Implante percutáneo de válvula pulmonar autoexpandible Venus P en niños. Primer caso en Colombia / Percutaneous implantation of the Venus P self-expandable pulmonary valve in children. First case in Colombia

Resumen En pacientes con cardiopatía congénita, el implante percutáneo de válvula pulmonar es el tratamiento de elección en tractos de salida del ventrículo derecho (TSVD) disfuncionales. La válvula autoexpandible Venus-P, fue aprobada recientemente para su uso en tractos nativos de gran tamaño. El objetivo de este estudio es reportar la experiencia del primer caso de implantación exitosa de válvula pulmonar Venus-P en Colombia. Paciente de 16 años con Tetralogía de Fallot, con corrección completa a los 11 meses de vida. Presenta insuficiencia pulmonar severa y deterioro de la clase funcional. Se realiza cateterismo cardíaco para la colocación de válvula Venus-P 34 x 30 mm, procedimiento que se lleva a cabo sin complicaciones, evidenciando mejoría significativa de la presión diastólica de la arteria pulmonar, sin gradiente final entre el ventrículo derecho y arteria pulmonar. Existen varios reportes de experiencias en el implante de válvula Venus P a nivel mundial con resultados favorables. La colocación percutánea de la válvula representa disminución en tiempos del procedimiento y estancia hospitalaria. Consideramos el reemplazo valvular percutáneo en posición pulmonar en TSVD nativos es una opción posible y segura para mejorar la insuficiencia pulmonar y la disfunción ventricular derecha en este tipo de pacientes.

Abstract In patients with congenital heart disease, transcatheter pulmonary valve implantation is the treatment of choice in dysfunctional right ventricular outflow tracts (RVOT). The self-expandable Venus-P valve was approved recently for use in large native tracs. It is reported the experience of the first case of successful implantation of Venus-P pulmonary valve in Colombia. Ours was a 16-year-old patient with Tetralogy of Fallot, with complete correction at 11 months of life. The patient has severe pulmonary insufficiency and functional class deterioration. Cardiac catheterization was performed to place a 34 x 30 mm Venus-P valve, a procedure carried out without complications, evidencing significant improvement in the diastolic pressure of the pulmonary artery, without final gradient between the right ventricle and pulmonary artery. Reports exist of experiences in Venus-P valve implant globally with favorable results; percutaneous valve placement represents decreased procedure times and hospital stays. We believe percutaneous valve replacement in pulmonary position in native RVOTs is a possible and safe option to improve pulmonary insufficiency and right ventricular dysfunction in these types of patients.

Management of right ventricular outflow tract with percutaneous Melody valve implantation in pediatric patients: experience in a high complexity center in Colombia.

BACKGROUND: Congenital heart disease poses a therapeutic challenge, specifically pulmonary valve stenosis. This has been treated for many years with invasive procedures and bioprostheses, which over time, become dysfunctional due to the accumulation of fibrous tissue and calcification. OBJECTIVE: The aim of this study is to describe the use of endovascular management in the right ventricular outflow tract, as the beginning of an ongoing effot to improve pediatric outcomes in developing countries. METHODS: Seven pediatric patients with endovascular management of the right outflow tract are presented. Three of them underwent surgical valvuloplasty with persistent pulmonary stenosis. They decided to insert a percutaneous transcatheter pulmonary valve (PPVI) with a Melody valve using the valve-in-valve technique, with 100% stenosis and no complications associated with the procedure. RESULTS: Four patients with successful percutaneous valve implantation had different congenital heart diseases. In addition, the case of a patient in whom an intentional pulmonary valve fracture was performed, an innovative procedure in pediatric endovascular management in the country, is highlighted. CONCLUSIONS: The procedure was minimally invasive, safe, and effective. The IVPP technique could be a viable option in our country for managing failed primary valve implantations or even in native tracts.

ANTECEDENTES: Las cardiopatías congénitas plantean un desafío terapéutico, específicamente la estenosis de la válvula pulmonar. Esta ha sido tratada durante muchos años con procedimientos invasivos e inserción de bioprótesis, que con el tiempo se vuelven disfuncionales y pueden reestenosarse por acumulación de tejido fibroso y calcificación. Debido a las complicaciones generadas por la injuria quirúrgica, se han descrito medidas menos invasivas para el manejo de la estenosis residual e inicial por medios endovasculares en adultos y más recientemente en población pediátrica. OBJETIVO: El objetivo de este reporte es describir la misma en el manejo endovascular del tracto de salida del ventrículo derecho, como el inicio de un trabajo continuo para la mejoría de los resultados pediátricos en países en vía de desarrollo. MÉTODOS: Se presentan siete casos pediátricos de manejo endovascular del tracto de salida derecho; tres de ellos sometidos a valvuloplastia quirúrgica con persistencia de la estenosis pulmonar, por lo cual se decidió inserción percutánea de una válvula pulmonar (IVPP) transcatéter con válvula Melody utilizando la técnica valve-in-valve, con lo que se consiguió una resolución del 100% de la estenosis y no se presentó ningún tipo de complicación asociada al procedimiento. RESULTADOS: En cuatro pacientes se logró una implantación exitosa de la válvula por vía percutánea en diferentes cardiopatías congénitas, siendo uno de ellos en tracto nativo; además, destaca el caso de un paciente en quien se realizó fractura intencional de la válvula pulmonar, procedimiento innovador en el manejo endovascular pediátrico en Colombia. CONCLUSIONES: En estos pacientes el procedimiento resultó ser poco invasivo, seguro y efectivo. La técnica IVPP podría ser considerada una opción viable en Colombia (y en otros países en desarrollo) para el manejo de implantes valvulares primarios fallidos o incluso en tractos nativos.

Manejo del tracto de salida del ventrículo derecho con implante percutáneo de válvula Melody en pacientes pediátricos: experiencia en un centro de alta complejidad en Colombia / Management of right ventricular outflow tract with percutaneous Melody valve implantation in pediatric patients: experience in a high complexity center in Colombia

Resumen Antecedentes: Las cardiopatías congénitas plantean un desafío terapéutico, específicamente la estenosis de la válvula pulmonar. Esta ha sido tratada durante muchos años con procedimientos invasivos e inserción de bioprótesis, que con el tiempo se vuelven disfuncionales y pueden reestenosarse por acumulación de tejido fibroso y calcificación. Debido a las complicaciones generadas por la injuria quirúrgica, se han descrito medidas menos invasivas para el manejo de la estenosis residual e inicial por medios endovasculares en adultos y más recientemente en población pediátrica. Objetivo: El objetivo de este reporte es describir la misma en el manejo endovascular del tracto de salida del ventrículo derecho, como el inicio de un trabajo continuo para la mejoría de los resultados pediátricos en países en vía de desarrollo. Métodos: Se presentan siete casos pediátricos de manejo endovascular del tracto de salida derecho; tres de ellos sometidos a valvuloplastia quirúrgica con persistencia de la estenosis pulmonar, por lo cual se decidió inserción percutánea de una válvula pulmonar (IVPP) transcatéter con válvula Melody utilizando la técnica valve-in-valve, con lo que se consiguió una resolución del 100% de la estenosis y no se presentó ningún tipo de complicación asociada al procedimiento. Resultados: En cuatro pacientes se logró una implantación exitosa de la válvula por vía percutánea en diferentes cardiopatías congénitas, siendo uno de ellos en tracto nativo; además, destaca el caso de un paciente en quien se realizó fractura intencional de la válvula pulmonar, procedimiento innovador en el manejo endovascular pediátrico en Colombia. Conclusiones: En estos pacientes el procedimiento resultó ser poco invasivo, seguro y efectivo. La técnica IVPP podría ser considerada una opción viable en Colombia (y en otros países en desarrollo) para el manejo de implantes valvulares primarios fallidos o incluso en tractos nativos.

Abstract Background: Congenital heart disease poses a therapeutic challenge, specifically pulmonary valve stenosis. This has been treated for many years with invasive procedures and bioprostheses, which over time, become dysfunctional due to the accumulation of fibrous tissue and calcification. Objective: The aim of this study is to describe the use of endovascular management in the right ventricular outflow tract, as the beginning of an ongoing effot to improve pediatric outcomes in developing countries. Methods: Seven pediatric patients with endovascular management of the right outflow tract are presented. Three of them underwent surgical valvuloplasty with persistent pulmonary stenosis. They decided to insert a percutaneous transcatheter pulmonary valve (PPVI) with a Melody valve using the valve-in-valve technique, with 100% stenosis and no complications associated with the procedure. Results: Four patients with successful percutaneous valve implantation had different congenital heart diseases. In addition, the case of a patient in whom an intentional pulmonary valve fracture was performed, an innovative procedure in pediatric endovascular management in the country, is highlighted. Conclusions: The procedure was minimally invasive, safe, and effective. The IVPP technique could be a viable option in our country for managing failed primary valve implantations or even in native tracts.

Cirugía de Ross en Chile: tasa libre de reoperación y supervivencia global en una cohorte de más de 10 años de seguimiento / Ross surgery in Chile: reoperation free and global survival rates after a 10 year follow up

Antecedentes: El autoinjerto de válvula pulmonar (VP) u operación de Ross (OpR) tiene excelentes resultados a largo plazo. Es superior a otros tipos de reemplazo valvular en jóvenes adultos, aunque no el estándar de primera línea. Un tiempo quirúrgico prolongado o alta morbimortalidad son importantes preocupaciones. Objetivos: Establecer la morbimortalidad asociada a la OpR por un período >10 años, considerando el tiempo quirúrgico, tasa de reoperación y supervivencia global (SG). Métodos: Cohorte prospectiva (1996-2012), en seguimiento hasta agosto-2023. La SG fue estimada desde la OpR hasta la última consulta o deceso. Mediante regresión de Cox (Hazard Ratio, HR) se estimaron factores asociados a la SG. Resultados: La serie consta de 161 pacientes: 118 de etiología congénita (73.3%), 17 infecciosa (10.6%), 26 reumática (16.1%). La lesión fue estenótica en 79 (49.1%), insuficiencia en 40 (24.8%), mixta en 42 (26.1%). La OpR fue urgente en 11 (6.8%). The median time of ECC and the operation was 149 y 232 minutos, respectivamente. Veintisiete pacientes requirieron reoperación (16.8%). Con una mediana de 19.7 años (17.2-22.2), 23 pacientes fallecieron (14.3%): 1/23 asociado a OpR, 17/23 por causa cardiovascular y 5/23 por causas no cardiovasculares. La lesión mixta se asoció a mayor mortalidad (HR 3.07; IC 95% 1.11-8.47; p=.029). Conclusiones: La OpR es un procedimiento con baja morbimortalidad. La lesión mixta es un factor de riesgo independiente de mayor mortalidad. Sin embargo, la mediana de tiempo de CEC y quirúrgico es prolongado frente a otras técnicas de reemplazo valvular.

Background: Pulmonary valve (PV) autograftor reoperation or Ross surgery (RS), presents excellent long-term results. It is superior to other types of PV replacement in young adults, although it is not the first-line gold standard. A longer operative time or high morbidity and mortality rates are important concerns. Aim: To establish the morbidity and mortality associated with RS for >10 years, considering operative time, reoperation rate and overall survival (OS). Methods: Prospective cohort (1996-2012), with a follow-up until August/2023. The OS was estimated from RS to the last consultation/death. Factors associated to OS were estimated using Cox regression (Hazard Ratio, HR) Results: 161 patients were included: the etiology was congenital (118, 73%), infectious (17, 10.6%), and rheumatic (26,16.1%). The lesion was stenotic in 79 (49.1%), heart failure in 40 (24.8%), mixed in 42 (26.1%). RS was urgent in 11 (6.8%). Extracorporeal circulation (ECC) and operative times were 149 and 232 minutes, respectively. Twenty-seven patients required reoperation (16.8%). With a median follow up of 19.7 years (17.2-22.2), 23 patients died (14.3%): 1/23 associated with RS, 17/23 due to cardiovascular causes, and 5/23 due to non-cardiovascular causes. Mixed injury was associated with higher mortality (HR 3.07; 95% CI 1.11-8.47; p=.029). Conclusions: RS is a procedure with low morbidity and mortality. Mixed injury is an independent risk factor for increased mortality. However, the median ECC and operative times were higher compared to other valvular replacement techniques.

A Systematic Review of Benefits and Risks of Fetal Surgery for Congenital Cardiac Defects Such as Pulmonary Valve Stenosis and Critical Aortic Stenosis.

INTRODUCTION: Congenital heart diseases (CHDs) constitute the most prevalent congenital pathology, and they are a consequence of structural and functional abnormalities during fetal development. The etiology of CHD involves the interaction of genetic and environmental factors. Fetal cardiac surgery aims at preventing natural pathways of CHD in utero, mitigating progression to more complex abnormalities. The goal of this review was to demonstrate the benefits and risks of fetal interventions in the two most prevalent CHDs, pulmonary stenosis and pulmonary atresia with an intact ventricular septum, but also critical aortic stenosis and hypoplastic left heart syndrome. METHODS: Original and relevant articles were selected by meta-aggregation to perform a qualitative analysis of fetal cardiac interventions for pulmonary stenosis and critical aortic stenosis. The Joanna Briggs Institute's Qualitative Assessment and Review Instrument (or JBI-QARI) was used for data quality appraisal. RESULTS: Of 61 potential articles, 13 were selected, and nine were finally included. Discussion: The present review demonstrated that fetal cardiac surgery increases right ventricular growth and hemodynamic flow in pulmonary stenosis, whereas in critical aortic stenosis it enables growth of the left ventricle and increases left ventricular pressure. However, it has a high complication rate, along with considerable morbidity and mortality. CONCLUSION: The benefits of fetal cardiac surgery for pulmonary stenosis and critical aortic stenosis are well-described in the literature; however, there is a significant risk of complications which can be reduced by the surgeon's technical expertise and well-structured hospital facilities.

A Systematic Review of Benefits and Risks of Fetal Surgery for Congenital Cardiac Defects Such as Pulmonary Valve Stenosis and Critical Aortic Stenosis

ABSTRACT Introduction: Congenital heart diseases (CHDs) constitute the most prevalent congenital pathology, and they are a consequence of structural and functional abnormalities during fetal development. The etiology of CHD involves the interaction of genetic and environmental factors. Fetal cardiac surgery aims at preventing natural pathways of CHD in utero, mitigating progression to more complex abnormalities. The goal of this review was to demonstrate the benefits and risks of fetal interventions in the two most prevalent CHDs, pulmonary stenosis and pulmonary atresia with an intact ventricular septum, but also critical aortic stenosis and hypoplastic left heart syndrome. Methods: Original and relevant articles were selected by meta-aggregation to perform a qualitative analysis of fetal cardiac interventions for pulmonary stenosis and critical aortic stenosis. The Joanna Briggs Institute's Qualitative Assessment and Review Instrument (or JBI-QARI) was used for data quality appraisal. Results: Of 61 potential articles, 13 were selected, and nine were finally included. Discussion: The present review demonstrated that fetal cardiac surgery increases right ventricular growth and hemodynamic flow in pulmonary stenosis, whereas in critical aortic stenosis it enables growth of the left ventricle and increases left ventricular pressure. However, it has a high complication rate, along with considerable morbidity and mortality. Conclusion: The benefits of fetal cardiac surgery for pulmonary stenosis and critical aortic stenosis are well-described in the literature; however, there is a significant risk of complications which can be reduced by the surgeon's technical expertise and well-structured hospital facilities.

Pulmonary atresia with intact ventricular septum: Intended strategies.

OBJECTIVE: Neonatal interventional strategies for pulmonary atresia with intact ventricular septum are based on tricuspid valve hypoplasia and right ventricle-dependent coronary circulation. We sought to evaluate long-term outcomes comparing biventricular (BiV) versus single-ventricle (SV) strategies. METHODS: Retrospective review was performed of 119 patients diagnosed with pulmonary atresia with intact ventricular septum from 1995 to 2018. Descriptive statistics summarized patient characteristics and a multivariable Cox survival model was used to compare treatment strategies. RESULTS: Of 119 patients, 62 (52.1%) were male and 13 (10.9%) had a chromosomal abnormality. BiV was pursued in 53.8% (64 out of 119) and SV in 46.2% (55 out of 119) with median tricuspid valve z scores of -1.59 (interquartile range, -3.03 to 0.21) and -5.12 (interquartile range, -5.60 to -4.06), respectively. The median follow-up was 6 years (interquartile range, 2-15 years). Overall survival at 1, 3, and 10 years was 82.4% (98 out of 119), 80.6% (96 out of 119) and 79.8% (95 out of 119), respectively. End states include 36 (30.3%) BiV, 33 (27.7%) SV, 22 (18.5%) alive without definitive end state, 21 (17.6%) death before end state, 4 (3.4%) 1-and-a-half ventricle, and 3 (2.5%) transplants. No SV were converted to BiV, whereas 4 out of 64 (6.3%) BiV were converted to SV. After adjusting for gender, chromosomal abnormalities, gestational age, and birth weight, SV patients had a significantly higher hazard of mortality (hazard ratio, 9.0; 95% CI, 2.65-30.69; P < .001). Mortality was higher in those with right ventricle-dependent coronary circulation (41.9% [13 out of 31]) compared with those without right ventricle-dependent coronary circulation (7.3% [6 out of 82]) (P < .001). CONCLUSIONS: Pulmonary atresia with intact ventricular septum remains a challenging lesion for those patients on the SV pathway, particularly with right ventricle-dependent coronary circulation.

[Outcomes of percutaneous balloon pulmonary valvuloplasty in pulmonary valve stenosis in the pediatric population in a single center, Lima - Peru]. / Resultados de la valvuloplastia percutánea con balón en la estenosis valvular pulmonar en población pediátrica en el Instituto Nacional Cardiovascular - INCOR, Lima - Perú.

Objective: To evaluate the effectiveness of the procedure and outcomes during follow-up. Methods: 80 patients with pulmonary valvular stenosis who underwent percutaneous balloon valvuloplasty between January 2014 and December 2019 are described. Demographic, echocardiographic, and hemodynamic characteristics of the procedure were evaluated. Follow-up included clinical, echocardiographic parameters, pulmonary regurgitation severity, and residual pulmonary gradient at each cutoff point. Results: The age range was 2 years (interquartile range: 10.5 months - 6 years), and the predominant sex was male with 56.2%. The transvalvular pulmonary gradient decreased from 61.7 mmHg +- 21.2 to 17 mmHg (interquartile range: 11-26 mmHg). The immediate success rate was 90%. Follow-up time showed a median of 21 months (interquartile range: 5-47.5 months). All patients at follow-up showed some degree of pulmonary insufficiency at each cutoff point; 17% of the cases at the end of their follow-up were found to have severe insufficiency. Three cases of long-term restenosis were found (3.8%), and 6 (7.5%) were admitted for valvuloplasty surgery or pulmonary valve replacement. The complications reported reached 10% of cases, two patients were admitted to surgery during the procedure for major complications. A significant association was found with severe pulmonary insufficiency at the end of follow-up and ring/balloon ratio. Conclusions: Percutaneous transluminal valvuloplasty with balloon is an effective technique in the treatment of pulmonary valvular stenosis, with reported complications but with good results during follow-up.

Podemos Acreditar no Ecocardiograma de Rotina para Avaliar o Ventrículo Direito e a Insuficiência Pulmonar? Um Estudo Comparativo com Ressonância Magnética Cardíaca / Can we Trust in Routine Echocardiography to Assess the Right Ventricle and Pulmonary Insufficiency? A Comparative Study with Cardiac Magnetic Resonance

Resumo Fundamento A ressonância magnética cardíaca (RMC) é o método de escolha para avaliar as dimensões e a função do ventrículo direito (VD), e a insuficiência pulmonar (IP). Objetivos Avaliar a acurácia da ecocardiografia bidimensional (ECO 2D) em estimar a função e as dimensões do VD e o grau de IP, e comparar os resultados obtidos pela ECO 2D com os da RMC. Métodos Comparamos os relatórios de ECO e RMC de pacientes cuja indicação para RMC havia sido para avaliar VD e IP. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados Incluímos 51 pacientes com cardiopatia congênita com idade mediana de 9,3 anos (7-13,3 anos). Observou-se uma baixa concordância entre ECO 2D e RMC quanto à classificação da dimensão (Kappa 0,19; IC 95% 0,05 a 0,33, p 0,004) e da função do VD (Kappa 0,16; IC 95% -0,01 a +0,34; p 0,034). O tamanho do VD foi subestimado pela ECO 2D em 43% dos casos, e a função do VD foi superestimada pela ECO 2D em 29% dos casos. O grau de concordância entre os métodos quanto à classificação da IP não foi significativo (Kappa 0,014; IC 95% -0,03 a +0,06; p 0,27). Houve uma tendência de a ECO 2D superestimar o grau da IP. Conclusões A ECO 2D mostrou baixa concordância com a RMC quanto às dimensões e função do VD, e grau de IP. Em geral, a ECO subestimou as dimensões do VD e superestimou a função do VD e o grau de IP quando comparada à RMC.

Abstract Background Cardiac magnetic resonance (CMR) is the method of choice for assessing right ventricular (RV) dimensions and function, and pulmonary insufficiency (PI). Objectives To assess the accuracy of two-dimensional echocardiography (2D ECHO) in estimating RV function and dimensions, and the degree of PI, and compare the 2D ECHO and CMR findings. Methods We compared ECHO and CMR reports of patients whose indication for CMR had been to assess RV and PI. A p-value < 0.05 was considered statistically significant. Results We included 51 congenital heart disease patients, with a median age of 9.3 years (7-13.3 years). There was poor agreement between 2D ECHO and CMR for classification of the RV dimension (Kappa 0.19; 95% CI 0.05 to 0.33, p 0.004) and function (Kappa 0.16; 95% CI -0.01 to +0.34; p 0.034). The RV was undersized by 2D ECHO in 43% of the cases, and RV function was overestimated by ECHO in 29% of the cases. The degree of agreement between the methods in the classification of PI was not significant (Kappa 0.014; 95% CI -0.03 to +0.06, p 0.27). 2D ECHO tended to overestimate the degree of PI. Conclusions The 2D ECHO showed a low agreement with CMR regarding the RV dimensions and function, and degree of PI. In general, ECHO underestimated the dimensions of the RV and overestimated the function of the RV and the degree of PI as compared with CMR.

A Hybrid Strategy for Geometrical Reshaping of the Main Pulmonary Artery and Transcatheter Pulmonary Valve Replacement.

Transcatheter pulmonary valve replacement has become an attractive alternative to surgical approach in patients with dysfunctional right ventricular outflow tract. However, in certain cases, an unfavorable anatomy might complicate optimal valve deployment and stability. Several techniques have been described to reshape the landing zone and allow proper implantation of the transcatheter valve. Among them, the hybrid approach has gained attention as an interesting method for off-pump pulmonary valve replacement in patients with dilated right ventricular outflow tract. But to date, there is no standardized method to resize and reshape the landing zone for the stented valve. Here, we describe a reproducible method based on simple geometric rules to allow adequate remodeling of the main pulmonary artery to the desired dimensions in a single attempt, followed by perventricular implantation of a Venus P-valve.

Short-term outcome of polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of right ventricular outflow tract in tetralogy of fallot: a randomized controlled trial

Abstract Introduction: Reconstruction of right ventricular outflow tract during primary repair of tetralogy of Fallot often requires the placement of a transannular patch which results in pulmonary regurgitation (PR). We compared the short-term outcomes of bicuspid polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of the right ventricular outflow tract. Methods: Thirty consecutive patients undergoing primary repair of tetralogy of Fallot were randomly allocated to two groups - polytetrafluoroethylene valve (PTFEV) group (n=15) and transannular pericardial patch (TAP) group (n=15). The two groups had similar preoperative demographic characteristics. We compared the short-term clinical and echocardiographic outcomes between these groups. The transthoracic echocardiographic follow-up was performed at one week, one month and six months after surgery. Results: The PTFEV group had significantly lower central venous pressure in the immediate postoperative period compared to the TAP group (7.60±2.06 vs. 10.13±1.73, P=0.002). Extubation time was significantly shorter in the PTFEV group compared to the TAP group (12.93±7.55 hrs vs. 22.23±15.11 hrs, P=0.04). PR in the PTFEV group was absent in five patients at 24 hours post-surgery. At the study endpoint, PR was absent in six, trivial in one and mild in eight patients in the PTFEV group compared to TAP group, where all 15 patients had severe PR. Conclusion: The bicuspid polytetrafluoroethylene membrane valves significantly decrease the central venous pressure in the immediate postoperative period, facilitate early extubation and, thus, prevent ventilator-related comorbidities. They achieve a high degree of pulmonary competence and do not increase the right ventricular outflow tract gradient in short-term follow-up.

Short-term outcome of Polytetrafluoroethylene Membrane Valve versus Transannular Pericardial patch Reconstruction of Right Ventricular Outflow Tract in Tetralogy of Fallot: a Randomized Controlled Trial.

INTRODUCTION: Reconstruction of right ventricular outflow tract during primary repair of tetralogy of Fallot often requires the placement of a transannular patch which results in pulmonary regurgitation (PR). We compared the short-term outcomes of bicuspid polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of the right ventricular outflow tract. METHODS: Thirty consecutive patients undergoing primary repair of tetralogy of Fallot were randomly allocated to two groups - polytetrafluoroethylene valve (PTFEV) group (n=15) and transannular pericardial patch (TAP) group (n=15). The two groups had similar preoperative demographic characteristics. We compared the short-term clinical and echocardiographic outcomes between these groups. The transthoracic echocardiographic follow-up was performed at one week, one month and six months after surgery. RESULTS: The PTFEV group had significantly lower central venous pressure in the immediate postoperative period compared to the TAP group (7.60±2.06 vs. 10.13±1.73, P=0.002). Extubation time was significantly shorter in the PTFEV group compared to the TAP group (12.93±7.55 hrs vs. 22.23±15.11 hrs, P=0.04). PR in the PTFEV group was absent in five patients at 24 hours post-surgery. At the study endpoint, PR was absent in six, trivial in one and mild in eight patients in the PTFEV group compared to TAP group, where all 15 patients had severe PR. CONCLUSION: The bicuspid polytetrafluoroethylene membrane valves significantly decrease the central venous pressure in the immediate postoperative period, facilitate early extubation and, thus, prevent ventilator-related comorbidities. They achieve a high degree of pulmonary competence and do not increase the right ventricular outflow tract gradient in short-term follow-up.

Pulmonary valve reconstruction using Ozaki's technique for infective endocarditis.

Simultaneous pulmonary and aortic endocarditis is extremely rare, and there is no consensus on its surgical management. Here, we report a case of infective endocarditis of pulmonary and aortic valves complicated by severe pulmonary regurgitation due to complete damage of valve cusps. We performed pulmonary valve reconstruction using autologous pericardium using Ozaki's technique, with excellent outcomes.

Three-step preoperative sequential planning for pulmonary valve replacement in repaired tetralogy of Fallot using computed tomography.

OBJECTIVES: Our goal was to compare results between a standard computed tomography (CT)-based strategy, the 'three-step preoperative sequential planning' (3-step PSP), for pulmonary valve replacement in repaired tetralogy of Fallot versus a conventional planning approach. METHODS: We carried out a retrospective study with unmatched and matched groups. The 3-step PSP comprised the planning of mediastinal re-entry, cannulation for cardiopulmonary bypass (CPB) and the main procedure, using standard 3-dimensional videos. Operative times (skin incision to CPB, CPB time, end of CPB to skin closure and cross-clamp time) as well as postoperative length of stay and in-hospital mortality were compared. RESULTS: Eighty-two patients (49% classical tetralogy of Fallot) underwent an operation (85% with pulmonary homograft) with 1.22% in-hospital mortality. The 3-step PSP (n = 14) and the conventional planning (n = 68) groups were compared. There were no statistically significant differences in the preoperative characteristics. Differences were observed in the total operative time (P = 0.009), skin incision to CPB (P = 0.034) and cross-clamp times (74 ± 33 vs 108 ± 47 min; P = 0.006), favouring the 3-step PSP group. Eight matched pairs were compared showing differences in the total operative time (263 ± 44 vs 360 ± 66 min; P = 0.008), CPB time (123 ± 34 vs 190 ± 43 min; P = 0.008) and postoperative length of stay (P = 0.031), favouring the 3-step PSP group. CONCLUSIONS: In patients with repaired tetralogy of Fallot undergoing pulmonary valve replacement, preoperative planning using a standard CT-based strategy, the 3-step PSP, is associated with shorter operative times and shorter postoperative length of stay.

Percutaneous pulmonary valve implant: Two Colombian case reports.

Los pacientes con cardiopatías congénitas que afectan la continuidad del ventrículo derecho con la arteria pulmonar deben someterse con frecuencia a intervenciones debido a la limitada vida útil de los conductos quirúrgicos, lo que lleva al desarrollo de disfunción ventricular derecha por cambios en la geometría ventricular y predisposición a arritmias letales, con el consiguiente riesgo de reintervenciones. El implante valvular percutáneo pulmonar es una nueva alternativa terapéutica, menos invasiva en comparación con la quirúrgica, para pacientes seleccionados. Se realiza una revisión de las publicaciones médicas actuales disponibles y se describe la experiencia inicial del implante valvular pulmonar percutáneo en un centro colombiano de alta complejidad para el tratamiento de enfermedades cardiovasculares, en dos pacientes con disfunción del homoinjerto aórtico en posición pulmonar con doble lesión valvular, en los cuales el implante valvular pulmonar percutáneo fue una conducta exitosa. Se eligió a pacientes con cardiopatías congénitas, conductos quirúrgicos disfuncionales con estenosis o insuficiencia pulmonar significativa, y disfunción y dilatación ventricular derechas. Se empleó la técnica regular para el implante de la válvula pulmonar Melody, sin documentarse complicaciones durante el procedimiento ni al año de seguimiento. El implante percutáneo de la válvula pulmonar es un gran avance en el tratamiento de pacientes con cardiopatías congénitas, con resultados favorables a corto y mediano plazos, lo cual hace posible la restauración de la función ventricular con riesgo mínimo, frente al reemplazo quirúrgico en pacientes seleccionados.Patients with congenital heart disease that involves reconstruction of the right ventricular outflow tract must frequently undergo interventions derived from the limited useful life of the surgical canals, which leads to the development of right ventricular dysfunction due to changes in the ventricular geometry and predisposition to lethal arrhythmias, with the consequent risk of reinterventions. The percutaneous pulmonary valvular implant is a new therapeutic alternative, less invasive, compared to surgery, for selected patients. A review of the available literature is made and the initial experience of percutaneous pulmonary valve implantation in a Colombian center of high complexity for the treatment of cardiovascular diseases is described, in two patients with aortic homograft dysfunction in a pulmonary position with double valvular lesion, in which the percutaneous pulmonary valve implant was a successful strategy. Patients with congenital heart disease were chosen, with dysfunctional surgical conduits with stenosis or significant pulmonary insufficiency, with dysfunction and right ventricular dilatation. The standard technique for the implantation of the Melody pulmonary valve was used, without complications during the procedure or one year of follow-up. Percutaneous implantation of the pulmonary valve is a great advance in the management of patients with congenital heart diseases, with favorable results in the short and medium term, allowing the restoration of ventricular function with minimal risk, compared to surgical replacement in selected patients.

Implante percutáneo de válvula pulmonar: a propósito de dos casos colombianos / Percutaneous pulmonary valve implant: Two Colombian case reports

Resumen Los pacientes con cardiopatías congénitas que afectan la continuidad del ventrículo derecho con la arteria pulmonar deben someterse con frecuencia a intervenciones debido a la limitada vida útil de los conductos quirúrgicos, lo que lleva al desarrollo de disfunción ventricular derecha por cambios en la geometría ventricular y predisposición a arritmias letales, con el consiguiente riesgo de reintervenciones. El implante valvular percutáneo pulmonar es una nueva alternativa terapéutica, menos invasiva en comparación con la quirúrgica, para pacientes seleccionados. Se realiza una revisión de las publicaciones médicas actuales disponibles y se describe la experiencia inicial del implante valvular pulmonar percutáneo en un centro colombiano de alta complejidad para el tratamiento de enfermedades cardiovasculares, en dos pacientes con disfunción del homoinjerto aórtico en posición pulmonar con doble lesión valvular, en los cuales el implante valvular pulmonar percutáneo fue una conducta exitosa. Se eligió a pacientes con cardiopatías congénitas, conductos quirúrgicos disfuncionales con estenosis o insuficiencia pulmonar significativa, y disfunción y dilatación ventricular derechas. Se empleó la técnica regular para el implante de la válvula pulmonar Melody, sin documentarse complicaciones durante el procedimiento ni al año de seguimiento. El implante percutáneo de la válvula pulmonar es un gran avance en el tratamiento de pacientes con cardiopatías congénitas, con resultados favorables a corto y mediano plazos, lo cual hace posible la restauración de la función ventricular con riesgo mínimo, frente al reemplazo quirúrgico en pacientes seleccionados.

Abstract Patients with congenital heart disease that involves reconstruction of the right ventricular outflow tract must frequently undergo interventions derived from the limited useful life of the surgical canals, which leads to the development of right ventricular dysfunction due to changes in the ventricular geometry and predisposition to lethal arrhythmias, with the consequent risk of reinterventions. The percutaneous pulmonary valvular implant is a new therapeutic alternative, less invasive, compared to surgery, for selected patients. A review of the available literature is made and the initial experience of percutaneous pulmonary valve implantation in a Colombian center of high complexity for the treatment of cardiovascular diseases is described, in two patients with aortic homograft dysfunction in a pulmonary position with double valvular lesion, in which the percutaneous pulmonary valve implant was a successful strategy. Patients with congenital heart disease were chosen, with dysfunctional surgical conduits with stenosis or significant pulmonary insufficiency, with dysfunction and right ventricular dilatation. The standard technique for the implantation of the Melody pulmonary valve was used, without complications during the procedure or one year of follow-up. Percutaneous implantation of the pulmonary valve is a great advance in the management of patients with congenital heart diseases, with favorable results in the short and medium term, allowing the restoration of ventricular function with minimal risk, compared to surgical replacement in selected patients.

Determination of antibiotics and detergent residues in decellularized tissue-engineered heart valves using LC-MS/MS.

Residual chemicals that are presented during tissue processing in human tissue banks can be a risk for the allograft recipient. Determine the residual concentrations of the antibiotics and detergent used in the process of human decellularized tissue-engineered heart valves stored in isotonic saline solution up to 18 months. A total of 24 human decellularized allografts were stored in sterile sodium chloride and analyzed immediately after the decellularization process (0 months) and after storage for 6, 12, and 18 months, which includes the use of sodium dodecyl sulfate (SDS) and antibiotics (cefoxitin, vancomycin hydrochloride, lincomycin hydrochloride, polymyxin B sulfate). These valves were used for suitability tests, the zone of inhibition evaluation, and direct contact cytotoxicity assay. The stock solution from 32 valves was used for LC-MS/MS analysis of antibiotics and SDS. Tissue samples from decellularized valves showed a zone of inhibition formation for S. aureus and B. subtilis, suggesting the presence of an inhibitory molecule in the tissue. Cytotoxicity tests were negative. Polymyxin B, vancomycin, and SDS were detected and quantified in human decellularized aortic and pulmonary allografts during all periods of the study. There were no traces of residual cefoxitin and lincomycin in the tissue stock solution. We found residual concentrations of the antibiotics and detergent used in the process of human decellularized tissue-engineered heart valves stored in isotonic saline solution up to 18 months.

Histological and Biomechanical Characteristics of Human Decellularized Allograft Heart Valves After Eighteen Months of Storage in Saline Solution.

Background: The best storage preservation method for maintaining the quality and safety of human decellularized allograft heart valves is yet to be established. Objective: The aim of the present study was to evaluate the stability in terms of extracellular matrix (ECM) integrity of human heart valve allografts decellularized using sodium dodecyl sulfate-ethylenediaminetetraacetic acid (SDS-EDTA) and stored for 6, 12, and 18 months. Methods: A total of 70 decellularized aortic and pulmonary valves were analyzed across different storage times (0, 6, 12, and 18 months) for solution pH measurements, histological findings, cytotoxicity assay results, biomechanical test results, and microbiological suitability test results. Continuous data were analyzed using one-way analysis of variance comparing the follow-up times. Results: The pH of the stock solution did not change during the different time points, and no microbial growth occurred up to 18 months. Histological analysis showed that the decellularized allografts did not present deleterious outcomes or signs of structural degeneration in the ECM up to 12 months. The biomechanical properties showed changes over time in different aspects. Allografts stored for 18 months presented lower tensile strength and elasticity than those stored for 12 months (p < 0.05). The microbiological suitability test suggested no residual antimicrobial effects. Conclusion: Changes in the structure and functionality of SDS-EDTA decellularized heart valve allografts occur after 12 months of storage.