Ann Thorac Surg 2008;85:632-634. doi:10.1016/j.athoracsur.2007.08.010
© 2008 The Society of Thoracic Surgeons
Case Reports
Hybrid Pulmonary Valve Implantation: Injection of a Self-Expanding Tissue Valve Through the Main Pulmonary Artery
Sven Dittrich, MDa,*,
Martin Gloeckler, MDa,
Raoul Arnold, MDa,
Koppany Sarai, MDb,
Matthias Siepe, MDb,
Friedhelm Beyersdorf, MDb,
Christian Schlensak, MDb
a Department of Congenital Heart Disease, Albert-Ludwigs University of Freiburg, Freiburg, Germany
b Department of Cardiovascular Surgery, Albert-Ludwigs University of Freiburg, Freiburg, Germany
Accepted for publication August 6, 2007.
* Address correspondence to Dr Dittrich, Department of Pediatric Cardiology, University of Erlangen, Loschgestrasse 15, Erlangen, D-91054, Germany (Email: sven.dittrich{at}kinder.imed.uni-erlangen.de).
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Abstract
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An 8-year-old (35 kg) boy presented with progressive right ventricular outflow tract enlargement (28 mm) and progressive tricuspid regurgitation after transannular repair of tetralogy of Fallot and was scheduled for pulmonary valve replacement. To spare reoperation on full sternotomy, a transverse mini-thoracotomy through the third intercostal space was used to implant an injectible 29-mm stented porcine valve directly through an incision of the pulmonary artery bifurcation. The procedure was performed while rapid ventricular pacing and right ventricular unload by a short running femorally implanted cardiopulmonary bypass. The stented valve was fixed with three single sutures to avoid embolization. The interventional result was well with full competence of the valve. The boy was discharged at day 4 after the procedure.
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Introduction
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The optimal timing of pulmonary valve replacement in patients with pulmonary valve regurgitation after repair of tetralogy of Fallot (TOF) still lacks clear criteria [1, 2]. Until now, putting in a tissue valve in the pulmonary position set the clock for life-long repeated exchange operations.
First corrective surgery on TOF was performed in this patient at the age of 15 months using a polytetrafluoroethylene patch to reconstruct an 8-mm right ventricular outflow tract (RVOT) to the diameter of 14 mm. Primary surgical outcome was good with no residual RVOT obstruction, no residual shunts, and an uneventful clinical course. On regular echocardiography follow-ups a continuous enlargement of the RVOT and the right ventricle was noticed. At the age of 5 years, right heart catheterization showed high-graded pulmonary regurgitation. Right ventricular pressure was 27/0 to 3 mm Hg, and diameter of the pulmonary valve annulus was 25 mm. Three years later at the age of 8 years (35 kg), an echocardiography showed further enlargement of the pulmonary valve annulus to 28 mm (Fig 1) and further enlargement of the right ventricle and tricuspid valve annulus with the development of tricuspid valve regurgitation on echocardiography, thus giving us indication for pulmonary valve replacement. To spare reopening of the median thoracotomy, the new technique was applied as follows: after exposure of the main pulmonary artery through the third intercostals space a pursestring suture was put on the upper side of the pulmonary artery bifurcation. After full heparinization (300 IE/kg/kg), the femoral artery and vein was cannulated and connected to the cardiopulmonary bypass. Off pump, the pulmonary artery was incised within the pursestring suture, and the introducer system with the stented valve was placed under transesophageal guidance into the RVOT (Figs 2, 3).
During a brief episode of rapid ventricular pacing, plus additional unloading of the right ventricle using the cardiopulmonary bypass, the valve was implanted. Thereafter, the introducer system was withdrawn and the pursestring suture was tightened. To avoid migration of the valve, the metal stent was anchored with three additional Prolene sutures (Ethicon Inc, Somerville, NJ) to the free wall of the pulmonary artery. Postoperative echocardiography demonstrated perfect valve function with no residual regurgitation (Fig 4). The patient recovered uneventfully and he was discharged on day 4 after surgery.
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Fig 1. (A) Transthoracic short-axis echocardiographic view. Arrows mark the pulmonary valve annulus, which is scaled with a diameter of 29 mm (blue line). There are no residual pulmonary valves to be identified. (B) Transthoracic short-axis echocardiographic view (3.5 mHz transducer) showing the pulmonary artery as before. Color flow Doppler echocardiography in diastole shows free regurgitation of the pulmonary artery (red colored flow signal directed backward into the right ventricular outflow tract [RVOT]). (Ao = aorta; LPA = left pulmonary artery; PA = main pulmonary artery; RPA = right pulmonary artery.)
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Fig 2. The introducer sheath is positioned into the main pulmonary artery through a transverse mini-thoracotomy in the third intercostal space with a pursestring suture on the upper side of the pulmonary artery bifurcation.
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Fig 3. The introducer sheath is positioned into the main pulmonary artery through a transverse mini-thoracotomy in the third intercostal space and a pursestring suture on the upper side of the pulmonary artery bifurcation. The arrow marks the introducer sheath (Intro) already put into the main pulmonary artery (PA).
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Fig 4. Postinterventional short-axis echocardiogram shows the anatomy of the leaflets of the new implanted prosthesis (arrows) in the right ventricular outflow tract (RVOT) position. Color flow Doppler showed no residual pulmonary valve regurgitation. (Ao = aorta; PA = main pulmonary artery.)
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Comment
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Transcatheter-based implantations of tissue valves for pulmonary regurgitation have been used sporadically as an alternative procedure to conventional valve surgery in recent years. Limitations of the method are given by the dimensions of the device ("too small") or the introducer materials ("too large"). Until now, transcatheter-based valve implantations of stented tissue valves have been reported in patients with an RVOT that does not exceed 22 mm in diameter and have been preferably used in calcified RVOTs [3, 4]. However, the most common condition after repair of TOF is pulmonary regurgitation and enlargement of the RVOT, not suitable for transcatheter sent fixation. To overcome this limitation, the Munich group has established a transventricular approach [5], which allows the implantation of stented porcine pulmonary valves with a diameter as great as 31 mm without the use of the cardiopulmonary bypass. However, this approach requires complete dissection of the heart after full sternotomy [5].
We believe this is the first report of a transpulmonal implantation of a 29-mm stented tissue valve (Shelhigh injectable porcine pulmonic valve; Shelhigh Inc, Fumedica Medizintechnik, Herne, Germany) through a transverse mini-thoracotomy in the third intercostals space in an 8-year-old boy (35 kg) after transannular repair of TOF. Our new technique allows the implantation of large stented tissue valves through a small mini-thoracotomy. Migration of the valve can be avoided after fixing the stent of the valve to the pulmonary artery wall with additional sutures, which might be important in patients with enlarged flexible RVOTs. The transpulmonary approach avoids ventriculotomy and myocardial damage. Although the procedure can theoretically be done without the use of cardiopulmonary bypass we recommend preparing the femoral vessels for cannulation to implant the stented valve safely during ventricular unloading and to be able to control unexpected events such as bleeding from the pulmonary artery or repositioning of the device.
In conclusion, hybrid implantation of large pulmonary valves can be safely performed without a full sternotomy. The available introducer system (stiff and straight) was developed for transventricular valve application and has to be modified for routine valve implantation through a mini-thoracotomy in a wide spectrum of different RVOT anatomies.
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References
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- Therrien J, Provost Y, Merchant N, Williams W, Colman J, Webb G. Optimal timing for pulmonary valve replacement after tetralogy of Fallot repair Am J Cardiol 2005;95:779-782.[Medline]
- Frigiola A, Redington AN, Cullen S, Vogel M. Pulmonary regurgitation is an important determinant of right ventricular contractile dysfunction in patients with surgically repaired tetralogy of Fallot Circulation 2004(Suppl 1):II153-II157.
- Bonhoeffer P, Boudjemline Y, Saliba Z, et al. Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction Lancet 2000;356:1403-1405.[Medline]
- Ghez O, Tsang VT, Frigiola A, et al. Right ventricular outflow tract reconstruction for pulmonary regurgitation after repair of tetralogy of Fallot: preliminary results Eur J Cardiothorac Surg 2007;31:654-658.[Abstract/Free Full Text]
- Schreiber C, Horer J, Vogt M, et al. A new treatment option for pulmonary valvar insufficiency: first experiences with implantation of a self-expanding stented valve without use of cardiopulmonary bypass Eur J Cardiothorac Surg 2007;31:26-30.[Abstract/Free Full Text]
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Abstract
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