Pulmonary Valve Replacement After Operative Repair of Tetralogy of Fallot

Abstract

Because the real benefit of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot who develop pulmonary insufficiency remains unclear, it is necessary to analyze the evidence published around the world. We performed a systematic review of studies that reported data about the effect of PVR in patients with repaired tetralogy of Fallot that developed pulmonary insufficiency, until December 2012. The variables chosen to represent the benefit were both right ventricular (RV) and left ventricular measures, QRS duration, and functional class. The principal summary measures were difference in means with 95% confidence interval and p values (considered statistically significant when p < 0.05). The differences in means were combined across studies with the weighted DerSimonian-Laird random effects model. Meta-analysis, sensitivity analysis, and meta-regression were completed with the software Comprehensive Meta-Analysis (version 2, Biostat, Inc., Englewood, New Jersey). Forty-eight studies involving 3,118 patients met the eligibility criteria. The pooled 30-day mortality was 0.87% (47 studies; 27 of 3,100 patients); the pooled 5-year mortality was 2.2% (24 studies; 49 of 2,231 patients); the pooled 5-year re-PVR was 4.9% (15 studies; 88 of 1,798 patients). The results of this meta-analysis demonstrate that after PVR: 1) the RV experiences improvement of its volumes and function; 2) the left ventricle experiences improvement of its function; 3) QRS duration decreases; 4) symptoms improve; 5) pre-operative RV geometry modulates the effect of PVR; and 6) there is important heterogeneity of the effects among the studies, and few publication biases. In conclusion, PVR seems to be a positive approach in the analyzed scenario.

Trends in Pulmonary Valve Replacement in Children and Adults With Tetralogy of Fallot

“…This finding is corroborated by a recent meta-analysis, in which the median age of patients in the 48 included studies ranged from 8 to 30 years 11 . Variability in practice reflects lack of consensus in patterns of PVR across children’s hospitals in the United States and uncertainty regarding optimal timing for PVR in TOF, highlighting the importance of determining these factors in children and adults with TOF.…”

“…The number of in-hospital deaths was too small to allow for meaningful analysis, but was consistent with pooled risk from meta-analyses 11,24 . No significant changes were seen in hospital or ICU LOS.…”

“…PVR results in improved symptoms 3,4 , shorter QRS duration 5–9 , smaller RV dimensions 4,6,8–14 , and improvement in RV systolic function 3,4,10,11,15 and LV systolic function 4,14 . However, these have not been accompanied by improvement in performance on exercise testing 10,16,17 , functional status 17 , risk of arrhythmia, sudden cardiac death, and all-cause mortality 10,18 .…”

Almanac 2014: Congenital Heart Disease.

“…37 A recent meta-analysis of outcomes after pulmonary valve replacement (PVR) including the data from more than 3100 patients, demonstrated that pooled 30-day mortality was 0.87% and 5-year mortality was 2.2%. 38 The risk for re-PVR was estimated to be 4.9% after 5 years. Although publication biases are a major limitation of these fi ndings, PVR appears to be a safe treatment option.…”

Differential Effect of the Ratio of Right Ventricular Volume to Left Ventricular Volume in Children with Repaired Tetralogy of Fallot

“…These patients will progress to severe dilation of the right ventricle (RV) and present poor exercising ability [2,3]. If PR continues to progress, pulmonary valve replacement should be considered to relieve the RV dysfunction [4]. The indication of pulmonary valve replacement includes RV dilatation, which is considered as one of the most important factors [5].…”