Patients who develop a severe stenosis in biological pulmonary conduits previously implanted for pulmonary outflow trunk reconstructions are treated either by surgical re-replacement, or by transcatheter stent-valve implantation through a femoral vein access. A catheter-based sub-xyphoidian access through the right ventricle for stent-valve positioning in a pulmonary conduit has rarely been proposed. We describe the case of a 20-year-old man who underwent a pulmonary trunk reconstruction for a congenital pulmonary valve dysplasia and a few years later developed a stenosis in the pulmonary conduit. He was successfully treated with a 23 mm Edwards Sapien© stent-valve implantation in pulmonary position, through an unusual right ventricular, sub-xyphoidian access and without contrast medium injections and pleura openin

Ferrari, Enrico

Rizzo, Elena

Sulzer, Christopher

von Segesser, Ludwig Karl

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Case reportTranscatheter stent-valve implantation in a stenoticpulmonary conduit via a sub-xyphoidian accessEnrico Ferrari a,*, Christopher Sulzer b, Elena Rizzo c, Ludwig Karl von Segesser aaDepartment of Cardiovascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, SwitzerlandbDepartment of Anaesthesia, University Hospital of Lausanne (CHUV), Lausanne, SwitzerlandcDepartment of Radiology, University Hospital of Lausanne (CHUV), Lausanne, SwitzerlandReceived 31 March 2009; received in revised form 15 April 2009; accepted 27 April 2009; Available online 12 June 2009AbstractPatients who develop a severe stenosis in biological pulmonary conduits previously implanted for pulmonary outflow trunk reconstructionsare treated either by surgical re-replacement, or by transcatheter stent-valve implantation through a femoral vein access. A catheter-basedsub-xyphoidian access through the right ventricle for stent-valve positioning in a pulmonary conduit has rarely been proposed. We describethe case of a 20-year-old man who underwent a pulmonary trunk reconstruction for a congenital pulmonary valve dysplasia and a few yearslater developed a stenosis in the pulmonary conduit. He was successfully treated with a 23 mm Edwards Sapien# stent-valve implantation inpulmonary position, through an unusual right ventricular, sub-xyphoidian access and without contrast medium injections and pleuraopening.# 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.Keywords: Transcatheter valve replacement; Pulmonary conduit; Valve stenosiswww.elsevier.com/locate/ejctsEuropean Journal of Cardio-thoracic Surgery 36 (2009) 595—5971. IntroductionThe stenosis is a severe complication following surgery forpulmonary outflow trunk reconstruction with biologicalconduits, as human cryopreserved homografts or bovinejugular veins (ContegraW, Medtronic, Minneapolis, USA). There-operation for pulmonary conduit replacement under re-sternotomy and cardiopulmonary bypass remains a high-riskprocedure with consistent morbidity and mortality [1]. Thearrival of new stent-valves has been heralded as an importantchange in concepts and, recently, the use of transcathetertechniques for pulmonary valve replacement through thefemoral vein (MelodyW valve, Medtronic, Minneapolis, USA)has become routine in specialised cardiac care units [2—4]. Inspite of that, there are a few limitations related to the use ofthis device in the presence of vena cava filters, femoral veinthrombosis/stenosis or very large pulmonary conduits(MelodyW valve limited to 22 mm). Moreover, the positioningof catheter-based valves requires the injection of contrastmedium which is nephro-toxic at high concentration. A sub-xyphoidian access for transcatheter valve implantation* Corresponding author. Address: Department of Cardiovascular Surgery,Centre Hoˆpitalier Universitaire Vaudois (CHUV), 46, rue du Bugnon, CH-1011 Lausanne, Switzerland. Tel.: +41 79 310 1386; fax: +41 21 314 2278.E-mail address: enricoferrari@bluewin.ch (E. Ferrari).1010-7940/$ — see front matter # 2009 European Association for Cardio-Thoracicdoi:10.1016/j.ejcts.2009.04.051without contrast medium injections, can be a valid alter-native in selected patients.2. Case reportWe hospitalised a 20-year-old man who underwent, 5years earlier, open heart surgery for pulmonary trunkreconstruction (ContegraW conduit 22 mm, Medtronic,Minneapolis, USA) in a congenital stenotic pulmonary valvedysplasia plus a concomitant interventricular defectclosure. He was symptomatic for dyspnoea, fever andfatigue and we made the diagnosis of conduit stenosis plussub-acute endocarditis; the trans-oesophageal echocardio-gram (TEE) showed a pulmonary peak gradient of 45 mmHgand a thick and dystrophic pulmonary valve with vegeta-tions. The sub-acute endocarditis was treated conserva-tively with intravenous antibiotics and 8 weeks later, thevegetation disappeared, but the patient developed atransitory antibiotic-related renal insufficiency. Todecrease the operative risk and prevent an acute renalfailure that could have occurred after cardiopulmonarybypass (in re-operation) or contrast medium employment(in trans-femoral approach), we decided for a sub-xyphoidian stent-valve implantation without contrastmedium. We performed a pre-operative three-dimensional(3D) computed tomography scan to analyse the pulmonarySurgery. Published by Elsevier B.V. All rights reserved.E. Ferrari et al. / European Journal of Cardio-thoracic Surgery 36 (2009) 595—597596Fig. 1. A three-dimensional computer tomography scan showing the severestenosis in the ContegraW pulmonary conduit.Fig. 2. A control computer tomography scan showing the implanted stent-valve (SapienW valve, Edwards, Irvine, CA, USA) in the stenotic pulmonaryconduit.conduit. Coronary anomalies were not found (Fig. 1). Theoperation was carried out under general anaesthesia.Following our protocol for transcatheter valve implanta-tion, a C-arm fluoroscopy, an intra-vascular ultrasound(IVUS) and a TEE were use to identify the landing zone. Thesurgical access was an uncommon sub-xyphoidianapproach: the scar of the previous surgical interventionwas extended for about 8 cm, with an incision under thexyphoid process. Then, the diaphragmatic face of the rightventricle was exposed and a pacemaker wire was fixed andtested for rapid pacing. A double 2/0 purse-string suturereinforced with pledgets was prepared in a zone ofmyocardium without coronary arteries. After heparinisa-tion (100 UI kg1), a guide wire and an 11 French sheetwere introduced into the right ventricle, towards thepulmonary trunk, and an IVUS probe (nine French) wasguided over-the-wire into the right ventricle and across thepulmonary valve. Once the stenosis and the pulmonarybifurcation were identified, we marked the zone, underfluoroscopy, with metal markers, as reported for endovas-cular aorta repairs [5,6]. Then, we performed a pulmonaryvalvuloplasty and a 23 mm Edwards SapienW valve implan-tation (Edwards Lifescience, Irvine, CA, USA). The entireprocedure was carried out without contrast mediuminjections and the result was excellent (Fig. 2); the TEEconfirmed low gradients and absence of paravalvularleakage. The postoperative recovery was uneventful andthe patient was discharged after 10 days.3. DiscussionSurgery for right ventricular outflow tract reconstruc-tion is necessary in case of pulmonary atresia and Tetralogyof Fallot, common arterial trunk and Rastelli operation ingreat vessels transposition and ventricular septal defectwith pulmonary stenosis. However, although the survival ofbiological conduits is improving, re-operations are quitecommon and they still involve morbidity and mortality.Trans-femoral pulmonary valve replacement is emerging asan alternative option and recent reports have confirmedgood short- and mid-term results [3,7—9]. The rightventricular sub-xyphoidian access seems a valid alternativein case of inaccessibility to the iliac/femoral vein axes, butit requires the exclusive use of Edwards SapienW stent-valves and needs more surgery when compared to the fullpercutaneous trans-femoral access. However, the SapienWvalve is available in bigger diameters (23 mm and 26 mm)and the indication can be extended to more adult patientswith larger conduits. Moreover the sub-xyphoidian access isa full intra-pericardial procedure and could be stronglyindicated in case of severe respiratory disease. In thisreport, the patient was suffering from a stenosedpulmonary conduit and we decided on a right ventricularsub-xyphoidian access. The procedure required less thantwo and a half hours, the pleura were never opened andthe patient was extubated immediately after surgery. Wedid not use a pulmonary pre-stenting (recommended forMelodyW valve implantation) and we have never usedcontrast medium: our present policy is to reduce (or avoid)the amount of contrast medium employed during endograftor stent-valve implantation and, as already demonstrated,the IVUS seems the ideal tool for this purpose [5,6]. InE. Ferrari et al. / European Journal of Cardio-thoracic Surgery 36 (2009) 595—597 597conclusion, transcatheter pulmonary valve replacementthrough a sub-xyphoidian access is feasible and can beperformed without contrast medium injections and pleuraopening.References[1] Morales DL, Zafar F, Arrington KA, Gonzalez SM, McKenzie ED, Heinle JS,Fraser Jr CD. Repeat sternotomy in congenital heart surgery: no longer arisk factor. Ann Thorac Surg 2008;86(September (3)):897—902.[2] Bonhoeffer P, Boudjemline Y, Saliba Z, Hausse AO, Aggoun Y, Bonnet D, SidiD, Kachaner J. Transcatheter implantation of a bovine valve in pulmonaryposition: a lamb study. Circulation 2000;102(7):813—6.[3] Coats L, Tsang V, Khambadkone S, van Doorn C, Cullen S, Deanfield J, deLeval MR, Bonhoeffer P. The potential impact of percutaneous pulmonaryvalve stent implantation on right ventricular outflow tract re-intervention.Eur J Cardiothorac Surg 2005;27(April (4)):536—43.[4] Attmann T, Jahnke T, Quaden R, Boening A, Muller-Hulsbeck S, Cremer J,Lutter G. Advances in experimental percutaneous pulmonary valve repla-cement. Ann Thorac Surg 2005;80(September (3)):969—75.[5] Marty B, Tozzi P, Ruchat P, Haesler E, von Segesser LK. Systematic andexclusive use of intravascular ultrasound for endovascular aneurysmrepair—the Lausanne experience. Interact Cardiovasc Thorac Surg2005;4(June (3)):275—9.[6] von Segesser LK, Marty B, Ruchat P, Bogen M, Gallino A. Routine use ofintravascular ultrasound for endovascular aneurysm repair: angiography isnot necessary. Eur J Vasc Endovasc Surg 2002;23(June (6)):537—42.[7] Khambadkone S, Bonhoeffer P. Percutaneous implantation of pulmonaryvalves. Expert Rev Cardiovasc Ther 2003;1(November (4)):541—8.[8] Rode´s-Cabau J, Houde C, Perron J, Benson LN, Pibarot P. Delayed improve-ment in valve hemodynamic performance after percutaneous pulmonaryvalve implantation. Ann Thorac Surg 2008;85(May (5)):1787—8.[9] Lurz P, Coats L, Khambadkone S, Nordmeyer J, Boudjemline Y, Schievano S,Muthurangu V, Lee TY, Parenzan G, Derrick G, Cullen S, Walker F, Tsang V,Deanfield J, Taylor AM, Bonhoeffer P. Percutaneous pulmonary valveimplantation: impact of evolving technology and learning curve on clinicaloutcome. Circulation 2008;117(April 15 (15)):1964—72.

Transcatheter stent-valve implantation in a stenotic pulmonary conduit via a sub-xyphoidian access

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