Intravascular Ultrasound Guidance for Transcatheter Pulmonary Valve Replacement

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Right ventricular outflow tract (RVOT) or conduit dysfunction and failed surgical bioprostheses undergoing transcatheter pulmonary valve replacement (TPVR) (n=16). Intervention: Intraprocedural large-field 0.035-inch intravascular ultrasound (IVUS) assessment during TPVR vs. Projection angiography and nominal reference dimensions. Primary outcome: IVUS-derived RVOT geometry, transcatheter heart valve (THV) cross-sectional area (CSA) expansion, and leaflet-defined geometric orifice area (GOA) vs angiography and follow-up echocardiographic gradients (Spearman rho -0.700 for GOA vs follow-up mean gradient, 95% CI -0.888 to -0.313, p=<=0.005).

Q: What does this research mean for the field?

Intraprocedural intravascular ultrasound during transcatheter pulmonary valve replacement reveals subnominal valve expansion and a leaflet-defined geometric orifice area that inversely correlates with follow-up transvalvular gradients. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Karol Artur Sadowski; Michał Kania; Wiktor Stark; Olgierd Woźniak; Yusuke Kobari; Jacek Kądziela; Gary S. Mintz; Ole De Backer; Marcin Demkow; Łukasz Kalińczuk

doi:10.1016/j.jacadv.2026.103309

October 6, 2026JACC AdvancesOpen Access

Intravascular Ultrasound Guidance for Transcatheter Pulmonary Valve Replacement

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Graphical abstract published by JACC Advances — Graphical abstract · Published by JACC Advances · CC BY

Why the study?

During transcatheter pulmonary valve replacement, computed tomography cannot provide intraprocedural feedback, and projection angiography cannot provide a true short-axis assessment of right ventricular outflow tract geometry, achieved valve expansion, or leaflet-defined geometric orifice area.

Can intraprocedural large-field IVUS provide tomographic assessment of RVOT and valve geometry, THV expansion, and leaflet-defined GOA during transcatheter pulmonary valve replacement compared with angiography and follow-up echocardiography?

Key Points

To determine whether intraprocedural large-field intravascular ultrasound provides accurate tomographic assessment of right ventricular outflow tract geometry, transcatheter heart valve expansion, and geometric orifice area.
Analyzed N=16 patients (mean age 30.4 ± 6.9 years; 87.5% with tetralogy of Fallot) undergoing transcatheter pulmonary valve replacement with SAPIEN 3 (n=12) or Melody (n=4) valves.
Performed 0.035-inch intravascular ultrasound at baseline, after prestenting, and after valve deployment to measure cross-sectional area, diameters, and leaflet-defined geometric orifice area.
Evaluated post-implantation hemodynamics using echocardiography over a median follow-up of 271 days (interquartile range: 95-721 days).
Intravascular ultrasound localized anatomical remodeling to the narrowest site, where minimal diameter increased from 17.8 ± 4.0 mm to 23.9 ± 4.5 mm and cross-sectional area expanded from 320.5 ± 124.3 mm² to 517.5 ± 167.6 mm².
Achieved valve expansion was subnominal, with cross-sectional area expansion remaining below 90% across the inflow (84.9% ± 12.7%), midframe (85.9% ± 16.5%), and outflow (84.8% ± 14.4%).
Follow-up mean gradient averaged 12.0 ± 5.7 mm Hg and correlated inversely with geometric orifice area (Spearman ρ = −0.700 [95% CI: −0.888 to −0.313], P ≤ 0.005).

Study Design

Type

Cohort (n=16)

Blinding

A single reader blinded to angiographic and echocardiographic outcomes performed an offline analysis

Multicenter

No

Structured PICO

Can intraprocedural large-field IVUS provide tomographic assessment of RVOT and valve geometry, THV expansion, and leaflet-defined GOA during transcatheter pulmonary valve replacement compared with angiography and follow-up echocardiography?

P

Population

16 adults (mean age 30.4 years, 37.5% female, 87.5% with tetralogy of Fallot) undergoing transcatheter pulmonary valve replacement with intraprocedural IVUS guidance, followed for a median of 271 days.

E

Exposure

Intraprocedural large-field 0.035-inch intravascular ultrasound (IVUS; 10-MHz, 8.5-F Visions PV 0.035-inch catheter; Philips Volcano) performed at baseline, after landing-zone prestenting, and after THV implantation (22-mm Melody THV [25.0%] or 29-mm SAPIEN 3 THV [75.0%], deployed nominally or with 4-mL overfilling).

C

Comparator

Serial projection angiography (diameters measured in the best projection), device- and deployment-specific nominal reference dimensions, and clinically indicated follow-up echocardiography.

O

Outcome

IVUS-derived RVOT geometry (cross-sectional area [CSA], minimal diameter [Dmin], maximal diameter [Dmax]), achieved THV expansion, and peak-systolic leaflet-defined geometric orifice area (GOA) compared with angiographic measurements and follow-up echocardiographic mean gradients (at median 271 [95-721] days).surrogate

Main Result

Effect estimate: Spearman rho -0.700 for GOA vs follow-up mean gradient (95% CI -0.888 to -0.313)

p-value: p=<=0.005

Limitations

Retrospective single-center design
Small sample size (n=16)
Selective IVUS use based on catheter availability and operator willingness
Heterogeneous devices (SAPIEN 3 and Melody valves)
Single-reader analysis without reproducibility testing or a core laboratory
Catheter noncentering and potential oblique acquisition
Qualitative pinwheeling assessment and limited near-field resolution of the 10-MHz platform
Underpowered paravalvular leak (PVL) analysis
Small sample size
Selective IVUS use
Heterogeneous devices
Catheter noncentering
Qualitative pinwheeling assessment
Limited near-field resolution
Underpowered PVL analysis

Implication

Intraprocedural large-field IVUS during TPVR detects focal RVOT circularization, widespread subnominal valve area expansion missed by projection angiography, and leaflet-defined geometric orifice area that correlates inversely with follow-up transvalvular gradients.

Abstract

[Figure: see text]

Discussion

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Cite This Study

Sadowski et al. (2026) conducted a cohort in Right ventricular outflow tract (RVOT) or conduit dysfunction and failed surgical bioprostheses undergoing transcatheter pulmonary valve replacement (TPVR) (n=16). Intraprocedural large-field 0.035-inch intravascular ultrasound (IVUS) assessment during TPVR vs. Projection angiography and nominal reference dimensions was evaluated on IVUS-derived RVOT geometry, transcatheter heart valve (THV) cross-sectional area (CSA) expansion, and leaflet-defined geometric orifice area (GOA) vs angiography and follow-up echocardiographic gradients (Spearman rho -0.700 for GOA vs follow-up mean gradient, 95% CI -0.888 to -0.313, p=<=0.005).

synapsesocial.com/papers/6ad9538fdc7c35b68767bb04 https://doi.org/10.1016/j.jacadv.2026.103309

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Intravascular Ultrasound Guidance for Transcatheter Pulmonary Valve Replacement

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Intravascular Ultrasound Guidance for Transcatheter Pulmonary Valve Replacement

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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