The Landscape of Subsequent Pulmonary Valve Replacements in US Pediatric Hospitals

M. Faateh¹, P. Dring², H. F.. Ahmed¹, A. Mehdizadeh-Shrifi¹, M. Ricci³, D. Lehenbauer¹, D. Morales⁴, A. Ashfaq^1
1Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio ²The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio ³Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Iowa City, Ohio ⁴Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical CenterCincinnati Children's Hospital Medical Center, Cincinnati, Ohio

Purpose: Congenital heart disease patients may need pulmonary valve replacements due to their underlying disease. Options include surgical pulmonary valve replacement(SPVR) and transcatheter pulmonary valve replacement(TPVR), posing them at risk for subsequent valve replacements. We sought to outline the landscape of patients needing subsequent PVR (either) performed in US pediatric hospitals.

Methods: The pediatric health information system database was queried to identify patients ≥10 years of age undergoing SPVR and TPVR from 1/1/2011 to 5/30/2024. The first PVR for a patient during the study period was marked as their index PVR. In-hospital outcomes including mortality, subsequent cardiac operations, length of stay(LOS), trends and costs for the index hospitalizations were compared for SPVR vs TPVR. In addition, indications, outcomes and costs of subsequent pulmonary valve re-interventions (surgical or transcatheter replacement) were compared, by stratifying into sub-groups: Initial SPVR reintervention subgroup: Subsequent SPVR (SPVR-SPVR) vs TPVR (SPVR-TPVR); Initial TPVR reintervention subgroup: Subsequent SPVR (TPVR-SPVR) vs TPVR (TPVR-TPVR).

Results: A total of 7,373 patients were included of which 4,623(63%) were in the SPVR group and 2,747(37%) in the TPVR group. The numbers of identified reinterventions were SPVR-SPVR: 73, SPVR-TPVR: 157, TPVR-SPVR: 73 and TPVR: 50. The median age at initial PVR was higher in TPVR(19 vs 17 y), p< 0.001. SPVR patients were more likely to have tetralogy of Fallot(50% vs 47%), p< 0.05. Post-op outcomes comparing TPVR vs SPVR including mortality(0.4% vs 0.4%) and ECMO use(0.3% vs 0.5%) were similar, p>0.05. SPVR group had a higher rate of post-op stroke(0.8% vs 0.4%), renal failure(3.2% vs 0.8%) and longer LOS(4 vs 1 d)(all p< 0.05). TPVR patients had a higher rate of subsequent cardiac operation during same hospitalization(2.2% vs 0.3%), p< 0.001.Repeat interventions due to endocarditis were higher in patients who had initial TPVR (41%) compared to those who underwent an initial SPVR (34%). For the index SPVR reintervention sub-group, SPVR-to-SPVR(vs SPVR-to-TPVR) patients had similar rates of in-hospital mortality and stroke. For the index TPVR reintervention sub-group, TPVR-to-SPVR(vs TPVR-to-PVR) patients also had similar mortality and stroke rates. Costs and LOS were greater in both SPVR-to-SPVR and TPVR-to-SPVR sub-groups.

Conclusion: The landscape of subsequent pulmonary valve replacements is evolving as there are several iterations that patients can undergo. Individualized patient decision making through a multidisciplinary discussion holds the key to offer the best valve replacement option for a patient.

Identify the source of the funding for this research project: None