Another Milestone accomplished by PGIMER
as a team comprising experts from Cardiology, CTVS & Anesthesia successfully perform
Transcatheter Pulmonary Valve Replacement
Patients with congenital heart disease affecting the right ventricle outflow tract often require surgery at a young age and right ventricle-pulmonary artery (RV-PA) conduit. Owing to degeneration and progressive pulmonary regurgitation and/or stenosis, these conduits require multiple surgical revisions leading to significant morbidity and mortality in these patients. In addition, free pulmonary regurgitation leads to right ventricle dilatation, failure, and arrhythmias.
Transcatheter pulmonary valve replacement (TPVR), first performed by Bonhoeffer et al. in 2000, is now an approved treatment for severe pulmonary regurgitation/stenosis and RV-PA conduit failure. Medtronic MelodyTM valve, Edwards SAPIENTM valve and Meril MyvalveTM are the three balloon-expandable valves which have been used for dysfunctional RV-PA conduits.
Department of Cardiology, PGIMER successfully implanted the first transcutaneous pulmonary valve in the region. The index patient is a 25 year old male, a known case of Tetralogy of Fallot (TOF), for which he was first operated at an age of 11 months. Due to severe pulmonary regurgitation and right heart enlargement, he underwent another open heart surgery in 2009 and a bioprosthetic pulmonary valve was implanted.
However, around 11 years after the second surgery, the implanted valve got dysfunctional with moderate stenosis and severe leakage. The patient and relatives were not keen on a third surgery. Besides, a redo open heart surgery (third time) to replace the valve would have been a technically challenging procedure; hence the patient was taken up for a percutaneous procedure. The technically challenging procedure to implant the pulmonary valve transcutaneously (MelodyTM (Medtronic)) was carried out by Prof (Dr) Manoj Kumar Rohit, Professor Cardiology, PGIMER. He has been discharged home and is doing well.
Second TPVR procedure was done in a 56 year old female, also a known case of TOF who underwent intracardiac repair at an age of 35 years. She was taken up for valve replacement due to right heart dilatation and severe pulmonary regurgitation. This patient was implanted with an Indian made valve Meril MyvalTM by a team consisting of Prof (Dr) Manoj Kumar Rohit . In both cases, the cardiac anaesthesia support was provided by Prof (Dr) GD Puri, Dean (Academics) & HOD Anaesthesia, PGIMER and Dr Sunder Negi, consultant Anaesthesia, PGIMER. Dr Shyam T, HOD & Professor cardiothoracic surgery, PGIMER and his team provided the required surgical backup.
Besides being less traumatic, the transcutaneously implanted pulmonary valve has a life similar to surgically placed valve. The short and long term outcomes of the valve are similar to ones placed surgically. With advent in technology, TPVR can now be done in a dysfunctional valve, as was done in our patient.
Prof (Dr) Manoj Kumar Rohit stated that we have many postoperative patients of TOF who develop right heart failure on long term follow up due to pulmonary regurgitation. Since most of them already have had one or more open heart surgeries in the past, a redo surgery becomes a very challenging procedure for them and many patients are unfit for surgery. He said that TPVR in such patients decrease periprocedural morbidity & mortality and the long term results remain comparable to surgically implanted valves. He also stressed on the point that at present TPVR remains a very costly alternative due to which many of our patients could not afford this treatment. He said that efforts should be made to make this procedure more affordable for our patients.
Cardiology:Dr Manojkumar Rohit, Professor & Incharge Cardiology 2 & Dr Navjot Kaur Senior Resident