Elsevier

The Annals of Thoracic Surgery

Volume 94, Issue 5, November 2012, Pages 1619-1626
The Annals of Thoracic Surgery

Original article
Pediatric cardiac
Impact of Pulmonary Valve Replacement in Tetralogy of Fallot With Pulmonary Regurgitation: A Comparison of Intervention and Nonintervention

https://doi.org/10.1016/j.athoracsur.2012.06.062Get rights and content

Background

The timing and indicators for surgical pulmonary valve replacement (PVR) in patients with pulmonary regurgitation (PR) after repair of tetralogy of Fallot (ToF) are controversial. In this study we tested the hypothesis that delaying PVR in patients with ToF and severe PR would lead to short-term progressive deterioration in right ventricular/left ventricular (RV/LV) dimensions or function. We compared PVR-treated patients with matched untreated patients who were eligible for PVR based on hemodynamic status.

Methods

A current cohort of 87 patients with ToF and free PR serial cardiovascular magnetic resonance (CMR) assessments at a median interval of 1.8 years (interquartile range [IQR], 1.4–2.1) were identified. During this interval, 51 patients had surgical PVR and 36 patients were managed conservatively. Twenty-five patients from each group were matched for comparison using propensity score matching (PSM). RV and LV measurements were assessed by CMR at rest at follow-up.

Results

There was no significant deterioration in RV or LV measurements in the matched untreated patients over a median of 1.8 years. “Normalization” of right ventricular end-diastolic volume (RVEDV) and end systolic volume (ESV) after PVR occurred in the majority of patients during the study period, and no absolute ceiling beyond which the right ventricle did not normalize could be discerned. In a group of treated patients who were not matchable because of severe baseline characteristics, there was a significant improvement in resting cardiac output (CO) after PVR (from 2.9 to 3.3 L/min/m2; p = 0.001).

Conclusions

Our data indicate that patients with intermediate RV dilatation and severe PR are at low risk for significant progression in the short term, which can guide the interval for CMR imaging and advise the timing for future PVR.

Section snippets

Patient Data Collection

Between 2003 and 2010, 87 patients (56 male patients, 31 female patients) with ToF and free PR (defined on echocardiography as flow reversal in the branch pulmonary arteries on color flow mapping), underwent at least 2 serial CMR examinations. After CMR examination, 51 patients were treated with surgical PVR and 36 patients did not undergo operation based on the preference of the attending cardiologist and surgeon. A second CMR assessment was then performed, with a median interval between scans

Patient Demographics

As expected there were significant differences at baseline between unmatched patients who underwent operation and those who did not (Table 1). Patients who subsequently had PVR had higher RVEDV and ESV and lower LVCO at first CMR examination. There were no differences in method of primary repair or time interval between assessments. New York Heart Association (NYHA) class was higher before and after matching in the PVR treatment group (NYHA class I, 26%; class II, 48%; class III, 26%) compared

Comment

This study confirms that in the majority of patients who have undergone repair of ToF, PVR normalizes the right ventricle and corrects the abnormal physiologic characteristics of PR. In contrast to other studies, we did not observe a low threshold or absolute ceiling beyond which PVR cannot normalize RV dimensions. Importantly, we observed no decline in patients with mild or moderate RV dilatation who were observed without treatment over 1.8 years' median follow-up.

The majority of studies of

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Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.