eISSN: 1897-4295
ISSN: 1734-9338
Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej
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vol. 16
Short communication

The Y-stenting technique for bifurcation stenosis and bioprosthetic valve frame fracture prior to valve-in-valve transcatheter pulmonary valve replacement in a child

Michał Gałeczka
Sebastian Smerdziński
Wojciech Sadowski
Marcin Demkow
Jacek Białkowski
Roland Fiszer

Department of Congenital Heart Defects and Paediatric Cardiology, FMS in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
Biocybernetics Laboratory, Prof. Z. Religa Foundation of Cardiac Surgery Development, Zabrze, Poland
Department of Coronary Artery and Structural Heart Diseases, Institute of Cardiology, Warsaw, Poland
Adv Interv Cardiol 2020; 16, 2 (60): 206–208
Online publish date: 2020/06/23
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Tetralogy of Fallot (TOF) corrective surgery, especially using a transannular patch, carries a high risk of reintervention [1]. Surgical pulmonary valve replacement with a bioprosthetic valve (BPV) is a well-established method of treating postoperative right outflow tract dysfunction [2]. Since BPV function deteriorates and patient-prosthesis mismatch increases with growth, reintervention is necessary. To avoid the reoperation risk, valve-in-valve (ViV) transcatheter pulmonary valve replacement (TPVR) has become an attractive alternative [3]. The BPV true inner diameter (ID) is shorter than the nominal BPV size by 2 mm or more, which limits the ViV therapy [4]. The valve implanted within the BPV makes the effective lumen even narrower. Since the first report by Tanase et al. [5], intentional fracture of the BPV frame using ultra-high-pressure balloons has become a valuable option to optimize the hemodynamic outcomes of ViV in the BPV in a pulmonic position [6].

Case report

The case concerns a 17-year-old, 69 kg, asymptomatic boy after a TOF complete repair with a transannular patch. The patient was re-operated at the age of 10 with a stentless valve and only 1 year later with a 23 mm Carpentier-Edwards Perimount Magna bioprosthetic valve (Edwards Lifesciences Inc., Irvine, USA). Pulmonary stenosis (PS) with maximum/mean gradient of 100/55 mm Hg, moderate pulmonary regurgitation, and dilated right ventricle were established during transthoracic echocardiography. Computed tomography (CT) revealed a 12 mm supravalvular PS and proximal narrowing of pulmonary arteries: right (RPA) to 9 and left (LPA) to 6 mm (Figure 1 A).
In order to test transcatheter treatment options, a 3D CT-derived silicone model of the aforementioned region with an embedded valve was prepared. Subsequently, the Y-stenting technique for bifurcation stenosis was selected. This includes implantation of a long hybrid-cell designed stent into the supravalvular PS and LPA and another stent into the RPA through the struts of the first stent (Figure 1 B). Moreover, an experimental bench test with cracking of the 23 mm Magna BPV using a 24 mm Atlas balloon (Bard Peripheral Vascular Inc., Tempe, USA) was performed. The lower restrictive frame of the valve cracked at 14 atm. A preprocedural CT scan excluded risk of coronary artery compression in the intended valve landing zone. Finally, the patient was qualified for ViV TPVR and informed consent was...

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