Percutaneous pulmonary valve replacement after different duration of free pulmonary regurgitation in a porcine model: effects on the right ventricle
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1 Percutaneous pulmonary valve replacement after different duration of free pulmonary regurgitation in a porcine model: effects on the right ventricle Mads Ersboll a, Niels Vejlstrup a, Jens Christian Nilsson a, Jesper Kjaergaard a, Wendy Norman b, Theis Lange d, Andrew Taylor b,c, Philipp Bonhoeffer b,c and Lars Sondergaard a a The Heart Centre, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark b Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom c UCL Institute of Child Health, London, United Kingdom d Department of Biostatistics, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
2 Presenter Disclosure Information Mads Ersboell, MD Percutaneous pulmonary valve replacement after different duration of free pulmonary regurgitation in a porcine model: effects on the right ventricle DISCLOSURE INFORMATION: No Disclosures
3 Background Free Pulmonary regurgitation after corrected Tetralogy of Fallot Progressive RV dilatation Excercise intolerance Arrythmias Pulmonary valve replacement Need for multiple procedures Longevity of conduit Child growth Irreversible RV failure
4 Study aims Effects of free PR on RV volumes over time Right ventricular end diastolic volume index (ml/m 2 ) Right ventricular end systolic volume index (ml/m 2 ) Remodeling of RV after pulmonary valve replacement Predictors of response to pulmonary valve replacement
5 Study design 44 farm pigs (8-9 weeks old, 13.5 kg) Divided into 4 groups (A,B,C,D) A,B & C: Free PR from bare metal stent in Pulmonary annulus (CP, Numed) D: Control with no intervention
6 Free PR by insertion of CP stent
7 Study design Group A,B & C Percutaneous pulmonary valve replacement after 1,2 & 3 months respectively (Melody, Medtronic) RV adaptation 1 month after pulmonary valve replacement
8 Implantation of Melody stent valve
9 Study design MRI & RV cath in group A,B & C Before PR Before pulmonary valve replacement After 1 month with valve MRI & RV cath in group D Baseline as well as 1,2,3 & 4 months
10 MRI Control after 3 months Free PR after 3 months
11 MRI 3 months free PR prior to PPVR Same animal 1 month after PPVR
12 Study design Group A Free PR PPVR Group B Free PR PPVR Group C Free PR PPVR Control
13 Effects of pulmonary regurgitation RVEDV index kg 24.6 kg 42.6 kg 60.8 kg 82.6 kg 300 RVEDV index (ml/m2) Sham operated control 3 month free PR 2 month free PR 1 month free PR Months
14 Effects of pulmonary regurgitation 140 RVESV index 120 RVESV index (ml/m2) Sham operated control 3 month free PR 2 month free PR 1 month free PR Months
15 Effects of pulmonary valve replacement 350 RVEDV index 300 RVEDV index (ml/m2) Sham operated control 3 month free PR 2 month free PR 1 month free PR Months
16 Effects of pulmonary valve replacement RVESV index RVESV index (ml/m2) Sham operated control 3 month free PR 2 month free PR 1 month free PR Months
17 Results RV volumes increased significantly during PR Response defined as decrease in RV volumes was found in all animals after 1 month treatment with PPVR. Significant variation in magnitude of response to treatment was observed.
18 Results Predictor of RV volumes 1 month after pulmonary valve replacement RV volume increase from baseline to valve replacement (p<0.001, R 2 =0.80) No predictive value Duration of PR Pulmonary regurgitant fraction RV & PA pressure Porcine Brain Natriuretic Peptide Degree of tricuspid regurgitation
19 Probability of full recovery Probability of full recovery and RV dilatation during free PR Full RV recovery after pulmonary valve replacement was defined as: RV EDVi and RV ESVi upper 2SD value of control animals. Full recovery was modeled as a function of increase in RV volume index during PR 350 RV ESV index RV EDV index Change in RV volume index from baseline to PPVR (ml/m 2 )
20 Limitations Short duration of PR compared to ToF 1. Rapid growth to adolescent/adult size RV non-restrictive at induction of PR No VSD patch or scarring of RVOT 2. Compliant RV amplify the response to volume overloading 3. Pure model of PR without fibrosis * Smith J, et al, Myocardial hypertrophy after pulmonary regurgitation and valve implantation in pigs, Int J Cardiol(2011), doi: /j.ijcard
21 Conclusion The model produces free PR with severe RV dilatation and absence of fibrosis. RV dilatation was succesfully reverted with PPVR in all animals. RV dilatation during PR was the only predictor of RV volume after pulmonary valve replacement. Full recovery of RV volume was only dependent on RV dilatation during PR. No other markers of pending RV failure could be identified.
22 Perspective Confirmation of retrospective data indicating point of no return of RV dilatation* RV dilatation without concomitant fibrosis is predictive in itself of full recovery after pulmonary valve replacement. Serial monitoring of RV function with MRI after ToF repair with trans annular patch. Oosterhof T, et al. Circulation jul;116(5): Vliegen HW, et al. Circulation sep;106(13): Therrien J, et al. Am J Cardiol mar 15;95(6):
23 Thank you
24 No difference in amount of fibrosis Control animal 3 months free PR Smith J, et al, Myocardial hypertrophy after pulmonary regurgitation and valve implantation in pigs, Int J Cardiol(2011), doi: /j.ijcard
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