Background
The percutaneous pulmonary valve implantation was the first percutaneous intervention in the treatment of regurgitant valve disease in humans. The most common indication for pulmonary valve implantation is residual right ventricular outflow tract lesion after correction of congenital heart disease that may be stenotic, regurgitant or mixed. Tetralogy of Fallot is one of the most common congenital heart lesions in this group.

Case report
A 45-year-old female patient was admitted to Cardiac Surgery OR after a complicated percutaneous pulmonary valve implantation. She had tetralogy of Fallot corrected in 1987 and reoperated in 1992 with placement of pulmonary homograft valve.
In the hemodynamic room, she developed hemodynamic instability with monomorphic VT with pulse. After 4 synchronised shocks and a loading dose of amiodarone sinus rhythm was observed. Due to severe hypotension noradrenaline infusion was initiated.
She arrived at the OR conscious and oriented, with no signs of respiratory difficulty and hemodynamically stable with perfusion noradrenaline.
A balanced general anaesthesia was performed with fentanyl, etomidate, rocuronium and sevoflurane.
Percutaneous valve prosthesis was removed and a bioprosthesis was surgically implanted in pulmonary position.
During the surgery she remained hemodynamically stable and no complications arose. She was transported to the ICU and was extubated 30h after surgery.
On the 3rd postoperative day, she developed dyspnoea and decreased saturation. She was reintubated and mechanically ventilated. During transport preparation to perform an angio-CT due to pulmonary thromboembolism suspicion, she developed CPR. Despite promptly resuscitation manoeuvres, dead followed.

Discussion
Although percutaneous implantation of cardiac valves is considered a safe and effective non-surgical therapeutic with high success rate, as an alternative to surgical valve replacement, embolization or valve migration is one of the possible complications of this procedure and may require emergency surgical treatment.

References
Ann Pediatr Cardiol.2012 Jan-Jun; 5(1): 53–60.
Glob Cardiol Sci Parct.2015; 2015(2): 23.
JACC. 2015.; 66

Learning points
We can conclude that this type of procedures should be performed in centers that can provide prompt cardiac surgical support.


08 / Percutaneous valve implantation – case report