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Editorial comment

Hôpital Necker – Enfants Malades, Paris 75015, France

^_* Corresponding author. Tel.: +33 1 44381867; fax: +33 1 44381911. (Email: pascal.vouhe{at}nck.aphp.fr).

The paper by Frigiola et al. is timely, dealing with a controversial issue [1]. An increasing number of patients, who have undergone right ventricular (RV) outflow tract repair for various malformations in infancy or childhood, need pulmonary valve implantation for severe pulmonary regurgitation when they reach adulthood. There is no doubt that pulmonary regurgitation, although well tolerated for a long time, does lead to increasing right ventricular volume, worsening exercise tolerance and ventricular arrhythmia. However, when and how should pulmonary valve implantation be performed remain a matter of debate. The paper by Frigiola et al. provides useful information regarding this issue and deserves several comments.

1. As stated by the authors themselves, this is not a comparative study between surgical and percutaneous pulmonary valve implantation. There are obviously two groups of patients. Some patients have, in addition to pulmonary regurgitation, associated lesions such as aneurysmal dilatation of RV infundibulum, residual stenosis of proximal pulmonary arteries, tricuspid regurgitation or residual septal defects. Only a conventional surgical approach can provide adequate repair of all lesions including, in addition to pulmonary valve implantation, RV remodeling, pulmonary artery augmentation, tricuspid valve repair or cryo-ablation surgery. The present study shows that the results are satisfactory with a very low operative risk, a normalization of RV volume and, even, a potential improvement in left ventricular (LV) function (a confirmation of the importance of RV/LV interaction). Another group of patients present with severe pulmonary regurgitation with moderate RV dilatation and no other residual lesion (particularly without aneurysmal dilatation of RV infundibulum); a majority of them had implantation of a valved conduit at initial operation. Percutaneous pulmonary valve implantation can be performed very safely and provides excellent short-term results with a normalization of RV volume and an improvement in LV function.
An important question then arises. Do these two groups of patients represent two different evolutive phases of the same pathological process? (And, as a consequence, should percutaneous implantation be performed, if applicable, early as a bridge to delay surgery?). This is, very likely, not the case [2]. Some patients have non-restrictive RV physiology and develop rapid and severe RV dilatation, particularly if anatomical residual lesions are associated; these patients should undergo surgery, RV remodeling being an important step of the repair [3]. Other patients with restrictive RV physiology have only moderate RV dilatation despite severe pulmonary regurgitation; percutaneous pulmonary valve implantation is an attractive alternative, if technically feasible. Therefore, the respective indications are that distinct and careful preoperative evaluation (particularly regarding RV volume and segmental function) is necessary.

2. The percutaneous technique used in the present report does not allow valve implantation in large right ventricular outflow tracts. This represents a major limitation to the clinical applicability of the technique. However, improvements in the percutaneous technique and the development of minimally-invasive transventricular techniques [4] may obviate, in the near future, this drawback and allow pulmonary valve implantation without cardiopulmonary bypass in a majority of potential candidates.

3. In the absence of ideal valve substitute, any implanted biological valve (whatever the technique of implantation may be) is prone to degeneration and iterative replacement. Every patient will need multiple valve implantations during his or her lifetime. Conventional and less invasive implantation techniques should not be regarded as exclusive, but as complementary. The different techniques may be indicated at various times in the same patient. Iterative conventional surgical procedures become more and more risky, as they multiply. Percutaneous or minimally-invasive techniques may reduce the number of conventional procedures. Although further experience is mandatory to clearly determine the respective indications of each technique, it is likely that percutaneous and minimally-invasive procedures may be particularly useful in patients who have previously undergone surgical pulmonary valve implantation (at initial repair or at previous reoperation).

	References

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1. Frigiola A, Tsang V, Nordmeyer J, Lurz P, Van Doorn C, Taylor AM, Bonhoeffer P, de Leval M. Current approaches to pulmonary regurgitation. Eur J Cardiothorac Surg 2008;34:576-581.[Abstract/Free Full Text]
2. Redington AN. Physiopathology of right ventricular failure. Semin Thorac Cardiovasc Surg Pediatr Card Surg Ann 2006;9:3-10.[CrossRef]
3. Ghez O, Tsang VT, Frigiola A, Coats L, Taylor A, Van Doorn C, Bonhoeffer P, de Leval M. Right ventricular outflow tract reconstruction for pulmonary regurgitation after repair of tetralogy of Fallot. Preliminary results. Eur J Cardiothorac Surg 2007;31:654-658.[Abstract/Free Full Text]
4. Schreiber C, Hörer J, Vogt M, Fratz S, Kunze M, Galm C, Eicken A, Lange R. A new treatment option for pulmonary valvar insufficiency: first experiences with implantation of a self-expanding stented valve without cardiopulmonary bypass. Eur J Cardiothorac Surg 2007;31:26-30.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pascal R. Vouhé Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Vouhé, P. R. Search for Related Content PubMed Articles by Vouhé, P. R.