Ventricular Fibrillation Arrest and Pulmonary Homograft Rupture During Transcatheter Pulmonary Valve: Successful Rescue by Heart Team

We describe a 31-year-old woman with pulmonary homograft rupture and ventricular fibrillation arrest complicating a transcatheter pulmonary valve (TPV) procedure. She underwent extracorporeal membrane oxygenation (ECMO) with immediate surgical repair including bioprosthetic pulmonary valve replacement. She had difficulty weaning off ECMO due to hyperacute failure of the valve and ultimately underwent successful hybrid TPV with complete recovery. This case illustrates the importance of the heart team approach during catheter and surgical interventions in adult congenital heart disease.

Aspergillus Endocarditis of Pulmonary Homograft in a Congenital Heart Disease Patient

Aspergillus endocarditis (AE) is a life-threatening condition with mortality rates approximating 80%. Herein, we describe the case of a 19-year-old patient with congenitally corrected transposition of great arteries, ventricular septal defect, and pulmonary atresia, who underwent seven cardiac surgical procedures in the past. The patient was operated for AE of a previously implanted pulmonary valve homograft associated with septic pulmonary embolism and right heart failure but succumbed to multi-organ failure three months later. To our knowledge, this is one of two reported cases of Aspergillus infection of a pulmonary homograft, indicating the rarity of the disease.

Outcomes Following Heterotopic Placement of Right Ventricle to Pulmonary Artery Conduits

Background: We sought to evaluate the outcomes following right ventricle to pulmonary artery (RV-PA) conduit placement in pediatric patients, excluding those with a RV-PA conduit for the Ross procedure which is associated with improved conduit durability, partly related to its orthotopic position. Methods: Outcomes for 119 patients who underwent RV-PA conduit placement at a single institution from January 2004 to December 2016 were reviewed. Primary outcome measures were reintervention-free survival (RFS) and overall survival. Survival analyses were performed using the Kaplan-Meier method, and risk factors associated with reintervention were evaluated. Results: The median age at the time of conduit placement was 6 months (interquartile range, IQR: 1-14), and the median length of follow-up was 63 months (range: 0-156). During follow-up, 39 patients required conduit-related reintervention, while 6 patients died perioperatively with an overall survival of 90% at 10 years. Among the remaining 113 patients, the RFS at one, five, and ten years was 91% (84%-95%), 72% (60%-80%), and 33% (16%-50%), respectively. The median time to conduit replacement in the series was 43.5 months (IQR: 19.3-76.2). The use of a pulmonary homograft was associated with improved RFS ( P = .03), and this was particularly pronounced in comparison with aortic homografts in neonates. Infection was the indication for replacement in only one patient. Conclusions: The majority of the conduits placed during the neonatal period required conduit replacement before the age of five years. Endocarditis was not a common indication for replacement. In neonates and infants, we prefer pulmonary homografts for most indications.

Mechanism of transcatheter heart valve deployment for right ventricular outflow tract insufficiency after surgical reconstruction in childhood as assessed with intravascular ultrasound

Introduction Transcatheter heart valve (THV) deployment can be used to treat right ventricular outflow tract (RVOT) insufficiency. Purpose To study deployment mechanism of a balloon expandable THV (Melody or Edwards SAPIEN [ES] 3) implanted for pulmonary homograft insufficiency using intravascular ultrasound (IVUS) with Visions PV.035 Digital Catheter (Philips) offering an imaging field of 60mm. Methods Sequential (baseline and post-THV) IVUS was performed in 6 pts (median age 33 [20–44] yrs, 3 ♀, all with Tetralogy of Fallot) who had undergone prior corrective surgery (4 transannular patch, 1 bioprosthetic valve or 1 pulmonary homograft), but who presented with significant RVOT insufficiency. IVUS-visualized homograft cross-sections were perpendicular to its long axis and were obtained along the entire homograft length (Fig. 1). Volumetric measurements included the native pulmonary homograft (inner lumen and outer dimension) and the corresponding inner-stent/inner-THV cross-sections post-THV for a total of 16 evenly spaced cross-sections per analyzed region. Each THV (1 Melody [Ø 22mm, 28mm nominal length] and 5 ES3 [Ø 23mm, 18mm height; 4 Ø 29mm, 22.5mm height]) was implanted after pre-stenting using stents of 36, 39, or 48mm length, deployed on a 24mm (n=1) or 30mm (n=4) balloon-in-balloon catheter. Results Overall, there were 96 paired cross-sections. There was significant increase in average lumen dimension after THV deployment (Δ of 97.5mm2) accompanied by the similar increase in outer pulmonary homograft dimensions (Δ of 84.0mm2) (Table 1). Whereas the maximal lumen diameter was unchanged, the minimal lumen diameter increased significantly resulting in substantial decrease in the ratio of max/min lumen diameter of 1.41±0.20 vs 1.16±0.13 (p<0.001) representing a reduction in lumen eccentricity. Conclusions During balloon-expandable THV implantation to treat RVOT insufficiency, there is a significant increase in baseline lumen dimensions accompanied by a substantial outer RVOT dimension increase to normalize lumen eccentricity. Figure 1. IVUS intraprocedural visualisation Funding Acknowledgement Type of funding source: None