tPVR a Less Invasive Option For RVOT Dysfunction in CHD Patients?
JACC in a Flash | Pulmonary valve replacement may be necessary in patients who have had certain types of congenital heart disease (CHD) repaired with reconstruction of the right ventricular outflow tract (RVOT), according to an expert consensus statement released March 24, 2015, by the ACC, Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), and The Society of Thoracic Surgeons (STS).
The statement, "SCAI/AATS/ACC/STS Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement, Part III: Pulmonic Valve," provides recommendations to guide transcatheter pulmonic valve replacement (tPVR) for children and adults with CHD.
As average life expectancy in CHD patients continues to increase, dysfunction of a reconstructed RVOT becomes more likely. The writing committee, led by Ziyah M. Hijazi, MD, MPH, suggests that patients experiencing a dysfunctional RVOT undergo tPVR, a less invasive procedure.
"Transcatheter valve treatments are allowing us to offer less invasive options to patients who were previously treatable only with open-heart surgery, or may not have been eligible for treatment at all," said Hijazi. "These procedures are complementing standard surgical approaches, allowing physicians to provide greater options for our patients."
The authors also suggest that specialists across intervention, surgery, noninvasive, anesthesiology, and radiology should collaborate when determining a course of treatment in CHD patients.
"There is strong consensus that these new valve therapies should be performed under the guidance of a multi-disciplinary heart team, involving both interventional cardiologists and surgeons," said Hijazi. "Increasing evidence shows a team-based approach provides the greatest quality care for patients with complex heart disease, including patients considering tPVR."
The statement further recommends that institutions offering tPVR perform at least 150 congenital/structural catheterization procedures per year, including 100 that are interventional, as well as 100 open-heart congenital surgical procedures. Institutions should have extracorporeal membrane oxygenation; echocardiography, cardiac CT and cardiac MRI imaging capabilities; a cardiovascular catheterization laboratory; and hemodynamic evaluation. Additionally, institutions should participate in a national registry. Because tPVR is a new treatment option, the writing committee stressed the importance of continuing to collect data on the procedure, including total numbers of tPVR in the U.S. and numbers of procedures by operator and institution.
Further, the statement suggests that physicians performing tPVR should perform at least 100 interventional cases per year, including 50 congenital/structural interventional cases. They should have experience with balloon valvuloplasty as well as stenting within pulmonary arteries and RVOT. The statement also recommends that physicians attend peer-to-peer training and a simulated case if available, and that the first three procedures performed should be under the guidance of an experienced physician.
"As physician experience with tPVR increases over time, complication rates are declining significantly, reflecting the importance of experience in improving patient outcomes," added Hijazi.
- Hijazi ZM, Ruiz CE, Zahn E, et al. J Am Coll Cardiol. 2015:doi:10.1016/j.jacc.2015.02.031.
Keywords: ACC Publications, CardioSource WorldNews
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