Pulmonary and tricuspid regurgitation after Tetralogy of Fallot repair: A case report

BACKGROUND Tetralogy of Fallot(TOF)is one of the most common congenital heart defects,and surgery is the primary treatment.There are no precise guidelines on the treatment protocol for tricuspid regurgitation(TR)as a common complication of TOF repair.The timing for treatment in patients presenting with valve regurgitation after TOF repair is often difficult to determine.Here,we report the first case of sequential treatment of pulmonary and TR using interventional therapy.CASE SUMMARY We present the case of a 52-year-old female patient,who had a history of TOF repair at a young age.A few years later,the patient presented with pulmonary and tricuspid regurgitation.The symptoms persisted and TR worsened following percutaneous pulmonary valve implantation.Preoperative testing revealed that the patient’s disease had advanced to an intermediate to advanced stage and that her general health was precarious.Because open-heart surgery was not an option for the patient,transcatheter tricuspid valve replacement was suggested.This procedure was successful,and the patient recovered fully without any adverse effects.This case report may serve as a useful resource for planning future treatments.CONCLUSION Treatment of both valves should be considered in patients with tricuspid and pulmonary regurgitations following TOF repair.The interventional strategy could be an alternative for patients with poor general health.

Percutaneous valve stent insertion to correct the pulmonary regurgitation： an animal feasibility study

Background Pulmonary regurgitation leads to progressive right ventricular dysfunction, susceptibility to arrhythmias,and sudden cardiac death. Percutaneous valve replacement has been developed in recent years, providing patients with an alternative option. Percutaneous pulmonary valve replacement has been recently introduced into clinical practice. The goal of this study was to evaluate the feasibility of percutaneous valve stent insertion to correct the pulmonary regurgitation in sheep using a cup-shaped valve stent.Methods Pulmonary regurgitation was created by percutaneous cylindrical stent insertion in native pulmonary annulus of 8 sheep. One month after the initial procedure, the sheep with previous cylindrical stent implanted underwent the same implantation procedure of pulmonary valve stent. The valve stent consisted of a cup-shaped stent and pericardial valves.Hemodynamic assessments of the bioprosthetic pulmonary valve were obtained by echocardiography at immediately post-implant and at 2 months follow up.Results Successful transcatheter cylindrical stent insertion was performed in 7 sheep but failed in 1 sheep because the cylindrical stent was released to right ventricle outflow tract. After one month the 7 sheep with pulmonary regurgitation underwent valve stent implantation successfully. Echocardiography confirmed the stents were in desired position during the follow-up. No evidence of pulmonary valve insufficiency occurred in any animals. Echocardiography showed all heart function markers were normal.Conclusions Percutaneous cylindrical stent insertion to induce significant pulmonary regurgitation in sheep was feasible, simple and reproducible. Percutaneous pulmonary valve stent implantation can reduce pulmonary regurgitation in a sheep model. Further development of animal model and clinical trials are warranted.

Outcomes of Self-Expanding Transcatheter Pulmonary Valves:Extended Follow-Up of a Prospective Trial

Background:The Venus-P valve was the first self-expanding valve used world-wide for transcatheter pulmonary valve replacement(TPVR)in patients with severe pulmonary regurgitation(PR).We intended to report the extended follow-up results from the prospective trial(No.NCT02590679).Methods:A total of 38 patients with severe PR(mean age 24.2±13.2)were included.Follow-up data were obtained after implanted at 1,6,and 12 months and yearly after.The frame geometry was assessed on post-implant computer tomography(CT)scanning by calculating the non-circularity[circularity ratio(minimum diameter/maximum diameter)<0.9]and under-expansion[expansion ratio(derived external valve area/nominal external valve area)<0.9).Adverse events(all-cause mortality,reintervention,valve dysfunction,stent fracture and endocarditis)were recorded.Results:All valves were implanted successfully with normal function at discharge.Geometric CT analysis showed underexpanded valve was detected in 22 patients(63%)and non-circular valve was seen in 16 patients(46%).During a median follow-up of 4.8 years(range 0.3-8.1),there were 1 death and 1 surgical explant,both resulting from endocarditis.Five-year freedom from valve dysfunction and stent fracture were 84.8%(95%CI 74.8-94.7)and 83.5%(95%CI 73.8-93.2).Endocarditis occurred in 3 patients at a median time of 7 months.Stent fracture was more common in patients with non-circularity stents.Conclusion:TPVR using Venus-P valve is associated with favorable outcomes at 5 years.Non-circular shapes in the valve level may have a higher risk of stent fracture.

In vitro bench testing using patient-specific 3D models for percutaneous pulmonary valve implantation with Venus P-valve

Background:Due to the wide variety of morphology,size,and dynamics,selecting an optimal valve size and location poses great difficulty in percutaneous pulmonary valve implantation(PPVI).This study aimed to report our experience with in vitro bench testing using patient-specific three-dimensional(3D)-printed models for planning PPVI with the Venus P-valve.Methods:Patient-specific 3D soft models were generated using PolyJet printing with a compliant synthetic material in 15 patients scheduled to undergo PPVI between July 2018 and July 2020 in Central China Fuwai Hospital of Zhengzhou University.Results:3D model bench testing altered treatment strategy in all patients(100%).One patient was referred for surgery because testing revealed that even the largest Venus P-valve would not anchor properly.In the remaining 14 patients,valve size and/or implantation location was altered to avoid valve migration and/or compression coronary artery.In four patients,it was decided to change the point anchoring because of inverted cone-shaped right ventricular outflow tract(RVOT)(n=2)or risk of compression coronary artery(n=2).Concerning sizing,we found that an oversize of 2-5 mm suffices.Anchoring of the valve was dictated by the flaring of the in-and outflow portion in the pulmonary artery.PPVI was successful in all 14 patients(absence of valve migration,no coronary compression,and none-to-mild residual pulmonary regurgitation[PR]).The diameter of the Venus P-valve in the 3D simulation group was significantly smaller than that of the conventional planning group(36[2]vs.32[4],Z=-3.77,P<0.001).Conclusions:In vitro testing indicated no need to oversize the Venus P-valve to the degree recommended by the balloon-sizing technique,as 2-5 mm sufficed.

Transthoracic Salus Valve Feasibility Study: Short-Term Outcomes of a Transcatheter Self-Expandable Pulmonary Valve

Objective:The size and morphology of the right ventricular outflow tract(RVOT)in patients suffering from long-term pulmonary regurgitation(PR)after native RVOT(NRVOT)reconstruction are important factors affecting the feasibility,safety,and effectiveness of transcatheter pulmonary valve replacement.The purpose of this study was to evaluate the feasibility,safety,and effectiveness of a transthoracic Salus valve(Balance Medical Technology Co.,Ltd,Beijing,China)in patients with moderate-to-severe PR after NRVOT reconstruction.Methods:Patients with moderate-to-severe PR after NRVOT reconstruction were selected between June 2021 and November 2021 at Beijing Anzhen Hospital.Demographic data as well as preoperative,intraoperative,and follow-up data were reviewed.Results:Ten patients with moderate-to-severe PR after NRVOT reconstruction underwent physical examination,transthoracic echocardiography,and cardiovascular magnetic resonance imaging.Seven patients were selected for transthoracic Salus valve replacement.Six patients underwent implantation of the Salus valve successfully.One valve migrated and was embolized during recovery of the delivery device;the Salus valve was surgically explanted and sutured to the inner wall of the main pulmonary artery.At a mean follow-up of(5.5±1.1)months,dysfunction or migration of the Salus valve embolism was not observed.Conclusions:This early feasibility study demonstrates the feasibility,safety,and effectiveness of transthoracic implantation of a Salus valve in patients with moderate-to-severe PR after NRVOT reconstruction.The short-term effectiveness is clear,medium and long-term effectiveness requires longer follow-up.

Long-term outcome of correction of tetralogy of Fallot in 56 adult patients

Background Although most patients with tetralogy of Fallot undergo radical repair during infancy and childhood,patients that remain undiagnosed and untreated until adulthood can still be treated.This study aimed to evaluate longterm outcomes of adult patients with tetralogy of Fallot who were treated surgically,and to determine the predictors of postoperative pulmonary regurgitation.Methods Fifty-six adult patients underwent complete surgical repair.Forty-three patients （76.8%） required a transannular patch.Systolic,diastolic,and mean pressure in the main pulmonary artery were measured after repair.Results The early mortality rate was 3.6%.The 16-year survival rate was （84.4±11.5）%.Late echocardiography revealed 41 patients with transannular patch who had pulmonary regurgitation,consisting of mild pulmonary regurgitation in 28 patients,moderate in eight,and severe regurgitation in five patients.In addition,there was right ventricular outflow tract stenosis in nine patients,moderate/severe tricuspid valve regurgitation in seven,and residual ventricular septal defect in five.Logistic regression analysis demonstrated that the mean pulmonary pressure measured just after repair predicted late pulmonary regurgitation.Conclusions The long-term survival of surgically treated adult patients with tetralogy of Fallot is acceptable.The mean pressure 〉20 mmHg in the main pulmonary artery measured right after surgical repair may be a feasible reference to time the reconstruction of the pulmonary valve.

The effect of transanular patch for the primary correction of tetralogy of Fallot in adulthood

Baekground Although a lot of studies have been performed on the long term outcome in adults with repaired tetralogy of Fallot （TOF） in developed countries, but rare information for primary correction of adult TOF is available. The research focusing on the effect of transanular patch （TAP） for primary correction of TOF in adulthood is still absent. Via retrograde analysis of 7-year follow-up, this study was designed to explore the effect of the transanular patch for primary correction in adult TOF on the surgical outcome, postoperative cardiac function and morbidity, as well as to address the management of the complication. Methods A total of 151 consecutive adult patients （age ≥ 18） who underwent primary radical correction of TOF form 2007-2014 were selected and divided into TAP demographic statistic characteristics, and non-TAP groups based on the EACTS database. Results of echocardiography, color-Doppler echocardiography, cardiovascular enhanced contrast computed tomography （CT）, and/or cardiac catheterization; intraoperative information, postoperative results and outcomes were reported. During follow-up, short term was defined within 3 months after discharge, and midterm was defined as 6-12 months after discharge. Results Total postoperative mortality was 5.96% in all the cases, 6.96% in TAP group, and 2.78% （1/36） in non-TAP group. There was no significant difference between two groups. Follow-up period ranged from 3 months to 62 months. Readmission occurred and was followed by medical treatment without re-do surgery in 6 cases （3.97%）. The short term echocardiography demonstrated that pulmonary regurgitation and short term tricuspid regurgitation after discharge in TAP group were more severe （P 〈 0.001）. The short term residual pulmonary stenosis （RVOTO） severity after discharge in TAP group was less severe （P = 0.018）. Midterm echocardiography after discharge demonstrated pulmonary regurgitation and tricuspid regurgitation in TAP group were still more severe （P = 0.003）. The severity of residual pulmonary stenosis in TAP group was less severe （P = 0.044）. Multivariate unconditional logistic regression analysis showed that risk factors for mortality of adult TOF primary correction included： the acquirement of repeated cardiopulmonary bypass, OR = 126.28 （5.17 - 3082.23）, P = 0.003; the application of DHCA, OR = 61.08（2.26 - 1652.51）, P = 0.015; postoperative pulmonary regurgitation, OR = 33.84（2.53 - 452.53）, P = 0.008, long intensive care time, OR = 1.00 （1.00 - 1.01）, P = 0.012. The first three variables were high risk factors. Conclusions Primary radical correction of adult TOF has a good outcome, acceptable morbidity and mortality rates with mid-term surgical outcome in terms of effort tolerance. The acquirement of repeated cardiopulmonary bypass, the application of DHCA and postoperative pulmonary regurgitation are high risk factors of mortality. IS Chin J Cardiol 2015; 16 （2）： 72 - 79]