Melody valve implant within failed bioprosthetic valves in the pulmonary position: a multicenter experience

Transcatheter Pulmonary Valve in Congenital Heart Disease

Over the last 2 decades, experience with transcatheter pulmonary valve replacement (TPVR) has grown significantly and has become an effective and reliable way of treating pulmonary valve regurgitation, right ventricular outflow (RVOT) obstruction, and dysfunctional bioprosthetic valves and conduits. With the introduction of self-expanding valves and prestents, dilated native RVOT can be addressed with the transcatheter approach. In this article, the authors review the current practices, technical challenges, and outcomes of TPVR.

Melody transcatheter pulmonary valve replacement: a single-center case series in Southeast Asia

BACKGROUND

Studies of transcatheter pulmonary valve replacement (TPVR) with the Melody valve have demonstrated good clinical and hemodynamic outcomes. Our study analyzes the midterm clinical and hemodynamic outcomes for patients who underwent Melody valve implantation in Southeast Asia.

METHODS

Patients with circumferential conduits or bioprosthetic valves and experiencing post-operative right ventricular outflow tract (RVOT) dysfunction were recruited for Melody TPVR.

RESULTS

Our cohort (n = 14) was evenly divided between pediatric and adult patients. The median age was 19 years (8-38 years), a male-to-female ratio of 6:1 with a median follow-up period of 48 months (16-79 months), and the smallest patient was an 8-year-old boy weighing 18 kg. All TPVR procedures were uneventful and successful with no immediate mortality or conduit rupture. The primary implant indication was combined stenosis and regurgitation. The average conduit diameter was 21 ± 2.3 mm. Concomitant pre-stenting was done in 71.4% of the patients without Melody valve stent fractures (MSFs). Implanted valve size included 22-mm (64.3%), 20-mm (14.3%), and 18-mm (21.4%). After TPVR, the mean gradient across the RVOT was significantly reduced from 41 mmHg (10-48 mmHg) to 16 mmHg (6-35 mmHg) at discharge, p < 0.01. Late follow-up infective endocarditis (IE) was diagnosed in 2 patients (14.3%). Overall freedom from IE was 86% at 79 months follow-up. Three patients (21.4%) developed progressive RVOT gradients.

CONCLUSION

For patients in Southeast Asia with RVOT dysfunction, Melody TPVR outcomes are similar to those reported for patients in the US in terms of hemodynamic and clinical improvements. A pre-stenting strategy was adopted and no MSFs were observed. Post-implantation residual stenosis and progressive stenosis of the RVOT require long term monitoring and reintervention. Lastly, IE remained a concern despite vigorous prevention and peri-procedural bacterial endocarditis prophylaxis.

Current status of transcatheter intervention for complex right ventricular outflow tract abnormalities

Various transcatheter interventions for the right ventricular outflow tract (RVOT) have been introduced and developed in recent decades. Transcatheter pulmonary valve perforation was first introduced in the 1990s. Radiofrequency wire perforation has been the approach of choice for membranous pulmonary atresia in newborns, with high success rates, although complication rates remain relatively common. Stenting of the RVOT is a novel palliative treatment that may improve hemodynamics in neonatal patients with reduced pulmonary blood flow and RVOT obstruction. Whether this option is superior to other surgical palliative strategies or early primary repair of tetralogy of Fallot remains unclear. Transcatheter pulmonary valve replacement has been one of the biggest innovations in the last two decades. With the success of the Melody and SAPIEN valves, this technique has evolved into the gold standard therapy for RVOT abnormalities with excellent procedural safety and efficacy. Challenges remain in managing the wide heterogeneity of postoperative lesions seen in RVOT, and various technical modifications, such as pre-stenting, valve ring modification, or development of self-expanding systems, have been made. Recent large studies have revealed outcomes comparable to those of surgery, with less morbidity. Further experience and multicenter studies and registries to compare the outcomes of various strategies are necessary, with the ultimate goal of a single-step, minimally invasive approach offering the best longer-term anatomical and physiological results.

Tricuspid valve annular tilt for assessment of pre- and post-intervention right ventricular volume in patients undergoing transcatheter pulmonary valve replacement

INTRODUCTION

Transcatheter pulmonary valve replacement serves as a successful alternative to surgical replacement of a right ventricle to pulmonary artery conduit. Guidelines for recommending transcatheter pulmonary valve replacement depend on MRI right ventricular volumes, which have been correlated to the echocardiographic measure of right ventricular annular tilt. We aim to assess whether right ventricular annular tilt can be a clinically useful alternative tool in the acute and long-term periods after transcatheter pulmonary valve replacement to assess right ventricular health.

METHODS

We reviewed 70 patients who underwent transcatheter pulmonary valve replacement at a single institution. Echocardiographic measurements were obtained prior to transcatheter pulmonary valve replacement, immediately after transcatheter pulmonary valve replacement, and within 6 months to 1 year after transcatheter pulmonary valve replacement. Right ventricular annular tilt measures the angle of the tricuspid valve plane relative to the mitral valve plane at end-diastole in the apical four-chamber view. Right ventricular fractional area change, right ventricular systolic strain, tissue Doppler velocity, and tricuspid annular plane systolic excursion Z-scores were obtained using published methods.

RESULTS

Right ventricular annular tilt decreased significantly immediately after transcatheter pulmonary valve replacement (p = 0.0004), and this reduction in right ventricular volume persisted at the mid-term follow-up (p < 0.0001). Fractional area change did not change significantly after transcatheter pulmonary valve replacement while right ventricular global strain improved at mid-term follow-up despite no significant difference immediately after transcatheter pulmonary valve replacement.

CONCLUSIONS

Right ventricular annular tilt decreases both immediately after transcatheter pulmonary valve replacement and at mid-term follow-up. Right ventricular strain also improved after transcatheter pulmonary valve replacement, corresponding to the improved volume load. Right ventricular annular tilt can be considered as an additional echocardiographic factor to assess right ventricular volume and remodeling after transcatheter pulmonary valve replacement.

Catheter-based Interventions in Tetralogy of Fallot Across the Lifespan

Surgical treatment of tetralogy of Fallot (TOF) involves surgical relief of right ventricular outflow tract (RVOT) obstruction and closure of ventricular septal defect. However, some patients may require staged palliation before surgical repair. This traditionally was achieved only with surgery but recently evolved to include catheter-based techniques. RVOT dysfunction occurs inevitably after the surgical repair of TOF and, depending on the surgical approach, manifests as either progressive stenosis, regurgitation, or a combination of both. This predisposes the individual to repeated RVOT interventions with the attendant risks of multiple open-heart surgeries. The advent of transcatheter pulmonary valve replacement has reduced the operative burden, and the expansion of transcatheter pulmonary valve replacement device platforms has widened the type and size of RVOT anatomies that can be treated. This review will discuss the transcatheter therapies available throughout the lifespan of the patient with TOF.

Surgical and transcatheter pulmonary valve replacement in patients with repaired tetralogy of Fallot: cardiac magnetic resonance imaging characteristics and morphology of right ventricular outflow tract

BACKGROUND

Pulmonary valve replacement is recommended in patients with repaired tetralogy of Fallot based on cardiac magnetic resonance imaging (MRI) criteria. This procedure is performed by surgical or transcatheter approaches.

OBJECTIVE

We aimed to investigate the differences in preprocedural MRI characteristics (volume, function, strain) and morphology of the right ventricular outflow tract and branch pulmonary arteries in patients for whom surgical or transcatheter pulmonary valve replacement was planned.

MATERIALS AND METHODS

Cardiac MRI of 166 patients with tetralogy of Fallot were analyzed. Of these, 36 patients for whom pulmonary valve replacement was planned were included. Magnetic resonance imaging characteristics, right ventricular outflow tract morphology, branch pulmonary artery flow distribution and diameter were compared between surgical and transcatheter groups. Spearman correlation and Kruskal-Wallis tests were performed.

RESULTS

Circumferential and radial MRI strain for the right ventricle were lower in the surgical group (P=0.045 and P=0.046, respectively). The diameter of the left pulmonary artery was significantly lower (P=0.021) and branch pulmonary artery flow and diameter ratio were higher (P=0.044 and P = 0.002, respectively) in the transcatheter group. There was a significant correlation between right ventricular outflow tract morphology and right ventricular end-diastolic volume index and global circumferential and radial MRI strain (P=0.046, P=0.046 and P= 0.049, respectively).

CONCLUSION

Preprocedural MRI strain, right-to-left pulmonary artery flow, diameter ratio and morphological features of the right ventricular outflow tract were significantly different between the two groups. A transcatheter approach may be recommended for patients with branch pulmonary artery stenosis, since both pulmonary valve replacement and branch pulmonary artery stenting can be performed in the same session.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Ten Years of Percutaneous Pulmonary Valve Implantation in Australia and New Zealand

OBJECTIVE

This study sought to investigate the characteristics, morbidity (including the rate of infective endocarditis and valve replacement) and mortality of individuals undergoing percutaneous pulmonary valve implantation in Australia and New Zealand since the procedure has been performed.

BACKGROUND

The outcomes of percutaneous pulmonary valve implantation in Australia and New Zealand have not been evaluated. Recent international data, including patients from New Zealand, suggests the rate of infective endocarditis is not insignificant.

METHODS

A retrospective multi-site cohort study was undertaken via medical record review at the centres where percutaneous pulmonary valve implantation has been performed. All procedures performed from 2009-March 2018 were included. Individuals were identified from local institution databases. Data was collected and analysed including demographics, details at the time of intervention, haemodynamic outcome, post procedure morbidity and mortality. Multi-site ethics approval was obtained.

RESULTS

One hundred and seventy-nine (179) patients attended the cardiac catheter laboratory for planned percutaneous pulmonary valve implantation. Of these patients, 172 underwent successful implantation. Tetralogy of Fallot and pulmonary atresia were the most common diagnoses. The median age at procedure was 19 years (range 3-60 yrs). There was a significant improvement in the acute haemodynamics in patients undergoing percutaneous pulmonary valve implantation for stenosis. Seven (7) patients (3.9%) experienced a major procedural/early post procedure complication (death, conversion to open procedure, cardiac arrest), including two deaths. The annualised rates of infective endocarditis and valve replacement were 4.6% and 3.8% respectively. There was one death related to infective endocarditis in follow-up.

CONCLUSIONS

Percutaneous pulmonary valve replacement is a relatively safe method of rehabilitating the right ventricular outflow tract.

First experiences with Myval Transcatheter Heart Valve System in the treatment of severe pulmonary regurgitation in native right ventricular outflow tract and conduit dysfunction

The rate of morbidity and mortality related to pulmonary regurgitation and pulmonary stenosis are big concerns after the surgery for CHD. Percutaneous pulmonary valve implantation has been established as a less invasive technique compared to surgery with promising results according to long-term follow-up of the patients. There are only two approved valve options for percutaneous pulmonary valve implantation until now, which are Melody (Medtronic, Minneapolis, Minn, USA) and Sapien (Edwards Lifesciences, Irvine, Ca, USA). Both valves have limitations and do not cover entire patient population. Therefore, the cardiologists need more options to improve outcomes with fewer complications in a such promising area. Herein, we present a case series applying for pulmonary position in conduits and native right ventricular outflow tract of a new transcatheter valve system Myval ® which is designed for transcatheter aortic valve implantation procedures. This is the first patient series in which the use of Myvalv in dysfunctional right ventricular outflow tracts is described, after surgical repair of CHD.

Pre- and Postprocedure Imaging of Transcatheter Pulmonary Valve Implantation

Transcatheter pulmonary valve replacement (TPVR) is a minimally invasive procedure for treatment of right ventricular outflow tract (RVOT) dysfunction in surgically repaired congenital heart diseases. TPVR is performed in these patients to avoid the high risk and complexity of repeat surgeries. Several TPVR devices are now available to be placed in the right ventricle (RV) to pulmonary artery (PA) conduit, native RVOT, or surgical bioprosthetic valves. Imaging is used before TPVR to determine patient eligibility and optimal timing, which is critical to avoid irreversible RV dilatation and failure. Imaging is also required for evaluation of contraindications, particularly proximity of the RVOT to the left main coronary artery and its branches. Cross-sectional imaging provides details of the complex anatomy in which the TPVR device will be positioned and measurements of the RVOT, RV-PA conduit, or PA. Echocardiography is the first-line imaging modality for evaluation of the RVOT or conduit to determine the need for intervention, although its utility is limited by the complex RVOT morphology and altered anatomy after surgery. CT and MRI provide complementary information for TPVR, including patient eligibility, assessment of contraindications, and key measurements of the RVOT and PA, which are necessary for procedure planning. TPVR, performed using a cardiac catheterization procedure, includes a sizing step in which a balloon is expanded in the RVOT, which also allows assessment of the risk for extrinsic coronary artery compression. Follow-up imaging with CT and MRI is used for evaluation of postprocedure remodeling and valve function and to monitor complications. ^©RSNA, 2022 Online supplemental material is available for this article.

Role of MDCT in evaluating prothesis size prior to percutaneous transcatheter closure of ostium secundum atrial septal defect

To investigate the feasibility and accuracy of cardiac multidetector computed tomography (MDCT) prosthesis sizing prior to ostium secundum atrial septal defect (ASD) percutaneous closure. Seventy consecutive patients were included in this retrospective bicentric study between May 2012 and June 2018. All underwent cardiac MDCT (primarily performed to rule out abnormal venous pulmonary return and coronary anomaly) and transesophageal echocardiography (TEE) before transcatheter closure: dimensions of the defect and peripheral rims were measured. Measurements of the defect obtained at TEE and MDCT were compared to prosthesis size. Our primary objective was the comparison of ASD maximal diameter obtained at MDCT (CT-Dmax) to prosthesis size. Intraclass correlation coefficient (ICC), Bland Altman plots and linear regression were calculated. Intra- and inter-observer agreements were calculated for MDCT defect measurements. Forty-three patients were finally included for defect measurements: 17 patients did not undergo transcatheter closure, and 10 had incomplete data. For CT-Dmax, ICC was 0.88 (CI 95% = [0.78-0.93]; p = 0.06); mean difference was - 0.8 ± 5.7 mm; regression linear equation was 0.9 × + 3.2 (p < 0.001). For maximal diameter at TEE versus prosthesis size, ICC was 0.46 (CI 95% = [0.21-0.61]; p = 0.003); mean difference was-6.0 ± 8.2 mm; regression linear equation was 0.91 × + 7.6 (p < 0.001). Intra- and inter-observer agreement for CT-Dmax were 0.97 (CI 95% = [0.95-0.98]) and 0.86 (CI 95% = [0.73-0.93]) respectively. MDCT is a reliable tool for sizing the defect of ostium secundum ASD, making it a complement or even an alternative to pre-procedural TEE.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Tissue Engineered Transcatheter Pulmonary Valved Stent Implantation: Current State and Future Prospect

Patients with the complex congenital heart disease (CHD) are usually associated with right ventricular outflow tract dysfunction and typically require multiple surgical interventions during their lives to relieve the right ventricular outflow tract abnormality. Transcatheter pulmonary valve replacement was used as a non-surgical, less invasive alternative treatment for right ventricular outflow tract dysfunction and has been rapidly developing over the past years. Despite the current favorable results of transcatheter pulmonary valve replacement, many patients eligible for pulmonary valve replacement are still not candidates for transcatheter pulmonary valve replacement. Therefore, one of the significant future challenges is to expand transcatheter pulmonary valve replacement to a broader patient population. This review describes the limitations and problems of existing techniques and focuses on decellularized tissue engineering for pulmonary valve stenting.

Valvular heart disease in congenital heart disease: a narrative review

Patients with congenital heart disease (CHD) are one of the fastest growing populations in cardiology, and valvular pathology is at the center of many congenital lesions. Derangements in valvular embryology lead to several anomalies prone to dysfunction, each with hemodynamic effects that require appropriate surveillance and management. Surgical innovation has provided new treatments that have improved survival in this population, though has also contributed to esotericism in patients who already have unique anatomic and physiologic considerations. Conduit and prosthesis durability are often monitored collaboratively with general and specialized congenital-focused cardiologists. As such, general cardiologists must become familiar with valvular disease with CHD for appropriate care and referral practices. In this review, we summarize the embryology of the semilunar and atrioventricular (AV) valves as a foundation for understanding the origins of valvular CHD and describe the mechanisms that account for heterogeneity in disease. We then highlight the categories of pathology from the simple (e.g., bicuspid aortic valve, isolated pulmonic stenosis) to the more complex (e.g., Ebstein's anomaly, AV valvular disease in single ventricle circulations) with details on natural history, diagnosis, and contemporary therapeutic approaches. Care for CHD patients requires collaborative effort between providers, both CHD-specialized and not, to achieve optimal patient outcomes.

Comparison of the investigational device exemption and post-approval trials of the Melody transcatheter pulmonary valve

OBJECTIVE

We compared 5-year outcomes of transcatheter pulmonary valve (TPV) replacement with the Melody TPV in the post-approval study (PAS) and the investigational device exemption (IDE) trial.

BACKGROUND

As a condition of approval of the Melody TPV after the IDE trial, the Food and Drug Administration required that a PAS be conducted to evaluate outcomes of TPV replacement in a "real-world" environment. The 5-year outcomes of the PAS have not been published, and the IDE and PAS trials have not been compared.

METHODS

The cohorts comprised all patients catheterized and implanted at 5 IDE sites and 10 PAS sites. Differences in trial protocols were detailed. Time-related outcomes and valve-related adverse events were compared between the two trials with Kaplan-Meier curves and log-rank testing.

RESULTS

167 patients (median age, 19 years) were catheterized and 150 underwent TPV replacement in the IDE trial; 121 were catheterized (median age, 17 years) and 100 implanted in the PAS. Freedom from hemodynamic dysfunction (p = .61) or any reintervention (p = .74) over time did not differ between trials. Freedom from stent fracture (p = .003) and transcatheter reintervention (p = .010) were longer in PAS, whereas freedom from explant (p = .020) and TPV endocarditis (p = .007) were shorter. Clinically important adverse events (AEs) were reported in 14% of PAS and 7.2% of IDE patients (p = .056); the incidence of any particular event was low in both.

CONCLUSIONS

Hemodynamic and time-related outcomes in the PAS and IDE trials were generally similar, confirming the effectiveness of the Melody TPV with real-world providers. There were few significant complications and limited power to identify important differences in AEs. The lack of major differences in outcomes between the two studies questions the usefulness of mandated costly post-approval studies as part of the regulatory process for Class III medical devices.

Mid-Term Outcomes Following Percutaneous Pulmonary Valve Implantation Using the "Folded Melody Valve" Technique

Background:

The folded valve is a manual shortening of the Melody device, which has been validated as a valuable therapeutic option for the management of dysfunctional right ventricular outflow tracts needing a short valved stent. In this article, we aimed to evaluate, in a multicenter cohort, the mid-term outcomes of patients in whom a percutaneous pulmonary valve implantation was performed using the folded valve technique.

Methods:

A 2012 to 2018 retrospective multicenter study was performed in 7 European institutions. All patients who benefit from percutaneous pulmonary valve implantation with a folded Melody valve were included.

Results:

A total of 49 patients (median age, 19 years [range 4–56], 63% male) were included. The primary percutaneous pulmonary valve implantation indication was right ventricular outflow tract stenosis (n=19; 39%), patched native right ventricular outflow tracts were the most common substrate (n=15; 31%). The folded technique was mostly used in short right ventricular outflow tracts (n=28; 57%). Procedural success was 100%. After a median follow-up of 28 months (range, 4–80), folded Melody valve function was comparable to the immediate postimplantation period (mean transvalvular peak velocity=2.6±0.6 versus 2.4±0.6 m/s, P>0.1; only 2 patients had mild pulmonary regurgitation). Incidence rate of valve-related reinterventions was 2.1% per person per year (95% CI, 0.1%–3.9%). The probability of survival without valve-related reinterventions at 36 months was 90% (95% CI, 76%–100%).

Conclusions:

The folded Melody valve is a safe technique with favorable mid-term outcomes up to 6.5 years after implantation, comparable with the usual Melody valve implantation procedure. Complications and reinterventions rates were low, making this technique relevant in selected patients.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Outcomes of percutaneous and surgical pulmonary valve implantation

BACKGROUND

The objective of this study is to describe the recent trends and in-hospital outcomes with percutaneous pulmonic valve implantation (PPVI) and surgical pulmonic valve implantation (SPVR) in adult hospitals in the US after the availability of both the Melody valve (Medtronic Inc., Minneapolis, Minnesota) and the Sapien XT valve (Edwards Lifesciences, Irvine, CA).

METHODS

We queried the National Inpatient Sample database (NIS) from January 2016 to December 2017 to identify hospitalizations for PPVI and SPVR.

RESULTS

We identified 5455 weighted discharges with PPVI and SPVR (PPVI=1140, SPVR=4305). PPVI procedures had increased in number over 2016 and 2017 (115 procedure at the first quarter of 2016, 195 procedures in the final quarter of 2017, P-trend=0.086), while SPVR volume remained constant. The incidence of in-hospital mortality was low with both procedures (SPRV: 1.6% vs. PPVI: 0.9%, p=0.071). SPVR had worse in-hospital outcomes, was associated with a longer length of stay [5 days vs. 1 day, p<0.001], and comparable cost of index hospitalization [$51,657 vs. $51,193] compared with PPVI.

CONCLUSION

After approval of the Sapien valve for commercial use in 2016, PPVI procedures have increased in frequency. PPVI is associated with lower procedural complications than SPVR, however, both carry a low risk of mortality. Despite the higher cost of the valves and delivery systems, PPVI is associated with a slightly lower cost of index hospitalization compared with SPVR, likely due to the higher in-hospital complications and LOS of the latter.

Percutaneous techniques for treatment of tricuspid valve dysfunction in congenital heart disease - an emerging therapy

Introduction: Tricuspid valve (TV) dysfunction treatment experiences exponential growth of the interest over the last years. New techniques for percutaneous tricuspid valve treatment are either on the market or in the early stages of development.Areas covered: Deficiency of uniform guideline-based recommendations leads to diverse TV dysfunction treatment options. The current review describes the development of surgical techniques for TV dysfunction in Ebstein's anomaly and transition to a variety of new technologies. Then, the focus is on the potential of percutaneous interventions to reduce the total number of open-heart surgeries in patients with congenital heart disease (CHD) after TV replacement with a bioprosthesis to improve TV function.Expert opinion: TV dysfunction is usually a complex combination of anatomical cardiac features in CHD. Compared to adults with secondary TV dysfunction, CHD patients usually are younger and have experienced several open-heart surgeries at a young age. Therefore, TV dysfunction can affect long-term life expectancy and quality of life significantly. So far, surgery was the gold standard for TV dysfunction treatment. The duration of TV plasty or bioprosthesis is limited, while the risk of re-do operations increases with every procedure. Percutaneous TV implantation may reduce the total number of open-heart surgeries over a patient's life.

Prevention and management of endocarditis after transcatheter pulmonary valve replacement: current status and future prospects

Introduction: Transcatheter pulmonary valve replacement (TPVR) has become an important tool in the management of congenital heart disease with abnormalities of the right ventricular outflow tract. Endocarditis is one of the most serious adverse long-term outcomes and among the leading causes of death in patients with congenital heart disease and after (TPVR).Areas covered: This review discusses the current state knowledge about the risk factors for and outcomes of endocarditis after transcatheter pulmonary valve replacement in patients with congenital and acquired heart disease. It also addresses practical measures for mitigating endocarditis risk, as well as diagnosing and managing endocarditis when it does occur.Expert opinion: With increasing understanding of the risk factors for and management and outcomes of endocarditis in patients who have undergone TPVR, we continue to learn how to utilize TPVR most effectively in this complex population of patients.

The Role of Novel Transcatheter Procedures in Patients With Congenital Heart Disease

The development of percutaneous structural interventions in patients with acquired heart disease is happening at an exponential rate, and some of this technology is being used to treat patients with congenital heart disease. This review describes the pathophysiology of valvular abnormalities specific to congenital heart disease and discusses the application of structural procedures in this population. Although the overall experience has been encouraging, especially in high-risk patients, this article will highlight the reasons that a cautious approach to adoption of this technology is necessary in these patients.

Transcatheter Interventions in Adult Congenital Heart Disease

This article provides a detailed review of the current practices and future directions of transcatheter interventions in adults with congenital heart disease. This includes indications for intervention, risks, and potential complications, as well as a review of available devices and their performance.

Percutaneous pulmonary valve implantation in a dysfunctional Trifecta® bioprothesis after high-pressure balloon fracturing

A percutaneous pulmonary valve-in-valve (PPVIV) implantation in small surgical tissue valves may be limited due to the valve's initial diameter. Fracturing of the valve's integrity by high-pressure balloons may enhance the diameter and facilitate subsequent PPVIV with a large valve. To the best of our knowledge, the Trifecta® valve seemed not to be accessible for fracturing. We report a case of successful 19-mm Trifecta valve fracturing, followed by PPVIV using a 26-mm Edwards SAPIEN 3 valve in pulmonary position. By repetitively using a high-pressure balloon 5 mm larger than the labeled valve size, we were able to fracture the valve's integrity and implant a 26-mm valve thereafter. Therefore, Trifecta valve appears to be suitable for valve ring fracturing and subsequent PPVIV in certain patients.

Transcatheter pulmonary valve replacement in pediatric patients

INTRODUCTION

Right ventricular outflow tract (RVOT) dysfunction is common among individuals with congenital heart disease (CHD). Surgical intervention often carries prohibitive risks due to the need for sequential pulmonary valve (PV) replacements throughout their life in the majority of cases. Transcatheter pulmonary valve replacement (tPVR) is one of the most exciting recent developments in the treatment of CHD and has evolved to become an attractive alternative to surgery in patients with RVOT dysfunction.

AREAS COVERED

In this review, we examine the pathophysiology of RVOT dysfunction, indications for tPVR, and the procedural aspect. Advancements in clinical application and valve technology will also be covered.

EXPERT OPINION

tPVR is widely accepted as an alternative to surgery to address RVOT dysfunction, but still significant numbers of patients with complex RVOT morphology deemed not suitable for tPVR. As the technology continues to evolve, new percutaneous valves will allow such complex RVOT patient to benefit from tPVR.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Comparison of Transcatheter Pulmonic Valve Implantation With Surgical Pulmonic Valve Replacement in Adults (from the National Inpatient Survey Dataset)

There are no large reports of comparative outcomes of transcatheter pulmonic valve implantation (TPVI) and surgical pulmonic valve replacement (SPVR). Prospective studies are unlikely to be feasible in the future also. Thus, we utilized a large adult inpatient database to compare the two with respect to temporal trends, in hospital outcomes and costs. Data from the National Inpatient Sample database from 2003 to 2014 was analyzed to extract patients who underwent TPVI and SPVR using unique ICD 9-CM codes. In-hospital outcomes and charges were then analyzed. All charges were converted to 2018 dollars and a loss of wages analysis was performed using the Bureau of Labor Statistics published median weekly wages. A total of 8,449 and 555 SPVR and TPVI discharges were identified. 5.8% SPVR procedures were done in rural setting versus 1.8% of TPVI. Complications including in-hospital mortality (2.3 vs 0.9%; p = 0.02) were higher in SPVR group. Length of stay was significantly shorter for the TPVI group (1 vs 5 days; p <0.001), which also contributed to lower loss of wages ($1028.57 vs $6042.86; p <0.001) with similar hospital charges. In conclusion, volumes of both TPVI and SPVR are increasing across adult hospitals in the United States, reflecting an overall increase in the adult congenital heart disease population. TPVI offers improved short-term outcomes and decreased loss of wages through shorter recovery time in this real-world database analysis.

3-Year Outcomes of the Edwards SAPIEN Transcatheter Heart Valve for Conduit Failure in the Pulmonary Position From the COMPASSION Multicenter Clinical Trial

OBJECTIVES

This study provides the 3-year follow-up results of the COMPASSION (Congenital Multicenter Trial of Pulmonic Valve Regurgitation Studying the SAPIEN Transcatheter Heart Valve) trial. Patients with moderate to severe pulmonary regurgitation and/or right ventricular outflow tract conduit obstruction were implanted with the SAPIEN transcatheter heart valve (THV).

BACKGROUND

Early safety and efficacy of the Edwards SAPIEN THV in the pulmonary position have been established through a multicenter clinical trial.

METHODS

Eligible patients were included if body weight was >35 kg and in situ conduit diameter was ≥16 and ≤24 mm. Adverse events were adjudicated by an independent clinical events committee. Three-year clinical and echocardiographic outcomes were evaluated in these patients.

RESULTS

Fifty-seven of the 63 eligible patients were accounted for at the 3-year follow-up visit from a total of 69 implantations in 81 enrolled patients. THV implantation was indicated for pulmonary stenosis (7.6%), regurgitation (12.7%), or both (79.7%). Twenty-two patients (27.8%) underwent implantation of 26-mm valves, and 47 patients received 23-mm valves. Functional improvement in New York Heart Association functional class was observed in 93.5% of patients. Mean peak conduit gradient decreased from 37.5 ± 25.4 to 17.8 ± 12.4 mm Hg (p < 0.001), and mean right ventricular systolic pressure decreased from 59.6 ± 17.7 to 42.9 ± 13.4 mm Hg (p < 0.001). Pulmonary regurgitation was mild or less in 91.1% of patients. Freedom from all-cause mortality at 3 years was 98.4%. Freedom from reintervention was 93.7% and from endocarditis was 97.1% at 3 years. There were no observed stent fractures.

CONCLUSIONS

Transcatheter pulmonary valve replacement using the Edwards SAPIEN THV demonstrates excellent valve function and clinical outcomes at 3-year follow-up.

Pulmonary Valve Replacement for Tetralogy of Fallot

Right ventricular outflow tract (RVOT) dysfunction is common following surgical repair of tetralogy of Fallot and other forms of complex congenital heart disease. This results in pulmonary stenosis or regurgitation and may ultimately lead to RV failure and dysrhythmias. Transcatheter valve technologies are now available to treat certain patients with RVOT dysfunction. Current devices include the Medtronic Melody valve and the Edwards Lifesciences SAPIEN XT. Although these valves are approved for use in dysfunctional circumferential RVOT conduits, they are increasingly being used off label for nonconduit outflow tracts. Procedural complications include but are not limited to conduit rupture and coronary compression. Longer-term complications include stent fracture and endocarditis. Outcomes with these valves have demonstrated durable relief of stenosis and regurgitation. The Medtronic Harmony valve and the Alterra Prestent from Edwards Lifesciences are investigational devices that are intended to treat the patulous RVOT that is too large to accommodate currently available valves. This review will focus on current indications to treat RVOT dysfunction, existing transcatheter valve technologies, and investigational devices undergoing clinical trials. Hopefully, within the not-too-distant future, transcatheter pulmonary valve implantation will be feasible in the vast majority of patients with RVOT dysfunction following surgical repair of congenital heart disease.

Intentional Fracture of Bioprosthetic Valve Frames in Patients Undergoing Valve-in-Valve Transcatheter Pulmonary Valve Replacement

BACKGROUND

Percutaneous transcatheter pulmonary valve replacement (TPVR) has good clinical and hemodynamic outcomes in treating dysfunctional bioprosthetic valves (BPV) in the pulmonary position. Valve-in-valve therapy can further decrease the inner diameter (ID), potentially resulting in patient-prosthesis mismatch in patients with smaller BPVs.

METHODS AND RESULTS

To evaluate feasibility and outcomes of intentional BPV fracture to enlarge the pulmonary valve orifice with TPVR, 37 patients from 13 centers who underwent TPVR with intended BPV fracture were evaluated. A control cohort (n=70) who underwent valve-in-valve TPVR without attempted fracture was evaluated. BPV was successfully fractured in 28 patients and stretched in 5 while fracture was unsuccessful in 4. A Melody valve was implanted in 25 patients with fractured/stretched frame and a Sapien (XT 3) valve in 8. Among patients whose BPV was fractured/stretched, the final ID was a median of 2 mm larger (0-6.5 mm) than the valve's true ID. The narrowest diameter after TPVR in controls was a median of 2 mm smaller ( P<0.001) than true ID. Right ventricular outflow tract gradient decreased from median 40 to 8 mm Hg in the fracture group. Cases with fracture/stretching were matched 1:1 (weight, true ID) to controls. Post-TPVR peak gradient was lower but not significant (8.3±5.2 versus 11.8±9.2 mm Hg; P=0.070). There were no fracture-related adverse events.

CONCLUSIONS

Preliminary experience shows intentional fracture of BPV frame can be useful for achieving larger ID and better hemodynamics after valve-in-valve TPVR.

Transcatheter Pulmonary Valve Replacement With the Melody Valve in Small Diameter Expandable Right Ventricular Outflow Tract Conduits

OBJECTIVES

This study sought to evaluate the safety, feasibility, and outcomes of transcatheter pulmonary valve replacement (TPVR) in conduits ≤16 mm in diameter.

BACKGROUND

The Melody valve (Medtronic, Minneapolis, Minnesota) is approved for the treatment of dysfunctional right ventricular outflow tract (RVOT) conduits ≥16 mm in diameter at the time of implant. Limited data are available regarding the use of this device in smaller conduits.

METHODS

The study retrospectively evaluated patients from 9 centers who underwent percutaneous TPVR into a conduit that was ≤16 mm in diameter at the time of implant, and reported procedural characteristics and outcomes.

RESULTS

A total of 140 patients were included and 117 patients (78%; median age and weight 11 years of age and 35 kg, respectively) underwent successful TPVR. The median original conduit diameter was 15 (range: 9 to 16) mm, and the median narrowest conduit diameter was 11 (range: 4 to 23) mm. Conduits were enlarged to a median diameter of 19 mm (29% larger than the implanted diameter), with no difference between conduits. There was significant hemodynamic improvement post-implant, with a residual peak RVOT pressure gradient of 7 mm Hg (p < 0.001) and no significant pulmonary regurgitation. During a median follow-up of 2.0 years, freedom from RVOT reintervention was 97% and 89% at 2 and 4 years, respectively, and there were no deaths and 5 cases of endocarditis (incidence rate 2.0% per patient-year).

CONCLUSIONS

In this preliminary experience, TPVR with the Melody valve into expandable small diameter conduits was feasible and safe, with favorable early and long-term procedural and hemodynamic outcomes.

Transcatheter Pulmonary Valve Replacement in Congenital Heart Disease

Patients with dysfunctional right ventricular outflow tracks comprise a large portion of patients with severe congenital heart disease. Transcatheter pulmonary valve replacement in patients with dysfunctional right ventricular outflow tracks is feasible, safe, and efficacious. This article reviews current transcatheter valve replacement technology for dysfunctional right ventricular outflow tract and pulmonary valvular disease and its applications to patients with congenital heart disease. Discussed are the approach and preprocedural planning, current options, and applications of transcatheter pulmonary valve therapy. Also considered are future directions in this field as the technologies begin to develop further.

Transcatheter pulmonary valve replacement: evolving indications and application

The introduction of transcatheter therapy for valvular heart disease has changed the spectrum of care of patients with a variety of cardiovascular conditions. Transcatheter valve placement has become established as a method of treating pathologic regurgitation or stenosis of the pulmonary valve, right ventricular outflow tract or a right ventricle to pulmonary artery conduit. In this review, we examine the pathophysiology of and indications for transcatheter pulmonary valve replacement along with procedural complications. Advancements in clinical application and valve technology will also be covered.

Mid-term outcomes of mechanical pulmonary valve replacement: a single-institutional experience of 396 patients

OBJECTIVES

Previous small-sized studies have demonstrated the safety and efficacy of mechanical pulmonary valve replacement (mPVR) in patients with congenital heart disease; however, the predictors of major complications and reoperation remained unclear.

METHODS

In a retrospective study, we reported the mid-term outcomes of a large-scaled series of patients, 396 patients, with congenital heart diseases who underwent mPVR in a single institution.

RESULTS

The patients' mean age at mPVR was 24.3 ± 9 years (4-58 years). Most patients (84.3%) underwent tetralogy of Fallot total correction. The median of follow-up was 36 months (24-49 months). Prosthetic valve malfunction caused by thrombosis or pannus formation developed in 12.1% of patients during follow-up period. Reoperation was performed in 7 cases with pannus formation and 6 cases with mechanical valve thrombosis. Freedom from reoperation at 1, 5, and 10 years was 99%, 97%, and 96%, respectively. Neither early nor mid-term mortalities were detected. Cox regression models showed that male gender and smaller valve size increased the risk of prosthetic valve failure. The age at mPVR, interval between congenital heart defect repair and mPVR, and concomitant procedures predicted reoperation. In multivariate analysis, younger age and the interval between first operation and mPVR predicted reoperation either.

CONCLUSIONS

The success rate of mPVR is excellent in mid-term follow-up. Younger age, longer interval between the repair of congenital defect and mPVR, and cooperation increased reoperation risk. However, strict adherence to life-long anticoagulation regimen and patient selection are of great importance for the implementation of mPVR.

Percutaneous Versus Surgical Pulmonic Valve Implantation for Right Ventricular Outflow Tract Dysfunction

BACKGROUND/PURPOSE

Percutaneous pulmonic valve implantation (PPVI) is an alternative treatment strategy to surgical pulmonic valve implantation (SPVI) for right ventricular outflow tract (RVOT) dysfunction. This study sought to compare outcomes of both treatment strategies.

METHODS

The study population was extracted from the 2014 Nationwide Readmissions Database (NRD) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for PPVI and SPVI. Study outcomes included all-cause in-hospital mortality, length of index hospital stay (LOS), post-procedural bleeding, mechanical complications of heart valve prosthesis, vascular complications (VC), infective endocarditis (IE), total hospitalization charges, and 30-day readmission rates.

RESULTS

A total of 975 patient discharges (176 in PPVI and 799 in SPVI group) were identified (average age 25.7 years; 57.5% male). PPVI was associated with significantly shorter median LOS (1 versus 5 days, p < 0.01), lower risk of bleeding (4.6% versus 26.4%, p < 0.01), and lower total hospitalization charges ($169,551.7 versus $210,681.8, p = 0.02). There was no significant difference between both groups in terms of all-cause in-hospital mortality (0% versus 1.4%, p = 0.12), mechanical complications of heart valve prosthesis (1.7% versus 2.0%, p = 0.78), VC (2.3% versus 2.0%, p = 0.82), IE (1.7% versus 3.1%, p = 0.31), or 30-day readmission rates (4.4% versus 7.6%, p = 0.16).

CONCLUSION

Compared with SPVI, PPVI was associated with shorter LOS, lower bleeding, and lower total charges. There was no significant difference between the two strategies in terms of all-cause in-hospital mortality, mechanical complications of heart valve prosthesis, VC, IE, or 30-day readmission rates.