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TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK...

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TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT HEART Dr Aphrodite Tzifa, MD(Res), FRCPCH Director, Paediatric and GUCH Cardiologist, Mitera Children's Hospital, Athens, Greece September 10, 2003
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Page 1: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

TRANSCATHETER VALVE IMPLANTATION IN

THE RIGHT HEART

Dr Aphrodite Tzifa, MD(Res), FRCPCH

Director, Paediatric and GUCH Cardiologist,

Mitera Children's Hospital, Athens, Greece

September 10, 2003

Page 2: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

FAILURE OF RIGHT HEART VALVES

CONGENITAL

S/P Tetralogy of Fallot repair with conduit stenosis

S/P Fallot / pulmonary atresia repair with conduit

stensois

Truncus arteriosus / Conduit obstruction

TGA post switch with PS etc.

STRUCTURAL

Stenosis of TV bioprosthetic valve

Stensosis of PV bioprosthetic valve

Page 3: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

TRANSCATHETER ALTERNATIVE of PVR

HIGH RISK PATIENTS

Multi-operated patients

Skoliosis or other skeletal anomalies

Lung hypoplasia or other significant respiratory problems

Syndromes

Other predisposing factors for a complicated post-op

course

Page 4: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Criteria for re-intervention

Συμπτωματικοί ασθενείς / peak VO2 < 60%

Ασυμπτωματικοί ασθενείς με 2 ή > από τα παρακάτω κριτήρια

Progressive volumetric changes on MRI

RVEDv > 160ml/kg/m2 or RV/LV EDV>2

RV ESv> 80ml/kg/m2

RV EF< 47%

LV EF< 55%

QRS> 140ms

Arrhythmias (1/3 to ½ of deaths in adult ToFs are sudden and 100% of those with sudden death had > moderate PR)

Page 5: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

TRANSCATHETER PPVI

COURSE OF APPROVAL FOR TRANSCATHETER

VALVE IMPLANTATION

Patient clinical details letter with justification against

surgery

Supporting documents:

Cardiac MRI

Cardiac cath

Exercise testing with MVO2

24hr tape

Page 6: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

IMPLANTATION IN THE RIGHT HEART

1. MELODY VALVE (requires a conduit or

bioprosthetic valve)

2. EDWARDS VALVE (26mm, 29mm XT): (requires

a conduit or bioprosthetic valve)

3. VENOUS P VALVE

Page 7: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Melody valve

Valved segment of bovine jugular vein sewn within a

balloon-expandable stent.

Used in patients with operated congenital heart disease

with pulmonary regurgitation, RVOT obstruction or both

> 8500 implants worldwide !

Page 8: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Edwards valve

700 valve implantations

worldwide

Available in 23-29mm

Diameters

Short stent. Landing zone with

prestenting is vital

Page 9: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Venous P valve

Nitinol self expandable

multi-level support frame

Integrated trileaflet porcine

pericardial tissue valve

On clinical trial: Europe, Asia

Can be implanted in native RVOT with transannular patch

Available up to 32mm diameter

Page 10: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

PPVI IN THE PULMONARY POSITION

Page 11: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

US MELODY VALVE TRIAL

Tetralogy of Fallot 65 (48)

Pulmonary atresia 40

Pulmonary stenosis 19

Absent pulmonary valve 5

Atrioventricular canal 1

Ross operation 28 (21)

TGA 15 (11)

Truncus arteriosus 14 (10)

Double-outlet right ventricle 8 (6)

Valvar pulmonary stenosis 3 (2)

Other 2 (1)

McElhinney et al. Short- and Medium-Term

Outcomes After Transcatheter Pulmonary

Valve Placement in the Expanded Multicenter

US Melody Valve Trial. Circulation 2011

Page 12: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Approved Melody use (INSIDE RV-PA conduits)

Page 13: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Approved Melody use (pulmonary homograft)

Page 14: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Off label Melody use (in native RVOT with or without

pericardial, bovine or PTFE transannular patch)

- jilkjlkj

Page 15: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

PV preimplantation assessment

Page 16: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

PV preimplantation assessment

Page 17: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

PV preimplantation assessment

Page 18: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Criteria for re-intervention – Other factors

Available access

Size of RVOT

Shape of RVOT

Location / angulations / underlying diagnosis

Page 19: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Not too big ……. Not too small….

Page 20: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

RVOT shape

Page 21: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Location – Relationships with neighboring

structures – co-existing problems

Page 22: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Assessment of RVOT relationship with coronaries

Page 23: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Test occlusion of RVOT with simultaneous

coronary angiogram

Page 24: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Test occlusion of RVOT with LCA occlusion

Page 25: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Cardiac catheterisation

Page 26: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Cardiac catheterisation

Page 27: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Prestenting: 1. CP stents , 2. Intrastents EV3,

Genesis stents

Page 28: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Stenting long conduit stenosis

Page 29: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Short landing zone - risky for Melody

Page 30: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Large RVOT – Venous P valve

Page 31: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Pulmonary BD during pre-assessment

Page 32: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

IMPLANTATION IN THE

TRICUSPID POSITION

Page 33: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Transcatheter replacement of TV with Melody or

Edwards valve

Replacement within bioprosthetic valves

Indicated for severe TS or TR or mixed disease

Patients with ascites / peripheral oedemas

SOB

Good functional result

Resolution of ascites

NYHA II-III to I-II

Page 34: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Melody in TV (previous Edwards Perimount 25mm)

Page 35: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Melody in tricuspid valve (Edwards 25mm)

Page 36: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Tzifa et al Eurointervention

2013

Edwards in TV

Page 37: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Transcatheter Tricuspid Valve-in-Valve Implantation for the

Treatment of Dysfunctional Surgical Bioprosthetic Valves:

An International, Multicenter Registry Study

152 patients: 150/152 technically successful

22 deaths at F/U (5 within 30d)

77% were NYHA I-II at F/U (functional improvement)

Mc Elhinney et al. Circulation 2016

Page 38: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Endocarditis

SBE occurring in 4-16% of the population as compared to 2%

in the surgical group

Heart 2015: “Infective endocarditis of a transcatheter

pulmonary valve in comparison with surgical implants”:

Melody vs Contegra vs Homografts

7.5% of Melodies, 20% of Contegra, 2.4 % of homografts

present with SBE and when vegetations cause obstructions

the mortality is very high

M Gewillig. Heart 2015

Page 39: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Conclusions

Transcatheter valve therapy for patients with congenital

heart disease has revolutionised their management

Timely recognition will pick-up the patients with significant

RVOT stenosis or regurgitation before the onset of right heart failure

Key to the success is the patient preparation and the availability of a

specialist team consisting of Radiologists, Cardiologists, Anaesthetists

and Surgeons with expertise in the management of congenital patients

Page 40: TRANSCATHETER VALVE IMPLANTATION IN THE RIGHT … · TRANSCATHETER ALTERNATIVE of PVR HIGH RISK PATIENTS Multi-operated patients Skoliosis or other skeletal anomalies Lung hypoplasia

Thank you

[email protected]


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