Trends in pulmonary valve replacement in children and adults with tetralogy of fallot

Abstract

Operative correction of tetralogy of Fallot frequently results in pulmonary insufficiency and chronic volume overload, which have been linked to increased risk for adverse outcomes. No consensus recommendations for the timing of pulmonary valve replacement (PVR) exist. The aim of this study was to examine the pattern of PVR in the United States from 2004 to 2012. The Pediatric Health Information Systems database was used to perform an observational study of children and adults ≥10 years of age with diagnoses of tetralogy of Fallot who underwent PVR at 35 centers in the United States from 2004 and 2012, to assess the rate of PVR and the age at which is performed. Mixed-effects multivariate regression was used to account for patient-level covariates and center-level covariance. Additional analyses assessed for trends in cost, hospital length of stay (LOS), intensive care unit LOS, and in-hospital mortality over the study period. In total, 799 subjects at 35 centers underwent PVR over the study period. The number of PVRs performed per year increased significantly over the study period. There was significant between-center heterogeneity in age at PVR (p <0.001). Age at PVR, intensive care unit LOS, hospital LOS, and cost did not change over the study period. In conclusion, PVR in patients with tetralogy of Fallot is being performed more frequently, without an accompanying change in the age at PVR or other measurable outcomes. There is significant variability in the age at which PVR is performed among centers across the United States. This highlights the need for additional research guiding the optimal timing of PVR.

Figure 1. Total number of pulmonary valve interventions (2004–2012) across PHIS centers

This bar plot demonstrates the total number of PVR across all 35 centers meeting inclusion criteria between 2004 and 2012.

Figure 2. Number of pulmonary valve interventions per center (2004–2012) across PHIS centers

This box and whiskers plot demonstrates changes across in number of PVR procedures performed at each of the 35 centers in PHIS database reported PVR. Horizontal line marks the median number of procedures. Upper and lower limits of the box 25^th and 75^th percentiles of the range. Whiskers are drawn to the adjacent value under the limit of 1.5 times the inter-quartile range. Values outside this limit are marked with filled circles.

Figure 3. Age at PVR over the study period

This scatter plot depicts the date of PVR on the x-axis and individual subject ages at PVR on the y-axis. Multivariate mixed effects regression model demonstrated that there was not a significant relationship between year and age at PVR (p=0.65).

Figure 4. Mean age at PVR (2004-2012) by center

This bar graph depicts the mean age at PVR across the 35 PHIS centers meeting inclusion criteria for this study. Test for heterogeneity in age between centers demonstrated significant heterogeneity in age at PVR by center mixed effects model (p<0.001).