316 Percutaneous right outflow tract valve implantation: when should we pre-stent?

IntroductionPercutaneous pulmonary valve insertion has been recently introduced in clinical setting. Patient selection is widely accepted. Initial results demonstrated early and differed stent fractures that make consider pre-stenting as a previous step for the procedure. To date, differed or intra-procedure pre-stenting are both accepted techniques.Patients and methodsWe reviewed patients included over the last 6 months in the prospective study (REVALV) for patients undergoing RVOT intervention for severe stenosis and/or insufficiency. Only valved stent group is analyzed here. All patients undergoing valved stent implantation are previously pre-stented with a bare metal stent according to present recommendations. Thirty-seven patients were included, distributed in two gropus according moment of pre-stenting: differed pre-stenting (bare metal stent implantation several days before valved stent implantation -20 patients-) and same procedure pre-stenting (bare metal stent implantation at the same procedure of valved stent implantation-17 patients-). For analytical purposes, we considered RVOT anatomy (homograft, synthetic tube, patch-extended RVOT or native outflow tract).ResultsOverall, no differences were found regarding mean procedure times (77,35 vs 96,88, p=NS) and time of hospitalization (2,95 vs 3,63, p=NS). Mean delay time from pre-stenting to valvulation was 196,5 + −68 days. Rv to Ao ratio improvement from basal to valvulation was significantly better in intra-procedure pre-stenting group (0,172 vs 0,373, p=0,009). Concerning complications, bare metal stent mobilization happened just after implantation while trying to place valved stent delivery gain. Two pelvic hematomas were observed (one of each group).ConclusionsIntra-procedure pre-stenting influences final result when considering RV-to-Ao ratio improvement, probably related to increase radial strength. The risk, however, remains higher as freshly implanted bare metal stent can mobilize, especially in native RVOT. Stratification of patient should be considered while choosing candidates for valved stent implantation

286 – Percutaneous right outflow tract valve implantation: substrate matters

IntroductionPercutaneous pulmonary valve insertion has been recently introduced in clinical setting. Patient selection is widely accepted. These candidates are however heterogeneous, in regard of heart defects, and type of surgical right ventricular outflow tract (RVOT) reconstruction. It is presently unclear in the literature if type of surgical reconstruction matters for the success of the pulmonary valve insertion. Our goal was to compare the hemodynamic results of percutaneous pulmonary valve in patients with homografts, prosthetic conduit or RVOT reconstructed with patch.Patients and methodsWe reviewed patients included over the last 6 months in the prospective study (REVALV) for patients undergoing RVOT intervention for severe stenosis and/or insufficiency. Only valved stent group is analyzed here. All patients undergoing valved stent implantation are previously pre-stented with a bare metal stent according to present recommendations. Thirty-seven patients were included, distributed in three groups according to type of RVOT reconstruction (homograft REVALV is a multicentric prospective study for patients undergoing RVOT intervention for severe stenosis and/or insufficiency. Patients are distributed in three groups according to type of RVOT reconstruction (homograft, n = 10; prosthetic conduit, n = 20; RVOT enlargement by patch, n = 7).ResultsOverall, all groups were similar in RV to AP gradient improvement (after pre-stenting mean 30,79 vs 28 p = NS; final result mean 23,71 vs 28,17, p = NS), RV to aorta pressures ratio (after pre-stenting 0,187 vs 0,3117 p = NS; final result man 0,315 vs 0,317, p = NS). If considering non-extensible synthetic tubes we observe that RV-to-AP improvement is significantly worst to the rest of the group (mean 7,07 vs 0,17, p = 0,005). When focusing on outflow tract diameter, results did not differ in homograft group and patch group. In contrast, diameter did play a role in those patients having a synthetic tube, with a cut-off at 20mm diameter. Below 20mm, relieve of outflow tract gradient was significantly worse than for bigger conduits.DiscussionPulmonary valve insertion is efficient in all type of RVOT reconstruction at least in the short term. The diameter of the conduits did not play a role in RVOT obstruction relief as long as surgical substrates are homografts or patch enlargement. In patients with prosthetic conduits, size matters. In non-extensible synthetic tubes results are worst. Reduced distensibility and progressive diameter reduction may lead to not consider these patients as good candidates for this procedure

Occlusion percutanée des communications intercardiaques

Since the first attempts in the 70's, transcatheter closure of secundum atrial septal defects has evolved, and has become an effective alternative therapy for most patients with secundum ASD. The initial rigid and large devices became softer and thinner, thanks to dramatic structural improvement. The technique for transcatheter closure has greatly improved with time, as well as the indications and limits. Nowadays, percutaneous device closure is a well-accepted alternative to surgery, even as first-intention treatment for the majority of secundum septal defects. The rate of major complications is low and transcatheter closure carries numerous advantages as compared to surgery. Transcatheter ventricular septal defect has also become an invaluable tool as an alternative to surgery. More often percutaneous closure represents an additional therapy to close apical defects unsuitable for surgical closure. Because this complex transcatheter procedure may be poorly tolerated in very young children, perventricular hybrid closure may sometimes be more appropriate. Regarding perimenbranous ventricular septal defects, transcatheter closure is now abandoned in France because of an elevated rate of complete atrioventricular block. Finally, long-term follow-up of any patient undergoing transcatheter closure of intracardiac shunt is mandatory since information on long-term outcome after such intervention is lacking. © 2011 Elsevier Masson SAS

The VALEO ® vascular stent for cardiovascular lesions in children

International audienceAims: The VALEO ® vascular stent is a stainless steel, pre-mounted, open-cell stent. Redilation to large diameters and low profile are advantages in growing children. Clinical experience is scarce. This study aimed to analyse our experience with the use of the VALEO ® vascular stent in children. Methods and results: Between June 2010 and December 2012, 41 VALEO ® stents were inserted during 30 transcatheter (group 1) and three perioperative procedures (group 2). Data were retrospectively analysed. Median age at implantation was 3.8 years (four days-23 years), and median weight was 13.3 kg (2.2-53 kg). Indications were: pulmonary artery (n=23), pulmonary vein (n=1) or subhepatic vein (n=1) stenosis, and ductus arteriosus stenting (n=8). Stent placement was achieved in all but one. Acute complications (n=11) included stent dislodgement in two patients and fracture in three patients, with vessel predilatation as a risk factor. Median " stent " follow-up reached 7.83 months (0.4-34.3 months) and included 26 recatheterisations (23 patients, median interval 6.2 months, range 0.2-33 months). Ten stents were redilated. Surgery in six patients (interval 1.9 to 10 months) showed patent endothelialised stents. No " late " type II or III stent fractures were seen. Conclusions: The VALEO ® stent is useful in children. Low radial force is counterbalanced by high flexibility , allowing implantation in distal and tortuous lesions. Early fractures occur. Longer-term follow-up is needed. KEYWORDS • bare metal stent • congenital heart diseases • ductus arteriosu