Long term outcome of mechanical valve prosthesis in the pulmonary position
Introduction
Pulmonary valve replacement is becoming increasingly common due to the development of long term complications in the growing population of adults with repaired congenital heart defects, particularly those diagnosed with tetralogy of Fallot. Long lasting severe pulmonary regurgitation with progressive right ventricular dilatation is the main indication for pulmonary valve replacement (PVR) in this cohort of patients.
When it comes to prosthesis selection, tissue valves are usually the preferred option [1] but their limited longevity [2], [3] makes reoperation almost unavoidable. Given the young age of these patients at the time of valve replacement, they may require repeated interventions during their lifespan, with an expected increasing surgical complexity.
Mechanical prostheses at pulmonary position have a less favorable reputation due to the increased risk of thrombosis reported in some limited old series [4], [5], [6]. However, more recent reports with appropriate anticoagulation management have failed to show such high risk of thrombosis,[7], [8], [9] proposing mechanical valve prosthesis as an alternative in patients with multiple reoperations given its potential longer durability.
The aim of our study was to evaluate the long term results of mechanical prostheses at pulmonary position implanted in our centre, with especial attention to hemorrhagic and thrombotic complications.
Section snippets
Patients and methods
After approval by the institutional research ethics board, 31 PVR procedures between February 1977 and October 2007 were identified using a prospectively maintained cardiovascular surgery database at the Hospital de la Santa Creu i Sant Pau. Of those, 6 procedures were tissue valve implants and 25 were mechanical valve prostheses, three of which were a second replacement. Therefore, our study sample consisted of 22 patients undergoing 25 pulmonary mechanical valve implantations. The selection
Results
There is complete follow up for all the patients except for a repaired tetralogy of Fallot male with severe pulmonary regurgitation and preoperative signs of overt heart failure who underwent PVR at 16 years of age. He continued follow up in another institution and no information about his current status could be retrieved. Two of the patients (patients 1 and 22) were initially lost to follow up. They returned to our outpatient clinic several years later (further details about these cases are
Discussion
In the last years an important change in the epidemiology of congenital heart diseases has occurred [11]. The good operative results achieved in the past decades and the improvement of survival in children with congenital heart disease repaired during childhood, are the main determinants for the increasing number of adults with residual lesions which may require reoperation during follow up. A major part of the reoperations in this population will consist of pulmonary valve implantation or
Limitations
Only the most recent patients in our series had preoperative cardiac magnetic resonance for assessment of right ventricular volumes and ejection fraction, which is currently considered the gold standard technique for assessment of right ventricular function. The majority of the patients had only qualitative estimate of right ventricular function on preoperative echocardiography and, in the oldest cases, description of the right ventricular performance was even lacking in the report.
Conclusions
According to our experience, mechanical prosthesis in the pulmonary position may be contemplated as an alternative to tissue valve prosthesis. Proper anticoagulation management is essential for good long-term results and addition of antiplatelet treatment should be considered. Patients with severe right ventricular dysfunction and congestive heart failure are suboptimal candidates, given the high risk of valve thrombosis in this cohort.
Acknowledgements
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [18].
References (18)
- et al.
Pulmonary valve replacement late after repair of tetralogy of Fallot
Ann Thorac Surg
(1997) - et al.
Experience with St. Jude Medical valve prosthesis in children. A word of caution regarding right-sided placement
J Thorac Cardiovasc Surg
(1987) - et al.
In vitro closing behavior of the St. Jude Medical heart valve in the pulmonary position. Valve incompetence originating in the prosthesis itself
J Thorac Cardiovasc Surg
(1992) - et al.
Cardiac valve prostheses in children without anticoagulation
J Thorac Cardiovasc Surg
(1984) - et al.
Mechanical valves in the pulmonary position: a reappraisal
J Thorac Cardiovasc Surg
(1998) - et al.
Is there a role for mechanical valved conduits in the pulmonary position?
Ann Thorac Surg
(2005) - et al.
Risk factors for arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: a multicentre study
Lancet
(2000) - et al.
Low-dose international normalized ratio self-management: a promising tool to achieve low complication rates after mechanical heart valve replacement
Ann Thorac Surg
(2005) Ethical authorship and publishing
Int J Cardiol
(2009)
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Long-term follow-up after pulmonary valve replacement in repaired tetralogy of fallot
2014, American Journal of Cardiology