Percutaneous pulmonary valve implantation guided by three-dimensional rotational angiography

Abstract

Objectives: To describe the workflow and value of three-dimensional rotational angiography (3DRA) in percutaneous pulmonary valve implantation (PPVI).

Background: 3DRA offers visualization of the entire topography in the chest and may enhance safety and reduce the risk for complications in PPVI through improved pre-procedural planning and per-procedural guidance.

Methods: All PPVI procedures with the use of 3DRA performed between August 2011 and December 2022 were reviewed. Success rate, complications and radiation dose were assessed. Radiation dose of the latest 3DRA protocol was compared to historical 3DRA data.

Results: PPVI was successful in 95 of 102 procedures. Seven procedures were aborted due to coronary compression after balloon testing (n = 3), main pulmonary artery (MPA) oversize (n = 3) and not passing of a Melody valve through a calcified Melody valve in situ (n = 1). PPVI was attempted in 61 homografts, 19 native right ventricular outflow tracts (including transannular patch), 4 previously implanted Melody valves, 2 in previously implanted Sapien valves and 16 in other bioprosthetic valves. A Melody valve was implanted in 43, a Sapien valve in 49 and a Pulsta valve in 1 patient. In 2 patients a Melody as well as a Sapien valve were subsequently implanted. Mean total dose area product (DAP) was 11813 mGycm² and 179 mGycm²/kg for all attempted PPVI's. For successful PPVI 9835 mGycm² and 174 mGycm²/kg. After optimizing the 3DRA protocols the mean dose reduced from 12677 mGycm² to 8551 mGycm² (200 mGycm²/kg to 163 mGycm²/kg). Four patients experienced one or more complications. There were no deaths peri-procedural or during follow-up. Complications were; need for cardiopulmonary resuscitation (n = 2), MPA paravasation (n = 1), valve dysfunction (n = 2).

Conclusions: The use of rotational angiography for the guidance of PPVI results in a high success rate, low number of complications with the use of a low amount of radiation.

Keywords: Congenital heart disease; Coronary compression; Percutaneous pulmonary valve implantation; Pulmonary artery stenting; Three-dimensional rotational angiography.

Fig. 1

a. “Entire Heart” protocol b “Interrogation” protocol.

Fig. 2

Three-dimensional angiography in bifurcation stenting. Stents in situ; EV3 max LD stents, RPA 36 mm stent on BIB balloon 16 × 30mm; strut opening to LPA and stent through strut to LPA: EV3 mega LD 36 mm on BIB 16 × 30mm (Y-technique) Post-dilatation stents with Atlas 16x20mm. PPVI with a Melody 22 mm valve was performed in a second procedure.

Fig. 3

Coronary compression not anticipated from pre-procedural CTA.

Fig. 4

“Interrogation protocol” shows an inflated balloon (blue) and high resolution calcified tissue in the RVOT (yellow). A close relation to the LCA is visible and high risk for CC was estimated in this patient. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 5

Proximal left main compression during balloon inflation in the RVOT.

Fig. 6

Paravalvular leakage assessed with RVOT interrogation with a balloon (CBV Crystal Balt) and simultaneous contrast injection in the RVOT.

Fig. 7

a. Pre-procedural CTA with an MPA diameter of 25,3 mm. 7b. Unstable 30 × 40mm balloon in RVOT with passing of contrast (poorly visible in still frame).