The impact of pulmonary valve replacement after tetralogy of Fallot repair: a matched comparison

Abstract

Objective: While there are no controlled studies, pulmonary valve replacement (PVR) after late tetralogy of Fallot repair is performed for patients with symptoms, arrhythmia or ventricular dysfunction. We sought to determine the impact of PVR on clinical outcomes. Methods: In a matched cohort study, 82 patients with PVR after tetralogy of Fallot repair without a history of ventricular arrhythmia were matched and compared with similarly followed non-PVR control subjects. A propensity-score adjusted analysis using repeated measures regression techniques was performed. Results: For the PVR subjects, the mean age was 28 years with a mean duration follow-up of 9 years. Before PVR, these subjects were significantly more likely than matched non-PVR subjects to have had non-ventricular arrhythmias, symptoms, lower functional class, longer QRS duration, lower right ventricular ejection fraction and higher right ventricular pressure, and reduced exercise duration but not aerobic capacity. During follow-up, sudden death occurred in four non-PVR subjects compared with no PVR subjects, with three episodes of ventricular tachycardia in the PVR subjects versus none in the non-PVR subjects ( p = 0.49). Symptoms and functional class improved in the PVR subjects with no change in the non-PVR subjects ( p < 0.001). The change in QRS duration was not significantly different between PVR and non-PVR subjects ( p = 0.48). Oxygen consumption at peak exercise did not significantly change in either group. For PVR subjects, there was a significant qualitative reduction in pulmonary ( p < 0.001) and tricuspid valve regurgitation ( p = 0.009) and right ventricular size ( p < 0.001) and dysfunction ( p < 0.001) noted on echocardiography. Conclusions: Symptoms and functional status are improved after late PVR, with a reduction in pulmonary and tricuspid valve regurgitation and right ventricular size and dysfunction. While a significant impact on arrhythmia was not detected, there were no sudden deaths in the PVR subjects. #

Clinical Outcomes of Surgical Pulmonary Valve Replacement After Repair of Tetralogy of Fallot and Potential Prognostic Value of Preoperative Cardiopulmonary Exercise Testing

“…When the deleterious effects of pulmonary regurgitation were more fully appreciated circa 2000, asymptomatic patients with pulmonary regurgitation were considered for PVR, including patients with lower or declining peak V . Our data confirm that surgical PVR is a low-risk operation, 10,14,[17][18][19][20][21][22][23][24][25][26][27][28][29][30] despite the fact that symptomatic patients and patients with multiple previous sternotomies were included in our report. All 5 patients who died early, however, died of right heart failure, suggesting that despite our modified, proactive approach for PVR, we still operate too late in some cases.…”

Right ventricular regional wall curvedness and area strain in patients with repaired tetralogy of Fallot

“…If left untreated, however, continued RV dilation may lead to adverse outcomes, including arrhythmias and sudden death (11,13,30). Repeat surgery with pulmonary valve replacement (PVR) may be necessary to preempt RV function deterioration and malignant ventricular arrhythmias (15,21,39,40,42). The optimal timing for PVR before irreversible RV functional deterioration, however, is not known (17,18,36,37).…”

Timing and Technique of Pulmonary Valve Replacement in the Patient With Tetralogy of Fallot

“…In a study from the group from Toronto, the presence of arrhythmias before PVR did not impact survival. 5,16 Among patients with supraventricular tachycardia, the addition of an arrhythmia procedure did result in improved freedom from arrhythmias among patients undergoing PVR. While improvement in arrhythmias or shortening of the QRS in any given patient is unpredictable, the association of PR, QRS prolongation, ventricular arrhythmias, and sudden death makes these electrophysiologic abnormalities reasonable indications for PVR.…”

“…3). 4,5 It is likely that patients submitted to PVR were identified by clinicians as tolerating PR less well than those who did not undergo PVR. Whether these differences, apparent somehow to the physicians caring for the patients, were owing to anatomic or other individual factors not identified, and therefore not accounted for, in matched control patients are likely.…”