Interventional treatment of acute right ventricular outflow track (RVOT) infectious endocarditis as bridge to surgery or percutaneous pulmonary valve implantation

Introduction

Infectious endocarditis (IE) is life threatening after pulmonary valve replacement. In case of obstructive cardiogenic shock or severe RVOTO an emergency percutaneous treatment can allow clinical stabilization to delay valve replacement.

Objective

This study aims to assess procedural success and clinical outcome in 16 consecutive patients (mean ± SD age 27.2 ± 15.7) with IE and primary percutaneous treatment.

Methods

Patients were retrospectively included.

Results

IE affected a Melody® valve in 9/16 (57%) cases (3/9 in a native RVOT, 1/9 with a Melody® valve in each PA, 1/9 in a Contegra VenPro™, 2/9 in a Hancock® bioprosthesis, 2/9 in a pulmonary homograft); a Contegra VenPro™ in 6/16 (37%); and a BioPulmonic Valve™ in 1/16 (6%).

Diagnosis of IE was 58.1 ± 34.3 months after last intervention/surgery and delay from diagnosis of IE to emergency percutaneous treatment was 9.8 ± 13.5 days. Clinical presentation was obstructive cardiogenic shock in 50%, septic shock in 25% or fever/shivering with severe RVOTO in 25%. At time of intervention 68% had an active bacteremia. On echo RVOT velocity was 4.6 ± 0.4 m/s and RV function was severely reduced in 68%.

Procedural time was 76 ± 48 min. Invasive RV-systolic-pressure 86 ± 21 mmHg, mean-PA pressure 19 ± 5 mmHg, and systolic-aortic-pressure 95 ± 13 mmHg. Procedural approach (Table 1) was dilatation in 3 patients, uncovered-stent implantation in 5, covered-stent implantation in 7, Melody® valve in 1.

Immediate resolution of the RVOTO was obtained in all patients. Post-procedural systolic-RV-pressure was 42 ± 11 mmHg, while RVOT systolic gradient was 19 ± 7 mmHg. There were no periprocedural deaths but one severe complication (rupture of a tricuspid valve corda, repaired with the following surgery).

Surgical repair (68%) and percutaneous pulmonary valve implantation (18%) were performed after 12 ± 34 months. One patient died of IE relapse after 3-months and one during surgery. One had cardiac transplantation due to uncontrolled sepsis.

Conclusion

Emergency interventional relieve of RVOTO was effective in all patients and permitted to delay pulmonary valve replacement in these critically ill patients.