Pulmonary regurgitation surgical therapy

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Pulmonic regurgitation Microchapters

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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]

Overview

Surgical management of pulmonic regurgitation may include pulmonary valve replacement. 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.[1]

Surgical therapy

Indications for Surgery

Indications for Pulmonary Valve Replacement include:[1]

  • 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)
  • Severe pulmonic regurgitation in a patient with another cardiac lesion that requires operative intervention

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.[2]
  • 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.[3]

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.[4]

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.[5]
  • Bioprosthetic valves are usually preffered over mechanical valve prosthesis and have a longevity of around 15years.[6][7][8][9]
  • Mechanical valves are preffered in patients who are at high risk of reoperation such as patients with RV dysfunction.[10]
  • 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.[11]
  • The current transcatheter valves are designed to treat conduit and bioprosthetic valve failure only.[12][13][14][15]
  • 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.[16][17]
  • Device instability and dislodgement[18]
  • Coronary compression due to stent placement[19]
  • Pulmonary artery obstruction

Outcomes

  • Patients with percutaneous pulmonary valve replacement have good outcome and are free of reintervention at 1year.[20]
  • 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. [6][21][22]


References

  1. ↑ 1.0 1.1 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)
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 6.0 6.1 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ 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.

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