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Cardiology
Transcatheter Pulmonary Valve Replacement (TPVR) An Evolving Technique and Technology in Tre
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
9 sections · 114 slides
Overview
- Scope of this presentation
Background and history
- Congenital lesions affecting the outflow tract
- Surgical options for the outflow tract
- Modes of failure of the repaired outflow tract
- Rationale for transcatheter replacement
- First-in-human implantation in 2000
- Evolution of percutaneous pulmonary valve technology
- Expansion from conduits to native outflow tracts
Outflow tract pathophysiology
- Consequences of chronic RVOT dysfunction
- Conduit degeneration and pressure overload
- Transannular patch and volume overload
- Ventricular interaction and left heart effects
- Determinants of right ventricular dysfunction after tetralogy repair
Imaging and the landing zone
- Imaging modalities before tPVR
- Strengths and limitations of CMR
- Four-dimensional flow cardiovascular magnetic resonance
- Role of cardiovascular computed tomography
- Right ventricular outflow tract morphological types
- Anatomical variations of the native outflow tract
- Definition of the landing zone
- Landing zone options
- Assessment of native and patched outflow tracts
- Virtual valve placement within a three-dimensional dataset
- Perimeter plots and device fit
- Perimeter plots of the outflow tract landing zone
- Assessment of conduits and bioprosthetic valves
- Assessment of coronary artery course
Indications and timing
- Aims of managing the dysfunctional outflow tract
- Basis of the published guidelines
- Summarizes Criteria to Identify Indications for Pulmonary Valve Replacement
- Common thresholds across the guidelines
- Timing in asymptomatic young adults
- Timing in children
- Right ventricular volume thresholds for remodelling
- Right ventricular ejection fraction as a predictor
- Mixed pathology and multidisciplinary decision-making
- QRS duration and arrhythmic risk
- QRS fragmentation
- Exercise capacity and peak oxygen consumption
- Integrating the timing decision
Transcatheter pulmonary valve technologies
- Two device families
- Valve types available for percutaneous pulmonary implantation
- Transcatheter pulmonary valve frames
- Melody valve construction
- Melody valve sizes and delivery
- Sapien valve construction
- Sapien XT compared with Sapien 3
- Medtronic Harmony valve
- Harmony TPV 22 and TPV 25
- Pulsta valve
- Pulsta delivery and early experience
- Venus P-valve
- Venus P-valve delivery and first implantation
- Meril Myval
- Myval delivery system and dog-bone configuration
- Med-Zenith PT-Valve
- Edwards Alterra adaptive prestent
- Alterra dimensions and deployment
- Current Available Transcatheter Pulmonary Valve and Comparison of Each Valve
The procedure
- Procedural sequence
- Pre-procedure evaluation
- Anaesthesia, prophylaxis and access
- Haemodynamic assessment
- Angiography and balloon sizing
- Coronary compression test
- Limitations of the balloon compression test
- Wire exchange and conduit preparation
- Indications for prestenting
- Stents used for landing zone preparation
- Balloon-expandable valve implantation
- Self-expanding valve implantation
- Confirming the result
- Self-expanding valve implantation in an aneurysmal outflow tract
- Post-procedure care
- Antiplatelet therapy after implantation
Complications
- Overall acute adverse events
- Coronary artery compression
- Ventricular arrhythmias after implantation
- Conduit rupture
- Infective endocarditis after tPVR
- Risk factors for endocarditis
- Endocarditis by valve and conduit type
- Endocarditis risk: Melody compared with Sapien
- Prevention of infective endocarditis
- Stent fracture after Melody implantation
- Prestenting and reintervention
- Stent fracture with other platforms
Outcomes and future directions
- Early and short-term outcomes
- Residual gradient and outcome
- Registry outcomes at eight years
- Reintervention in the registry cohort
- Transcatheter compared with surgical valve replacement
- Outcomes with self-expanding valves
- Heart valve tissue engineering
- Conclusions
- Key numbers to remember
- References
- References (continued)
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- References (continued)
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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