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A new transventricular aproach for pulmonary valve implantation in a patient with severe valve disease after tetralogy-of-Fallot repair
  1. Georg D Duerr1,
  2. Johannes Breuer2,
  3. Wolfgang Schiller1
  1. 1Department of Cardiac Surgery, University Clinical Center of Bonn, Bonn, NRW, Germany
  2. 2Department of Pediatric Cardiology, University Clinical Center of Bonn, Bonn, NRW, Germany
  1. Correspondence to Dr Georg Daniel Duerr, Department of Cardiac Surgery, University Clinical Center Bonn, Sigmund-Freud-Str. 25, Bonn, NRW 53105, Germany; Daniel.duerr{at}

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One-third of all patients with tetralogy-of-Fallot (TOF) repair are developing symptomatic pulmonary regurgitation or stenosis.1 Percutaneous pulmonary valve (PV) implantation via the femoral vein is an accepted method reducing numbers of repeat operations.2 We present the case of a 44-year-old man with symptomatic PV regurgitation after TOF repair at the age of 10 years. The right ventricle (RV) was severely dilated. Due to severely impaired RV function, percutaneous approach for valve replacement was chosen. Potential coronary compression was ruled out. As the PV annulus, measuring 26 mm in diameter (figure 1A and B), was too large for currently available transcatheter pulmonary valves, a SAPIEN-XT 29 mm designed for transapical aortic valve implantation was used. First, a vascular stent (AS48XXL, Andramed) was implanted in the PV annulus with a 28 mm balloon under fluoroscopy and 3D-transoesophageal echocardiography (TEE) guidance (figure 1C and D) via transapical access. However, correct placement of the SAPIEN-XT valve into the stent was not feasible due to extremely sharp angulation of the delivery pathway (figure 1E and F). Hence, we switched to subxiphoid mini-sternotomy and direct access through the free RV wall which offered straight insertion and easy implantation of the valve into the stented pulmonary position (figure 1G and H). Correct placement was confirmed by TEE. The patient was discharged after 1 week. One year follow-up revealed functional improvement from New York Heart Association (NYHA) class-IV to class-I, significant regression of RV diameter, and normal PV function (figure 1I). We conclude, that the subxiphoid transventricular access for catheter-based PV implantation is a feasible alternative in TOF patients if open surgery or transfemoral access are high risk.

Figure 1

(A) 2D echocardiography of PV annulus. (B–F) Transapical access. (B) Pigtail catheter insertion into the right ventricular outflow tract (RVOT). (C) Transapical placement of the stent-introducer (14F) was difficult because of kinking (arrow). (D) Correct implantation of the vascular stent (*: stent dimensions) with a 28 mm balloon in PV annulus, length: 34 mm. (E and F) Sharp angulation of the pathway did not allow passage of the stent's edge (x) with the valve. (G and H) Transventricular access. (G) Subxiphoidal mini-thoracotomy and puncture of the free right ventricle wall offered straightforward antegrade insertion of the valve into the stent. (H) Correct position of the SAPIEN-XT 29 mm valve (§) in the stent. (I) Follow-up 2D echocardiography of the RVOT in parasternal short axis after 1 year showing the stent (arrows) and intact valvular leaftlets (*). Ao: aorta, PV: pulmonary valve. Inset: Doppler echocardiography of the RVOT in parasternal short axis revealing a low gradient.


We would like to thank Dr Ulrike Herberg very much for her excellent assistance with the echocardiographic examinations.


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  • Contributors GDD: surgeon, involved in the surgical procedure of valve implantation, writing and handling of the manuscript. WS: surgeon, involved in the surgical procedure of valve implantation, planning of the surgical procedure. JB: paediatric cardiologist, involved in the surgical procedure of valve implantation, planning of the surgical procedure.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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