Author + information
- Received March 21, 2017
- Accepted April 6, 2017
- Published online June 14, 2017.
- Pieter Alexander Verhoeven, MD,
- Christopher P. Learn, MD,
- Nicole M. Brown, MD and
- Bryan H. Goldstein, MD∗ ()
- ↵∗Address for correspondence:
Dr. Bryan H. Goldstein, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, Ohio 45229.
- congenital heart disease
- right ventricular outflow tract conduit, tetralogy of Fallot
- transcatheter pulmonary valve replacement
Transcatheter pulmonary valve (TPV) replacement has emerged as an effective therapy for treatment of right ventricle–to–pulmonary artery conduit dysfunction (1). Stent fracture and infective endocarditis account for most post-implantation TPV dysfunction. Noninfective TPV thrombosis has been reported (2) but is more common following transcatheter aortic valve replacement (3). Herein, we present this uncommon phenomenon.
A 37-year-old man presented for routine follow-up with repaired tetralogy of Fallot and absent pulmonary valve syndrome. Severe right ventricle–to–pulmonary artery conduit obstruction with moderate insufficiency, severe right ventricular (RV) dilation, and severe biventricular systolic dysfunction were evident, with symptoms of right heart failure. He underwent transcatheter conduit rehabilitation with placement of bare-metal stents and a Melody TPV (Medtronic, Minneapolis, Minnesota), implanted at 22 mm (Figure 1). RV systolic pressure improved from 73 to 42 mm Hg, and the conduit peak systolic gradient decreased from 50 to 16 mm Hg. RV size and function subsequently normalized, and right heart failure symptoms resolved.
Seventeen months after implantation, routine follow-up echocardiography demonstrated new right ventricle–to–pulmonary artery conduit obstruction (peak gradient 69 mm Hg) and mild RV systolic dysfunction (Figure 2). He reported mildly reduced exercise tolerance and good adherence to his daily aspirin regimen. No infectious symptoms were reported, and laboratory evaluation for bloodstream infection was negative. Stent compression or fracture were not evident. Right ventriculography demonstrated a filling defect within the TPV complex (Figure 3, Online Videos 1 and 2). Intracardiac echocardiography revealed a large, mobile, organized thrombus on the ventricular side of the TPV complex, which was obstructive (Figures 4 and 5, Online Videos 3 and 4). The TPV leaflets appeared thin and mobile, without intrinsic pathology. Because of the relative lack of symptoms and absence of valve leaflet abnormalities, no transcatheter intervention was performed. A diagnosis of noninfective TPV thrombosis was made, and warfarin anticoagulation was initiated (4). Three-month follow-up with echocardiography demonstrated near complete resolution of the TPV obstruction by Doppler interrogation.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 21, 2017.
- Accepted April 6, 2017.
- 2017 American College of Cardiology Foundation
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