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Original research article
A propensity score-adjusted analysis of clinical outcomes after pulmonary valve replacement in tetralogy of Fallot
  1. Jouke P Bokma1,2,
  2. Tal Geva3,
  3. Lynn A Sleeper3,
  4. Sonya V Babu Narayan4,
  5. Rachel Wald5,
  6. Kelsey Hickey3,
  7. Katrijn Jansen5,
  8. Rebecca Wassall4,
  9. Minmin Lu3,
  10. Michael A Gatzoulis4,
  11. Barbara JM Mulder1,2,
  12. Anne Marie Valente3
  1. 1 Department of Cardiology, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands
  2. 2 Netherlands Heart Institute, Utrecht, Netherlands
  3. 3 Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  4. 4 Department of Adult Congenital Heart Disease, Royal Brompton Hospital, London, UK
  5. 5 Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
  1. Correspondence to Dr Anne Marie Valente, Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; anne.valente{at}


Objective To determine the association of pulmonary valve replacement (PVR) with death and sustained ventricular tachycardia (VT) in patients with repaired tetralogy of Fallot (rTOF).

Methods Subjects with rTOF and cardiac magnetic resonance from an international registry were included. A PVR propensity score was created to adjust for baseline differences. PVR consensus criteria were predefined as pulmonary regurgitation >25% and ≥2 of the following criteria: right ventricular (RV) end-diastolic volume >160 mL/m2, RV end-systolic volume >80 mL/m2, RV ejection fraction (EF) <47%, left ventricular EF <55% and QRS duration >160 ms. The primary outcome included (aborted) death and sustained VT. The secondary outcome included heart failure, non-sustained VT and sustained supraventricular tachycardia.

Results In 977 rTOF subjects (age 26±15 years, 45% PVR, follow-up 5.3±3.1 years), the primary and secondary outcomes occurred in 41 and 88 subjects, respectively. The HR for subjects with versus without PVR (time-varying covariate) was 0.65 (95% CI 0.31 to 1.36; P=0.25) for the primary outcome and 1.43 (95% CI 0.83 to 2.46; P=0.19) for the secondary outcome after adjusting for propensity and other factors. In subjects (n=426) not meeting consensus criteria, the HR for subjects with (n=132) versus without (n=294) PVR was 2.53 (95% CI 0.79 to 8.06; P=0.12) for the primary outcome and 2.31 (95% CI 1.07 to 4.97; P=0.03) for the secondary outcome.

Conclusion In this large multicentre rTOF cohort, PVR was not associated with a reduced rate of death and sustained VT at an average follow-up of 5.3 years. Additionally, there were more events after PVR compared with no PVR in subjects not meeting consensus criteria.

  • cardiac magnetic resonance (cmr) imaging
  • congenital heart disease
  • tetralogy of fallot

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  • Contributors All authors attributed to both the conception, design, critical revision and final approval of this manuscript. LAS and ML performed statistical analyses. JPB interpreted the data and drafted the manuscript under supervision of senior authors BJMM, AMV and TG.

  • Funding This work was supported by the Netherlands Heart Institute (NL-HI) and Nuts Ohra foundation. The work described in this study was carried out in the context of the Parelsnoer Institute. Parelsnoer Institute is part of and funded by the Dutch Federation of University Medical Centers. This work was also supported by the Higgins Family Noninvasive Research Fund at Boston Children’s Hospital, the Lerner Research, NIH/NHLBI 1 R01HL089269-01A2, and British Heart Foundation (SVB-N; FS/11/38/28864). SVB-N, REW and MAG were supported by the NIHR Cardiovascular Biomedical Research Unit of Royal Brompton and Harefield NHS. RMW was supported by the Canadian Institutes of Health Research MOP 119353. Foundation Trust and Imperial College London. This report is independent research by the National Institute for Health Research Biomedical Research Unit Funding Scheme.

  • Competing interests None declared.

  • Ethics approval Boston Children’s Hospital and participating centers.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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