Post-Ross Pulmonary Homograft Failure: A Series of Unfortunate Events
Presenter
Georges Ephrem, M.D., FSCAI, Indiana University School of Medicine, Zionsville, IN
Georges Ephrem, M.D., FSCAI1, Rolf Peter Kreutz, M.D., FSCAI2, John Brown, M.D.3 and Philip Hess, M.D.3, (1)Indiana University School of Medicine, Zionsville, IN, (2)Indiana University School of Medicine, Indianapolis, IN, (3)Indiana University Schhool of Medicine, Indianapolis, IN
Keywords: Adult Congenital Heart Disease (ACHD), Drug-eluting Stent (DES) and TPVR/Pulmonary Valve
Background
Post Ross Pulmonary Homograft Failure: A Series of Unfortunate Events
Methods
50-year-old woman, BAV s/p Ross procedure (30 mm homograft) in 2019, hypertension, pulmonary hypertension, asthma, & obesity, had failure of homograft 2ary to distortion of the extension, discussed at ACHD MDT conference with decision for TPVR given comorbidities & risk of re-operation. Major concern was coronary compression, discussed at length at conference & in clinic.
Results
Diagnostic cath showed 40 mmHg peak to peak gradient across the homograft & 40% stenosis of reimplanted LCA button. Cardiac MRI showed a distorted homograft. Several coronary compression tests with 26x40 Atlas Gold balloon were performed & were favorable. Prestenting with Palmaz XL P4010 stent was complicated by almost complete compression of LCA with hypotension & PEA arrest requiring CPR. Emergent PCI with 4.0 x 12 mm Synergy DES improved hemodynamic status followed by TPVR with 26 mm Sapien S3 valve with excellent outcome for both valve & stent. The patient was discharged home 4 days later with unremarkable post procedure echocardiogram. A new diastolic murmur was noted in clinic. She was requiring escalating diuretics. Repeat echocardiogram & CTA chest were unremarkable. 2 months later, she presented with bacteremia & endocarditis of her Sapien valve with an aorto-pulmonary fistula by TEE & CTA chest. She underwent removal of the infected Sapien valve & replacement with a 30 mm homograft, removal of the LCA stent, & bovine pericardial closure of the aorto-pulmonary fistula with excellent outcome.
Conclusions
Coronary compression is a catastrophic complication of TPVR (5%), especially in Ross patients. Extreme attention must be given in the periprocedural phase to predict it & avoid it. Operators must be ready to intervene if it occurs despite appropriate testing. Salvage PCI is not a guarantee for long term success as the interaction between the conduit & the stented artery can have detrimental consequences such as stent fracture, erosion, perforation, fistulization... More reliable prediction algorithms & technology for simulation/virtual rendering would be helpful in identifying such cases a priori & directing them towards a surgical intervention.