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Review
. 2022 Dec;37(12):5144-5152.
doi: 10.1111/jocs.17156. Epub 2022 Nov 15.

Preserving the pulmonary valve in Tetralogy of Fallot repair: Reconsidering the indication for valve-sparing

Umar Siddiqi  1 , Adedotun Adewale  2 , Emily Pena  2 , Kelci Schulz  2 , Michel Ilbawi  2 , Chawki El-Zein  2 , Luca Vricella  1   2 , Narutoshi Hibino  1
Affiliations
Review

Preserving the pulmonary valve in Tetralogy of Fallot repair: Reconsidering the indication for valve-sparing

Umar Siddiqi et al. J Card Surg. 2022 Dec.

Abstract

Background: Tetralogy of Fallot (TOF) repair is a frequent procedure, and although valve-sparing (VS) repair is preferred, determining which patients can successfully undergo this operation remains controversial. We sought to identify parameters to determine a selective, accurate indication for VS repair.

Methods: We reviewed 71 patients (82%) undergoing VS repair. We analyzed hemodynamic data, intraoperative reports, and follow-up echocardiography results to identify acceptable indications. Patients requiring pulmonary valve (PV) reintervention versus no reintervention were compared.

Results: PV annulus size at repair was z-score of -2.0 (-5.3, 1.3). Approximately half (51%) had a z-score less than -2. Cox regression results showed this was not a risk factor for reintervention (p = .59). Overall, 1-, 3-, 5-, and 10-year freedom from PV reintervention rates were 95.8%, 92.8%, 91% and 77.8%, respectively. Residual pulmonary stenosis (PS) at initial repair was relatively higher in the reintervention group compared with no reintervention group (40 [28, 51] mmHg vs. 30 [22, 37] mmHg; p = .08). For patients with residual PS, pressure gradient (PG) was consistent over time across both groups (PV reintervention: -3 [-15, 8] mmHg vs. no reintervention: 0 [-9, 8] mmHg). The risk of PV reintervention is 3.7-fold higher when the PG from intraoperative TEE is greater than 45 mmHg (p = .04).

Conclusions: Our review of the midterm outcomes of expanded indication for VS suggests intraoperative decision to convert to transannular patch is warranted if intraoperative postprocedure TEE PG is greater than 45 mmHg or RV pressure is higher than half of systemic pressure to prevent reintervention.

Keywords: Tetralogy of Fallot; pulmonary valve; transannular patch; valve-sparing.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Freedom from pulmonary valve reintervention. Freedom from reintervention was favorable. Ten‐year freedom was 77.8% (95% CI 66.1–91.4). Median follow‐up time was 6.28 years.
Figure 2
Figure 2
Freedom from reintervention by z‐score. Patients were divided into (1) z‐score > −2 or (2) z‐score < −2. Freedom from pulmonary valve reintervention was statistically comparable between the two groups.
Figure 3
Figure 3
Postoperative right ventricular pressure (RVP) in pulmonary valve re‐intervention group and no reintervention group. RVP after the operation was significantly lower in patients who did not require reintervention compared to those who did. RV, right ventricle.
Figure 4
Figure 4
Change in pressure gradient (PG) between initial postoperative ECHO and outpatient follow‐up ECHO. The change in PG was statistically comparable for patients who required reintervention as well as those who did not. ECHO, echocardiogram.
Figure 5
Figure 5
Freedom from reintervention by residual stenosis. Patients were divided into (1) residual gradient <45 or (2) residual gradient >45. Freedom from pulmonary valve reintervention was significantly lower in the group with residual gradient >45.
Figure 6
Figure 6
Freedom from moderate + regurgitation. The endpoint was defined as either moderate or severe pulmonary regurgitation. Freedom from greater than moderate regurgitation was much lower than that of reintervention.
Figure 7
Figure 7
Freedom from moderate + stenosis. The endpoint was defined as either moderate or severe pulmonary stenosis. Freedom from greater than moderate stenosis was acceptable.
See this image and copyright information in PMC

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