E-Case

JACC

Lots of interesting abstracts and cases were submitted for TCTAP 2023. Below are the accepted ones after a thorough review by our official reviewers. Don¡¯t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

TCTAP C-179

A Challenging Case Report: Percutaneous Pulmonary Valve (Pulsta Valve) Implantation in an Elderly Tetralogy of Fallot Patient With Challenging Pulmonary Artery Morphology.

By Seung Min Baek, Gi-Beom Kim

Presenter

Seung Min Baek

Authors

Seung Min Baek1, Gi-Beom Kim1

Affiliation

Seoul National University Children¡¯s Hospital, Korea (Republic of)1,
View Study Report
TCTAP C-179
STRUCTURAL HEART DISEASE - Congenital Heart Disease (ASD, PDA, PFO, VSD)

A Challenging Case Report: Percutaneous Pulmonary Valve (Pulsta Valve) Implantation in an Elderly Tetralogy of Fallot Patient With Challenging Pulmonary Artery Morphology.

Seung Min Baek1, Gi-Beom Kim1

Seoul National University Children¡¯s Hospital, Korea (Republic of)1,

Clinical Information

Patient initials or Identifier Number

MOS

Relevant Clinical History and Physical Exam

A 63-year-old female with Tetralogy of Fallot (TOF) was referred to Seoul National University Children¡¯s Hospital (SNUCH). She had been diagnosed with TOF while receiving treatment for a brain abscess around the age of 20. After receiving TOF correction operation she was doing well, until she was recently admitted to a nearby hospital for dyspnea. Echocardiography revealed severe pulmonary regurgitation (PR, figure A) with right heart volume overload (figure B) and she was referred to SNUCH.

Relevant Test Results Prior to Catheterization

Electrocardiography showed atrial fibrillation with slow ventricular rate (figure C). Echocardiography showed severe PR, mild supravalvar pulmonary stenosis (PS), and mild left ventricular dysfunction. Peak/mean pressure gradient of PS was 36.6 / 20.9 mmHg. Main pulmonary artery (MPA) showed large diameter with web-like structure at the distal MPA. Ejection fraction measured by m-mode was 48.3 %. Cardiac computed tomography also showed severe dilatation of MPA, right ventricle, and right atrium.

Relevant Catheterization Findings

Catheterization data was summarized in table 1. Peak pressure gradient of PS was 19 mmHg, and pulmonary artery diastolic pressure was 5 mmHg. Angiography showed severe PR with marked pulmonary artery dilatation. MPA showed tortuous pyramidal shape with distal web-like narrowing. The diameter of pulmonary annulus was 29.4 mm and the MPA diameter was 33.8 mm at the mid portion and 43.3 mm just before bifurcation site. The narrowest diameter was 25.7 mm at the distal web-like structure (figure D).

Interventional Management

Procedural Step

Under general anesthesia, femoral artery and vein were punctured (5 Fr sheath on left femoral artery, 6 Fr sheath on left femoral vein, and 11 Fr sheath on right femoral vein). While Lunderquist wire (COOKMEDICAL, Bloomington, IN, USA) was placed on right lower pulmonary artery, 34mm Cocoon sizing balloon (Vascular Innovations, Thailand) and 26mm Tyshak dilatation balloon catheter (NuMed, Canada Inc) was inserted sequentially. Aortography while the Cocoon sizing balloon was inflated show no coronary artery compression (figure E). While MPA was occluded with 26 mm Tyshak balloon catheter, right ventriculography did not show contrast-dye leakage. Pulsta valve (32mm, Tae Woong Medical Co,Gyeonggi-do, South Korea) was introduced through the Lunderquist wire (figure F). After successful implantation, the Pulsta valve showed good position with no residual pulmonary regurgitation (figure G). Mild pulmonary stenosis also was relieved and diastolic pulmonary artery pressure increased.


Case Summary

This was an unusual case with successful percutaneous pulmonary valve implantation on an elderly patient with unfavorable MPA morphology. Atrial fibrillation and left ventricular dysfunction were also significant risk factors. By percutaneous pulmonary valve implantation, we could successfully relieved pulmonary stenosis as well as severe pulmonary regurgitation. After the procedure, echocardiography showed trivial PR and no significant PS. In the context of growing population of adult congenital heart disease, this case could be a good index for many future interventions on elderly patients with congenital heart disease and various risk factors.