Pulmonic regurgitation treatment

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Pulmonic regurgitation Microchapters

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Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differential diagnosis

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Electrocardiogram

Chest X-Ray

Echocardiography

Cardiac MRI

Severity Assessment

Treatment

Medical Therapy

Surgical therapy

Follow up

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2], Aysha Anwar, M.B.B.S[3]

Overview

Treatment of pulmonic regurgitation may be divided into medical and surgical treatment. Medical management of pulmonic regurgitation may include use of diuretics in patients with RV dysfunction. ACE inhibitors and B blockers may be used to reverse neurohormonal activation and improve symptoms. Antibiotic prophylaxis may be indicated in certain conditions such as patients with cyanotic heart disease, prosthetic heart valves, rheumatic heart disease, and patients previously having sustained bacterial endocarditis. Surgical management of pulmonic regurgitation may include replacement of pulmonary valve. The major indications for pulmonic valve replacement may include symptomatic patients with arrythmias or NYHA class higher than II, ejection Fraction of less than 40% when assessed with CMR, patients with progressive right ventricular regurgitation(right ventricular end- diastolic volume ≥160 mL/m2 or end-systolic volume ≥82 mL/m2 on CMR), moderate to severe tricuspid valve regurgitation, resulting from annular dilation, patients at risk of developing arrythmias and with prolonged QRS duration.(total QRS duration ≥180 msec, or QRS duration increase >3.5 msec per year and severe pulmonic regurgitation in a patient with another cardiac lesion that requires operative intervention. Follow up of patients with pulmonic regurgitation requires regular echocardiographic monitoring after PVR, oral anticoagulation in patients with mechanical or bioprosthetic valves and lifelong follow up to monitor pulmonary valve morphology and RV function.

Treatment

Treatment of pulmonic regurgitation may be divided into medical and surgical treatment:

Medical Therapy

  • There are no specific medical measures for management of PR.
  • Diuretics are recommended in patients with RV dysfunction for maintenance of fluid balance.
  • In patients with repaired tetralogy of fallot, ACE inhibitors or beta-blockers are used to reverse the neuroharmonal activation and improve the symptoms.[1][2]

Antiobiotic prophylaxis

The American Heart Association Recommendations on Prevention of Bacterial Endocarditis indicate that antibiotic prophylaxis is not necessary for pulmonic regurgitation in those patients with otherwise structurally normal pulmonic valves, particularly if there is no diastolic murmur. It should be noted, though, that those patients with the following conditions may warrant antibiotic prophylaxis:

  1. Complex cyanotic heart disease
  2. Prosthetic heart valves
  3. Patients with congenital heart disease and pulmonic regurgitation
  4. Acquired pulmonic valve regurgitation as the result of rheumatic heart disease
  5. Patients with complex cyanotic heart disease
  6. In patients who have previously sustained bacterial endocarditis

Surgical Therapy

Indications for Surgery

Indications for Pulmonary Valve Replacement include:[3]

  • Symptomatic patients with arrythmias or NYHA class higher than II
  • Ejection Fraction of less than 40% when assessed with CMR
  • Patients with progressive right ventricular regurgitation(right ventricular end- diastolic volume ≥160 mL/m2 or end-systolic volume ≥82 mL/m2 on CMR)
  • Moderate to severe tricuspid valve regurgitation, resulting from annular dilation
  • Patients at risk of developing arrythmias and with prolonged QRS duration.(total QRS duration ≥180 msec, or QRS duration increase >3.5 msec per year)
  • Severe pulmonic regurgitation in a patient with another cardiac lesion that requires operative intervention

Timing Of Surgery

  • Timing of pulmonary valve replacement is not well defined as in aortic and mitral regurgitation. However timely intervention is advised before the onset of RV dysfunction.[4]
  • Delayed intervention has shown to have poor outcomes and higher rate of re-intervention.
  • The prime goals of pulmonary valve replacement include improved functional class and quality of life, maintenance of right (and left) ventricular function, risk modification of arrhythmia and sudden cardiac death.[5]

Surgical Options

Pulmonary Valve Replacement(PVR) by surgical and percutaneous approach is the definitive treatment for the management of chronic PR and has proven to improve RV function, New York Heart Association Functional Class status, quality of life, and reduce risk for development of RV tachyarrhythmias and sudden cardiac death.[6]

Surgical Valve Implantation

  • Various valved conduits are placed to replace the pulmonic valve which include Homografts from cadavers, valved conduits, and the Contegra bovine jugular vein graft or a bioprosthetic valve implanted directly in the RV outflow tract.[7]
  • Bioprosthetic valves are usually preffered over mechanical valve prosthesis and have a longevity of around 15years.[8][9][10][11]
  • Mechanical valves are preffered in patients who are at high risk of reoperation such as patients with RV dysfunction.[12]
  • Stenosis of the conduit is the major limitation and 25% of patients have to undergo a repeat intervention.
Transcatheter Pulmonary Valve Replacement
  • The Melody transcatheter pulmonary valve(Medtronic) is approved by FDA in 2010.[13]
  • The current transcatheter valves are designed to treat conduit and bioprosthetic valve failure only.[14][15][16][17]
  • They are not useful to treat patients who had a RVOT reconstruction by transannular patching.
Complications
  • Stent fracture:It leads to an increase in RV outflow tract gradient and RV pressure and its incidence is around 21% in 1 series that used the Melody valve and was the major reason for a repeat intervention.[18][19]
  • Device instability and dislodgement[20]
  • Coronary compression due to stent placement[21]
  • Pulmonary artery obstruction

Outcomes

  • Patients with percutaneous pulmonary valve replacement have good outcome and are free of reintervention at 1year.[22]
  • Patients with CMR derived pre operative right ventricular end diastolic volume index of less than 160ml/m² and end systolic volume index of less than 80ml/m² showed better outcomes. [8][23][24]

Follow Up

  • All the patients should undergo a baseline transthoracic echocardiogram after PVR.[25][26]
  • Anticoagulation is recommended in patients with mechanical valves and aspirin for patients with bioprosthetic valves.[9]
  • Oral anticoagulation in patients with bioprosthetic valves is recommended only when other indications such as atrial arrhythmia or prior thromoembolic event are present.
  • All patients are advised for a lifelong follow up to assess the valve morphology and RV systolic function.


References

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  12. Waterbolk TW, Hoendermis ES, den Hamer IJ, Ebels T (2006). "Pulmonary valve replacement with a mechanical prosthesis. Promising results of 28 procedures in patients with congenital heart disease". Eur J Cardiothorac Surg. 30 (1): 28–32. doi:10.1016/j.ejcts.2006.02.069. PMID 16730181.
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  19. Lurz P, Coats L, Khambadkone S, Nordmeyer J, Boudjemline Y, Schievano S; et al. (2008). "Percutaneous pulmonary valve implantation: impact of evolving technology and learning curve on clinical outcome". Circulation. 117 (15): 1964–72. doi:10.1161/CIRCULATIONAHA.107.735779. PMID 18391109.
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