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View large Download slide View large Download slide OBJECTIVES The aim of this study was to compare the performance of pulmonary homografts with stentless bioprosthetic valves [Medtronic Freestyle™ (Medtronic, Minneapolis, MN, USA)] in the pulmonary position in patients with congenital heart disease (CHD) younger than 20 years. METHODS Between January 2000 and December 2017, 215 patients were retrospectively identified from hospital databases in 3 congenital heart centres in Australia. Valve performance was evaluated using standard criteria. Propensity score matching was used to balance the 2 treatment groups. RESULTS Freedom from reintervention for patients who received a pulmonary homograft (n  = 163) was 96%, 88% and 81% at 5, 10 and 15 years and for patients who received a Freestyle™ valve (n  = 52) was 98%, 89% and 31% at 5, 10 and 15 years, respectively. Freedom from structural valve degeneration for patients with a homograft was 92%, 87% and 77% at 5, 10 and 15 years and for patients with a Freestyle valve was 96%, 80% and 14% at 5, 10 and 15 years, respectively. In the first 10 years, there was no difference in outcomes [reintervention hazard ratios (HR) = 0.69, 95% confidence intervals (CI) (0.20–2.42), P  = 0.56; structural valve degeneration HR = 0.92 (0.34–2.51), P  = 0.87]. After 10 years, the recipients of the Freestyle valves were at higher risk of both outcomes [reintervention HR = 7.89; 95% CI (2.79–22.34), P  < 0.001; structural valve degeneration HR = 7.41 (2.77–19.84), P  < 0.001]. The findings were similar when analysed by implantation in the orthotopic position and in the propensity-matched groups. CONCLUSIONS The Freestyle stentless bioprosthetic valve is a comparable alternative to cryopreserved pulmonary homografts up to 10 years after implantation when implanted in an orthotopic pulmonary position in patients younger than 20 years with CHD. [ABSTRACT FROM AUTHOR]

Transcatheter pulmonary valve replacement in the dysfunctional native right ventricular outflow tract (RVOT) provides an ongoing challenge. Currently available transcatheter pulmonary valves were developed for implantation within surgically placed conduits and bioprosthetic valves, and are often inadequately sized for the dilated native RVOT. The Medtronic Harmony™ (Medtronic, Minneapolis, MN), the Alterra Adaptive Prestent™ (Edwards Life Sciences, Irvine, CA), and the Venus P-valve™ (Venus Medtech, Shanghai, China) are three devices that have been developed in recent years, for the dedicated indication of transcatheter pulmonary valve replacement in the dysfunctional native RVOT. In this article, we describe each of these devices and review the clinical experience with them to date. • The geometry of the dilated, dysfunctional native RVOT often precludes the use of currently available transcatheter pulmonary valves. • The Medtronic Harmony™, the Alterra Adaptive Prestent™, and the Venus P-valve™ are new transcatheter devices for pulmonary valve replacement in the native RVOT. • All three devices have thus far demonstrated favorable clinical outcomes, and offer a less invasive alternative to surgical pulmonary valve replacement. [ABSTRACT FROM AUTHOR]

In the 20 years following the first described transcatheter pulmonary valve replacement (TPVR), there has been significant progress made in understanding the application and performance of this technology. For the Melody TPV (Medtronic, Minneapolis, MN) there is now over 10 years of follow-up data from prospective studies and multicenter registries that provide insight on acute procedural results, long-term valve performance, and risks to valve function such as stent fracture and infection. For the Sapien XT and S3 valves (Edwards Lifesciences, Irvine, CA) the duration of follow-up is shorter, but the breadth of experience is growing. Our understanding of procedural risks such a conduit injury and coronary compression has improved, as have our techniques for managing these potential complications. Studies have demonstrated that small conduits can be over-expanded and small bioprosthetic valves can be fractured to extend TPVR to a broader population of patients than originally envisioned. TPVR has been successfully applied to the patient with the native or patched right ventricular outflow tract (RVOT) and our understanding of pre-procedural imaging and screening for the native RVOT continues to improve. Future investigations should focus on the impact of TPVR on survival and long term health of the right ventricle as well as identifying and reducing risk factors that lead to infective endocarditis which continues to be a challenge in this patient population. • Long-term follow-up of the Melody TPV demonstrates stable valve function. Melody valve stent fracture and infective endocarditis (IE) are significant contributors to valve dysfunction and are the primary drivers of RVOT re-intervention. • TPVR has been extended to patients with smaller RVOT conduits and bioprosthetic valves (BPV) with acute procedural results and procedural complication rates similar to most major studies. • Rates of procedural success for TPVR in the native or patched RVOT remain lower than those for conduits or BPVs, typically due to the large and dynamic nature of the native RVOT. The Sapien S3 has extended TPVR technology to more patients with a native RVOT. • IE remains a concern in this population with an annualized incidence between 2-3% per patient year. Younger age, residual RVOT gradient post TPVR, and immunocompromised status are emerging as risk factors for E that should be considered when educating patients and families about pulmonary valve replacement. [ABSTRACT FROM AUTHOR]