Coronary Artery Anomalies and Their Impact on the Feasibility of Percutaneous Pulmonary Valve Implantation
Anja Hanser1, Jörg Michel1, Andreas Hornung1
1Department of Pediatric Cardiology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany.
Insights
Coronary artery anomalies (CAAs) crossing the right ventricular outflow tract (RVOT) occur in 8% of patients evaluated for percutaneous pulmonary valve implantation (PPVI). These anomalies do not preclude successful PPVI, with implantation achieved in most cases.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Congenital Heart Disease
Background:
- Percutaneous pulmonary valve implantation (PPVI) is a minimally invasive procedure for treating pulmonary valve disease.
- Proximity of coronary artery branches to the right ventricular outflow tract (RVOT) is a significant challenge for PPVI.
- Coronary artery anomalies (CAAs) can further complicate PPVI by increasing the risk of coronary obstruction.
Purpose of the Study:
- To determine the frequency of CAAs in patients undergoing evaluation for PPVI.
- To assess the impact of CAAs, particularly those crossing the RVOT, on the feasibility of PPVI.
- To evaluate the safety and success of PPVI in patients with relevant CAAs.
Main Methods:
- Retrospective single-center study of 90 patients evaluated for PPVI between January 2010 and January 2020.
- Identification and characterization of CAAs using invasive testing, including balloon testing of the RVOT and selective coronary angiographies.
- Assessment of landing zone suitability and procedural success of PPVI in patients with CAAs.
Main Results:
- CAAs were identified in 7 patients (8%), with major branches crossing the RVOT.
- In 5 of these 7 patients, a suitable landing zone for PPVI was confirmed.
- PPVI was successfully performed in 4 patients, with 2 requiring a modified technique; one patient could not undergo PPVI due to RVOT dimensions.
Conclusions:
- Coronary artery anomalies involving major branches crossing the RVOT occur in approximately 8% of PPVI candidates.
- These CAAs should not be considered absolute contraindications for PPVI, as successful implantation is feasible in many cases.
- Careful pre-procedural assessment, including coronary angiography, is crucial to determine PPVI candidacy in patients with CAAs.
Abstract:
One of the major obstacles preventing successful percutaneous pulmonary valve implantation (PPVI) is related to the close proximity of coronary artery branches to the expected landing zone. The aim of this study was to assess the frequency of coronary artery anomalies (CAAs) especially those associated with major coronary branches crossing the right ventricular outflow tract (RVOT) and to describe their relevance for the feasibility of percutaneous pulmonary valve implantation (PPVI). In our retrospective single-center study 90 patients were evaluated who underwent invasive testing for PPVI in our institution from 1/2010 to 1/2020. CAAs were identified in seven patients (8%) associated with major branches crossing the RVOT due to origin of the left anterior descending (LAD) or a single coronary artery from the right aortic sinus. In 5/7 patients with CAAs balloon testing of the RVOT and selective coronary angiographies revealed a sufficiently large landing zone distal to the coronary artery branch. While unfavorable RVOT dimensions prevented PPVI in one, PPVI was performed successfully in the remaining four patients. The relatively short landing zone required application of the "folded" melody technique in two patients. All patients are doing well (mean follow-up 3 years). CAAs associated with major coronary branches crossing the RVOT can be expected in about 8% of patients who are potential candidates for PPVI. Since the LAD crossed the RVOT below the plane of the pulmonary valve successful distal implantation of the valve was possible in 4/7 patients. Therefore these coronary anomalies should not be considered as primary contraindications for PPVI.
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