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Percutaneous implantation of Edwards SAPIEN valve into pulmonary bioprosthesis (valve-in-valve)

Lombardi, Maristella; Violini, Roberto; Fiorella, Annalisa; Tagliente, Maria Rosaria; Vairo, Ugo

Journal of Cardiovascular Medicine: January 2013 - Volume 14 - Issue 1 - p 74–75
doi: 10.2459/JCM.0b013e3283528fa9
Images in cardiovascular medicine

We report the case of a 14-year-old boy affected by Tetralogy of Fallot and pulmonary atresia, who had already undergone multiple surgical procedures. He had later developed a steno-insufficiency of the pulmonary bioprosthesis. We performed a percutaneous pulmonary valve implantation (PPVI), which is a minimally invasive treatment, as effective as conventional valve surgery and associated with less morbidity and mortality. Up to now PPVI has been carried out in patients with chronic pulmonary vascular resistance (PVR) in the presence of a right ventricular outflow tract (RVOT) patch by prior deployment of an intravascular stent as an artificial conduit that makes subsequent valve implantation possible. The peculiarity of our procedure was that we implanted the valve directly on to the annulus of the bioprosthesis (valve-in-valve), without performing a prestenting of the prosthetic valve.

aPediatric Cardiology, Azienda Policlinico - Ospedale Pediatrico Giovanni XXIII, Bari, Italy

bInterventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy

Correspondence to Maristella Lombardi, MD, Azienda Policlinico-Ospedale Pediatrico Giovanni XXIII, Bari, Italy Tel: +39 0805596698; fax: +39 0805596835; e-mail:

Received 30 October, 2011

Revised 31 December, 2011

Accepted 7 February, 2012

D.T. is a 14-year-old boy with a history of Tetralogy of Fallot and pulmonary atresia. He was palliated neonatally by means of a Blalock–Taussig shunt and a pulmonary homograft patch repair when he was 1 year old. He had a right ventricular (RV) outflow tract reconstruction and a Carpentier–Edwards valve n.21 implantation following the development of severe pulmonary regurgitation and RV dilation at the age of 8. Due to prosthetic valve stenosis, two balloon valvuloplasty procedures were performed, yet the results were not satisfactory. MRI performed at the age of 14 documented stenosis/insufficiency of the prosthetic valve (regurgitant fraction 25–30%) and right-ventricular dilation (end-diastolic volume 154 ml/m2 – Z-value +4.7, ejection fraction 50%); thus percutaneous pulmonary valve implantation (PPVI) was recommended.1 The procedure was performed under general anesthesia using fluoroscopic guidance. Hemodynamic and angiographic evaluation was used to determine the severity and location of the stenosis. The patient underwent percutaneous implantation of an Edwards SAPIEN valve n.23. The valve was implanted on to the annulus of the Carpentier–Edwards bioprosthesis without prestenting (‘valve-in-valve’) via the right femoral vein using the Edwards RetroFlex 3 Transfemoral Delivery System. The timed fluorine per minute procedure was 20/163. The ratio between RV and systemic pressure decreased from 80/100 mmHg (preprocedure) to 40/100 mmHg (postprocedure). At angiography pulmonary insufficiency appeared severe (Fig. 1). After deployment of the Edwards SAPIEN valve, control angiography showed no pulmonary regurgitation (Fig. 2). The procedure had no complications. Two days after the procedure two-dimensional echo showed no right ventricle–pulmonary artery (RV–PA) gradient and confirmed the absence of pulmonary regurgitation (Fig. 3). The patient was discharged on antiplatelet therapy (aspirin 100 mg/day).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

PPVI provides a less invasive treatment alternative to surgery for failed conduits and valves.2–4 It is currently employed to prolong the lifespan of RV–PA conduits1 and thereby to postpone open heart surgery. Native or patched outflow tracts after surgical repair for Tetralogy of Fallot tend to be dilated and dynamic and therefore do not provide a secure implantation site.5 A stent acts as a landing zone for the PPVI. In our patient the pre-existent annulus of the Carpentier–Edwards bioprosthesis provided a suitable support for the implantation of the Edwards SAPIEN valve, thus avoiding the need for prestenting, which is usually required in this type of procedure. In addition to a recent publication,6 our study indicates that this valve can be proposed for a less invasive and effective treatment of pulmonary valve dysfunction.

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We thank Dr Francesco Latrofa for his useful suggestions in the draft of the manuscript.

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2. McElhinney DB, Hellenbrand WE, Zahn EM, et al. Short- and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US Melody valve trial. Circulation 2010; 122:507–516.
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5. Momenah TS, El Oakley R, Al Najashi K, Khoshhal S, Al Qethamy H, Bonhoeffer P. Extended application of percutaneous pulmonary valve implantation. J Am Coll Cardiol 2009; 53:1859–1863.
6. MacDonald ST, Carminati M, Butera G. Percutaneous implantation of an Edwards SAPIEN valve in a failing pulmonary bioprosthesis in palliated Tetralogy of Fallot. Eur Heart J 2011; 32:1534.

congenital heart disease; interventional cardiology; percutaneous pulmonary valve implantation

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