Surgical or transcatheter pulmonary valve replacement, how to choose ?

Introduction

Pulmonary valve replacement (PVR) is indicated for right ventricle outflow tract (RVOT) dysfunction. The choice between the transcatheter PVR (TPVR) and the surgical PVR (SPVR) is debated.

Objective

We aimed to compare the TPVR to the SPVR, considered previously as the gold standard, to determine the best choice for each patient.

Methods

A retrospective observational study was conducted in Lille University hospital. All patients who had PVR between January 2012 and May 2021 were included. The primary outcome was the incidence of valve failure defined as the occurrence of death, endocarditis or the need for secondary intervention.

Results

In total, 273 patients were included (100 patients with TPVR (36.6%) and 173 with SPVR (63.4%)). Age at the intervention was 25.1 ± 14.8 years for TPVR and 34.9 ± 15.7 years for SPVR. The outlet malformation was the main pathology (65% of TPVR and 61.3% of SPVR) followed by the Ross intervention (18% of TPVR and 11.6% of SPVR). The mean duration of the follow-up was 3.6 ± 2,8 years for TPVR and 3.9 ± 0,9 years for SPVR. Valve diameters were higher in the SPVR group (9% < 20 mm – 44% 20–22 mm and 47% > 22 mm for TPVR; and 3.6% < 22 mm and 96,4% > 22 mm for SPVR) and post-intervention transvalvular gradient was higher in the TPVR group.

The primary outcome was not significantly different in TPVR than in SPVR (16.33% vs. 8.7% respectively, P = 0.846), and the freedom from primary outcome at 9 years of follow up was 57% in TPVR and 84% in SPVR (Figure 1), after adjusting for predefined confounders (age at the intervention, size of the valve, and disease).

The risks factors for primary outcome were number of previous surgeries (P = 0.0190) and small size of the valve (threshold < 22 mm, hazard ratio 0.27, P = 0.0363).

Conclusion/Perspectives

The choice between TPVR and SPVR should be individualized based on each patient, their risk factors and the size of their right ventricle outflow tract. A larger size of the valve (> 22 mm if possible) may be preferable mainly in patients with several previous surgeries.