Outcomes Of Pulmonary Valve Replacement By Prosthetic Type In Adults With Congenital Heart Disease
Dane C. Paneitz, Selena Li, Ami Bhatt, Duke E. Cameron, Jordan P. Bloom.
Massachusetts General Hospital, Boston, MA, USA.
Objectives: Pulmonary valve replacements (PVR) are increasingly common in the adult congenital heart disease (ACHD) population. We sought to compare important outcomes by the type of prosthetic valve implanted.
Methods: This was a retrospective analysis of a single institutional cohort which included ACHD patients with a history of surgical intervention who subsequently required a PVR between 2004-2020. The valve types were categorized as pericardial, porcine, or mechanical. Comparisons were made using Wilcoxon rank-sum, Fisher's exact, and log-rank tests as appropriate.
Results: Table 1 displays the total and valve-specific characteristics and results of the comparisons. There was no difference in 30-day mortality or 1-year mortality between the valve types. Patients who received a mechanical valve were more likely to develop new atrial fibrillation (69.2%) compared to pericardial (28.7%) and porcine valves (44.7%, P = 0.01). Over a median follow-up of 63 months, there was no difference in survival (P=0.18). There was no difference in the rates of stroke, pulmonary embolism, or endocarditis between the valve types. Overall, three patients (2.0%) developed moderate pulmonary stenosis, and 6 patients (4.1%) required a reoperation.
Conclusions: Pulmonary valve replacement can be safely performed in the ACHD population with excellent long-term survival and valvular function, although further investigation is warranted to determine the optimal prosthetic valve type. Mechanical valves were associated with increased risk of atrial fibrillation.
| Table 1. Patient Characteristics and Results | |||||
| Congenital Diagnosis | Pericardial (n=94) | Porcine (n=38) | Mechanical (n=13) | Total (n=145) | P value |
| Tetralogy of Fallot/TOF-PA | 62 (66.0) | 28 (73.7) | 9 (69.2) | 99 (68.3) | 0.67 |
| Congenital Pulmonary Stenosis | 19 (20.2) | 5 (13.2) | 1 (7.7) | 25 (17.2) | 0.51 |
| VSD | 6 (6.4) | 0 | 2 (15.4) | 8 (5.5) | 0.06 |
| Other | 7 (7.4) | 5 (13.2) | 1 (7.7) | 13 (9.0) | 0.54 |
| Age at First Operation, median (IQR) | 10.0 (4.0, 20.0) | 7.0 (2.0, 15.0) | 19.0 (14.0, 22.0) | 8.0 (4.0, 29.0) | 0.049 |
| Age at Definitive Repair, median (IQR) | 14.0 (7.0, 27.0) | 16.0 (6.0, 31.3) | 27.0 (17.0, 33.0) | 17.0 (7.0, 30.0) | 0.12 |
| Type of Prior Palliation | |||||
| Received Any Type of Intervention | 30 (31.9) | 14 (36.8) | 6 (46.2) | 50 (34.5) | 0.54 |
| Shunt | 27 (28.7) | 12 (31.6) | 4 (30.8) | 43 (29.7) | 0.96 |
| Blalock-Thomas-Taussig | 25 (26.6) | 10 (26.3) | 2 (15.4) | 37 (25.5) | 0.76 |
| Waterston | 2 (2.1) | 3 (7.9) | 2 (15.4) | 7 (4.8) | 0.045 |
| Potts | 1 (1.1) | 0 | 0 | 1 (0.7) | 0.99 |
| Pulmonary Artery Banding | 1 (1.1) | 0 | 2 (15.4) | 3 (2.1) | 0.02 |
| Type of Definitive Repair | |||||
| Transannular Patch | 23 (24.5) | 13 (34.2) | 0 | 36 (24.8) | 0.03 |
| RV/PA conduit | 4 (4.3) | 0 | 1 (7.7) | 5 (3.4) | 0.25 |
| Pulmonic Valvotomy | 7 (7.4) | 2 (5.3) | 2 (15.4) | 11 (7.6) | 0.47 |
| PVR/Valvuloplasty | 13 (13.8) | 2 (5.3) | 1 (7.7) | 16 (11.0) | 0.45 |
| VSD Closure/Patch | 23 (24.5) | 2 (5.3) | 5 (38.5) | 30 (20.7) | 0.01 |
| Ross Procedure | 2 (2.1) | 1 (2.6) | 0 | 3 (2.1) | 0.99 |
| Arterial Switch | 1 (1.1) | 0 | 0 | 1 (0.7) | 0.99 |
| Unspecified | 33 (35.1) | 18 (47.4) | 6 (46.2) | 57 (39.3) | 0.36 |
| Additional Congenital Cardiac Abnormalities | |||||
| Patent Foramen Ovale | 23 (24.5) | 12 (31.6) | 1 (7.7) | 36 (24.8) | 0.23 |
| Aortic Dilation (Root, Ascending) | 15 (16.0) | 1 (2.6) | 5 (38.5) | 21 (14.5) | 0.01 |
| Atrial Septal Defect | 11 (11.7) | 4 (10.5) | 3 (23.1) | 18 (12.4) | 0.45 |
| Right Aortic Arch | 11 (11.7) | 3 (7.9) | 1 (7.7) | 15 (10.3) | 0.91 |
| Transposition of the Great Arteries | 2 (2.1) | 0 | 0 | 2 (1.4) | 0.99 |
| Left Superior Vena Cava | 0 | 3 (7.9) | 0 | 3 (2.1) | 0.04 |
| Patent Ductus Arteriosus | 5 (5.3) | 2 (5.3) | 0 | 7 (4.8) | 0.99 |
| Dextrocardia | 1 (1.1) | 0 | 0 | 1 (0.7) | 0.99 |
| Known syndrome or gene abnormality | 15 (16.0) | 6 (15.8) | 4 (30.8) | 25 (17.2) | 0.37 |
| Results | |||||
| 30-day Mortality | 2 (2.1) | 1 (2.6) | 1 (7.7) | 4 (2.8) | 0.37 |
| 1-year Mortality | 2 (2.1) | 2 (5.3) | 2 (15.4) | 6 (4.1) | 0.07 |
| Redo PVR | 4 (4.4) | 1 (2.7) | 1 (8.3) | 6 (4.3) | 0.64 |
| Endocarditis | 2 (2.1) | 1 (2.6) | 0 | 3 (2.1) | 0.99 |
| Arrythmia | 27 (28.7) | 17 (44.7) | 9 (69.2) | 53 (36.5) | 0.01 |
| Stroke | 1 (1.1) | 0 | 1 (7.7) | 2 (1.4) | 0.24 |
| Pulmonary Embolism | 1 (1.1) | 1 (2.6) | 0 | 2 (1.4) | 0.58 |
| IQR, Interquartile Range; PA, Pulmonary Atresia; PVR, Pulmonary Valve Replacement; RV/PA, Right Ventricle/Pulmonary Artery; TOF, Tetralogy of Fallot; TOF-PA, Tetralogy of Fallot-Pulmonary Atresia; VSD, Ventricular Septal Defect | |||||
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