Transcatheter pulmonary valve replacement after arterial switch operation.
Nageotte S, Salavitabar A, Zablah JE, Ligon RA, Turner ME, El-Said H, Guyon P, Boucek D, Alvarez-Fuente M, McElhinney DB, Balzer D, Shahanavaz S. Catheter Cardiovasc Interv. 2024 Sep;104(3):531-539. doi: 10.1002/ccd.31152. Epub 2024 Jul 20. PMID: 39033329
Take Home Points:
- TPVR is a viable but challenging option for ASO patients, with a 66% success rate and relatively high risk of coronary compression or aortic root distortion (24% vs. 5–6% in the general TPVR population).
- Long-term durability concerns remain, with 32% of patients requiring reintervention within 5 years due to stent fracture, restenosis, or endocarditis.
- Pre-procedural imaging advancements (e.g., 3D CT, AI modeling) could improve patient selection and procedural success, reducing failure rates and complications.
Commentary from Dr. Konstantin Averin (Cohen Children’s Heart Center), catheterization section editor of Pediatric Cardiology Journal Watch:
The study by Nageotte et al. investigates the feasibility and safety of transcatheter pulmonary valve replacement (TPVR) in patients who have previously undergone an arterial switch operation (ASO) for D-transposition of the great arteries (D-TGA). While TPVR is a well-established intervention for right ventricular outflow tract (RVOT) dysfunction, patients with prior ASO present unique anatomical and procedural challenges, particularly coronary compression and aortic root distortion.
This retrospective multicenter study included 33 patients across nine centers of which TPVR was successfully performed in 22 patients (66%) – Melody (n=19) and SAPIEN (n=3) valves. Pre-stenting was performed in nearly all cases. In the cases that were technically successful TPVR significantly improved RVOT obstruction, reducing the RVOT peak gradient from 43 mmHg to 9 mmHg (p<0.001) and resolving pulmonary regurgitation (PR). Coronary compression was the primary reason for inability to perform TPVR 8 patients (24%) and aortic root distortion with severe aortic regurgitation in 2 (6%). One case was complicated by valve embolization requiring emergency surgical removal. During a median follow-up of 4 years, 7 patients (32%) required RVOT reintervention, and 3 cases of endocarditis occurred (2 surgical explants and one being medically treated). The study is limited by its retrospective design, small sample size, lack of long-term data and heterogeneous patient population.
This study provides compelling evidence that TPVR can be an effective strategy for managing RVOT dysfunction after ASO, though higher procedural failure rates and mid-term reinterventions warrant careful patient selection and long-term monitoring. The high rate of coronary compression and aortic root distortion raises an important question: Can we improve pre-procedural screening of ASO patients with RVOT dysfunction to identify those that will not be able to undergo TPVR? Emerging computed tomography (CT) and three-dimensional (3D) modeling could eventually provide a non-invasive, pre-procedural risk assessment. By optimizing selection criteria providers may ultimately be able to decrease the high procedural failure rate in ASO patients being considered for TPVR.
