I am a 43 year old man in general good health. I have a repaired Tet (Feb/1970) and follow up PV replacement in 2005.
Currently, I am experience severe pulmonary regurgitation, and I am awaiting consultation with my physicians pending their review of my records from 2005 procedure.
Multiple questions, but to try to summarize:
I understand that in certain circumstances a Melody TPV could be indicated. I know this is a more recent technology, and I would like to know is that a solution or is it a band-aid? (i.e. does the TPV delay open heart procedure versus replacing OHS?)
Secondly, I am quite concerned about having a 3rd open heart surgery. Ironically, for the second surgery I had no fear or apprehension. For a third one, I am scared. I am curious about the complications other than the standard stuff that can occur from OHS x3. If I listen to the surgeon, the actual work on replacing the valve is somewhat routine. Being opened and closed a 3rd time is what I am concerned about.
Thirdly, since it appears to me that the two possible options will be TPV or OHS, my understanding is delaying either only has downside, particularly from a RVentricle function perspective.
Finally, and maybe most importantly, what questions am I missing (I have a big list already, including the above).
One of the things that we have seen with the old way of repairing tetralogy of Fallot is that a transannular patch was often placed. This means that the pulmonary valve annulus was widened with a patch. However, it takes a stenotic (obstructive) but competent valve and now makes it no longer obstructive but leaky. Over time, the chronic leak of the valve causes the right ventricle (RV) to enlarge, which eventually leads to RV dysfunction, sometimes lethal arrhythmias, and decreased exercise tolerance.
One of the great new interventions that has come out in the last few years is the Melody valve. This is a bovine (cow) jugular venous valve mounted inside a metal stent. The valve is deployed with a catheter into the pulmonary artery. The stent is expanded and the valve stays in place, eliminating the pulmonary valve leak. This can allow the RV to recover, either partially or even fully, depending on how long it has been volume loaded. There are a few factors that determine whether the Melody valve can be placed. One is if there is a valve conduit in place already--if there is, then the Melody can be used. Unfortunately, native pulmonary artery (PA) cannot hold the valve and stent. Another is how large the diameter of the PA is--it can't be too big, or the stent won't be able to be seated. We don't know how long these valves will last, though, but if you can get 10 years out of it, that's quite good. And, it may be that you could have another one placed inside that one later. As well, there are some newer valves coming on the market in the near future that may be able to be used in either larger PAs or native PAs.
Overall, I would definitely recommend looking into this as an option, and having it placed at an institution that has experience and training to do this. If you can delay or prevent repeat surgery, that would be ideal, as the risks for surgery increase each time you go in to do one. As you suggest, the risks of entering the chest are the greatest, with having to go through lots of adhesions and scar tissue the biggest problem. Without evaluating you, I cannot say how long you could wait to have any intervention. There are criteria by ECG and by MRI that suggest when intervention should be done. You should be evaluated by an adult congenital heart disease specialist (ACHD) and discuss all this at that time.
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