Bail out use of the gore excluder following pulmonary conduit rupture during transcatheter pulmonary valve replacement

Predictors and outcomes of right ventricular outflow tract conduit rupture during percutaneous pulmonary valve implantation: a multicentre study

AIMS

Conduit rupture is a serious complication encountered during percutaneous pulmonary valve implantation (PPVI). We sought to evaluate the incidence and predictors of conduit rupture during right ventricular outflow tract (RVOT) transcatheter treatment.

METHODS AND RESULTS

All consecutive patients who underwent transcatheter RVOT treatment from May 2008 to December 2011 were prospectively studied. Baseline demographics along with incidence, predictors and outcomes of conduit rupture with various transcatheter therapies were reviewed. Conduit rupture occurred in nine out of 99 patients (9.09%). All conduit ruptures occurred during balloon dilatation. Significant risk factors included heavy calcification (p<0.05, OR=16 [1.87-357]), and conduit type (homograft/others; p<0.05, OR=4.37 [1.1-17.8]). Other factors such as prolonged time interval between prior surgical RVOT repair and interventions, use of high-pressure balloons, balloon diameter, and overexpansion of conduit statistically failed to show any association. All patients were managed in the cardiac catheterisation laboratory. There were no delayed complications during a mean follow-up period of 2.3±0.95 years.

CONCLUSIONS

Conduit rupture is a serious complication. Heavy calcification and homograft conduit were significant predictors. Immediate diagnosis with the use of targeted interventional therapies should be attempted before proceeding with PPVI.

Resolution of inferior venous baffle leak and total venous occlusion using a bare stent and the gore(®) excluder( ®) aortic extension in transposition of the great arteries after mustard procedure

We present a patient with a history of Mustard repair for transposition of the great arteries. The patient presented with complete inferior venous baffle obstruction and a large baffle leak after several years of cyanosis. Complete relief of the obstruction and exclusion of the baffle leak were accomplished with the use of a combination of bare metal stenting and the Gore(®) Excluder(®) aortic extender. To our knowledge, this represents the first reported use of the Gore(®) Excluder(®) aortic extender in the setting of inferior venous baffle leak and associated total inferior vena cava obstruction. © 2015 Wiley Periodicals, Inc.

Iatrogenic aortopulmonary communications after transcatheter interventions on the right ventricular outflow tract or pulmonary artery: Pathophysiologic, diagnostic, and management considerations

OBJECTIVES

To investigate the spectrum, etiology, and management of traumatic aortopulmonary (AP) communications after transcatheter interventions on the pulmonary circulation.

BACKGROUND

An iatrogenic AP communication is an unusual complication after balloon pulmonary artery (PA) angioplasty or stenting, or transcatheter pulmonary valve replacement (TPVR). However, with the increasing application of transcatheter therapies for postoperative PA stenosis and right ventricular outflow tract (RVOT) dysfunction, including percutaneous pulmonary valve replacement, consideration of the etiology, diagnosis, and management of this problem is important for interventional cardiologists performing such procedures.

METHODS AND RESULTS

We present three new cases, as well as gross anatomy and histopathology data, related to AP communications after PA interventions. We also review the literature relevant to this topic. Including these new cases, there have been 18 reported cases of iatrogenic AP communication after transcatheter interventions on the PAs or RVOT, primarily patients with transposition of the great arteries who underwent PA angioplasty after an arterial switch operation, or after TPVR in patients who had undergone a Ross procedure. The likely cause of such defects is PA trauma plus distortion of the neo-aortic anastomosis resulting from angioplasty or stenting of the RVOT or central PAs, with subsequent dissection through the extravascular connective tissue and into the closely adjacent vessel through the devitalized tissue at the anastomosis.

CONCLUSIONS

Cardiologists performing PA or RVOT interventions should be aware of the possibility of a traumatic AP communication and consider this diagnosis when confronted with suggestive signs and symptoms.

Transcatheter pulmonary valve replacement

Transcatheter pulmonary valve replacement (tPVR) has evolved into a viable alternative to surgical conduit or bioprosthetic valve replacement. This procedure has paved the way for a more advanced approach to congenital and structural interventional cardiology. Although many successes have been noted, there are still a number of challenges with this procedure, including large delivery systems, the need for a conduit or a bioprosthetic valve as a landing zone for the valve, optimal timing of the procedure to prevent right ventricular failure, arrhythmias, and possible death. Research is ongoing to broaden the use of this technology when treating patients with dilated right ventricular outflow tracts, and early experience with a self-expanding valve model has been reported. Affordability is an important factor that must be considered especially in developing nations. The aim of this review is to emphasize the advancement of tPVR, the benefits and challenges of valve implantation, the current state, and the future innovations associated with this approach.