Comparison of Long-term Outcomes of Valve-Sparing and Transannular Patch Procedures for Correction of Tetralogy of Fallot

Abstract

IMPORTANCEThe choice of the right surgical technique for correction of tetralogy of Fallot (TOF) is contentious for patients with a moderate to severe right outflow tract obstruction. The use of a transannular patch (TAP) exposes patients to chronic pulmonary regurgitation, while valve-sparing (VS) procedures may incompletely relieve pulmonary obstruction.OBJECTIVE To compare 30-year outcomes of TOF repair after a VS procedure vs TAP. DESIGN, SETTING, AND PARTICIPANTSThis retrospective population-based cohort study was conducted among all patients with TOF born in the province of Quebec, Canada, from 1980 to 2015 who underwent complete surgical repair. Patients who received a TAP or VS procedure were matched using a propensity score based on preoperative factors in a 1:1 ratio. Data were analyzed from March 2020 through April 2021.EXPOSURES The study groups were individuals who received TAP and those who received VS. The VS group was further stratified by the presence of residual pulmonary stenosis. MAIN OUTCOMES AND MEASURESThe primary outcome was all-cause mortality, with 30-year survival evaluated using Cox proportional-hazards models. Secondary outcomes included the cumulative mean number of cardiovascular interventions, pulmonary valve replacements (PVRs), and cardiovascular hospitalizations were evaluated using marginal means/rates regressions. RESULTSAmong 683 patients with TOF (401 patients who underwent TAP [58.7%] and 282 patients who underwent a VS procedure [41.3%]), adequate propensity score matching was achieved for 528 patients (264 patients who underwent a VS procedure and 264 patients who underwent TAP). Among this study cohort, 307 individuals (58.1%) were men. The median (interquartile range [IQR]) follow-up was 16.0 (8.1-25.4) years, for a total of 8881 patient-years, including 63 individuals (11.9%) followed up for more than 30 years. Individuals who received a VS procedure had an increased 30-year survival of 99.1% compared with 90.4% for individuals who received TAP (hazard ratio [HR], 0.09 [95% CI, 0.02-0.41]; P = .002). Patients who underwent TAP had an increased 30-year cumulative mean number of cardiovascular interventions compared with patients who underwent a VS procedure without residual pulmonary stenosis (2.0 interventions [95% CI, 1.5-2.7 interventions] vs 0.7 interventions [95% CI, 0.5-1.1 interventions]; mean ratio [MR], 0.36 [95% CI, 0.25-0.50]; P < .001) and patients who underwent a VS procedure with at least moderate residual stenosis (1.3 interventions [95% CI, 0.9-1.9 interventions]; MR, 0.65 [0.45-0.93]; P = .02). Results were similar for PVR, with a 30-year cumulative mean 0.3 PVRs [95% CI, 0.1-0.7PVRs] for patients who underwent a VS procedure without residual pulmonary stenosis (MR, 0.22 [95% CI, 0.12-0.43]; P < .001) and 0.6 PVRs (95% CI, 0.2-1.5 PVRs) for patients with at least moderate residual stenosis (MR, 0.44 [95% CI, 0.21-0.93]; P = .03), compared with 1.4 PVRs (95% CI, (continued) Key Points Question Do valve-sparing (VS) operations have better long-term outcom...

Long-Term Results after Fallot Repair

“…[15][16][17] There has been a growing enthusiasm for TOF repair techniques implying preservation of the pulmonary valve and its annulus, thus prolonging time until PVR. 12 Historical series confirm that late PVR is significantly less common whenever the annulus remained intact. However, whether all forms of valve preservation translate into late clinical advantages is difficult to prove.…”

“…Since the first successful TOF-repair by Lillehei and colleagues in the 1950s, outcomes have significantly improved, with excellent long-term survival and low risks for late sudden death. 12 13 14 However, long-term studies after TOF-repair have all shown frequent need for PVR due to progressive pulmonary valve regurgitation, right ventricular dysfunction, and decreased functional capacity. 15 16 17 There has been a growing enthusiasm for TOF repair techniques implying preservation of the pulmonary valve and its annulus, thus prolonging time until PVR.…”

“…However, long-term survival for any chosen type of repair is described as excellent. [10][11][12] This report analyzes the influences of different surgical techniques on the long-term need of PVR regarding the implication of transannular patch repair (TAP), valve sparing repair (VSR), and primary placement of valved right ventricle to the pulmonary artery conduit (RVPA conduit) with respect to the anatomical variations of the disease, ranging from tetralogy of Fallot-pulmonary stenosis (TOF-PS), TOF-pulmonary atresia (TOF-PA) toward TOF-double outlet right ventricle type (TOF-DORV).…”

End‐Diastolic Forward Flow and Restrictive Physiology in Repaired Tetralogy of Fallot: A Systematic Review and Meta‐Analysis

“… 68 Current surgical practices with more valve‐sparing operations and fewer transannular patches for ToF are likely already influencing the context in which EDFF is observed, so research into the implications of EDFF may differ from the historical baselines established in this analysis. 69 …”

Surgical Strategies for Preservation of Pulmonary Valve Function in a Radical Operation for Tetralogy of Fallot: A Systematic Review and Meta-Analysis

“…However, the predicted disadvantage of this procedure, the postoperative pulmonary regurgitation (PR), was affirmed in a significant number of patients who suffered pulmonary insufficiency (PI), heart failure, arrhythmia, and even sudden cardiac death ( 13 , 14 ). Preserving or reconstructing pulmonary valve function is the best way to prevent PR and reduce the risk of adverse cardiovascular events ( 15 ). All procedures, including commissurotomy, PCA, pulmonary valve reconstruction, and IBPV can be performed to maintain pulmonary valve function to some extent.…”