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Pulmonary Valve Replacement and Repair: Valvuloplasty Device – Tissue (bioprosthetic) or mechanical valve;  Surgery type – Transcatheter Pulmonary Valve Replacement (TPVR) vs Open Heart, Valve Repair – Commissurotomy, Valve-ring Annuloplasty

Reporter: Aviva Lev-Ari, PhD, RN

SOURCE

Journal of the American College of Cardiology

http://www.onlinejacc.org/content/60/11/1005

Pulmonary valve repair and replacement at Mayo Clinic

Mayo Clinic’s approach

Types

1. Annuloplasty
2. Valvuloplasty

Why it’s done

Image Source: Mayo Clinic

• Pulmonary valve regurgitation

Pulmonary valve disease treatment depends on the severity of your condition, whether or not you’re experiencing signs and symptoms, and if your condition is getting worse.

Many types of pulmonary valve disease are caused by heart conditions present at birth (congenital heart disease). Types of pulmonary valve disease that may require treatment with pulmonary valve repair or pulmonary valve replacement include:

Pulmonary valve regurgitation is a leaky pulmonary valve. The leaky valve allows blood to flow backward into the heart rather than directly to the lungs for oxygen.

The most common cause of pulmonary valve regurgitation is pulmonary hypertension. Other causes of pulmonary valve regurgitation are congenital heart disease (specifically, tetralogy of Fallot or congenital pulmonary valve stenosis), bacterial infection of the heart (infective endocarditis), complications after heart surgery, and rarely rheumatic fever.

Pulmonary valve stenosis occurs when the pulmonary valve becomes thickened or obstructed, which makes it harder for it to open properly and for the heart to pump blood into the pulmonary artery and to the lungs.

The cause of pulmonary valve stenosis is usually unknown. It often affects children and may be caused by congenital heart disease or an infection in the mother during pregnancy. It can also occur in adults as a result of a rare type of cancer that affects the heart (carcinoid heart disease).

Pulmonary atresia is a congenital heart defect in which a child is born without a well-defined pulmonary valve. In pulmonary atresia, blood can’t flow from the right ventricle into the pulmonary artery. The only blood flow to the lungs is through an open passageway between the pulmonary artery and the main artery supplying blood to the body (aorta).

The cause is usually unknown. Children born with pulmonary atresia may also have other heart defects.

For some people with mild pulmonary valve disease without symptoms, careful monitoring under a doctor’s supervision may be all that’s needed.

But in many cases, pulmonary valve disease and dysfunction progress in adulthood and get worse without medical treatment. Most pulmonary valve conditions are mechanical problems that cannot be adequately treated with medications alone and will eventually require surgery to reduce symptoms and the risk of complications, such as heart failure, or death due to advanced heart failure or sudden cardiac arrest.

The decision to repair or replace a damaged pulmonary valve depends on many factors, including:

• The severity of your pulmonary valve disease
• Your age and overall health
• Whether you need heart surgery to correct another heart problem in addition to pulmonary valve disease, such as another valve surgery, for example, tricuspid valve repair or replacement, so both conditions can be treated at once

In general and whenever possible, heart valve repair is the preferred option because it is associated with a lower risk of infection, preserves valve strength and function, and eliminates the need to take blood-thinning medications, which may be necessary with valve replacement.

But not all valves can be repaired, and heart valve repair surgery is often harder to do than valve replacement. Your best option will depend on your individual situation as well as the expertise and experience of your health care team.

Pulmonary valve repair and pulmonary valve replacement may be performed via traditional open-heart surgery, which involves a cut (incision) in the chest (sternotomy), or via minimally invasive methods that involve smaller incisions in the chest (hybrid approach) or a catheter-based approach.

What type of procedure you have depends on the severity of your pulmonary valve disease, overall health and whether you need additional heart surgery to treat other issues.

A number of patients with congenital heart disease have problems with their pulmonary valve, either since birth, or after cardiac surgery. For many patients, a valve replacement may be recommended.

Until the last decade replacing a faulty pulmonary valve could only be done with open heart surgery. Because all surgically implanted valves have a limited life-span, patients faced many surgeries over the course of their life to replace the pulmonary valve. The percutaneous, non-surgical option to replace the pulmonary valve has revolutionized the care of these patients.

Image Source: Medtronic, 2017

Who can benefit from TPVR?

Patients who may benefit from a transcatheter pulmonary valve include those with:

• Tetralogy of Fallot who have had prior surgery but now have a leaky or narrowed pulmonary valve, especially if they have undergone a prior surgical replacement.
• Patients with other underlying diagnoses who also have a surgically implanted pulmonary valve (such as a homograft or a bioprosthetic valve) that is no longer working well; including patients with truncus arteriosus, patients with aortic valve disease who have had a Ross procedure, and some patients with pulmonary stenosis or atresia.

The goals of transcatheter pulmonary valve replacement is to replace the pulmonary valve non-surgically and decrease the number of heart surgeries a patient will need over their life-time.

Evaluation

To see if you are a possible candidate for treatment with the transcatheter pulmonary valve, you’ll have a comprehensive evaluation by a multidisciplinary team. The evaluation focuses on the patient’s condition, anatomy, and management options and will include:

• Physical exam.
• Diagnostic tests including an echocardiogram, cardiac MRI, or cardiac CT scan (the latter if you cannot have an MRI due to, for example, having a pacemaker).

Treatment

There are 2 valves currently approved by the FDA for this indication, the Melody valve and the Edwards SAPIEN XT valve. Both are tissue valves that are sutured to a stent, which is a thin metal cylinder that is mounted on a balloon catheter.

TPVR Procedure

The procedure is performed in a pediatric and adult congenital cardiac catheterization lab by an interventional cardiologist with expertise in congenital cardiac interventions, utilizing fluoroscopy and angiography to see the anatomy and evaluate the function of the heart valves.

A catheter is placed through a small incision into the femoral vein (in the groin) or the jugular vein in the neck.

A compressed tissue heart valve is placed on a balloon catheter; advanced through the vein to the heart, and is positioned directly inside the diseased pulmonary valve. Once in position, the balloon is inflated expanding the stent and the valve is secured in place. The new valve immediately begins to work. The catheter is then removed.

Patients are observed overnight and discharged the following morning. Usually you can return to your normal activities in 7 days.

Physicians with expertise in catheter interventions for congenital heart disease have been performing this procedure at the Cleveland Clinic since 2010. Both the Melody valve and the Edwards SAPIEN valve have been used, depending on the size needed for a particular patient. No patient with underlying congenital heart disease has had a severe complication and no patient has required removal of the valve to date.

SOURCE

https://my.clevelandclinic.org/health/treatments/17571-transcatheter-pulmonary-valve-replacement-tpvr

Pulmonary Valve Surgery at John Hopkins 

Why doesn’t my heart valve work properly?

From The Illustrated Field Guide to Congenital Heart Disease and Repair – Second Edition courtesy of Scientific Software Solutions Inc.

The valves in your heart may be damaged due to infection, rheumatic heart disease or birth (congenital) defects. The affected valve leaflets (cusps) may grow thick and brittle from scar tissue or calcium deposits, or they may become thin and weak resulting in an inefficient valve.

There are several terms referring to valve disease.

• Stenosis – the opening of the valve becomes smaller, thus allowing less blood to flow through.
• Regurgitation/Insufficiency (leaky valve) – the valve does not close properly and allows blood to flow backward as well as forward in the heart.

How will I feel?

Due to the damaged valve, your heart must work harder to pump blood throughout the body.  You may tire easily and feel short of breath with less activity or exercise.  You may experience an irregular heartbeat due to over-stretching of the heart muscle as in mitral stenosis, or dizziness and near fainting due to decreased blood flow to the brain as in aortic stenosis.

How will my valve be fixed?

Depending on the extent of your valve disease, you may need to have the valve repaired or replaced.  To repair the valve, your surgeon may perform a commissurotomy or implant a valve ring.  A commissurotomy is performed for a tight valve (stenosis).  The valve leaflets are cut to loosen the valve slightly, allowing blood to pass easily.  Another type of valve repair is a valve ring annuloplasty, which is sewn in place when the valve is leaking (regurgitant or insufficient).  The valve leaflets are tucked in place with the ring.

Often the valve cannot be repaired and the surgeon must replace the damaged valve with a tissue (bioprosthetic) or mechanical valve.  Tissue valve are valves from animals (e.g., cow, pig).  They generally do not require long-term anticoagulation and are not as durable as mechanical valves.  Mechanical valves are made from materials such as plastic or metal.  They require long-term anticoagulation and are considered extremely durable, lasting longer than tissue valves.

Your surgeon will discuss the need for repair or replacement of the valve with you prior to surgery as well as the type of valve (tissue or mechanical) should replacement be necessary.

Annuloplasty Ring

Tissue Valve

Mechanical Valve

Valve Replacement Surgery: What else should I know?

Prevention of Valve Infection

To prevent an infection (endocarditis) from occurring around the new heart valve or ring, you should receive antibiotics before having any procedures that could permit bacteria to enter your body.  Among these procedures are:

• All dental procedures (cleaning, filling, removing teeth, root canals, gum or ulcer treatment). You may use dental floss, In fact, we encourage you to reduce tartar with any approved method.
• Surgical procedures such as colonoscopy, cystoscopy, or other surgical procedures.

SOURCE

https://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/treatments/valve_pulmonary.html