RVOTO adult and post-op
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1 Right ventricular outflow tract obstruction in the adult: native and post-op Helmut Baumgartner Westfälische Wilhelms-Universität Münster Adult Congenital and Valvular Heart Disease Center University of Muenster Germany Morphology - level of obstruction - subinfundibular (double chambered RV) - infundibular - valvular - supravalvular / peripheral - combinations - conduit Hemodynamics - RVOTO (gradient) - PR grading - TR grading / TR velocity / RVP RV size, RVH, RVF RA / IVC / PA Associated lesions (VSD, ASD...)
2 Limited evaluation of RVOT/PA morphology due to poor image quality Limited evaluation of RVOT/PA morphology due to poor image quality CMR (CT) Limited evaluation of RVOT/PA morphology due to poor image quality CMR (CT) Limitations of RVOT gradient estimation - Doppler angle (underestimation) - Pressure recovery (overestimation)
3 Limited evaluation of RVOT/PA morphology due to poor image quality CMR (CT) Limitations of RVOT gradient estimation - Doppler angle (underestimation) - Pressure recovery (overestimation) RVP (TR-velocity) Limited evaluation of RVOT/PA morphology due to poor image quality CMR (CT) Limitations of RVOT gradient estimation - Doppler angle (underestimation) - Pressure recovery (overestimation) RVP (TR-velocity) catheterization Limited evaluation of RVOT/PA morphology due to poor image quality CMR (CT) Limitations of RVOT gradient estimation - Doppler angle (underestimation) - Pressure recovery (overestimation) RVP (TR-velocity) catheterization Assessment of RV volumes and function by echocardiography still limited
4 Limited evaluation of RVOT/PA morphology due to poor image quality CMR (CT) Limitations of RVOT gradient estimation - Doppler angle (underestimation) - Pressure recovery (overestimation) RVP (TR-velocity) catheterization Assessment of RV volumes and function by echocardiography still limited CMR Valvular Pulmonic Stenosis
5 PV Valvular Pulmonic Stenosis Grading Mild Moderate Severe Peak vel (m/s) Peak grad (mmhg) <3 3-4 >4 < >60 68mmHg TR 90mmHg RVOT Obstruction INDICATIONS FOR INTERVENTION ESC Guidelines 2010 Symptoms: PG / MG >50/>30 mmhg Less than moderate PR Baumgartner H et al Eur Heart J 2010 No Symptoms: PG / MG >60/>40 mmhg and less than moderate PR RVOT Obstruction INDICATIONS FOR INTERVENTION ESC Guidelines 2010?? Intervention in the presence of ASD, VSD, and/or arrhythmias may be indicated?class / Level? Baumgartner H et al Eur Heart J 2010
6 Female, 53 years Female, 53 years Male, 62 years Restrictive VSD
7 Male, 62 years Restrictive VSD Double chambered right ventricle Invasive RVP inflow 105/0-8mmHg, Gradient 68mmHg RVOTO - Stenoses in series Fixed subv. AS Dynamic subv. AS Gradient Calculation by CW-Doppler BERNOULLI EQUATION p 1 p 2 = 1 ( 2 v 2 2 dv 2 v 1 ) + ds + R μ, v dt Convective acceleration p = 1 2 ( ( p = v 2 v 1 p = 4 v 2 1 Flow acceleration 2 2 v 2 v 1 ) ( ) Viscous friction ) V 1 : subv. velocity (LVOT) 1m/s
8 Pressure Recovery Pressure recovery in RVOTO: - Stenoses in series - Long, tubular stenoses - Hypoplastic PA Pulmonary Artery Stenoses
9 Complex CHD with RVOT repair Residual / recurrent stenosis Pulmonary regurgitation Conduit - non-valved - homograft - xenograft (Contegra ) Tetralogy of Fallot Severe PR after ToF repair assessment of pulmonary regurgitation (grading) RVOT morphology RV volumes RV function (EF) TR (velocity, grading additional lesions (VSD, peri.ps, AR, Ao) LV
10 Grading of PR after ToF repair Grading of PR after ToF repair Measurement of regurtitant volume and regurgitant fraction Severe PR after ToF repair
11 Severe PR after ToF repair: RV volume/function Tetralogy of Fallot After Repair Severe PR Timing of Intervention RV LV RV LV Prior to PVR After PVR Pulmonary Regurgitation after TOF Repair Response of the RV to valve replacement Oosterhof Th et al Circulation. 2007;116:
12 Indications for Intervention After Repair of Tetralogy of Fallot Class a Level b Aortic valve replacement should be performed in patients with severe AR with symptoms or signs of LV dysfunction I C PVRep should be performed in symptomatic patients with severe PR and/or stenosis (RV systolic pressure > 60 mmhg, TR velocity > 3.5 m/sec) I C PVRep should be considered in asymptomatic patients with severe PR and/or PS when at least one of the following criteria is present: decrease in objective exercise capacity (CPET) progressive RV dilation progressive RV systolic dysfunction progressive TR (at least moderate) RVOTO with RV systolic pressure > 80 mmhg (TR velocity > 4.3 m/sec) sustained atrial/ventricular arrhythmias IIa C VSD closure should be considered in patients with residual VSD and significant LV volume overload or if the patient is undergoing pulmonary valve surgery IIa c Baumgartner H et al Eur Heart J 2010 Male, 65 yrs ToF, repair 1982 re-op for VSD Female, 22 yrs ToF, repair+contegra 2002
13 Male, 16 yrs ToF, repair 1995, re-op 1998 homograft 21mm 2000 Male, 16 yrs ToF, repair 1995, re-op 1998 homograft 21mm 2000 Male, 16 yrs ToF, repair 1995, re-op 1998 homograft 21mm
14 Male, 16 yrs ToF, repair 1995, re-op 1998 homograft 21mm 2000 Male, 16 yrs ToF, repair 1995, re-op 1998 homograft 21mm 2000 Male, 16 yrs ToF, repair 1995, re-op 1998 homograft 21mm 2000
15 Thank you for your attention!
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