Instead of open-heart surgery, a valve within a valve
Date: March 1, 2012
At age 18, the patient is already a veteran of multiple invasive operations and too many lengthy hospital stays. Now, he and his parents are gearing up for yet another procedure. Born with tetralogy of Fallot, this young man has had his pulmonary valve repaired twice, but the replacement conduit has become dangerously narrowed by severe stenosis. This time, however, it’s going to be different—thanks to a valve within a valve, placed during a minimally invasive, transcatheter procedure.
The operation, percutaneous pulmonary valve replacement, “is not surgery,” says Rich Ringel, one of the few pediatric interventional cardiologists worldwide who performs it. “But in many situations it can replace surgery. And there is no long hospital stay; most patients can go home the next day.”
Instead of cracking the chest—and risking all the potential complications that can accompany open-heart surgery—this procedure involves making a small hole in the groin, threading a balloon-tipped catheter through the femoral vein and up to the pulmonary valve. On the catheter is a stent-mounted biprosthetic valve. “Once it’s in place,” says Ringel, “we expand it to hold open the existing valve.”
The procedure, still new, has proven successful in clinical trials in the United States and Europe, and has been approved by the FDA as a humanitarian-use device.
In some young patients with aortic valve disease, surgeons replace the diseased aortic valve with the patient’s own pulmonary valve, an operation known as the Ross procedure. The patient’s pulmonary valve is then replaced with a cadaver valve known as a homograft. But over time, the cadaveric valve may become obstructed and require yet another valve replacement through open-heart surgery.
“When the surgeon puts in a homograft, we hope that it will last 20 years,” says Ringel. “But too often, it lasts only a few years. Our hope is that by inserting this valve, we will give that homograft the years it was designed to get.”
Ringel also hopes to reduce the number of open-heart procedures that patients with congenital heart defects—who are living longer than ever, thanks to advances such as this—will need.
This innovative means of fixing a congenitally flawed aortic valve marks the latest evolution in a series of breakthroughs that began with the famous “blue baby operation,” first performed in 1944 by Johns Hopkins surgeon Alfred Blalock and developed with the help of pediatric cardiologist Helen Taussig and surgical technician Vivien Thomas.