Mohamed Abdullah, MD and Barry Love, MD
Icahn School of Medicine at Mount Sinai, New York, NY, USA
Essential Operative Steps
- General endotracheal anesthesia
- Vascular access: large bore femoral venous access for delivery of the valve. Contralateral femoral venous access may be
needed for angiography. Femoral arterial access for arterial pressure monitoring, blood gas sampling, and coronary
angiography during compression testing (if required) - Hemodynamic assessment: right heart catheterization and documentation of the degree and levels of RVOT obstruction
(if present). Right atrial and wedge pressure assessment - Angiography: biplane fluoroscopy with an angiographic catheter in the MPA to assess anatomy and landing zone for prestenting (if needed) and valve delivery
- For balloon-expandable valve/pre-stenting: the relationship between the aortic root and coronary arteries to the RVOT is
assessed by aortic root angiography - Coronary artery compression testing: simultaneous RVOT balloon angiography and coronary artery angiography
- For stenotic conduits, pre-stenting of the landing zone may be required
- Bioprosthetic valve preparation
- Transcatheter valve replacement
- Vascular closure: e.g. two suture mediated closure systems (Perclose) for venous preclosure. For large-bore venous
access, a figure of 8 skin suture may be used instead and is simple and effective
Potential Complications and Pitfalls
- Consider using ultrasound guidance and micropuncture for the venous access
- Coronary artery compression testing is necessary when using balloon-expandable stents but usually not necessary for selfexpanding platforms: compression testing should be performed with an angioplasty balloon containing dilute contrast
inflated to a diameter that closely approximates the desired final diameter of the RVOT - Care should be taken to not over expand the right ventricle to pulmonary artery homografts as rupture may occur. While
small tears are common, larger tears with uncontrolled bleeding can occur. Large-diameter covered stents need to be
available as a “bail-out” should conduit rupture occur - Excellent wire position in a lower lobe branch of the PA with a stiff wire is required
- Pre-stenting is required for long segment stenosis of homograft obstructions or when implanting valves with less robust
wire frames (eg: Medtronic Melody) - Following deployment, repeat hemodynamics and pulmonary artery angiography should generally demonstrate
significant reductions in RVOT gradient and a competent pulmonary valve - There is a lifetime risk of endocarditis with pulmonary valve replacement: good dental care should be ensured prior to
the procedure and lifelong dental care with appropriate bacterial endocarditis prophylaxis should be followed
Template Dictation
Preoperative Diagnosis: Symptomatic Severe Pulmonary Regurgitation OR Congenital Heart Disease Status-post Repair
with a Right Ventricle to Pulmonary Artery Homograft
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Transcatheter Pulmonary Valve Replacement with [BLANK SIZED VALVE]
Attending Surgeon: [BLANK]
Attending Cardiologist: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] old [SEX] with a history of [BLANK] who has undergone the following surgical
procedures [BLANK]. Preoperative echocardiography reveals [FINDINGS]. CTA shows an RVEDi [BLANK] with an RVEF
of [BLANK]. The patient underwent an evaluation for potential [BLANK] valve and was found to be a candidate.
The procedure, its purpose, the risks, benefits and alternatives, was discussed with the patient and family and they decided to
proceed.
Operative Findings:
- Right heart hemodynamics showed: [BLANK]
- Angiography showed: [BLANK]
Description of the Procedure: The patient was prepped and draped using standard sterile technique and the procedure was
performed under general anesthesia. Percutaneous femoral venous and arterial access was obtained. Heparin was administered
and the ACT was ([BLANK] – ideally >250 seconds). Right heart hemodynamics showed [BLANK]. An angiographic catheter
was placed in the pulmonary artery and contrast injection showed [BLANK]. The [BLANK] stiff guidewire was positioned
with the tip in the distal right / left lower branch PA.
For self-expanding valves (Medtronic Harmony): The RFV access was exchanged for a [BLANK] sheath. The [make,
model, size] valve was loaded into the delivery catheter, per protocol. The delivery system was advanced with the loaded valve
over the wire into the MPA and delivered in the planned position in the MPA. Appropriate position of the valve was confirmed
by angiography and the valve was released from the delivery catheter.
For balloon-expandable valves (Medtronic Melody / Edwards Sapien): The homograft was pre-dilated with a [make,
model] balloon and coronary compression testing performed. The homograft was then pre-stented with [make, size] stent
mounted on a [make, size] balloon. The pulmonary valve [make, model] was then delivered and expanded to [balloon
diameter]. Hemodynamics and angiography after valve placement showed [BLANK].
For both self-expanding and balloon-expandable valves: The delivery system was removed and hemostasis at the largebore venous access site was obtained with [BLANK]. Hemostasis at the arterial access site was achieved with [BLANK]. The
patient transferred to the recovery area in a stable condition.
Complications: [BLANK]
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
