Impact of Right-Sided-Catheter-Based Valve Implantation on Decision-Making in Congenital Heart Disease

Outcomes of Hypoattenuating Leaflet Thickening Post-Transcatheter Pulmonary Valve Replacement

BACKGROUND

Transcatheter pulmonary valve replacement (TPVR) is a mainstay of therapy for right ventricular outflow tract dysfunction, especially in adult congenital heart disease.

OBJECTIVES

This study aimed to assess the prevalence, characteristics, and clinical implications of hypoattenuating leaflet thickening (HALT) and hypoattenuation affecting motion (HAM) after TPVR.

METHODS

This was a retrospective cohort study of TPVR performed from 2018 to 2024. Computed tomography angiography (CTA) assessed for HALT/HAM and echocardiography assessed valve gradients. Random forests for survival were used to assess the association between the rate of change in echocardiographic gradient and the time-related likelihood of HALT.

RESULTS

Of 106 patients with TPVR, 46 (39.6%) underwent CTA at 8.4 (6.1-24) (median [Q1-Q3]) months after TPVR. Twenty-six were in native right ventricular outflow tract, 12 were valve-in-valve, and 8 were in homografts. Eight patients (17.4%) had evidence of HALT ± HAM on CTA, 3 with valve deterioration. The median follow-up was 10 (2.4-23) months. No HALT/HAM was noted in patients on anticoagulation. Of the 5 with only HALT, one resolved, while one progressed. Three patients had HAM (6.5%), of which 2 had echocardiographic valve deterioration: one with mean gradient increase of 10 mm Hg, and one with ≥1-grade progression of regurgitation. All were treated with anticoagulation.

CONCLUSIONS

In this series of patients with TPVR, there was a 17.4% prevalence of HALT and 6.5% prevalence of HAM, with evidence of echocardiographic valve deterioration. Increases in valve gradients were associated with a higher likelihood of HALT. This is critical in adult congenital heart disease patients, where valve longevity is essential to reduce repeated interventions.

Tricuspid Valve S-Curves and Chamber Views: Implications for Transcatheter Tricuspid and Pulmonary Valve Interventions, Part 2 of the S-Curves and Chamber Views Series

Despite the challenges associated with periprocedural imaging, transcatheter tricuspid valve interventions have shown important impact on outcomes. A comprehensive understanding of the anatomy of the right heart and surrounding structures is crucial. One way to optimize these interventions is by identifying the optimal fluoroscopic viewing angles along the S-curve of the tricuspid valve. Integration of chamber views using multimodality imaging (multislice computed tomography, fluoroscopy, and echocardiography) may increase operator confidence and reduce procedural duration, radiation exposure, contrast volume, and complication rates.

Tricuspid Regurgitation in Patients with Tetralogy of Fallot

Tricuspid regurgitation in patients with repaired tetralogy of Fallot is an important finding with a wide spectrum of primary and secondary etiologies. Moderate or severe tricuspid regurgitation is associated with a greater incidence of atrial tachyarrhythmias in these patients. It remains uncertain which patients with repaired tetralogy of Fallot may benefit from a tricuspid valve intervention at the time of pulmonary valve replacement.

Electrophysiology and structural interventions in adults with congenital heart disease: Comparison of combined versus separate procedures

BACKGROUND

Electrophysiologic (EP) and structural interventions in adult congenital heart disease (ACHD) are typically completed during separate hospital encounters. With planning/coordination, these cases can be combined.

OBJECTIVES

We hypothesized that this integrated approach would yield patient and health system benefits.

METHODS

Consecutive ACHD patients undergoing combined interventions were matched to controls with identical but separate procedures. Primary endpoints of total hospital length of stay and cost were compared.

RESULTS

Sixty-six combined cases and 120 controls were identified (45% male, mean age 36.2 ± 14.2 years). The most common diagnoses were Fontan (27%), tetralogy of Fallot (23%), and transposition complexes (20%). The most common EP procedure was catheter ablation (n = 30) followed by electrophysiologic study (n = 13); the most common structural intervention was transcatheter valve replacement (n = 16) followed by angioplasty/stenting (n = 14). Compared to controls, cases showed shorter anesthesia duration (323 [IQR 238-405] vs. 355 minutes [270-498], P = 0.06), smaller contrast dose (130 [50-189] vs. 177 mL [94-228], P = 0.045), fewer venipunctures (4 [3-4] vs. 6 [5-7], P < 0.001), and fewer work days missed (2 [2-5] vs. 4 [4-6], P < 0.001). There was shorter hospital stay (30 [19-35] vs. 38 hours [26-50], P = 0.023) and a 37% reduction in hospital charges ($117,894 vs. $187,648; P = 0.039) and 27% reduction in payments ($65,757 vs. $88,859; P = 0.016), persisting after adjustment for group differences. There were no significant differences in number of complications or efficacy.

CONCLUSIONS

There appear to be advantages to combining ACHD interventional procedures that include reductions in hospital length of stay and cost, without detectable difference in procedural outcome.

Percutaneous valve implantation in "tricuspid" position after a Fontan-Björk operation

BACKGROUND

A 30-year-old female with tricuspid valve atresia, ventricular septal defect, and atrial septal defect had a neonatal modified Blalock Taussig shunt and a Fontan-Björk operation performed at five years of age. She did well initially but progressively developed signs of systemic congestion due to severe homograft stenosis and underwent successful percutaneous implantation of a Melody^® pulmonary valve (Medtronic, Minneapolis, MN, USA) in the "tricuspid" position.