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A Melody for the Elderly

Updated: May 7, 2021

Aphrodite Tzifa, MD, FRCPCH; Dimosthenis Avramidis, MD; Dimitra Loggitsi, MD, PhD; Konstantinos Spargias, MD, PhD

Transcatheter implantation of pulmonary valves for treatment of Right Ventricular Outflow Tract dysfunction was first reported in 2000.[1] Since then, over 10,000 patients have received transcatheter therapy with a Melody percutaneous valve for failed pulmonary conduits. The vast majority of these patients have been children or young adults, mostly because Complex Congenital Heart Disease surgery started taking place after the 1970’s. However, older patients who have received a pulmonary conduit for other indications, such as the Ross procedure for Aortic Valve Disease, may present with conduit failure at a more advanced age. A contributing factor to the latter is also the fact that the pulmonary homograft longevity is superior in the Ross setting rather than in other Congenital Heart Disease entities.[2]

We report the case of an 81-year-old patient who presented with pulmonary homograft dysfunction and received transcatheter valve therapy in the pulmonary position with the use of a 22mm Melody valve inside a 31-year old pulmonary homograft. To the best of our knowledge, this is the oldest patient to date who has received transcatheter pulmonary valve implantation therapy.

FIGURE 1 Transparent Volume-Rendering image (VRT) - Lateral RVOT view with demonstration of the heavily calcified homograft.

The patient presented with aortic stenosis at the age of 50 years and underwent a Ross operation in 1986 by Professor Donald Ross. His homograft was noted to be calcified and stenosed 14 years later, but due to good clinical condition, the patient had refused a re-operation. He remained under frequent follow-up and became symptomatic with clinical signs of pedal oedema and ascites, requiring multiple hospitalisations, one year before the patient was referred for transcatheter therapy.

Non-invasive imaging with CT and MRI showed a heavily calcified and stenosed homograft (Figures 1,2), with the coronary arteries at a safe distance from the area of interest (Figure 3a, b). Echocardiographic peak Doppler derived pressure gradient across the pulmonary homograft was 60mmHg and pulmonary regurgitant fraction as assessed by MRI phase contrast flows was 28%. Right ventricular ejection fraction was 55% and RVEDV measured 115ml/m.[2] Due to advanced age and multiple vascular operations, the patient also underwent an MRI assessment of his femoral veins to delineate the vascular anatomy and to choose the entry point for insertion of the 22Fr Melody Ensemble system. The procedural steps were the usual with pre-implantation of a covered stent followed by implantation of a 22mm Melody valve. Although the 31-year old homograft was heavily calcified, the stent and valve were implanted without any disruption to the calcified homograft wall. After valve implantation, haemodynamic assessment revealed an RV-PA pressure gradient drop from 40mmHg to 5mmHg, whilst MPA angiogram showed no residual pulmonary valve regurgitation.

To read the full article, please go to the October 2019 Issue of CCT.


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