Transcatheter pulmonic valve implantation: Techniques, current roles, and future implications

Abstract

Right ventricular outflow tract (RVOT) obstruction is present in a variety of congenital heart disease states including tetralogy of Fallot, pulmonary atresia/stenosis and other conotruncal abnormalities etc. After surgical repair, these patients develop RVOT residual abnormalities of pulmonic stenosis and/or insufficiency of their native outflow tract or right ventricle to pulmonary artery conduit. There are also sequelae of other surgeries like the Ross operation for aortic valve disease that lead to right ventricle to pulmonary artery conduit dysfunction. Surgical pulmonic valve replacement (SPVR) has been the mainstay for these patients and is considered standard of care. Transcatheter pulmonic valve implantation (TPVI) was first reported in 2000 and has made strides as a comparable alternative to SPVR, being approved in the United States in 2010. We provide a comprehensive review in this space–indications for TPVI, detailed procedural facets and up-to-date review of the literature regarding outcomes of TPVI. TPVI has been shown to have favorable medium-term outcomes free of re-interventions especially after the adoption of the practice of pre-stenting the RVOT. Procedural mortality and complications are uncommon. With more experience, recognition of risk of dreaded outcomes like coronary compression has improved. Also, conduit rupture is increasingly being managed with transcatheter tools. Questions over endocarditis risk still prevail in the TPVI population. Head-to-head comparisons to SPVR are still limited but available data suggests equivalence. We also discuss newer valve technologies that have limited data currently and may have more applicability for treatment of native dysfunctional RVOT substrates.

Keywords: Pulmonary valve, Congenital heart defects, Heart valve prosthesis implant, Pulmonary valve insufficiency, Pulmonary atresia, Pulmonary valve stenosis

Core Tip: As patients with congenital heart defects continue to survive well into adult life, right ventricular function preservation and management of the right ventricular outflow tract has become increasingly important and sophisticated. As an alternative to surgical pulmonary valve replacement (PVR), the advent of transcatheter pulmonic valve therapy has offered a less invasive approach for many patients. Improved techniques and technologies have rapidly expanded its use in increasingly complex anatomy. In this review we summarize the indications for PVR, transcatheter pulmonic valve implantation techniques, clinical outcomes and also future directions of this treatment.