17571 Transcatheter Pulmonary Valve Replacement Tpvr

Overview

Transcatheter pulmonary valve replacement (TPVR) is a procedure that puts a new valve into the heart without open-heart surgery. The pulmonary valve is the one-way door between the right lower chamber of the heart and the artery that carries blood to the lungs. When this valve becomes narrow (too tight) or leaky (not closing properly), blood does not flow to the lungs the way it should. In TPVR, a doctor guides a thin, flexible tube called a catheter through a blood vessel — usually in the groin — up to the heart. A folded-up replacement valve is carried on the tube and then opened into place inside the old valve or inside a man-made tube (called a conduit) that was put there in earlier surgery.

TPVR is a specialised procedure and is not common in the general population. It is carried out in specialist heart centres by teams who look after people with congenital heart disease (heart problems present from birth). Numbers have grown steadily as the technique has improved and more people become suitable for it.

It is mostly used for children, teenagers and adults who were born with a heart problem and had surgery in childhood — especially those born with conditions such as Tetralogy of Fallot, where a man-made tube (conduit) carrying blood to the lungs can become narrow or leaky over time. It can also be considered for some people whose replacement tissue valve has worn out. Some adults with other valve problems may also be assessed for it.

Symptoms

Common symptoms

• Shortness of breath when walking, climbing stairs or exercising
• Feeling unusually tired or lacking energy
• Awareness of your heartbeat, such as a racing, fluttering or pounding feeling
• Chest discomfort, especially with activity
• Dizziness or fainting
• Swelling in the legs, ankles or feet
• A bluish tint to the lips or skin in some people with long-standing heart problems

Symptoms in children

• Tiring quickly during feeding, with sweating or falling asleep before finishing a feed
• Slow weight gain or poor growth
• Fast or heavy breathing
• Getting out of breath sooner than other children during play
• Being more sleepy or less active than expected
• Fainting or dizzy spells, which should always be checked

Symptoms in older adults

• Breathlessness that slowly gets worse over months
• Reduced stamina compared with a few years ago
• Fluid build-up causing swollen ankles or a bloated feeling
• Palpitations or an irregular heartbeat
• Feeling light-headed when standing up

Causes

Main causes

• Congenital heart disease (a heart problem present from birth) — the most common reason. Many people had a man-made tube or a tissue valve placed in childhood, and these can narrow or leak over the years.
• A previously implanted biological (tissue) valve wearing out or failing
• Scarring or narrowing of the pathway between the heart and the lungs after earlier surgery
• Infection of the heart valve (endocarditis), which can damage a valve
• Rheumatic heart disease, which can damage valves over time (more common in some parts of the world)

Risk factors

• Being born with a heart condition that needed surgery in childhood
• Having a conduit or tissue valve already in place that is now narrowed or leaking
• Previous infection of a heart valve or the lining of the heart
• A history of rheumatic fever
• Growing — as children grow, a valve or conduit that was once the right size can become too small for the heart's needs

When to see a doctor

See a doctor urgently if:

• Sudden worsening of breathlessness, or breathlessness at rest
• Fainting, near-fainting, or chest pain with activity
• A new, fast or irregular heartbeat that lasts
• Fever with feeling unwell, particularly if you have a heart valve or conduit in place
• New or rapidly increasing swelling in the legs or abdomen

Book a routine appointment if:

• You feel more tired or breathless than usual over weeks or months
• Your exercise tolerance has dropped and you want to understand why
• You have questions about your follow-up scans or whether TPVR might be an option for you
• You are planning a pregnancy and have a heart valve or conduit in place
• You are due a dental procedure and need advice about infection precautions

Diagnosis

The heart team builds a picture from your symptoms, an examination, and detailed imaging of your heart. The key question is not only how well the valve is working, but also whether its shape and size would allow a catheter-delivered valve to sit securely. That decision is usually made by a multidisciplinary team — cardiologists, imaging specialists and surgeons — who review your scans together.

Tests that may be done

• Echocardiogram (ultrasound scan of the heart) — shows how well the valve opens and closes and how hard the heart is working
• Cardiac MRI — gives detailed information about the heart's chambers, blood flow and the conduit
• CT scan of the heart — maps the exact shape and size of the valve area to plan the procedure
• Cardiac catheterisation — a thin tube is passed into the heart to measure pressures and confirm how the valve is behaving
• Electrocardiogram (ECG) — records the heart's electrical rhythm
• Exercise test — shows how your heart and lungs cope with activity
• Routine blood tests before any procedure

What to expect at your appointment

The assessment usually happens over one or more outpatient visits. Scans are painless, though an MRI means lying still for a while and a CT may involve an injection of dye that gives a warm flush for a few moments. Planning may take weeks because the team needs to decide whether TPVR is safe and suitable for your anatomy, or whether open surgery would be better. You should be told the risks, benefits and alternatives before you decide, and you can bring someone with you and ask questions.

Treatment

TPVR is a procedure, not a cure for the underlying heart condition. It aims to restore good blood flow to the lungs, ease symptoms and take strain off the right side of the heart. It is done under general anaesthetic or deep sedation in a catheter laboratory. A tube is passed through a vein in the groin up to the heart, a balloon may be used to open up the old valve or conduit, and the new valve is then expanded into position. The whole thing usually takes a couple of hours, and most people stay in hospital for a short time afterwards.

Self-care at home

• Follow the instructions about the groin puncture site: keep it clean and dry, and avoid heavy lifting, straining or strenuous exercise for the time your team advises
• Take your medicines exactly as prescribed and do not stop any of them without asking
• Attend all follow-up appointments and scans, even when you feel well
• Look after your teeth: brush twice daily and see a dentist regularly — good dental health lowers the risk of infection reaching the heart
• Tell any dentist, doctor or nurse that you have a heart valve or conduit in place before procedures, so they can advise on infection prevention
• Carry any information your heart team has given you about your valve or device
• Stop smoking if you smoke, and ask for help — it is one of the most effective things you can do for your heart

Medical treatments

Treatment is tailored to the individual. Some people are monitored with regular scans for a period before any procedure is needed. Where fluid build-up or strain on the heart is a problem, doctors may prescribe medicines to help the heart pump more effectively or to remove extra fluid — the exact choice is made by your heart team. Some people first have a balloon procedure to stretch a narrowed valve or conduit. TPVR itself is the main procedure when the anatomy is suitable. Open-heart surgery to replace the valve remains an option, and is sometimes the better or only choice.

When is surgery considered?

Open-heart surgery may be recommended instead of, or later than, TPVR if the existing valve or conduit is the wrong shape or size for a catheter-delivered valve, if there is an infection that must be cleared surgically, if the valve is leaking in a way that a catheter valve cannot fix, or if another heart operation is needed at the same time. Your heart team will explain which option they believe is safest for you and why.

Living with this condition

Most people notice better energy and easier breathing within weeks to a few months, though it can take longer. You will have follow-up appointments and scans for the long term, because the replacement valve is monitored and may eventually need replacing again. Many people return to work, school, driving and gentle exercise fairly quickly; your team will tell you when it is safe to resume each activity. Travel is usually fine — just check with your team before long trips and make sure you have enough of your medicines.

Lifestyle tips

• Build activity back gradually, following your team's advice on what and when
• Ask about contact sports and heavy weight training specifically — advice varies depending on your valve and anatomy
• Keep to a heart-healthy diet with plenty of vegetables, fruit, whole grains and less salt and processed food
• Stay at a healthy weight and have your blood pressure checked regularly
• Avoid smoking and limit alcohol
• Get enough sleep and pace yourself during busy periods
• Plan pregnancy with your heart team well in advance if this applies to you, so medicines and monitoring can be reviewed

Diet and exercise

A balanced, lower-salt diet helps keep fluid build-up and blood pressure in check. Exercise is encouraged, but the right type and amount depends on your heart, your valve and your fitness. Many people are advised to choose walking, swimming, cycling or similar steady activities, and to build up slowly. Your team can tell you whether any activities should be avoided. If you feel breathless, dizzy or unwell during exercise, stop and rest, and mention it at your next appointment.

Mental health and emotional wellbeing

It is very normal to feel anxious before a heart procedure, or to feel low while recovering. Some people feel worried about the valve wearing out, about future procedures, or about keeping up with work and family. These feelings matter and are worth talking about. If low mood, worry or poor sleep is lasting more than a couple of weeks or affecting daily life, please tell your doctor or heart team — support such as talking therapies is available and helps. If you ever feel you cannot cope or have thoughts of harming yourself, contact your local emergency number or a crisis support service straight away, or ask someone to stay with you until help arrives.

Prevention

The heart conditions that lead to TPVR usually cannot be prevented, because they are present from birth. What can be managed is how closely the valve is watched and how early problems are picked up. Attending follow-up appointments, treating infections promptly, and looking after your general heart health all help you get the right treatment at the right time.

Vaccines

Keep up to date with routine vaccinations, and ask your heart team about any extra ones they recommend, such as flu and pneumonia vaccines. Vaccination against respiratory infections is particularly important for people with heart conditions.

Screening programmes

There is no general screening programme for this. Instead, people known to have a conduit or a replaced pulmonary valve are monitored with regular echocardiograms and, from time to time, MRI or CT scans. If you were born with a heart condition, it is important to stay in specialist follow-up even if you feel completely well — this is sometimes called lifelong congenital heart disease care.

Complications

If left untreated

• The right side of the heart can become enlarged and work less well (heart failure)
• Increasing breathlessness and tiredness, with less ability to do everyday activities
• Fluid build-up in the legs, abdomen or lungs
• Irregular heart rhythms
• Higher risk of infection of the valve or conduit (endocarditis)
• In some people, a bluish tint to the skin from poorly oxygenated blood

Long-term outlook

For most people who are suitable for TPVR, the outlook is good. Many notice easier breathing, more energy and better exercise tolerance, and the procedure has a good safety record in experienced centres. It is important to know that the replacement valve is not permanent — it will be monitored over the years and may need replacing again in the future, sometimes with another catheter procedure. Complications can happen, including bleeding, infection, valve movement, or rhythm problems, and your team will discuss your personal risks with you beforehand. With regular follow-up and good day-to-day care, most people get back to the activities they enjoy.

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