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Original article
Individualised prediction of pulmonary homograft durability in tetralogy of Fallot
  1. Jouke P Bokma1,2,
  2. Michiel M Winter1,
  3. Thomas Oosterhof1,
  4. Hubert W Vliegen3,
  5. Arie P van Dijk4,
  6. Mark G Hazekamp5,6,
  7. Dave R Koolbergen5,6,
  8. Maarten Groenink1,
  9. Barbara JM Mulder1,2,
  10. Berto J Bouma1,2
  1. 1Department of Cardiology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
  2. 2Interuniversity Cardiology Institute of the Netherlands, The Netherlands
  3. 3Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
  4. 4Department of Cardiology, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
  5. 5Department of Cardiothoracic Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
  6. 6Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
  1. Correspondence to Dr Berto J Bouma, Department of Cardiology, Academic Medical Center Amsterdam, Room B2-256, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands; b.j.bouma{at}


Background In patients with repaired tetralogy of Fallot (rTOF), multiple reoperations or percutaneous interventions after pulmonary valve replacement (PVR) may be necessary due to limited homograft durability. However, data to guide individualised prediction of homograft durability remain scarce. The aim of this study was to provide risk models for RV to pulmonary artery homograft durability.

Methods This retrospective multicentre study included consecutive patients with rTOF who had undergone PVR at an age of >12 years. Homograft dysfunction was defined as at least moderate pulmonary regurgitation (PR) or pulmonary stenosis (PS) (pressure gradient ≥36 mm Hg) as assessed by echocardiography. Reintervention was defined as percutaneous intervention or redo-PVR.

Results A total of 153 patients with rTOF were included (62% male, mean age at PVR 31±11 years, pulmonary homograft 96%, follow-up 9.6 years (IQR 5.9, 13.3)). Average freedom from homograft dysfunction and reintervention after 10 years was 74% and 89%, respectively. In multivariable Cox proportional hazards analysis, postoperative PS ≥20 mm Hg (HR 6.52, 95% CI 3.09 to 13.7), postoperative PR ≥ grade 1 (HR 3.13, 95% CI 1.45 to 6.74) and age at PVR <18 years (HR 3.52, 95% CI 1.64 to 7.53) were independently predictive for homograft dysfunction. In patients without any risk factor, 10-year freedom from homograft dysfunction and reintervention was excellent (91% and 96%, respectively) in contrast to patients with ≥2 risk factors (25% and 73%, respectively).

Conclusions Individualised prediction of homograft durability in patients with rTOF can be guided by early postoperative echocardiography. In adult patients without early postoperative PS or PR, homograft dysfunction and reintervention are unlikely to occur within 10 years, and follow-up may be less stringent.

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