Updated: July 2, 2021 10:24:16 pm
PATIENTS with congenital heart disease affecting the right ventricle outflow tract often require surgery at a young age and right ventricle-pulmonary artery (RV-PA) conduit.
Owing to degeneration and progressive pulmonary regurgitation and/or stenosis, these conduits require multiple surgical revisions leading to significant morbidity and mortality. In addition, free pulmonary regurgitation leads to right ventricle dilatation, failure, and arrhythmias.
Transcatheter Pulmonary Valve Replacement (TPVR), first performed by Bonhoeffer et al in 2000, is now an approved treatment for severe pulmonary regurgitation/stenosis and RV-PA conduit failure. Medtronic MelodyTM valve, Edwards SAPIENTM valve and MerilMyvalveTM are the three balloon-expandable valves that have been used for dysfunctional RV-PA conduits.
The Department of Cardiology, PGIMER, has successfully implanted the first transcutaneous pulmonary valve in a 25-year-old male, who is a known case of Tetralogy of Fallot (TOF), for which he was first operated on at the age of 11 months. Due to severe pulmonary regurgitation and right heart enlargement, he underwent another open heart surgery in 2009 and a bioprosthetic pulmonary valve was implanted.
However, around 11 years after the second surgery, the implanted valve became dysfunctional with moderate stenosis and severe leakage. The patient and relatives were not keen on a third surgery. Besides, a redo open heart surgery (third time) to replace the valve would have been a technically challenging procedure. Hence, the patient was taken up for a percutaneous procedure. The technically challenging procedure to implant the pulmonary valve transcutaneously (MelodyTM (Medtronic) was carried out by Prof Manoj Kumar Rohit, Professor Cardiology, PGIMER.
The second TPVR procedure was done in a 56-year-old woman, also a known case of TOF, who underwent intracardiac repair at the age of 35 years. She was taken up for valve replacement due to right heart dilatation and severe pulmonary regurgitation.
This patient was implanted with an Indian made valve MerilMyvalTM by a Prof Rohit. In both cases, the cardiac anaesthesia support was provided by Prof GD Puri, Dean (Academics) and Head of Department Anaesthesia and Dr Sunder Negi, consultant anaesthesia. Dr Shyam T, Head of Department and Professor of cardiothoracic surgery, PGIMER and his team provided the required surgical backup.
Besides being less traumatic, the transcutaneously implanted pulmonary valve has a life similar to a surgically-placed valve. The short and long term outcomes of the valve are similar to ones placed surgically. With the advent of technology, TPVR can now be done in a dysfunctional valve.
Prof. Rohit said, “We have many postoperative patients of TOF who develop right heart failure on long-term follow-up due to pulmonary regurgitation (leakage). Since most of them already have had one or more open-heart surgeries in the past, a redo surgery becomes a very challenging procedure for them and many patients are unfit.”
He said that TPVR in such patients decreases periprocedural morbidity and mortality and the long-term results remain comparable to surgically implanted valves. Prof Rohit also added that at present TPVR remains a costly alternative due to which many patients cannot afford this treatment and efforts should be made to make this procedure more affordable.
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