Pulmonic regurgitation treatment
|
Pulmonic regurgitation Microchapters |
|
Diagnosis |
|---|
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
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.[1][2] 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.[3] 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.[4]
Treatment
Treatment of pulmonic regurgitation may be divided into medical and surgical treatment:
Medical Therapy
- There are no specific medical measures for management of PR.
- Diuretics are recommended in patients with RV dysfunction for maintenance of fluid balance.
- In patients with repaired tetralogy of fallot, ACE inhibitors or beta-blockers are used to reverse the neuroharmonal activation and improve the symptoms.[1][2]
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:
- Complex cyanotic heart disease
- Prosthetic heart valves
- Patients with congenital heart disease and pulmonic regurgitation
- Acquired pulmonic valve regurgitation as the result of rheumatic heart disease
- Patients with complex cyanotic heart disease
- In patients who have previously sustained bacterial endocarditis
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.[5]
Indications for Surgery
Indications for pulmonary valve replacement (PVR) include:[3][6][7][5]
- Symptomatic patients with arrythmias or NYHA class higher than II.
- Ejection fraction of less than 40% when assessed with cardiac MRI. Both right and left ventricular dysfunction serve as an indication.
- Patients with progressive right ventricular dysfunction (right ventricular end-diastolic volume ≥160 mL/m2 or end-systolic volume ≥82 mL/m2 on CMR).
- Moderate to severe tricuspid 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 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 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.[8]
- Pulmonary valve should be replaced before RV end-diastolic volume-index (EDVI) exceeds 163 mL/m2 or RV end-systolic volume index (ESVI) exceeds 80 mL/m2. RV ESVI is the major factor to be considered.[9]
- 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.[10]
Choice of prosthetic valve
- Bioprosthetic valves:
- Usually preferred over mechanical valve prosthesis and have a longevity of around 15years.[11][12][13][14]
- Bioprosthesis utilizes biological tissue that are usually harvested from the [[pericardium}pericardial sac]] of either cows or horses.[15]
- Do not require anticoagulation.[16]
- Indications[17]: 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.[18]
- Some of the examples include bileaflet (Carbomedics), titing disc (Medtronic-Hall), and the cage.[19]
- Require long-term anticoagulation.[20]
- Indications[21]: 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
- 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.[22]
- Surgical repair may combine pulmonary valve insertion with correction of the associated defects such as reduction of aneurysmal RVOT or intraoperative cryoablation.[7]
- 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.[5]
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.[23]
- 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) was approved by FDA in 2010.[24]
- The current transcatheter valves are designed to treat conduit and bioprosthetic valve failure only.[25][26][27][28]
- For transcatheter valve replacement eligibility, the morphology of RVOT (determined viaCT or MRI) serves as the major criterion. a determination that may easily be made at CT or MRI.[5]
- Contraindications:
- Patients with an aneurysmal appearance of RVOT do not qualify for transcatheter pulmonary valve implantation.[5]
- They are not useful to treat patients who had a RVOT reconstruction by transannular patching.
Complications
- Common complications of pulmonary regurgitation (PR) treatment include:
- Complications post pulmonic valve replacement (PVR) are[11]:
- Prosthetic valve failure (PVR or interventional catheter procedure is required to be redone).
- 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 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.[29][30]
- Device instability and dislodgement[31]
- Coronary compression due to stent placement[32]
- Pulmonary artery obstruction.
- Complications post transcatheter pulmonic valve implantation (TPVI) are:
- Infective endocarditis is not an uncommon complication. A few patients (such as of streptococcal infection) may be managed medically and surgical or percutaneous reintervention may be required for others.[33]
- Complications post pulmonic valve replacement (PVR) are[11]:
Outcomes
- Patients with percutaneous pulmonary valve replacement have good outcome and are free of reintervention at 1 year.[34]
- 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. [11][35][36]
Treatment of arrhythmia
- An invasive electrophysiological study to ablate atrial flutter, and map (if not ablate) ventricular tachycardia is recommended among patients with documented atrial flutter or ventricular tachycardia.[7]
- Before a patient reaches endstage heart failure, resynchronization therapy is the suggested treatment for dilated right ventricles with the RBBB.[7]
- 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.[37]
References
- ↑ 1.0 1.1 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.
- ↑ 2.0 2.1 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.
- ↑ 3.0 3.1 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.
- ↑ Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "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". J Am Coll Cardiol. 52 (23): e143–263. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.
- ↑ 5.0 5.1 5.2 5.3 5.4 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.
- ↑ 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.
- ↑ 7.0 7.1 7.2 7.3 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 11.0 11.1 11.2 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
- ↑ 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.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 9780199654901.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.