The standing of percutaneous pulmonary valve implantation compared to surgery in a non-preselected cohort with dysfunctional right ventricular outflow tract - Reasons for failure and contraindications.

BACKGROUND: Percutaneous pulmonary valve implantation (PPVI) numbers are rising but are still minor compared to surgery due to several contraindications. We sought to analyze the impact of PPVI compared to standard surgery in an unselected cohort with dysfunctional right ventricular outflow tract (RVOT). Reasons for PPVI failure and possible contraindications were explored. METHODS: Between 2010 and 2015 all consecutive patients who underwent surgery or intervention for a dysfunctional RVOT were investigated. RESULTS: A total of 382 cases was identified - 246 patients underwent successful valve insertion: 166 surgeries (166/246=67.4%) with 55/166 homografts (33.1%), 106 Contegra® grafts (63.8%), 5 Hancock valves (3.0%). Overall, 70/246 patients presented a priori with an enlarged RVOT>28mm (28.5%) not appropriate for PPVI and 14/246 (5.7%) had additional defects necessitating surgery. Some 31/246 patients had surgery for initial repair of congenital defects or were too small (<20kg) for PPVI (12.6%). 80 underwent successful PPVI (32.5% of 246 valves implanted) [51 Edwards Sapien® valves (63.7%), 29 Melody valves (36.3%)]. The RVOT was too large for PPVI in 22/246 patients (8.9%). A total 20/246 patients (8.1%) showed coronary compression after balloon interrogation. In 4/246 patients PPVI was not possible due to technical issues (1.4%). CONCLUSION: PPVI could be performed successfully in 80/382 patients (20.9%). An enlarged RVOT, small patient size, and coronary compression were the major obstacles for interventional management. Future developments for larger RVOTs and smaller body weight may expand the indication for PPVI.

The risk of bacterial endocarditis after percutaneous and surgical biological pulmonary valve implantation.

OBJECTIVE: This single center study compared the risk of bacterial endocarditis (BE) after surgical and percutaneous pulmonary valve implantation. METHODS: Between Jan 1st 2010 and Dec 31st 2015 all patients who received a biological pulmonary valve (surgical/interventional) were identified. The clinical follow-up was analyzed with regard to BE applying the modified Duke criteria and echocardiographic findings. RESULTS: We identified 246 patients who underwent a biological pulmonary valve implantation. The mean age was 15.9 years, (SD 12.7, Median 13.1). There were 166 surgical patients (67.5%), with 55 homografts (22.4%, mean diameter 27.4 mm), 106 Contegra® grafts (43.1%, mean diameter 17.4) and 5 Hancock® valves (2.0, mean diameter 25.6 mm) and 80 percutaneous pulmonary valve implantations (PPVI) (32.5%) with 51 Edwards Sapien® valves (20.7%, mean diameter 25.2 mm) and 29 Melody® valves (11.8%, mean diameter 21.9 mm). Patients with a bovione jugular conduit as the biologiocal substrate had an increased risk for BE and patients with Melody® valves had the highest risk for BE that was 5-8 times higher as compared to other valves. BE episodes were detected in 5/106 Contegras® (4,7%, 1.5 per 100 person-years), and in 6/29 of the Melody® valves (20.7%, 4.8 per 100 person-years). There were no cases of BE in patients treated with Edwards Sapien®, homografts or Hankock® valves. CONCLUSION: Whereas homografts and Edwards Sapien® valves seem to have a very low risk of BE, this risk is increased in Contegra® conduits and in Melody® valves.

The "Dog Bone Technique" A Novel Easy and Safe Catheter Maneuver for Aortic Arch and Coarctation Stenting.

BACKGROUND: Various techniques are described to facilitate stable stent implantation in aortic arch stenosis or coarctation. We describe an alternative technique, which due to its unique appearance during stent implantation, we have named "Dog Bone Technique" (DBT). TECHNIQUE: The stent/balloon assembly is placed across the stenosis, the long sheath is retrieved to uncover the distal 20-50% of the stent. The balloon is inflated with the pressure inflator just to expand slightly the stent. Thereafter the sheath is pulled back and the proximal end is uncovered and partially inflated; therewith the assembly takes the typical "dog bone" shape before complete inflation and final positioning. Repositioning of the stent and control angiography is possible at each time of this procedure. RESULTS: Between 1/2010 and 12/2014 we implanted 91 stents in 87 patients (mean age 20.2 years). About 71 patients had native or re-coarctation and 16 patients had transverse aortic arch stenosis. In 38 patients (44%) a pharmacological exercise test with Orciprenaline was performed during implantation resulting in high-cardiac output. In none of the patients reduction of cardiac output by adenosine or a rapid pacing of the right ventricle was required for stable stent implantation. All stents were implanted in the targeted position using this single balloon technique. There were no acute or short-term complications detected. CONCLUSION: DBT is a safe and feasible technique for aortic stent implantation even at high-cardiac output. Other additional techniques for stent placement are not necessary to obtain a stable final position in the target region.