Good results after catheter-based reintervention in patients with congenital heart disease
A transcatheter valve-in-valve procedure was just as good as repeat surgery for patients with failed bioprosthetic pulmonary valves, operators reported.
Among 66 patients at Emory Healthcare in Atlanta with congenital heart disease (CHD) needing revision procedures during 2007-2017, the 36 who got transcatheter pulmonary valve replacement (PVR) had the same outcomes after a median of 2.1 years of follow-up as the 30 undergoing surgical PVR redo:
- Mortality 2.8% versus 0.0% (P=1.00)
- Repeat PV intervention 0.0% versus 3.3% (P=0.46)
- Cardiovascular readmission 19.4% versus 16.7% (P=1.00)
Echocardiography showed lower peak PV gradients after transcatheter PVR (38.5 versus 55.5 mm Hg, P=0.05), but no difference in mean PV gradient between groups (25.4 versus 30.0 mm Hg, P=0.29), according to Vasilis Babaliaros, MD, of Emory University Hospital in Atlanta, and colleagues reporting online in JACC: Cardiovascular Interventions.
"The single death in the transcatheter PVR cohort was partially attributed to difficulty obtaining an airway," they said, concluding that transcatheter valve-in-valve PV implantation may be an "attractive alternative" to repeat surgical PVR in patients with failing bioprostheses.
There was less right ventricular (RV) dysfunction at 30 days among the transcatheter PVR group (2.9% versus 46.7%, P<0.01), though this difference was no more by 3 years. No endocarditis was observed in either group.
"One of the most important factors in the treatment of RV outflow tract lesions in operated CHD remains the timing of intervention. In absence of a valve substitute that would last for a lifetime, the best time to intervene remains an elusive holy grail in congenital cardiology," commented Sachin Khambadkone, MD, of London's Great Ormond Street Hospital Foundation, in an accompanying editorial.
The study by Babaliaros and colleagues, he said, "brings to attention now, more than ever before, the need for surgical techniques to accommodate and facilitate less invasive strategies in the lifetime management of congenital heart disease."
It is important to ensure that bioprosthetic valves inserted at the time of surgery are big enough to achieve as large an internal diameter as possible, Khambadkone suggested. Operators should also consider how pre-stenting might affect this internal diameter, he added.
Patients included in the study had congenital heart disease and received their repeat PV intervention at a median age of 30 years old, approximately 13-15 years after their previous surgical PVR. Median follow-up after revision was 776 days.
"In these younger patients, early discharge and ease of recovery may be more desirable as it allows patients to return to work, school, and other daily activities. Additionally, there may be unmeasured psychological merits of transcatheter PVR in CHD patients due to shorter hospitalizations and easier recoveries in patients with a history of significant hospital exposure," according to Babaliaros' group.
The transcatheter group all got Sapien or Melody balloon-expandable valves. As a whole, the patients included fewer men, and tended to have lower creatine and more New York Heart Association Class III/IV symptoms than the surgery arm.
More patients got surgery than transcatheter PVR for combined pulmonary stenosis and regurgitation (70.0% versus 47.2%, P=0.03).
On top of relying on a retrospective, single-center analysis, the complexity and diversity of the CHD cases makes it hard to directly compare between a transcatheter and surgical PVR, the authors acknowledged.
"The hemodynamic improvement is quite comparable in the two groups, but the use of echocardiography to assess tricuspid regurgitation and RV dysfunction has limitations, and use of cardiac MRI would have greatly enhanced the study," according to Khambadkone.
Babaliaros reported consulting for and receiving research support from Abbott Vascular and Edwards Lifesciences.
Khambadkone disclosed proctoring and consulting to Medtronic.
JACC: Cardiovascular Interventions
Source Reference: Caughron H, et al "Repeat pulmonary valve replacement: similar intermediate-term outcomes with surgical and transcatheter procedures" JACC Cardiovasc Interv 2018; DOI: 10.1016/j.jcin.2018.07.042.
JACC: Cardiovascular Interventions
Source Reference: Khambadkone S "Transcatheter pulmonary valve replacement for bio-prosthetic valve dysfunction -- an ode to the Hammurabi code" JACC Cardiovasc Interv 2018; DOI: 10.1016/j.jcin.2018.09.012.
Read the original article on Medpage Today: Redo PV Intervention Doesn't Have to Mean Surgery