Abstract
Percutaneous pulmonary valve implantation (PPVI) can replace surgery for treatment of right ventricular outflow tract (RVOT) dysfunction after repair of congenital heart disease. Commonly accepted indications are:
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(a, b, c) Angiographies are performed in RVOT and/or RV and ascending aorta. Anteroposterior (AP) view with cranial angulation and left anterior oblique (LAO) view (a): Relationship between the bifurcation and distal end of the stent; Landing zone, final target diameter to be achieved with Melody valve. Lateral (LL) view (b and c): Anterior chest, landing zone and proximal end of the stent; Coronary arteries during balloon interrogation of RVOT (MOV 11905 kb)
(a, b, c) Angiographies are performed in RVOT and/or RV and ascending aorta. Anteroposterior (AP) view with cranial angulation and left anterior oblique (LAO) view (a): Relationship between the bifurcation and distal end of the stent; Landing zone, final target diameter to be achieved with Melody valve. Lateral (LL) view (b and c): Anterior chest, landing zone and proximal end of the stent; Coronary arteries during balloon interrogation of RVOT (MOV 9922 kb)
Coronary artery compression/distortion has to be ruled out before PPVI. Pre-interventional evaluation with cMRI or angio-CT scan may identify patients at high risk of coronary involvement. However, aortography or selective coronary angiography in multiple projections and during balloon interrogation of RVOT are required in all patients in whom PPVI is attempted: Low-pressure dilatation if both coronary arteries are distant from RVOT; Full balloon inflation (with either low or high-pressure balloons) if coronary arteries are near. If coronary compression occurs or appears highly probable, PPVI is contraindicated (MOV 10816 kb)
Coronary artery compression/distortion has to be ruled out before PPVI. Pre-interventional evaluation with cMRI or angio-CT scan may identify patients at high risk of coronary involvement. However, aortography or selective coronary angiography in multiple projections and during balloon interrogation of RVOT are required in all patients in whom PPVI is attempted: Low-pressure dilatation if both coronary arteries are distant from RVOT; Full balloon inflation (with either low or high-pressure balloons) if coronary arteries are near. If coronary compression occurs or appears highly probable, PPVI is contraindicated (MOV 6829 kb)
Pre-stenting. A 14Fr Mullins long sheath is used. Length of the stent should be enough to cover the stenotic area and the entire length of the Melody valve. Implant a second or third stent in case of significant recoil at fluoroscopy. Repeat coronary angiogram before further dilation in case of any doubt, Covered stent(s) are used in case of extravasation or in cases with significant calcifications (MOV 6157 kb)
Valve implantation into the landing zone. Inner balloon is already inflated. It’s important to have a simultaneous view of right atrium, target zone, and distal tip of wire (MOV 16391 kb)
Post-dilatation of the valve may be needed in the presence of a residual gradient (>20 mmHg) and incomplete expansion of the valved stent. Use appropriately sized ultra-high-pressure balloon with a maximum balloon size of 24 mm (MOV 8979 kb)
Final angiographies in the infundibulum (LL, AP with cranial angulation) and the pulmonary trunk/stent (AP with cranial angulation ± LAO) are performed to: rule out extravasations of contrast; evaluate stent apposition to the walls of RVOT, valve competence and flow into the pulmonary branches (MOV 8133 kb)
Final angiographies in the infundibulum (LL, AP with cranial angulation) and the pulmonary trunk/stent (AP with cranial angulation ± LAO) are performed to: rule out extravasations of contrast; evaluate stent apposition to the walls of RVOT, valve competence and flow into the pulmonary branches (MOV 10175 kb)
Final angiographies in the infundibulum (LL, AP with cranial angulation) and the pulmonary trunk/stent (AP with cranial angulation ± LAO) are performed to: rule out extravasations of contrast; evaluate stent apposition to the walls of RVOT, valve competence and flow into the pulmonary branches (MOV 10371 kb)
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Butera, G., Lunardini, A., Chessa, M. (2019). Melody Valve Implantation in Pulmonary Position. In: Butera, G., Chessa, M., Eicken, A., Thomson, J.D. (eds) Atlas of Cardiac Catheterization for Congenital Heart Disease. Springer, Cham. https://doi.org/10.1007/978-3-319-72443-0_26
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DOI: https://doi.org/10.1007/978-3-319-72443-0_26
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