HWN Suggests

Pulmonary Regurgitation- Is the Future Percutaneous or Surgical?

For decades, surgical replacement of the pulmonary valve has been seen as the gold-standard technique. Until the advent of Medtronic's Melody valve, it was the only option. Whilst radical changes in surgical techniques have not been forthcoming, rapid and substantial developments in the techniques and available technology for percutaneous valves now cause us to ask if the gold-standard moniker now belongs in the cath lab.

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Articles of Interest

Current approaches to pulmonary regurgitation

The number of patients requiring re-intervention for right ventricular outflow tract (RVOT) dysfunction following initial repair of a wide spectrum of congenital heart diseases is constantly increasing. This is secondary to improved survival combined with growing awareness of the detrimental long-term effects of pulmonary regurgitation. Long standing pulmonary regurgitation is now widely recognised to have adverse effects on exercise tolerance, right ventricular function, and ventricular and atrial arrhythmia susceptibility

Problem: Pulmonary Valve Regurgitation

Pulmonary regurgitation (PR, also called pulmonic regurgitation) is a leaky pulmonary valve. This valve helps control the flow of blood passing from the right ventricle to the lungs. A leaky pulmonary valve allows blood to flow back into the right ventricle before it gets to the lungs for oxygen.

Pulmonary regurgitation after repaired tetralogy of Fallot: surgical versus percutaneous treatment

Pulmonary regurgitation is the most important sequellae after correction of Tetralogy of Fallot and has a considerable impact over the right ventricle. Surgery has demonstrated low early mortality after pulmonary valve replacement and good long-term outcomes, remaining nowadays the gold standard treatment of pulmonary regurgitation in rTOF patients. Nevertheless, transcatheter pulmonary valve implantation has emerged as a new, safe and efficient alternative to surgical valve replacement.

Pulmonary regurgitation in congenital heart disease

The most important and best described clinical context for pulmonary regurgitation occurs in patients with repaired Tetralogy of Fallot.

Pulmonary regurgitation: not a benign lesion

Pulmonary regurgitation (PR) is a common complication after surgical or percutaneous relief of pulmonary stenosis and following repair of tetralogy of Fallot. Significant PR is usually well tolerated in childhood. However, in the long term, chronic PR has a detrimental effect on right ventricular (RV) function and exercise capacity and leads to an increased risk of arrhythmia and sudden cardiac death (SCD). Recent advances in non-invasive imaging and, in particular, wider availability of cardiovascular magnetic resonance (CMR), have improved the assessment of PR and RV function in these patients.

Pulmonary Valve Insufficiency

Pulmonary valve insufficiency rarely if ever occurs in isolation. Most often, congenital regurgitation of the pulmonic valve occurs in association with a pulmonary outflow obstruction such as in the absent pulmonary valve syndrome.

Pulmonary Valve Regurgitation

Many forms of congenital heart disease (CHD) repaired in infancy and childhood involve surgery on the pulmonary valve and right ventricular outflow tract (RVOT). Sometimes, these CHD conditions may require a pulmonary valve replacement later in life.

Pulmonary Valve Regurgitation: Neither Interventional Nor Surgery Fits All

PV implantation is indicated for severe PV regurgitation after surgery for congenital heart defects, but debates accompany the following issues: timing of PV implantation; choice of the approach, percutaneous interventional vs. surgical PV implantation, and choice of the most suitable valve.

Resources

The Harmony™ Transcatheter Pulmonary Valve (TPV)

The Harmony™ transcatheter pulmonary valve was an early pulmonary valve to be approved for use in the United States by the FDA. It was one of the first of its kind in the world, and Stanford Medicine Children’s Health was one of just three hospitals nationwide to provide it to children. Soon after, other large pediatric heart centers followed suit to offer the Harmony™ TPV. It achieved 89% effectiveness during clinical trials of both children and adults...

Transcatheter Pulmonary Valve Replacement (TPVR)

TPVR is typically a treatment for adults with congenital heart diseases who had a procedure to replace their pulmonary valve in childhood. Some of these patients had a Ross procedure, in which a surgeon replaced their aortic valve with their pulmonary valve. Others received a prosthetic valve or conduit (tube) during a prior operation.

StatPearls

Pulmonary hypertension and congenital heart defects, particularly tetralogy of Fallot, are the leading causes of a dysfunctional pulmonary valve resulting in regurgitation. Less frequently observed causes of pulmonary regurgitation encompass infective endocarditis, carcinoid syndrome, and rheumatic fever.