Article

Delayed Improvement in Valve Hemodynamic Performance After Percutaneous Pulmonary Valve Implantation

Québec Heart Institute-Laval Hospital, Québec City, Québec, Canada.
The Annals of thoracic surgery (Impact Factor: 3.85). 06/2008; 85(5):1787-8. DOI: 10.1016/j.athoracsur.2007.11.007
Source: PubMed
ABSTRACT
We report the case of a 21-year-old woman with a severely stenotic pulmonary homograft who underwent percutaneous pulmonary valve implantation, with no significant change in transvalvular gradient within the 24 hours after the procedure. Major improvement in hemodynamic valve performance of more than 60% decrease in transvalvular gradient and more than 30% increase in pulmonary valve area was observed 3 months after the procedure, showing that hemodynamic improvement can occur late after pulmonary valve implantation. An echocardiogram after 3 months should be done before concluding the procedure failed and that reintervention is necessary.

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Available from: Jean Perron, Mar 30, 2014
DOI: 10.1016/j.athoracsur.2007.11.007
2008;85:1787-1788 Ann Thorac Surg
Josep Rodés-Cabau, Christine Houde, Jean Perron, Lee N. Benson and Philippe Pibarot
Pulmonary Valve Implantation
Delayed Improvement in Valve Hemodynamic Performance After Percutaneous
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Delayed Improvement in Valve
Hemodynamic Performance After
Percutaneous Pulmonary Valve
Implantation
Josep Rodés-Cabau, MD, Christine Houde, MD,
Jean Perron, MD, Lee N. Benson, MD, and
Philippe Pibarot, DVM, PhD
Québec Heart Institute–Laval Hospital, Centre Hospitalier
Universitaire Laval, Québec City, Québec; and Hospital for
Sick Children, Toronto, Ontario, Canada
We report the case of a 21-year-old woman with a
severely stenotic pulmonary homograft who underwent
percutaneous pulmonary valve implantation, with no
significant change in transvalvular gradient within the 24
hours after the procedure. Major improvement in hemo-
dynamic valve performance of more than 60% decrease in
transvalvular gradient and more than 30% increase in
pulmonary valve area was observed 3 months after the
procedure, showing that hemodynamic improvement can
occur late after pulmonary valve implantation. An echo-
cardiogram after 3 months should be done before con-
cluding the procedure failed and that reintervention is
necessary.
(Ann Thorac Surg 2008;85:1787– 8)
© 2008 by The Society of Thoracic Surgeons
P
ercutaneous pulmonary valve implantation (PVI) has
been recently proposed as an alternative to surgical
repair for the treatment of diseased right ventricle-to-
pulmonary artery conduits [1]. Pulmonary valve implan-
tation generally leads to an immediate and significant
improvement of transvalvular gradient in most patients
with predominantly stenotic conduits [2]. The present
case demonstrates that hemodynamic improvement can
occur late after PVI implantation.
A 21-year-old woman with a history of bicuspid aortic
valve leading to severe aortic stenosis and insufficiency
underwent a Ross procedure at the age of 10 years, with
implantation of a 22-mm homograft in the pulmonary
position. She presented with exertional dyspnea 11 years
after this operation, and the chest roentgenogram
showed the presence of significant calcification at the
level of the pulmonary homograft. A Doppler echocar-
diographic examination revealed a peak gradient of 75
mm Hg and mean gradient of 46 mm Hg across the
pulmonary homograft, a pulmonary valve effective orifice
area of 0.65 cm
2
, and moderate pulmonary insufficiency.
The patient underwent maximum exercise stress test.
The peak workload was 150 W, and oxygen consumption
was 32 mL/kg/min. The transvalvular gradients in-
creased markedly during exercise (peak, 110 mm Hg;
mean, 74 mm Hg). The decision was made to implant a
percutaneous pulmonary valve, and written informed
consent was obtained from the patient.
The procedure was performed by femoral approach,
under general anesthesia. Right systolic ventricular pres-
sure was 60 mm Hg, with a peak systolic gradient across
the pulmonary homograft of 42 mm Hg. Angiography
performed at the level of the pulmonary homograft
allowed the calculation of a minimal lumen diameter of
16 mm at the mid portion of the homograft.
A Melody valve (Medtronic, Minneapolis, MN), which
consists of a bovine jugular valve sutured within a
platinum-iridium stent, was mounted in a 22-mm balloon
delivery system and inserted through an extra-stiff
guidewire up to the pulmonary homograft. After valve
implantation, balloon dilation was performed with a
20-mm Mullins high-pressure balloon (Numed Canada
Inc, Cornwall, Ontario, Canada).
At the end of the procedure, the right systolic ventric-
ular pressure was 56 mm Hg, and the peak transvalvular
gradient was 39 mm Hg. Pulmonary angiography showed
the absence of pulmonary regurgitation (Fig 1). The day
after the procedure, Doppler echocardiography showed
no improvement in the peak transvalvular gradient (75
mm Hg) and only slight improvement in the mean
transvalvular gradient (37 mm Hg) compared with values
before the procedure. There was, nonetheless, a moder-
ate improvement in valve effective orifice area (0.96 cm
2
).
No right ventricular outflow tract obstruction was ob-
served at anytime. A chest roentgenogram showed the
correct position of the valve in the pulmonary homograft
and the absence of any stent fracture.
The possibility of immediate reintervention (surgical
homograft replacement or homograft stent implantation)
was considered, but after a meeting with the physician
responsible for the patient and the interventional team, it
was decided that close clinical follow-up rather than
immediate reintervention would be undertaken.
In the weeks after intervention, the patient reported a
progressive improvement of symptoms and was com-
pletely asymptomatic at the 3-month follow-up. At that
time, the chest roentgenogram showed the correct posi-
tion of the valve, the absence of any stent fracture, and no
significant change in stent diameters compared with
those obtained 24 hours after the procedure. Doppler
echocardiography revealed significant improvement in
the transvalvular gradient (peak, 26 mm Hg; mean, 16
mm Hg), further improvement in the effective orifice area
Accepted for publication Nov 5, 2007.
Address correspondence to Dr Rodés-Cabau, Québec Heart Institute–
Laval Hospital 2725, Chemin Ste-Foy, G1V 4G5, Quebec City, Canada;
e-mail: josep.rodes@crhl.ulaval.ca.
1787Ann Thorac Surg CASE REPORT RODÉS-CABAU ET AL
2008;85:1787–8 LATE HEMODYNAMIC IMPROVEMENT AFTER PVI
© 2008 by The Society of Thoracic Surgeons 0003-4975/08/$34.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2007.11.007
FEATURE ARTICLES
by on May 29, 2013 ats.ctsnetjournals.orgDownloaded from
Page 2
(1.27 cm
2
), and the absence of pulmonary regurgitation.
Serial changes in pulmonary valve hemodynamics after
PVI are summarized in Table 1. During stress echocardi-
ography, the transvalvular gradient increased up to 69/45
mm Hg, and the effective orifice area increased to 1.43
cm
2
. Peak exercise workload was 180 W, and oxygen
consumption was 37 mL/kg/min.
Comment
Several studies have reported that the hemodynamic
performance of stentless bioprosthetic valves may im-
prove progressively during the 3 to 6 months after aortic
valve replacement [3, 4]. A reduction in gradient of up to
30% and an increase in effective orifice of about 5% to
10% have been observed between the predischarge and
the late postoperative measurements.
The present report demonstrates that progressive im-
provement in valve hemodynamic performance may also
occur after percutaneous implantation of a pulmonary
bioprosthesis, and that the magnitude of such improve-
ment may be much higher than what was reported in
previous studies on aortic stentless bioprostheses [3, 4].
In this patient, implantation of a tissue valve was associ-
ated with minimal hemodynamic improvement immedi-
ately after its implantation, but a dramatic reduction of
transvalvular gradients (60%) and an increase in effec-
tive orifice area (30%) was noted within 3 months after
the intervention.
The occurrence of perivalvular edema/hematoma and
inflammation after valve implantation and its progressive
postoperative regression [4], as well as the long-term
exposure to pulsatile transvalvular flow and intraluminal
radial forces, may have contributed to the optimization of
the three-dimensional configuration of the valve and to
the improvement in the valve-opening kinetics. These
mechanisms may contribute to explain the time-related
hemodynamic changes observed in the present case.
Percutaneous PVI is an evolving technology that will
probably undergo significant expansion in the next few
years. The information provided by the present report
might have important clinical implications with regard to
this procedure. Given that major hemodynamic improve-
ment can occur within the next few months after PVI, one
should repeat the echocardiographic examination at 3
months before concluding that the procedure failed and
considering reintervention. Also, effective orifice area
rather than transvalvular gradient might be a better
index to determine the hemodynamic performance of the
valve after PVI in patients with predominantly stenotic
lesions. Larger series are needed to evaluate the exact
incidence of this phenomenon and further explore the
potential mechanisms responsible for this delayed im-
provement in valve hemodynamic performance.
References
1. Khambadkone S, Bonhoeffer P. Nonsurgical pulmonary valve
replacement: why, when, and how? Catheter Cardiovasc
Interv 2004;62:401–8.
2. Coats L, Khambadkone S, Derrick G, et al. Physiological and
clinical consequences of relief of right ventricular outflow
tract obstruction late after repair of congenital heart defects.
Circulation 2006;113:2037–44.
3. Dumesnil JG, LeBlanc MH, Cartier PC, et al. Hemodynamic
features of the freestyle aortic bioprosthesis compared with
stented bioprosthesis. Ann Thorac Surg 1998;66:S130–3.
4. Bortolotti U, Scioti G, Milano A, Borzoni G, Nardi C, Tartarini
G. The Edwards Prima stentless valve: hemodynamic perfor-
mance at one year. Ann Thorac Surg 1999;68:2147–51.
Fig 1. Lateral angiogram (A) before and (B)
after percutaneous pulmonary valve
implantation.
Table 1. Pulmonary Valve Hemodynamic Changes After
Percutaneous Pulmonary Valve Implantation Determined by
Doppler Echocardiography
Variable Baseline
After PVI
24 hours 3 months
Transvalvular
velocity
Peak (cm/s) 433 432 255
Mean (cm/s) 327 286 194
Transvalvular
gradient
Peak (mm Hg) 75 75 26
Mean (mm Hg) 46 37 16
Valve area (cm
2
)
0.65 0.96 1.27
PVI pulmonary valve implantation.
1788 CASE REPORT RODÉS-CABAU ET AL Ann Thorac Surg
LATE HEMODYNAMIC IMPROVEMENT AFTER PVI 2008;85:1787–8
FEATURE ARTICLES
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DOI: 10.1016/j.athoracsur.2007.11.007
2008;85:1787-1788 Ann Thorac Surg
Josep Rodés-Cabau, Christine Houde, Jean Perron, Lee N. Benson and Philippe Pibarot
Pulmonary Valve Implantation
Delayed Improvement in Valve Hemodynamic Performance After Percutaneous
& Services
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