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Ueyama HA, Greenbaum AB, Leshnower BG, Keeling B, Block PC, Byku I, Ligon RA, Grier E, Shekiladze N, Gleason PT, Xie J, Kim DW, Babaliaros VC, Duwayri Y. Physician-Modified Endograft-Facilitated Transcatheter Pulmonary Valve Replacement in Large Right Ventricular Outflow Tract. Circ Cardiovasc Interv 2023; 16:e013123. [PMID: 37577788 DOI: 10.1161/circinterventions.123.013123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Transcatheter pulmonary valve replacement (TPVR) in patients with a congenital or acquired abnormality resulting in enlarged right ventricular outflow tract (RVOT) is challenging and may preclude treatment with dedicated devices. We describe a technique using a physician-modified endograft to facilitate TPVR. METHODS Six patients underwent physician-modified endograft-facilitated TPVR for severe symptomatic pulmonary insufficiency with enlarged RVOT. The fenestration was created in a commercially available endograft before implantation, which was then deployed from the dominant branch pulmonary artery into the RVOT, with the fenestration aligned with the ostium of the nondominant pulmonary artery. A covered stent was placed through the fenestration into the nondominant branch pulmonary artery, and a transcatheter heart valve was deployed within the endograft at the level of the original pulmonary valve. RESULTS Four patients had tetralogy of Fallot, 1 had pulmonary atresia, and 1 had rheumatic valve disease. The RVOT/main pulmonary artery was severely enlarged (diameter, 44.2 [43.5-50.6] mm). All patients had reduced right ventricular (RV) function and dilated RVs (RV end-diastolic volume, 314 [235-316] mL). Successful endograft, covered stent, and transcatheter heart valve deployment were achieved in all cases without stent/valve embolization, vascular complications, or bleeding complications. At 30 days, 1 patient had mild pulmonary insufficiency, while others had none. The RV size measured by echocardiography was significantly reduced after TPVR (RV area, 34.4 [baseline] versus 29.0 [pre-discharge] versus 25.3 [30 days] cm2; P=0.03). During median follow-up of 221.5 (range, 29-652) days, there were no deaths or need for pulmonary valve reintervention. One patient developed severe tricuspid regurgitation due to entrapment of the anterior tricuspid leaflet by the endograft. The patient underwent successful tricuspid replacement and resection of the offending endograft with preservation of the pulmonary valve prosthesis. CONCLUSIONS Simple fenestration of an off-the-shelf endograft and associated covered stent placement through the fenestration allows TPVR for patients with dysfunctional native or patch-repaired pulmonary valves and RVOT enlargement.
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Affiliation(s)
- Hiroki A Ueyama
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - Adam B Greenbaum
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery (B.G.L., B.K.), Emory University School of Medicine, Atlanta, GA
| | - Brent Keeling
- Division of Cardiothoracic Surgery (B.G.L., B.K.), Emory University School of Medicine, Atlanta, GA
| | - Peter C Block
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - Isida Byku
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - R Allen Ligon
- Division of Cardiology, Children's Healthcare of Atlanta (R.A.L., D.W.K.), Emory University School of Medicine, Atlanta, GA
| | - Elizabeth Grier
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - Nikoloz Shekiladze
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - Patrick T Gleason
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - Joe Xie
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - Dennis W Kim
- Division of Cardiology, Children's Healthcare of Atlanta (R.A.L., D.W.K.), Emory University School of Medicine, Atlanta, GA
| | - Vasilis C Babaliaros
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., A.B.G., P.C.B., I.B., E.G., N.S., P.T.G., J.X., V.C.B.)
| | - Yazan Duwayri
- Division of Vascular and Endovascular Therapy (Y.D.), Emory University School of Medicine, Atlanta, GA
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Bruce CG, Khan JM, Rogers T, Yildirim DK, Babaliaros VC, Greenbaum AB, Lederman RJ. Transcatheter Electrosurgery: A Narrative Review. Circ Cardiovasc Interv 2023; 16:e012019. [PMID: 36799217 PMCID: PMC10108249 DOI: 10.1161/circinterventions.122.012019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/04/2023] [Indexed: 02/18/2023]
Abstract
Transcatheter electrosurgery describes the ability to cut and traverse tissue, at a distance, without an open surgical field and is possible using either purpose-built or off-the-shelf devices. Tissue traversal requires focused delivery of radiofrequency energy to a guidewire tip. Initially employed to cross atretic pulmonary valves, tissue traversal has enabled transcaval aortic access, recanalization of arterial and venous occlusions, transseptal access, and many other techniques. To cut tissue, the selectively denuded inner curvature of a kinked guidewire (the Flying-V) or a single-loop snare is energized during traction. Adjunctive techniques may complement or enable contemporary transcatheter procedures, whereas myocardial slicing or excision of ectopic masses may offer definitive therapy. In this contemporary review we discuss the principles of transcatheter electrosurgery, and through exemplary clinical applications highlight the range of therapeutic options offered by this versatile family of procedures.
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Affiliation(s)
- Christopher G. Bruce
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jaffar M. Khan
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Toby Rogers
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- MedStar Washington Hospital Center, Washington, DC, USA
| | - D. Korel Yildirim
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Adam B. Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA, USA
| | - Robert J. Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Lugones I, Barbosa JD, Schvartz G, Ackerman J, Laudani V, Vitorino AM, Lucini V, Garay F. A Hybrid Strategy for Geometrical Reshaping of the Main Pulmonary Artery and Transcatheter Pulmonary Valve Replacement. World J Pediatr Congenit Heart Surg 2021; 12:643-648. [PMID: 34597212 DOI: 10.1177/21501351211024994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Transcatheter pulmonary valve replacement has become an attractive alternative to surgical approach in patients with dysfunctional right ventricular outflow tract. However, in certain cases, an unfavorable anatomy might complicate optimal valve deployment and stability. Several techniques have been described to reshape the landing zone and allow proper implantation of the transcatheter valve. Among them, the hybrid approach has gained attention as an interesting method for off-pump pulmonary valve replacement in patients with dilated right ventricular outflow tract. But to date, there is no standardized method to resize and reshape the landing zone for the stented valve. Here, we describe a reproducible method based on simple geometric rules to allow adequate remodeling of the main pulmonary artery to the desired dimensions in a single attempt, followed by perventricular implantation of a Venus P-valve.
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Affiliation(s)
- Ignacio Lugones
- Departamento de Cirugía Cardiovascular, Hospital General de Niños "Dr. Pedro de Elizalde," Buenos Aires, Argentina
| | - Jesús Damsky Barbosa
- Departamento de Cardiología, Hospital General de Niños "Dr. Pedro de Elizalde," Buenos Aires, Argentina
| | - Guillermo Schvartz
- Departamento de Cardiología, Hospital General de Niños "Dr. Pedro de Elizalde," Buenos Aires, Argentina
| | - Judith Ackerman
- Departamento de Cardiología, Hospital General de Niños "Dr. Pedro de Elizalde," Buenos Aires, Argentina
| | - Verónica Laudani
- Departamento de Cirugía Cardiovascular, Hospital General de Niños "Dr. Pedro de Elizalde," Buenos Aires, Argentina
| | - Adelia Marques Vitorino
- Departamento de Cardiología, Hospital General de Niños "Dr. Pedro de Elizalde," Buenos Aires, Argentina
| | - Victorio Lucini
- Departamento de Cardiología, Hospital General de Niños "Dr. Pedro de Elizalde," Buenos Aires, Argentina
| | - Francisco Garay
- Departamento de Cardiología Pediátrica y Enfermedades Respiratorias, Hospital Clínico de la Universidad Católica de Chile, Santiago, Chile
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