engleski

Percutaneous pulmonary valve implantation and surgical valve replacement in patients with right ventricular outflow tract dysfunction : a complementary treatment concept

Today, surgical pulmonary valve replacement (SPVR) [1] and percutaneous pulmonary valve implantation (PPVI) [2] are the treatment options for right ventricular outflow tract (RVOT) dysfunction. The aim of this retrospective study was to evaluate the results of SPVR and PPVI in a single center. This was a retrospective analysis of 109 consecutive patients who were scheduled for PPVI (53) or SPVR (56) between 05/2006 and 11/ 2010 at the German Heart Center Munich. The median age at intervention was 20.2 years (8–65 years) Both groups did not differ in age and gender. The median number of previous surgical procedureswas significantly higher in the PPVI group (2 vs 3 procedures, respectively) (Table 1). The indication for treatment (SPVR/PPVI) was defined according to current recommendations [3, 4]. Patients with prevailing stenosis and a RVOT diamter b22 mm were treated with a Medtronic Melody® valve and patients with larger outflowtracts, usually presenting severe pulmonary regurgitation, were treated surgically. All patients received a transthoracic echocardiographical examination [5] before the intervention, at hospital discharge and at the latest follow-up. For calculation of RVOT obstruction, the mean Doppler gradients were used. Wilcoxon rank sum tests were used to assess differences between the PPVI and surgical group. Themedian peak Doppler velocity across the RVOTwas significantly higher before PPVI than before SPVR 4.1 m/s (1.7–5.1) vs 2.9 (1.3–5.7) (p b 0.001) indicating that stenosis was the leading lesion in this group of patients. The peak Doppler flow velocity in the PPVI group decreased significantly from a median value of 4.1 m/s (1.7–5.1) to 2.7 (1.8–4.3) (Fig. 1 ; p b 0.0001) at the latest echocardiographic examination. In the SPVR group, the peakDoppler flowvelocity decreased significantly from a median value of 2.9 m/s (1.3–5.7) to 2.1 (0.8–4.0) (p b 0.0001 ; Fig. 1). Pulmonary regurgitation was more prominent in the surgical group. In analogy to the results in term of stenosis, the PPVI patients with lower grades of pulmonary regurgitation before the procedure had significantly lower grades of pulmonary regurgitation after the procedure (p b 0.001, Fig. 2). The median follow-up period was similar in both groups. Following PPVI, one patient developed endocarditis (Staphylococcus aureus) six months after PPVI. The Melody® valve was replaced by a homograft. In the surgical group, two patients with severe recurrent pulmonary regurgitation needed a PPVI two and 24 months after surgery, respectively. Another patient underwent sternum re-fixation two years after surgery. The median hospital-stay after PPVI was significantly shorter after PPVI than after SPVR (2 days [1–26] vs 17 [9–56] days ; p b 0.001). Early complications were significantly more frequent in the surgical group (21/56 ; 38% vs 2/53 ; 4% ; p b 0.001). Complications after surgery were: urgent re-operation because of bleeding n = 2, pacemaker implantation (AV-block III) n = 1, seizures n = 1, fever of unknown origin n = 13, and arrhythmia n = 4. After PPVI one patient was febrile, one had transient atrioventricular conduction block. To our knowledge this is the first description of surgical valve replacement and PPVI for patients with RVOT dysfunction as a complementary treatment concept. Based on the individual morphology our interdisciplinary approach offered the adequate treatment. Patients, who were eligible for PPVI benefited from shorter hospitalization and fewer periprocedural complications. Following hospital discharge, patients after PPVI can go back to their usual daily activitieswhich is not possible after an open heart operation.

Right ventricular outflow tract dysfunction

nije evidentirano