First Transcatheter Pulmonary Valve Replacement in Tanzania

Figures

• 

  Visual Summary. Key Insights From the First TPVI Procedures Performed at JKCI, Tanzania JKCI = Jakaya Kikwete Cardiac Institute; TPVI = transcatheter pulmonary valve implantation.

• 

  Figure 1. Transthoracic Echocardiogram Images of Case 1 (A) Apical four-chamber view showing dilated right atrium and ventricle. (B) Color Doppler in parasternal short axis showing accelerated flow across stenotic pulmonary homograft. (C) Continuous wave Doppler across the pulmonary homograft demonstrating moderate pulmonary homograft stenosis with a peak gradient of 57 mm Hg and severe regurgitation.

• 

  Figure 2. Axial Cardiac CT Angiogram of Case 1 at the Level of the Ascending Aorta and Pulmonary Artery (A) Narrowed, calcified homograft conduit measuring 12 × 16 mm (orange arrow), proximal RVOT diameter of 27 × 18 mm, with severe LPA stenosis with a diameter of 12 × 14 mm (red arrow). (B) Coronary arteries (LMCA and LAD) appear distant from the calcified homograft (white arrows). CT = computed tomography; LAD = left anterior descending; LMCA = left main coronary artery; LPA = left pulmonary artery; RVOT = right ventricular outflow tract.

• 

  Figure 3. Series of Pulmonary Cinograms Demonstrating the Steps of TPVI in the First Case (A) Pulmonary angiogram displaying severe conduit stenosis with sizing balloon across it. (B) BIB technique plus simultaneous coronary angiography showing no coronary compression. (C) Prestenting the pulmonary homograft with a 3.9-cm 8-zig covered CP stent. (D) Prestented RVOT. (E) A 20-mm TPV is positioned in the middle of the stent. (F) Final angiogram showing a well-positioned valve with no PR. BIB = balloon-in-balloon; CP = Cheatham Platinum; PR = pulmonary regurgitation; RVOT = right ventricular outflow tract; TPV = transcatheter pulmonary valve; TPVI = transcatheter pulmonary valve implantation.

• 

  Figure 4. Transthoracic Echocardiogram Images of Case 2 (A) Apical 4-chamber view showing right ventricular hypertrophy without dilation of the right atrium and right ventricle. (B) Color Doppler in the parasternal short axis showing accelerated flow across the prosthetic pulmonary valve (Trifecta). (C) Continuous wave Doppler showing severe PS with a pressure gradient of 67 mm Hg and severe PR with pan-diastolic flow reversal and presystolic antegrade flow in the pulmonary artery, with atrial contraction consistent with restrictive right ventricular physiology. PR = pulmonary regurgitation; PS = pulmonary stenosis.

• 

  Figure 5. Axial CT Angiogram of the Chest at the Level of the Ascending Aorta and Pulmonary Artery (A) Calcified narrow prosthetic pulmonary valve (red arrow) with a diameter of 17 × 16 mm with dilated pulmonary arteries. (B) Adequate distance of at least 4 mm between LAD (orange arrow) and PT, indicating a low risk of coronary compression. AsAo = ascending aorta; LAD = left anterior descending; LPA = left pulmonary artery; CT = computed tomography; PT = pulmonary trunk; RPA = right pulmonary artery.

• 

  Figure 6. Fluoroscopic Images of TPVI in Case 2 (A) Pulmonary angiogram showed severely stenotic prosthetic valve with severe regurgitation. (B) A 20-mm TPV positioned across the prosthetic valve and successfully implanted by inflating the inner balloon, followed by the outer balloon. (C) Repeat pulmonary artery angiogram showed a well-positioned valve and no PR. PR = pulmonary regurgitation; TPV = transcatheter pulmonary valve; TPVI = transcatheter pulmonary valve implantation.

• 

  Figure 7. Preparation of Melody Valve (A) Rinsing the valve in saline 3 times for 1 minute each. (B) Well-rinsed Melody valve ready for implantation. (C) Hand-crimping the 20-mm Melody valve onto the 20-mm Ensemble system.