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J Thorac Cardiovasc Surg 2003;125:741-742
© 2003 The American Association for Thoracic Surgery

Letters to the Editor

Percutaneous valve insertion: A new approach?

Service de Cardiologie Pédiatrique, Hôpital Necker Enfants Malades, Paris, France^a, Cardiothoracic Unit, Great Ormond Street Hospital for Children, NHS Trust, London, United Kingdom^b

To the Editor:

The recently published article on percutaneous aortic valve replacement Lutter and associates ¹ strengthens our belief that nonsurgical valve replacement will soon become a reality in the replacement of semilunar cardiac valves.

Andersen, Knudsen, and Hasenkam ² reported a nonsurgical heart valve replacement as early as 1992, and this was followed by similar attempts by other groups. Many technical problems have been encountered. The size of the vascular access required was too big, the function of the valve after compression and re-expansion could be compromised, and finally the newly implanted valve could obstruct the coronary orifices in aortic implantations. We reported our first experimental studies in 2000 for percutaneous pulmonary valve replacement and, after ethical approval, the first human heart valve implantation was performed by us in September 2000. ^3,4. In parallel, we reported our first successful aortic implantations in an experimental setup without creating coronary obstruction due to a newly designed stent with a two-step deployment strategy. ⁵ In April 2002, the French newspapers reported the first successful percutaneous implantation of an aortic valve as an emergency procedure in a 47-year-old man in cardiogenic shock. This came as a result of an ongoing research project by Alain Cribier in Rouen, France.

The article by Lutter and associates reports their experience with aortic implantations. As in our early aortic work, they have experimented with valve implantations in the supracoronary position. In this position, the valve implant does not obstruct the coronary orifices and the pressure difference over the closed valve is significantly smaller. This decreases the force to dislodge the valve after implantation and leads to reduced stress on the functioning valve leaflets. In our experience, implantation in this position was technically easy. However, in contrast to Lutter and coworkers, we had significant problems with coronary perfusion. ⁶ This was not unexpected, because implantation in the supracoronary position reduced the diastolic coronary flow volume. All of our animals that had this procedure died within 24 hours of implantation. The experiments performed by Lutter and colleagues experiments were ended at an earlier stage, and we would express concern as to the midterm feasibility of this type of implantation. Lutter's group also reported success of implantation in a low subcoronary position in 2 animals. Implantation in this position is physiologically clearly preferable but technically much more demanding. Further, the requirements of durability and stability of the valve are higher. Low subcoronary implantation in our experience led to paravalvular leaks and mitral valve injury. The orientation mechanism, with the two-step implantation technique developed by us, solved this problem and is one way to avoid coronary obstruction during valve implantation. Using this technique, we were able to implant aortic valves in the annular position in 5 consecutive lambs in 2001.

The increased interest in the field of percutaneous valve implantation and ongoing research will lead to safer and more effective valve replacements avoiding conventional surgery.

References

1. Lutter G, Kuklinski D, Berg G, Von Samson P, Martin J, Handke M, et al. Percutaneous aortic valve replacement: an experimental study. I. Studies on implantation. J Thorac Cardiovasc Surg. 2002;123:768-76.[Abstract/Free Full Text]
   
2. Andersen HR, Knudsen LL, Hasenkam JM. Transluminal implantation of artificial heart valves. Description of new expandable aortic valve and initial results with implantatin by catheter technique in close chest pigs. Eur Heart J. 1992;13:704-8.[Abstract/Free Full Text]
   
3. Bonhoeffer P, Boudjemline Y, Saliba Z, Merckx J, Aggoun Y, Bonnet D, et al. Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction. Lancet. 2000;356:1403-5.[Medline]
   
4. Bonhoeffer P, Boudjemline Y, Qureshi SA, Le Bidois J, Iserin L, Acar P, et al. Percutaneous insertion of the pulmonary valve. J Am Coll Cardiol. 2002;39:1664-9.[Abstract/Free Full Text]
   
5. Boudjemline Y, Bonhoeffer P. Steps toward percutaneous aortic valve replacement. Circulation. 2002;105:775-8.[Abstract/Free Full Text]
   
6. Boudjemline Y, Bonnet D, Sidi D, Bonhoeffer P. Percutaneous implantation of a biological valve in the aorta to treat aortic valve insufficiency: a sheep study. Med Sci Monit. 2002;8:BR113-6.[Medline]
   

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