Chang-Ha|last4=Kwak|first4=Jae Gun|last5=Park|first5=Chun Soo|last6=Song|first6=Jin Young|last7=Shim|first7=Woo-Sup|last8=Choi|first8=Eun Young|last9=Lee|first9=Sang Yun|last10=Baek|first10=Jae Suk|title=Outcomes of Pulmonary Valve Replacement in 170 Patients With Chronic Pulmonary Regurgitation After Relief of Right Ventricular Outflow Tract Obstruction|journal=Journal of the American College of Cardiology|volume=60|issue=11|year=2012|pages=1005–1014|issn=07351097|doi=10.1016/j.jacc.2012.03.077}}</ref>
*Delayed intervention has shown to have poor outcomes and higher rate of re-intervention.
*Delayed intervention has shown to have poor outcomes and higher rate of re-intervention.
*The prime goals of pulmonary valve replacement include improved functional class and quality of life, maintenance of right (and left) ventricular function, risk modification of arrhythmia and sudden cardiac death.<ref name="pmid11174741">{{cite journal| author=Discigil B, Dearani JA, Puga FJ, Schaff HV, Hagler DJ, Warnes CA et al.| title=Late pulmonary valve replacement after repair of tetralogy of Fallot. | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 121 | issue= 2 | pages= 344-51 | pmid=11174741 | doi=10.1067/mtc.2001.111209 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11174741  }} </ref>
*The prime goals of pulmonary [[valve replacement]] include improved functional class and quality of life, maintenance of right (and left) ventricular function, risk modification of [[arrhythmia]] and [[sudden cardiac death]].<ref name="pmid11174741">{{cite journal| author=Discigil B, Dearani JA, Puga FJ, Schaff HV, Hagler DJ, Warnes CA et al.| title=Late pulmonary valve replacement after repair of tetralogy of Fallot. | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 121 | issue= 2 | pages= 344-51 | pmid=11174741 | doi=10.1067/mtc.2001.111209 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11174741  }} </ref>
 
===Choice of prosthetic [[valve]]===
*'''[[Bioprosthetic valves]]''':
**Usually preferred over [[mechanical valve]] prosthesis and have a longevity of around 15years.<ref name="pmid22921969">{{cite journal| author=Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY et al.| title=Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 11 | pages= 1005-14 | pmid=22921969 | doi=10.1016/j.jacc.2012.03.077 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22921969  }} </ref><ref name="pmid22561653">{{cite journal| author=Jang W, Kim YJ, Choi K, Lim HG, Kim WH, Lee JR| title=Mid-term results of bioprosthetic pulmonary valve replacement in pulmonary regurgitation after tetralogy of Fallot repair. | journal=Eur J Cardiothorac Surg | year= 2012 | volume= 42 | issue= 1 | pages= e1-8 | pmid=22561653 | doi=10.1093/ejcts/ezs219 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22561653  }} </ref><ref name="pmid21444054">{{cite journal| author=Burchill LJ, Wald RM, Harris L, Colman JM, Silversides CK| title=Pulmonary valve replacement in adults with repaired tetralogy of Fallot. | journal=Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu | year= 2011 | volume= 14 | issue= 1 | pages= 92-7 | pmid=21444054 | doi=10.1053/j.pcsu.2011.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444054  }} </ref><ref name="pmid19764864">{{cite journal| author=Oosterhof T, Hazekamp MG, Mulder BJ| title=Opportunities in pulmonary valve replacement. | journal=Expert Rev Cardiovasc Ther | year= 2009 | volume= 7 | issue= 9 | pages= 1117-22 | pmid=19764864 | doi=10.1586/erc.09.89 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19764864  }} </ref>
**Bioprosthesis utilizes biological [[tissue]] that are usually harvested from the [[pericardium}pericardial sac]] of either cows or horses.<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 9780199654901 }}</ref>
**Do not require [[anticoagulation]].<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 9780199654901 }}</ref>
**Indications<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 9780199654901 }}</ref>: Informed [[patient]]'s desire or if there are [[contraindications]]/high risk to [[anticoagulation]].
*'''Mechanical valves''':
**Preferred among [[patients]] at high risk of reoperation such as [[patients]] with [[RV dysfunction]].<ref name="pmid16730181">{{cite journal| author=Waterbolk TW, Hoendermis ES, den Hamer IJ, Ebels T| title=Pulmonary valve replacement with a mechanical prosthesis. Promising results of 28 procedures in patients with congenital heart disease. | journal=Eur J Cardiothorac Surg | year= 2006 | volume= 30 | issue= 1 | pages= 28-32 | pmid=16730181 | doi=10.1016/j.ejcts.2006.02.069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16730181  }} </ref>
**Some of the examples include bileaflet (Carbomedics), titing disc (Medtronic-Hall), and the cage.<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 9780199654901 }}</ref>
**Require long-term [[anticoagulation]].<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 9780199654901 }}</ref>
**Indications<ref>{{cite book | last = Khavandi | first = Ali | title = Essential revision notes for the cardiology KBA | publisher = Oxford University Press | location = Oxford | year = 2014 | isbn = 9780199654901 }}</ref>: Age <65-70 years and long life expectancy, informed [[patient]]'s desire, another heart [[valve]] contains a mechanical implant, [[patient]] is on [[anticoagulation]] already or there are no [[contraindications]] to [[anticoagulation]]. Patients requiring a redo surgery are high-risk.


====Surgical Options====
===Surgical Options===
Pulmonary Valve Replacement(PVR) by surgical and percutaneous approach is the definitive treatment for the management of chronic PR and has proven to improve RV function, New York Heart Association Functional Class status, quality of life, and reduce risk for development of RV [[tachyarrhythmias]] and [[sudden cardiac death]].<ref name="pmid20837914">{{cite journal| author=Geva T, Gauvreau K, Powell AJ, Cecchin F, Rhodes J, Geva J et al.| title=Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery. | journal=Circulation | year= 2010 | volume= 122 | issue= 11 Suppl | pages= S201-8 | pmid=20837914 | doi=10.1161/CIRCULATIONAHA.110.951178 | pmc=2943672 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20837914  }} </ref>
*Pulmonary [[valve replacement]] (PVR) by surgical and [[percutaneous]] approach is the definitive treatment for the management of [[chronic PR]] and has proven to improve [[RV]] function, [[New York Heart Association]] Functional Class status, quality of life, and reduce risk for development of RV [[tachyarrhythmias]] and [[sudden cardiac death]].<ref name="pmid20837914">{{cite journal| author=Geva T, Gauvreau K, Powell AJ, Cecchin F, Rhodes J, Geva J et al.| title=Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery. | journal=Circulation | year= 2010 | volume= 122 | issue= 11 Suppl | pages= S201-8 | pmid=20837914 | doi=10.1161/CIRCULATIONAHA.110.951178 | pmc=2943672 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20837914  }} </ref>
*Surgical repair may combine [[pulmonary valve]] insertion with correction of the associated defects such as reduction of aneurysmal [[right ventricular outflow tract|RVOT]] or intraoperative [[cryoablation]].<ref name="pmid17569817">{{cite journal |vauthors=Chaturvedi RR, Redington AN |title=Pulmonary regurgitation in congenital heart disease |journal=Heart |volume=93 |issue=7 |pages=880–9 |date=July 2007 |pmid=17569817 |pmc=1994453 |doi=10.1136/hrt.2005.075234 |url=}}</ref>
*The indications for both surgical or transcatheter [[pulmonary valve]] replacement are similar.
*In the case of free [[PR]] with severe discrepancy (>35%) between right and left pulmonary blood flow, [[patients]] should undergo [[balloon dilation]], with/without an [[endoluminal stent]] implantation.<ref name="SaremiGera2014">{{cite journal|last1=Saremi|first1=Farhood|last2=Gera|first2=Atul|last3=Yen Ho|first3=S.|last4=Hijazi|first4=Ziyad M.|last5=Sánchez-Quintana|first5=Damián|title=CT and MR Imaging of the Pulmonary Valve|journal=RadioGraphics|volume=34|issue=1|year=2014|pages=51–71|issn=0271-5333|doi=10.1148/rg.341135026}}</ref>


====Surgical Valve Implantation====
====Surgical Valve Implantation====
*Various valved conduits are placed to replace the pulmonic valve which include Homografts from cadavers, valved conduits, and the Contegra bovine jugular vein graft or a bioprosthetic valve implanted directly in the RV outflow tract.<ref name="pmid11082375">{{cite journal| author=Tweddell JS, Pelech AN, Frommelt PC, Mussatto KA, Wyman JD, Fedderly RT et al.| title=Factors affecting longevity of homograft valves used in right ventricular outflow tract reconstruction for congenital heart disease. | journal=Circulation | year= 2000 | volume= 102 | issue= 19 Suppl 3 | pages= III130-5 | pmid=11082375 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11082375  }} </ref>
*Various valved conduits are placed to replace the [[pulmonic valve]] which include homografts from cadavers, valved conduits, and the contegra bovine [[jugular vein]] graft or a [[bioprosthetic valve]] implanted directly in the [[RV outflow tract]].<ref name="pmid11082375">{{cite journal| author=Tweddell JS, Pelech AN, Frommelt PC, Mussatto KA, Wyman JD, Fedderly RT et al.| title=Factors affecting longevity of homograft valves used in right ventricular outflow tract reconstruction for congenital heart disease. | journal=Circulation | year= 2000 | volume= 102 | issue= 19 Suppl 3 | pages= III130-5 | pmid=11082375 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11082375  }} </ref>
*Bioprosthetic valves are usually preffered over mechanical valve prosthesis and have a longevity of around 15years.<ref name="pmid22921969">{{cite journal| author=Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY et al.| title=Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 11 | pages= 1005-14 | pmid=22921969 | doi=10.1016/j.jacc.2012.03.077 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22921969  }} </ref><ref name="pmid22561653">{{cite journal| author=Jang W, Kim YJ, Choi K, Lim HG, Kim WH, Lee JR| title=Mid-term results of bioprosthetic pulmonary valve replacement in pulmonary regurgitation after tetralogy of Fallot repair. | journal=Eur J Cardiothorac Surg | year= 2012 | volume= 42 | issue= 1 | pages= e1-8 | pmid=22561653 | doi=10.1093/ejcts/ezs219 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22561653  }} </ref><ref name="pmid21444054">{{cite journal| author=Burchill LJ, Wald RM, Harris L, Colman JM, Silversides CK| title=Pulmonary valve replacement in adults with repaired tetralogy of Fallot. | journal=Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu | year= 2011 | volume= 14 | issue= 1 | pages= 92-7 | pmid=21444054 | doi=10.1053/j.pcsu.2011.01.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444054  }} </ref><ref name="pmid19764864">{{cite journal| author=Oosterhof T, Hazekamp MG, Mulder BJ| title=Opportunities in pulmonary valve replacement. | journal=Expert Rev Cardiovasc Ther | year= 2009 | volume= 7 | issue= 9 | pages= 1117-22 | pmid=19764864 | doi=10.1586/erc.09.89 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19764864  }} </ref>
*[[Stenosis]] of the conduit is the major limitation and 25% of [[patients]] have to undergo a repeat intervention.
*Mechanical valves are preffered in patients who are at high risk of reoperation such as patients with RV dysfunction.<ref name="pmid16730181">{{cite journal| author=Waterbolk TW, Hoendermis ES, den Hamer IJ, Ebels T| title=Pulmonary valve replacement with a mechanical prosthesis. Promising results of 28 procedures in patients with congenital heart disease. | journal=Eur J Cardiothorac Surg | year= 2006 | volume= 30 | issue= 1 | pages= 28-32 | pmid=16730181 | doi=10.1016/j.ejcts.2006.02.069 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16730181  }} </ref>
*Stenosis of the conduit is the major limitation and 25% of patients have to undergo a repeat intervention.
=====Transcatheter Pulmonary Valve Replacement=====
*The Melody transcatheter pulmonary valve(Medtronic) is approved by FDA in 2010.<ref name="pmid20644013">{{cite journal| author=McElhinney DB, Hellenbrand WE, Zahn EM, Jones TK, Cheatham JP, Lock JE et al.| title=Short- and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial. | journal=Circulation | year= 2010 | volume= 122 | issue= 5 | pages= 507-16 | pmid=20644013 | doi=10.1161/CIRCULATIONAHA.109.921692 | pmc=4240270 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20644013  }} </ref>
*The current transcatheter valves are designed to treat conduit and bioprosthetic valve failure only.<ref name="pmid19850214">{{cite journal| author=Zahn EM, Hellenbrand WE, Lock JE, McElhinney DB| title=Implantation of the melody transcatheter pulmonary valve in patients with a dysfunctional right ventricular outflow tract conduit early results from the u.s. Clinical trial. | journal=J Am Coll Cardiol | year= 2009 | volume= 54 | issue= 18 | pages= 1722-9 | pmid=19850214 | doi=10.1016/j.jacc.2009.06.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19850214  }} </ref><ref name="pmid16103239">{{cite journal| author=Khambadkone S, Coats L, Taylor A, Boudjemline Y, Derrick G, Tsang V et al.| title=Percutaneous pulmonary valve implantation in humans: results in 59 consecutive patients. | journal=Circulation | year= 2005 | volume= 112 | issue= 8 | pages= 1189-97 | pmid=16103239 | doi=10.1161/CIRCULATIONAHA.104.523266 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16103239  }} </ref><ref name="pmid19540390">{{cite journal| author=Romeih S, Kroft LJ, Bokenkamp R, Schalij MJ, Grotenhuis H, Hazekamp MG et al.| title=Delayed improvement of right ventricular diastolic function and regression of right ventricular mass after percutaneous pulmonary valve implantation in patients with congenital heart disease. | journal=Am Heart J | year= 2009 | volume= 158 | issue= 1 | pages= 40-6 | pmid=19540390 | doi=10.1016/j.ahj.2009.04.023 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19540390  }} </ref><ref name="pmid20398873">{{cite journal| author=Vezmar M, Chaturvedi R, Lee KJ, Almeida C, Manlhiot C, McCrindle BW et al.| title=Percutaneous pulmonary valve implantation in the young 2-year follow-up. | journal=JACC Cardiovasc Interv | year= 2010 | volume= 3 | issue= 4 | pages= 439-48 | pmid=20398873 | doi=10.1016/j.jcin.2010.02.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20398873  }} </ref>
*They are not useful to treat patients who had a RVOT reconstruction by transannular patching.
======Complications======
*Stent fracture:It leads to an increase in RV outflow tract gradient and RV pressure and its incidence is around 21% in 1 series that used the Melody valve and was the major reason for a repeat intervention.<ref name="pmid17339542">{{cite journal| author=Nordmeyer J, Khambadkone S, Coats L, Schievano S, Lurz P, Parenzan G et al.| title=Risk stratification, systematic classification, and anticipatory management strategies for stent fracture after percutaneous pulmonary valve implantation. | journal=Circulation | year= 2007 | volume= 115 | issue= 11 | pages= 1392-7 | pmid=17339542 | doi=10.1161/CIRCULATIONAHA.106.674259 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17339542  }} </ref><ref name="pmid18391109">{{cite journal| author=Lurz P, Coats L, Khambadkone S, Nordmeyer J, Boudjemline Y, Schievano S et al.| title=Percutaneous pulmonary valve implantation: impact of evolving technology and learning curve on clinical outcome. | journal=Circulation | year= 2008 | volume= 117 | issue= 15 | pages= 1964-72 | pmid=18391109 | doi=10.1161/CIRCULATIONAHA.107.735779 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18391109  }} </ref>
*Device instability and dislodgement<ref name="pmid18255307">{{cite journal| author=Kostolny M, Tsang V, Nordmeyer J, Van Doorn C, Frigiola A, Khambadkone S et al.| title=Rescue surgery following percutaneous pulmonary valve implantation. | journal=Eur J Cardiothorac Surg | year= 2008 | volume= 33 | issue= 4 | pages= 607-12 | pmid=18255307 | doi=10.1016/j.ejcts.2007.12.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18255307  }} </ref>
*Coronary compression due to stent placement<ref name="pmid21536996">{{cite journal| author=Feltes TF, Bacha E, Beekman RH, Cheatham JP, Feinstein JA, Gomes AS et al.| title=Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 22 | pages= 2607-52 | pmid=21536996 | doi=10.1161/CIR.0b013e31821b1f10 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21536996  }}</ref>
*Pulmonary artery obstruction


====Outcomes====
====Transcatheter Pulmonary Valve Replacement====
*Patients with percutaneous pulmonary valve replacement have good outcome and are free of reintervention at 1year.<ref name="pmid22958883">{{cite journal| author=Boudjemline Y, Brugada G, Van-Aerschot I, Patel M, Basquin A, Bonnet C et al.| title=Outcomes and safety of transcatheter pulmonary valve replacement in patients with large patched right ventricular outflow tracts. | journal=Arch Cardiovasc Dis | year= 2012 | volume= 105 | issue= 8-9 | pages= 404-13 | pmid=22958883 | doi=10.1016/j.acvd.2012.05.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22958883 }} </ref>
*The Melody transcatheter pulmonary valve (Medtronic) was approved by [[FDA]] in 2010.<ref name="pmid20644013">{{cite journal| author=McElhinney DB, Hellenbrand WE, Zahn EM, Jones TK, Cheatham JP, Lock JE et al.| title=Short- and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial. | journal=Circulation | year= 2010 | volume= 122 | issue= 5 | pages= 507-16 | pmid=20644013 | doi=10.1161/CIRCULATIONAHA.109.921692 | pmc=4240270 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20644013 }} </ref>
*Patients with CMR derived pre operative right ventricular end diastolic volume index of less than 160ml/m²  and end systolic volume index of less than 80ml/m² showed better outcomes. <ref name="pmid22921969">{{cite journal| author=Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY et al.| title=Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 11 | pages= 1005-14 | pmid=22921969 | doi=10.1016/j.jacc.2012.03.077 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22921969 }} </ref><ref name="pmid17620511">{{cite journal| author=Oosterhof T, van Straten A, Vliegen HW, Meijboom FJ, van Dijk AP, Spijkerboer AM et al.| title=Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance. | journal=Circulation | year= 2007 | volume= 116 | issue= 5 | pages= 545-51 | pmid=17620511 | doi=10.1161/CIRCULATIONAHA.106.659664 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17620511 }} </ref><ref name="pmid15028368">{{cite journal| author=Geva T, Sandweiss BM, Gauvreau K, Lock JE, Powell AJ| title=Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 6 | pages= 1068-74 | pmid=15028368 | doi=10.1016/j.jacc.2003.10.045 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15028368 }}</ref>
*The current transcatheter valves are designed to treat conduit and [[bioprosthetic valve]] failure only.<ref name="pmid19850214">{{cite journal| author=Zahn EM, Hellenbrand WE, Lock JE, McElhinney DB| title=Implantation of the melody transcatheter pulmonary valve in patients with a dysfunctional right ventricular outflow tract conduit early results from the u.s. Clinical trial. | journal=J Am Coll Cardiol | year= 2009 | volume= 54 | issue= 18 | pages= 1722-9 | pmid=19850214 | doi=10.1016/j.jacc.2009.06.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19850214 }} </ref><ref name="pmid16103239">{{cite journal| author=Khambadkone S, Coats L, Taylor A, Boudjemline Y, Derrick G, Tsang V et al.| title=Percutaneous pulmonary valve implantation in humans: results in 59 consecutive patients. | journal=Circulation | year= 2005 | volume= 112 | issue= 8 | pages= 1189-97 | pmid=16103239 | doi=10.1161/CIRCULATIONAHA.104.523266 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16103239 }} </ref><ref name="pmid19540390">{{cite journal| author=Romeih S, Kroft LJ, Bokenkamp R, Schalij MJ, Grotenhuis H, Hazekamp MG et al.| title=Delayed improvement of right ventricular diastolic function and regression of right ventricular mass after percutaneous pulmonary valve implantation in patients with congenital heart disease. | journal=Am Heart J | year= 2009 | volume= 158 | issue= 1 | pages= 40-6 | pmid=19540390 | doi=10.1016/j.ahj.2009.04.023 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19540390  }} </ref><ref name="pmid20398873">{{cite journal| author=Vezmar M, Chaturvedi R, Lee KJ, Almeida C, Manlhiot C, McCrindle BW et al.| title=Percutaneous pulmonary valve implantation in the young 2-year follow-up. | journal=JACC Cardiovasc Interv | year= 2010 | volume= 3 | issue= 4 | pages= 439-48 | pmid=20398873 | doi=10.1016/j.jcin.2010.02.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20398873 }} </ref>
*For [[transcatheter]] [[valve replacement]] eligibility, the [[morphology]] of [[RVOT]] (determined via[[CT]] or [[MRI]]) serves as the major criterion. a determination that may easily be made at [[CT]] or [[MRI]].<ref name="SaremiGera2014">{{cite journal|last1=Saremi|first1=Farhood|last2=Gera|first2=Atul|last3=Yen Ho|first3=S.|last4=Hijazi|first4=Ziyad M.|last5=Sánchez-Quintana|first5=Damián|title=CT and MR Imaging of the Pulmonary Valve|journal=RadioGraphics|volume=34|issue=1|year=2014|pages=51–71|issn=0271-5333|doi=10.1148/rg.341135026}}</ref>
*[[Contraindications]]:
**Patients with an [[aneurysm|aneurysmal]] appearance of [[RVOT]] do not qualify for transcatheter pulmonary valve implantation.<ref name="SaremiGera2014">{{cite journal|last1=Saremi|first1=Farhood|last2=Gera|first2=Atul|last3=Yen Ho|first3=S.|last4=Hijazi|first4=Ziyad M.|last5=Sánchez-Quintana|first5=Damián|title=CT and MR Imaging of the Pulmonary Valve|journal=RadioGraphics|volume=34|issue=1|year=2014|pages=51–71|issn=0271-5333|doi=10.1148/rg.341135026}}</ref>
**They are not useful to treat patients who had a [[RVOT]] reconstruction by [[Transannular interaction|transannular]] patching.


====Follow Up====
===Complications===
*All the patients should undergo a baseline transthoracic echocardiogram after PVR.<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e143-263 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677 }} </ref><ref name="pmid20801927">{{cite journal| author=Baumgartner H, Bonhoeffer P, De Groot NM, de Haan F, Deanfield JE, Galie N et al.| title=ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). | journal=Eur Heart J | year= 2010 | volume= 31 | issue= 23 | pages= 2915-57 | pmid=20801927 | doi=10.1093/eurheartj/ehq249 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20801927 }} </ref>
*Common complications of [[pulmonary regurgitation]] (PR) [[treatment]] include:
*Anticoagulation is recommended in patients with mechanical valves and aspirin for patients with bioprosthetic valves.<ref name="pmid22561653">{{cite journal| author=Jang W, Kim YJ, Choi K, Lim HG, Kim WH, Lee JR| title=Mid-term results of bioprosthetic pulmonary valve replacement in pulmonary regurgitation after tetralogy of Fallot repair. | journal=Eur J Cardiothorac Surg | year= 2012 | volume= 42 | issue= 1 | pages= e1-8 | pmid=22561653 | doi=10.1093/ejcts/ezs219 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22561653 }} </ref>
**Complications post [[pulmonic valve]] replacement (PVR) are<ref name="pmid22921969">{{cite journal |vauthors=Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY, Shim WS, Choi EY, Lee SY, Baek JS |title=Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement |journal=J. Am. Coll. Cardiol. |volume=60 |issue=11 |pages=1005–14 |date=September 2012 |pmid=22921969 |doi=10.1016/j.jacc.2012.03.077 |url=}}</ref>:
*[[Oral anticoagulation therapy|Oral anticoagulation]] in patients with [[Bioprosthetic valves|bioprosthetic valve]]<nowiki/>s is recommended only when other indications such as atrial arrhythmia or prior thromoembolic event are present.
**#[[Prosthetic valve]] failure (PVR or interventional catheter procedure is required to be redone).
*All patients are advised for a lifelong follow up to assess the valve morphology and RV systolic function.
**#[[Prosthetic valve]] dysfunction (death due to [[prosthetic valve]] dysfunction is very rare).
**#[[Atrial fibrillation]] and [[atrial flutter]] are rare complications.
**#Stent fracture: It leads to an increase in [[RVOT|RV outflow tract]] gradient and [[RV pressure]] and its incidence is around 21% in 1 series that used the Melody valve and was the major reason for a repeat intervention.<ref name="pmid17339542">{{cite journal| author=Nordmeyer J, Khambadkone S, Coats L, Schievano S, Lurz P, Parenzan G et al.| title=Risk stratification, systematic classification, and anticipatory management strategies for stent fracture after percutaneous pulmonary valve implantation. | journal=Circulation | year= 2007 | volume= 115 | issue= 11 | pages= 1392-7 | pmid=17339542 | doi=10.1161/CIRCULATIONAHA.106.674259 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17339542 }} </ref><ref name="pmid18391109">{{cite journal| author=Lurz P, Coats L, Khambadkone S, Nordmeyer J, Boudjemline Y, Schievano S et al.| title=Percutaneous pulmonary valve implantation: impact of evolving technology and learning curve on clinical outcome. | journal=Circulation | year= 2008 | volume= 117 | issue= 15 | pages= 1964-72 | pmid=18391109 | doi=10.1161/CIRCULATIONAHA.107.735779 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18391109 }} </ref>
**#Device instability and dislodgement<ref name="pmid18255307">{{cite journal| author=Kostolny M, Tsang V, Nordmeyer J, Van Doorn C, Frigiola A, Khambadkone S et al.| title=Rescue surgery following percutaneous pulmonary valve implantation. | journal=Eur J Cardiothorac Surg | year= 2008 | volume= 33 | issue= 4 | pages= 607-12 | pmid=18255307 | doi=10.1016/j.ejcts.2007.12.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18255307  }} </ref>
**#Coronary compression due to stent placement<ref name="pmid21536996">{{cite journal| author=Feltes TF, Bacha E, Beekman RH, Cheatham JP, Feinstein JA, Gomes AS et al.| title=Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 22 | pages= 2607-52 | pmid=21536996 | doi=10.1161/CIR.0b013e31821b1f10 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21536996 }}</ref>
**#[[Pulmonary artery]] obstruction.
**Complications post transcatheter [[pulmonic valve]] implantation (TPVI) are:
**#[[Infective endocarditis]] is not an uncommon complication. A few [[patients]] (such as of [[streptococcus|streptococcal infection]]) may be managed medically and surgical or [[percutaneous]] reintervention may be required for others.<ref name="AbdelghaniNassif2018">{{cite journal|last1=Abdelghani|first1=Mohammad|last2=Nassif|first2=Martina|last3=Blom|first3=Nico A.|last4=Van Mourik|first4=Martijn S.|last5=Straver|first5=Bart|last6=Koolbergen|first6=David R.|last7=Kluin|first7=Jolanda|last8=Tijssen|first8=Jan G.|last9=Mulder|first9=Barbara J. M.|last10=Bouma|first10=Berto J.|last11=de Winter|first11=Robbert J.|title=Infective Endocarditis After Melody Valve Implantation in the Pulmonary Position: A Systematic Review|journal=Journal of the American Heart Association|volume=7|issue=13|year=2018|issn=2047-9980|doi=10.1161/JAHA.117.008163}}</ref>


===Outcomes===
*Patients with [[percutaneous]] pulmonary [[valve replacement]] have good outcome and are free of reintervention at 1 year.<ref name="pmid22958883">{{cite journal| author=Boudjemline Y, Brugada G, Van-Aerschot I, Patel M, Basquin A, Bonnet C et al.| title=Outcomes and safety of transcatheter pulmonary valve replacement in patients with large patched right ventricular outflow tracts. | journal=Arch Cardiovasc Dis | year= 2012 | volume= 105 | issue= 8-9 | pages= 404-13 | pmid=22958883 | doi=10.1016/j.acvd.2012.05.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22958883  }} </ref>
*Patients with [[CMR]] derived pre operative right ventricular end diastolic volume index of less than 160ml/m²  and end systolic volume index of less than 80ml/m² showed better outcomes. <ref name="pmid22921969">{{cite journal| author=Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY et al.| title=Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 11 | pages= 1005-14 | pmid=22921969 | doi=10.1016/j.jacc.2012.03.077 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22921969  }} </ref><ref name="pmid17620511">{{cite journal| author=Oosterhof T, van Straten A, Vliegen HW, Meijboom FJ, van Dijk AP, Spijkerboer AM et al.| title=Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance. | journal=Circulation | year= 2007 | volume= 116 | issue= 5 | pages= 545-51 | pmid=17620511 | doi=10.1161/CIRCULATIONAHA.106.659664 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17620511  }} </ref><ref name="pmid15028368">{{cite journal| author=Geva T, Sandweiss BM, Gauvreau K, Lock JE, Powell AJ| title=Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging. | journal=J Am Coll Cardiol | year= 2004 | volume= 43 | issue= 6 | pages= 1068-74 | pmid=15028368 | doi=10.1016/j.jacc.2003.10.045 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15028368  }}</ref>
==Treatment of arrhythmia==
*An invasive [[Electrophysiology|electrophysiological study]] to ablate [[atrial flutter]], and map (if not ablate) [[ventricular tachycardia]] is recommended among [[patients]] with documented [[atrial flutter]] or [[ventricular tachycardia]].<ref name="pmid17569817">{{cite journal |vauthors=Chaturvedi RR, Redington AN |title=Pulmonary regurgitation in congenital heart disease |journal=Heart |volume=93 |issue=7 |pages=880–9 |date=July 2007 |pmid=17569817 |pmc=1994453 |doi=10.1136/hrt.2005.075234 |url=}}</ref>
* Before a [[patient]] reaches end­stage [[heart failure]], [[Cardiac resynchronization therapy|resynchronization therapy]] is the suggested treatment for dilated [[right ventricles]] with the [[RBBB]].<ref name="pmid17569817">{{cite journal |vauthors=Chaturvedi RR, Redington AN |title=Pulmonary regurgitation in congenital heart disease |journal=Heart |volume=93 |issue=7 |pages=880–9 |date=July 2007 |pmid=17569817 |pmc=1994453 |doi=10.1136/hrt.2005.075234 |url=}}</ref>
* Among [[patients]] with [[arrhythmias]], intraoperative electrophysiological mapping with [[cryoablation]] during [[pulmonary valve]] replacement has demonstrated promising results. Complete resolution of pre‐existing [[arrhythmias]] has been reported.<ref name="pmid11369690">{{cite journal |vauthors=Therrien J, Siu SC, Harris L, Dore A, Niwa K, Janousek J, Williams WG, Webb G, Gatzoulis MA |title=Impact of pulmonary valve replacement on arrhythmia propensity late after repair of tetralogy of Fallot |journal=Circulation |volume=103 |issue=20 |pages=2489–94 |date=May 2001 |pmid=11369690 |doi=10.1161/01.cir.103.20.2489 |url=}}</ref>


==References==
==References==

Latest revision as of 20:12, 7 August 2020

Pulmonic regurgitation Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differential diagnosis

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Electrocardiogram

Chest X-Ray

Echocardiography

Cardiac MRI

Severity Assessment

Treatment

Medical Therapy

Surgical therapy

Follow up

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2], Aysha Anwar, M.B.B.S[3], Javaria Anwer M.D.[4]

Overview

Treatment of pulmonic regurgitation (PR) may be divided into medical and surgical treatment. Medical management of PR may include use of diuretics among patients with RV dysfunction. ACE inhibitors and beta blockers may be used to reverse neurohormonal activation and improve symptoms. Antibiotic prophylaxis may be indicated in certain conditions such as patients with cyanotic heart disease, prosthetic heart valves, rheumatic heart disease, and previously sustained bacterial endocarditis. Surgical management of PR may include pulmonary valve replacement (PVR). The major indications for PVR may include symptomatic patients with arrythmias or NYHA class higher than II, an ejection fraction of less than 40% when assessed with CMR, patients with progressive right ventricular regurgitation(right ventricular end-diastolic volume ≥160 mL/m2 or end-systolic volume ≥82 mL/m2 on CMR), moderate to severe tricuspid valve regurgitation, resulting from annular dilatation, patients at risk of developing arrythmias and with prolonged QRS duration (total QRS duration ≥180 msec, or QRS duration increase >3.5 msec per year and severe PR among patients with another cardiac lesion that requires operative intervention. Timing of pulmonary valve replacement is not well defined. However timely intervention is advised before the onset of RV dysfunction. Among patients with arrhythmias, intraoperative electrophysiological mapping with cryoablation during pulmonary valve replacement has demonstrated promising results.

Treatment

Treatment of pulmonic regurgitation (PR) may be divided into medical and surgical treatment:

Medical Therapy

Antiobiotic prophylaxis

The American Heart Association Recommendations on Prevention of Bacterial Endocarditis indicate that antibiotic prophylaxis is not necessary for pulmonic regurgitation in those patients with otherwise structurally normal pulmonic valves, particularly if there is no diastolic murmur. It should be noted, though, that those patients with the following conditions may warrant antibiotic prophylaxis:[4]

  1. Complex cyanotic heart disease
  2. Prosthetic heart valves
  3. Patients with congenital heart disease and PR
  4. Acquired PR as the result of rheumatic heart disease
  5. Patients with complex cyanotic heart disease
  6. In patients who have previously sustained bacterial endocarditis

Heart failure therapy

Carcinoid heart disease[7][8]

Subcutaneously administered octreotide in 2–4 divided doses (50–1500 μg/day) provides symptomatic and biochemical benefit. Octreotide (somatostatin analog) binds to somatostatin receptors, and reduces the vasoactive peptides that provoke carcinoid syndrome. Concomitant monitoring of BSL and blood glucose levels is required. Lanreotide (BIM23014, angiopeptin and somatuline) is a newer somatostatin analog, has an advantage of less frequent administrations, and can be used as an alternative to octreotide.

Surgical Therapy

Pulmonary valve replacement (PVR) is one of the most common procedures performed among adults with congenital heart disease, due to different diseases causing regurgitation or stenosis. Patients may undergo reoperations during their lifetime.[9]

Indications for Surgery

Indications for pulmonary valve replacement (PVR) include:[10][11][6][9]

Timing Of Surgery

Choice of prosthetic valve

Surgical Options

Surgical Valve Implantation

Transcatheter Pulmonary Valve Replacement

Complications

Outcomes

  • Patients with percutaneous pulmonary valve replacement have good outcome and are free of reintervention at 1 year.[38]
  • Patients with CMR derived pre operative right ventricular end diastolic volume index of less than 160ml/m² and end systolic volume index of less than 80ml/m² showed better outcomes. [15][39][40]

Treatment of arrhythmia

References

  1. ↑ Fauci, Anthony (2008). Harrison's principles of internal medicine. New York: McGraw-Hill Medical. ISBN 978-0071466332.
  2. ↑ Bolger AP, Sharma R, Li W, Leenarts M, Kalra PR, Kemp M; et al. (2002). "Neurohormonal activation and the chronic heart failure syndrome in adults with congenital heart disease". Circulation. 106 (1): 92–9. PMID 12093776.
  3. ↑ Davos CH, Davlouros PA, Wensel R, Francis D, Davies LC, Kilner PJ; et al. (2002). "Global impairment of cardiac autonomic nervous activity late after repair of tetralogy of Fallot". Circulation. 106 (12 Suppl 1): I69–75. PMID 12354712.
  4. ↑ Seiler C (2004). "Management and follow up of prosthetic heart valves". Heart. 90 (7): 818–24. doi:10.1136/hrt.2003.025049. PMC 1768319. PMID 15201262.
  5. ↑ Wald RM, Adatia I, Van Arsdell GS, Hornberger LK (September 2005). "Relation of limiting ductal patency to survival in neonatal Ebstein's anomaly". Am. J. Cardiol. 96 (6): 851–6. doi:10.1016/j.amjcard.2005.05.035. PMID 16169376.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Chaturvedi RR, Redington AN (July 2007). "Pulmonary regurgitation in congenital heart disease". Heart. 93 (7): 880–9. doi:10.1136/hrt.2005.075234. PMC 1994453. PMID 17569817.
  7. ↑ 7.0 7.1 Fox DJ, Khattar RS (October 2004). "Carcinoid heart disease: presentation, diagnosis, and management". Heart. 90 (10): 1224–8. doi:10.1136/hrt.2004.040329. PMC 1768473. PMID 15367531.
  8. ↑ Janmohamed S, Bloom SR (April 1997). "Carcinoid tumours". Postgrad Med J. 73 (858): 207–14. doi:10.1136/pgmj.73.858.207. PMC 2431281. PMID 9156122.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Saremi, Farhood; Gera, Atul; Yen Ho, S.; Hijazi, Ziyad M.; Sánchez-Quintana, Damián (2014). "CT and MR Imaging of the Pulmonary Valve". RadioGraphics. 34 (1): 51–71. doi:10.1148/rg.341135026. ISSN 0271-5333.
  10. ↑ Geva T (2006). "Indications and timing of pulmonary valve replacement after [[tetralogy of Fallot]] repair". Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu: 11–22. doi:10.1053/j.pcsu.2006.02.009. PMID 16638542. URL–wikilink conflict (help)
  11. ↑ Warnes, Carole A.; Williams, Roberta G.; Bashore, Thomas M.; Child, John S.; Connolly, Heidi M.; Dearani, Joseph A.; del Nido, Pedro; Fasules, James W.; Graham, Thomas P.; Hijazi, Ziyad M.; Hunt, Sharon A.; King, Mary Etta; Landzberg, Michael J.; Miner, Pamela D.; Radford, Martha J.; Walsh, Edward P.; Webb, Gary D. (2008). "ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Executive Summary". Circulation. 118 (23): 2395–2451. doi:10.1161/CIRCULATIONAHA.108.190811. ISSN 0009-7322.
  12. ↑ Therrien J, Provost Y, Merchant N, Williams W, Colman J, Webb G (2005). "Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair". Am J Cardiol. 95 (6): 779–82. doi:10.1016/j.amjcard.2004.11.037. PMID 15757612.
  13. ↑ Lee, Cheul; Kim, Yang Min; Lee, Chang-Ha; Kwak, Jae Gun; Park, Chun Soo; Song, Jin Young; Shim, Woo-Sup; Choi, Eun Young; Lee, Sang Yun; Baek, Jae Suk (2012). "Outcomes of Pulmonary Valve Replacement in 170 Patients With Chronic Pulmonary Regurgitation After Relief of Right Ventricular Outflow Tract Obstruction". Journal of the American College of Cardiology. 60 (11): 1005–1014. doi:10.1016/j.jacc.2012.03.077. ISSN 0735-1097.
  14. ↑ Discigil B, Dearani JA, Puga FJ, Schaff HV, Hagler DJ, Warnes CA; et al. (2001). "Late pulmonary valve replacement after repair of tetralogy of Fallot". J Thorac Cardiovasc Surg. 121 (2): 344–51. doi:10.1067/mtc.2001.111209. PMID 11174741.
  15. ↑ 15.0 15.1 15.2 Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY; et al. (2012). "Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement". J Am Coll Cardiol. 60 (11): 1005–14. doi:10.1016/j.jacc.2012.03.077. PMID 22921969.
  16. ↑ Jang W, Kim YJ, Choi K, Lim HG, Kim WH, Lee JR (2012). "Mid-term results of bioprosthetic pulmonary valve replacement in pulmonary regurgitation after tetralogy of Fallot repair". Eur J Cardiothorac Surg. 42 (1): e1–8. doi:10.1093/ejcts/ezs219. PMID 22561653.
  17. ↑ Burchill LJ, Wald RM, Harris L, Colman JM, Silversides CK (2011). "Pulmonary valve replacement in adults with repaired tetralogy of Fallot". Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 14 (1): 92–7. doi:10.1053/j.pcsu.2011.01.016. PMID 21444054.
  18. ↑ Oosterhof T, Hazekamp MG, Mulder BJ (2009). "Opportunities in pulmonary valve replacement". Expert Rev Cardiovasc Ther. 7 (9): 1117–22. doi:10.1586/erc.09.89. PMID 19764864.
  19. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
  20. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
  21. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
  22. ↑ Waterbolk TW, Hoendermis ES, den Hamer IJ, Ebels T (2006). "Pulmonary valve replacement with a mechanical prosthesis. Promising results of 28 procedures in patients with congenital heart disease". Eur J Cardiothorac Surg. 30 (1): 28–32. doi:10.1016/j.ejcts.2006.02.069. PMID 16730181.
  23. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
  24. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
  25. ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
  26. ↑ Geva T, Gauvreau K, Powell AJ, Cecchin F, Rhodes J, Geva J; et al. (2010). "Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery". Circulation. 122 (11 Suppl): S201–8. doi:10.1161/CIRCULATIONAHA.110.951178. PMC 2943672. PMID 20837914.
  27. ↑ Tweddell JS, Pelech AN, Frommelt PC, Mussatto KA, Wyman JD, Fedderly RT; et al. (2000). "Factors affecting longevity of homograft valves used in right ventricular outflow tract reconstruction for congenital heart disease". Circulation. 102 (19 Suppl 3): III130–5. PMID 11082375.
  28. ↑ McElhinney DB, Hellenbrand WE, Zahn EM, Jones TK, Cheatham JP, Lock JE; et al. (2010). "Short- and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial". Circulation. 122 (5): 507–16. doi:10.1161/CIRCULATIONAHA.109.921692. PMC 4240270. PMID 20644013.
  29. ↑ Zahn EM, Hellenbrand WE, Lock JE, McElhinney DB (2009). "Implantation of the melody transcatheter pulmonary valve in patients with a dysfunctional right ventricular outflow tract conduit early results from the u.s. Clinical trial". J Am Coll Cardiol. 54 (18): 1722–9. doi:10.1016/j.jacc.2009.06.034. PMID 19850214.
  30. ↑ Khambadkone S, Coats L, Taylor A, Boudjemline Y, Derrick G, Tsang V; et al. (2005). "Percutaneous pulmonary valve implantation in humans: results in 59 consecutive patients". Circulation. 112 (8): 1189–97. doi:10.1161/CIRCULATIONAHA.104.523266. PMID 16103239.
  31. ↑ Romeih S, Kroft LJ, Bokenkamp R, Schalij MJ, Grotenhuis H, Hazekamp MG; et al. (2009). "Delayed improvement of right ventricular diastolic function and regression of right ventricular mass after percutaneous pulmonary valve implantation in patients with congenital heart disease". Am Heart J. 158 (1): 40–6. doi:10.1016/j.ahj.2009.04.023. PMID 19540390.
  32. ↑ Vezmar M, Chaturvedi R, Lee KJ, Almeida C, Manlhiot C, McCrindle BW; et al. (2010). "Percutaneous pulmonary valve implantation in the young 2-year follow-up". JACC Cardiovasc Interv. 3 (4): 439–48. doi:10.1016/j.jcin.2010.02.003. PMID 20398873.
  33. ↑ Nordmeyer J, Khambadkone S, Coats L, Schievano S, Lurz P, Parenzan G; et al. (2007). "Risk stratification, systematic classification, and anticipatory management strategies for stent fracture after percutaneous pulmonary valve implantation". Circulation. 115 (11): 1392–7. doi:10.1161/CIRCULATIONAHA.106.674259. PMID 17339542.
  34. ↑ Lurz P, Coats L, Khambadkone S, Nordmeyer J, Boudjemline Y, Schievano S; et al. (2008). "Percutaneous pulmonary valve implantation: impact of evolving technology and learning curve on clinical outcome". Circulation. 117 (15): 1964–72. doi:10.1161/CIRCULATIONAHA.107.735779. PMID 18391109.
  35. ↑ Kostolny M, Tsang V, Nordmeyer J, Van Doorn C, Frigiola A, Khambadkone S; et al. (2008). "Rescue surgery following percutaneous pulmonary valve implantation". Eur J Cardiothorac Surg. 33 (4): 607–12. doi:10.1016/j.ejcts.2007.12.034. PMID 18255307.
  36. ↑ Feltes TF, Bacha E, Beekman RH, Cheatham JP, Feinstein JA, Gomes AS; et al. (2011). "Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association". Circulation. 123 (22): 2607–52. doi:10.1161/CIR.0b013e31821b1f10. PMID 21536996.
  37. ↑ Abdelghani, Mohammad; Nassif, Martina; Blom, Nico A.; Van Mourik, Martijn S.; Straver, Bart; Koolbergen, David R.; Kluin, Jolanda; Tijssen, Jan G.; Mulder, Barbara J. M.; Bouma, Berto J.; de Winter, Robbert J. (2018). "Infective Endocarditis After Melody Valve Implantation in the Pulmonary Position: A Systematic Review". Journal of the American Heart Association. 7 (13). doi:10.1161/JAHA.117.008163. ISSN 2047-9980.
  38. ↑ Boudjemline Y, Brugada G, Van-Aerschot I, Patel M, Basquin A, Bonnet C; et al. (2012). "Outcomes and safety of transcatheter pulmonary valve replacement in patients with large patched right ventricular outflow tracts". Arch Cardiovasc Dis. 105 (8–9): 404–13. doi:10.1016/j.acvd.2012.05.002. PMID 22958883.
  39. ↑ Oosterhof T, van Straten A, Vliegen HW, Meijboom FJ, van Dijk AP, Spijkerboer AM; et al. (2007). "Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance". Circulation. 116 (5): 545–51. doi:10.1161/CIRCULATIONAHA.106.659664. PMID 17620511.
  40. ↑ Geva T, Sandweiss BM, Gauvreau K, Lock JE, Powell AJ (2004). "Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging". J Am Coll Cardiol. 43 (6): 1068–74. doi:10.1016/j.jacc.2003.10.045. PMID 15028368.
  41. ↑ Therrien J, Siu SC, Harris L, Dore A, Niwa K, Janousek J, Williams WG, Webb G, Gatzoulis MA (May 2001). "Impact of pulmonary valve replacement on arrhythmia propensity late after repair of tetralogy of Fallot". Circulation. 103 (20): 2489–94. doi:10.1161/01.cir.103.20.2489. PMID 11369690.

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