Feasibility of Percutaneous Pulmonary Valve Implantation: Reasons for Failure and Contraindications

Objective: Percutaneous pulmonary valve implantation (PPVI) was established in our institution in 2010. Unfortunately PPVI is not possible in all suitable patients. We identified the reasons for implantation failure and possible contraindications over a 5 year period.

Methods: Between January 1, 2010, and June 30, 2015, all patients who received a pulmonary valve or a catheter investigation for a potential PPVI were investigated. We tried to identify the reasons why a surgical implantation was performed instead of a PPVI based on imaging techniques (ECHO, MRI) and catheter investigation. In addition the catheter protocols were analyzed for contraindications of PPVI.

Results: We identified 221 patients with a biological pulmonary valve implantation. There were 149 surgical patients (67.5%) with51 homografts (23%)and 98 Contegra® grafts (44.3%); and 72 patients for PPVI (32.5%) with44 Edwards valves (twice by 1 patient) (19.9%) (mean diameter: 24.6 mm)and 29 Melody valves (12.7%) (mean diameter: 21 mm). Based on MRI or ECHO, 101 patients presented with an extremely enlarged RVOT with aneurysm (45.7%) so that a PPVI was not feasible when assessed in our interdisciplinary conference. 3 patients suffered from an endocarditis (1.4%) and were operated. 9 patients had additional defects and PPVI was not considered (4%). 1 patient refused PPVI for personal reasons (0.4%). 35 patients had surgery for initial repair of congenital defects or were too small for PPVI (15.8%). 147 patients were assessed during catheter investigation with the option for PPVI. 10 (6.8%) were treated with stent implantation in a supravalvular or subvalvular position and in 29 patients balloon dilatation was performed so that PPVI was not necessary at all (19.7%). In the remaining 108 patients balloon interrogation revealed an RVOT too large for PPVI in 14 patients (12.9%). In 17 patients (15.7%) we identified coronary abnormalities with coronary compression and PPVI was aborted. In 2 patients (1.8%) additional heart defects necessitating surgery were diagnosed, in 2 patients (1.8%) stent dislocation occurred and the patients were referred to surgery. 3 Edwards valves dislocated, by 2 of them was direct surgery necessary.

Conclusion: Based on this analysis, there were 207 patients theoretically suitable for PPVI. In 72/207 (34.7%) PPVI was possible, in 17/207 coronary abnormalities restricted PPVI (8.2%) and in 115/207 (48.9%) the RVOT was too large to enable PPVI with the current available technology.