TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT HEART

Transcription

1 TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT HEART Dr Aphrodite Tzifa, MD(Res), FRCPCH Director, Paediatric and GUCH Cardiologist, Mitera Children's Hospital, Athens, Greece September 10, 2003

2 FAILURE OF RIGHT HEART VALVES CONGENITAL S/P Tetralogy of Fallot repair with conduit stenosis S/P Fallot / pulmonary atresia repair with conduit stensois Truncus arteriosus / Conduit obstruction TGA post switch with PS etc. STRUCTURAL Stenosis of TV bioprosthetic valve Stensosis of PV bioprosthetic valve

3 TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia or other significant respiratory problems Syndromes Other predisposing factors for a complicated post-op course

4 Criteria for re-intervention Συμπτωματικοί ασθενείς / peak VO2 < 60% Ασυμπτωματικοί ασθενείς με 2 ή > από τα παρακάτω κριτήρια Progressive volumetric changes on MRI RVEDv > 160ml/kg/m2 or RV/LV EDV>2 RV ESv> 80ml/kg/m2 RV EF< 47% LV EF< 55% QRS> 140ms Arrhythmias (1/3 to ½ of deaths in adult ToFs are sudden and 100% of those with sudden death had > moderate PR)

5 TRANSCATHETER PPVI COURSE OF APPROVAL FOR TRANSCATHETER VALVE IMPLANTATION Patient clinical details letter with justification against surgery Supporting documents: Cardiac MRI Cardiac cath Exercise testing with MVO2 24hr tape

6 IMPLANTATION IN THE RIGHT HEART 1. MELODY VALVE (requires a conduit or bioprosthetic valve) 2. EDWARDS VALVE (26mm, 29mm XT): (requires a conduit or bioprosthetic valve) 3. VENOUS P VALVE

7 Melody valve Valved segment of bovine jugular vein sewn within a balloon-expandable stent. Used in patients with operated congenital heart disease with pulmonary regurgitation, RVOT obstruction or both > 8500 implants worldwide!

8 Edwards valve 700 valve implantations worldwide Available in 23-29mm Diameters Short stent. Landing zone with prestenting is vital

9 Venous P valve Nitinol self expandable multi-level support frame Integrated trileaflet porcine pericardial tissue valve On clinical trial: Europe, Asia Can be implanted in native RVOT with transannular patch Available up to 32mm diameter

10 PPVI IN THE PULMONARY POSITION

11 US MELODY VALVE TRIAL Tetralogy of Fallot 65 (48) Pulmonary atresia 40 Pulmonary stenosis 19 Absent pulmonary valve 5 Atrioventricular canal 1 Ross operation 28 (21) TGA 15 (11) Truncus arteriosus 14 (10) Double-outlet right ventricle 8 (6) Valvar pulmonary stenosis 3 (2) Other 2 (1) McElhinney et al. Short- and Medium-Term Outcomes After Transcatheter Pulmonary Valve Placement in the Expanded Multicenter US Melody Valve Trial. Circulation 2011

12 Approved Melody use (INSIDE RV-PA conduits)

13 Approved Melody use (pulmonary homograft)

14 Off label Melody use (in native RVOT with or without pericardial, bovine or PTFE transannular patch) - jilkjlkj

15 PV preimplantation assessment

16 PV preimplantation assessment

17 PV preimplantation assessment

18 Criteria for re-intervention Other factors Available access Size of RVOT Shape of RVOT Location / angulations / underlying diagnosis

19 Not too big. Not too small.

20 RVOT shape

21 Location Relationships with neighboring structures co-existing problems

22 Assessment of RVOT relationship with coronaries

23 Test occlusion of RVOT with simultaneous coronary angiogram

24 Test occlusion of RVOT with LCA occlusion

25 Cardiac catheterisation

26 Cardiac catheterisation

27 Prestenting: 1. CP stents, 2. Intrastents EV3, Genesis stents

28 Stenting long conduit stenosis

29 Short landing zone - risky for Melody

30 Large RVOT Venous P valve

31 Pulmonary BD during pre-assessment

32 IMPLANTATION IN THE TRICUSPID POSITION

33 Transcatheter replacement of TV with Melody or Edwards valve Replacement within bioprosthetic valves Indicated for severe TS or TR or mixed disease Patients with ascites / peripheral oedemas SOB Good functional result Resolution of ascites NYHA II-III to I-II

34 Melody in TV (previous Edwards Perimount 25mm)

35 Melody in tricuspid valve (Edwards 25mm)

36 Tzifa et al Eurointervention 2013 Edwards in TV

37 Transcatheter Tricuspid Valve-in-Valve Implantation for the Treatment of Dysfunctional Surgical Bioprosthetic Valves: An International, Multicenter Registry Study 152 patients: 150/152 technically successful 22 deaths at F/U (5 within 30d) 77% were NYHA I-II at F/U (functional improvement) Mc Elhinney et al. Circulation 2016

38 Endocarditis SBE occurring in 4-16% of the population as compared to 2% in the surgical group Heart 2015: Infective endocarditis of a transcatheter pulmonary valve in comparison with surgical implants : Melody vs Contegra vs Homografts 7.5% of Melodies, 20% of Contegra, 2.4 % of homografts present with SBE and when vegetations cause obstructions the mortality is very high M Gewillig. Heart 2015

39 Conclusions Transcatheter valve therapy for patients with congenital heart disease has revolutionised their management Timely recognition will pick-up the patients with significant RVOT stenosis or regurgitation before the onset of right heart failure Key to the success is the patient preparation and the availability of a specialist team consisting of Radiologists, Cardiologists, Anaesthetists and Surgeons with expertise in the management of congenital patients

40 Thank you