Pulmonary Valve Replacement for Regurgitation after Repair of Tetralogy of Fallot

doi:10.1016/S0003-4975(10)60279-2

The Annals of Thoracic Surgery

Volume 36, Issue 6, December 1983, Pages 684-691

https://doi.org/10.1016/S0003-4975(10)60279-2 Get rights and content

Abstract

In general, it has been thought that pulmonary valve insufficiency is well tolerated when the valve is excised or when the pulmonary annulus has been widened with an outflow patch during repair of tetralogy of Fallot. However, when pulmonary regurgitation is massive or when it is combined with other causes of right ventricular failure, progressive right ventricular dilation may occur in some patients. Pulmonary valve replacement has not been commonly used in the past. From January, 1980, to August, 1982, 12 patients, 11 months to 17 years old, had pulmonary regurgitation treated by insertion of a valve in the pulmonary position 4½ months to 11 years after initial repair of tetralogy of Fallot. All patients had progressive right ventricular failure not responsive to medical management. There were no major outflow tract obstructions, residual ventricular septal defects, or persistent aortopulmonary shunts.

All 12 patients underwent patch reconstruction of the right ventricular outflow tract that allowed placement of a larger valve. There have been no operative or late deaths, and each patient has had improvement in functional status. One patient required tricuspid valve replacement 1½ years after pulmonary valve replacement to achieve sustained relief of symptoms. Only 1 other patient required subsequent operation; this was for pacemaker lead changes. These early results suggest that in patients with right ventricular failure, attention should be directed to pulmonary regurgitation since this is a component of failure that is reversible; pulmonary valve replacement carries a low risk, and it can relieve symptoms and prevent further deterioration of right ventricular function.

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Cited by (58)

Implanting a mechanical valve in the pulmonary position: What's your bias?
2017, Journal of Thoracic and Cardiovascular Surgery
Pulmonary valve replacement based solely on right ventricular size is appropriate in the asymptomatic tetralogy patient
2012, Progress in Pediatric Cardiology
Citation Excerpt :
Patients with significant PR and dilated RVs have an increased QRS width and patients with a QRS width ≥ 180 ms are at increased risk of syncope and sudden death. Surgical PVR in adult patients with significant PR can be done safely with a low mortality [9,10]. Oeschlin et al. report a 0% perioperative mortality and an actuarial 10 year survival rate of ~ 92 ± 6% [11].
Although the long term outcome of patients with repaired tetralogy of Fallot (TOF) is favorable [1], the initial repair to relieve the right ventricular (RV) outflow tract obstruction often results in significant pulmonary regurgitation (PR). PR in the repaired TOF patient is usually well tolerated for long periods of time. The low resistance, high capacitance reservoir of the pulmonary circulation minimizes the actual regurgitant volume in the face of severe PR. However, over time, chronic PR results in volume overloading of the RV [2]. Volume overloading of the RV eventually leads to an increase in right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RV-ESV), and RV systolic dysfunction [3]. The ensuing RV dilatation and dysfunction for one predispose the patient to exercise intolerance [4], congestive heart failure, and atrial and ventricular arrhythmias, and may contribute to the incidence of sudden cardiac death [5]. In order to know whether pulmonary valve replacement (PVR) based solely on RV size is appropriate in the asymptomatic tetralogy of Fallot (TOF) patient we will review: 1) the effect of long term PR in patients with repaired TOF; 2) the results and hemodynamic effect of surgical as well as percutaneous PVR; 3) what we know about timing of PVR in these patients; and, finally, 4) the known determinants of morbidity and mortality in repaired TOF patients with severe PR.
Transpulmonary arterial repair of type 1 ventricular septal defect will induce pulmonary regurgitation: Appraisal of subpulmonic approach
2011, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
When PR is significant, progressive right ventricular dilation and failure refractory to medical management will be inevitable. Significant PR is also an important cause of morbidity and even mortality necessitating eventual pulmonary valve implantation.19-21 Therefore, the deteriorating fate of the right ventricle and possible need of pulmonary valve implantation in patients after transpulmonary arterial repair of type I VSD will be the critical issues in the future.
A transpulmonary arterial approach to repair type I ventricular septal defect is the standard. However, the possible adverse effect on the pulmonary valve by this technique has not been investigated.
A retrospective study reviewing type I ventricular septal defect repair from January 1991 to May 2010 was conducted. Of the 142 cases, the ventricular septal defect was repaired via the transpulmonary arterial route in 77 patients (54.2%, PA group) and via the subpulmonic route in 65 patients (45.8%, SP group). All patients received serial annual transthoracic color Doppler echocardiographic evaluation of pulmonary valve function.
The age at operation ranged from 1.2 to 272 months (median, 35.0 months; mean, 50.4 months). The mean follow-up period was 96.2 months (range, 2–234 months). Between the PA and SP groups, there was no significant difference in age, body weight, ventricular septal defect size, left to right shunt amount, mean pulmonary arterial pressure, and preoperative pulmonary stenosis or regurgitation. Postoperatively, there was no significant difference in the ejection fraction or incidence of residual ventricular septal defect, right bundle branch block, and pulmonary stenosis. However, the incidence of postoperative pulmonary regurgitation of more than moderate and the total scale of postoperative pulmonary regurgitation were both significantly higher in the PA group (16.9% vs 4.6% and 1.7 ± 0.1 vs 1.4 ± 0.1, P = .031 and .019, respectively).
Although the transpulmonary arterial approach for type I ventricular septal defect repair has been advocated for decades, considering the adverse effect on pulmonary valve competency, the subpulmonic approach may be an alternative.
Pulmonary Valve Replacement: A Comparison of Three Biological Valves
2008, Annals of Thoracic Surgery
Citation Excerpt :
In this report, 2 of 3 hospital deaths secondary to severe biventricular dysfunction occurred in 19 patients in whom tricuspid valve repair for severe tricuspid regurgitation was required (19 of 82; 23%). Moreover, we observed that among 60 patients with less than severe tricuspid regurgitation, if PVR is performed early, then the reduction in RV dimension will be accompanied by a regression in tricuspid regurgitation [16]. In patients requiring PVR, the effective orifice area of the selected prosthesis is critical.
We retrospectively reviewed the performance of the mosaic porcine, bovine pericardial, and homograft prostheses for pulmonary valve replacement to correct chronic pulmonary insufficiency.
From January 1995 to August 2006, 82 patients (mean age, 22.7 years) underwent valve replacement with porcine (49 patients), bovine pericardial (18 patients), or pulmonary homograft (15 patients) prosthesis at a mean of 15.3 years after initial outflow tract reconstruction. Excluded were patients with extracardiac conduits, monocusp valves, or the Ross procedure. The groups were similar with respect to age, body surface area, degree of regurgitation, right ventricular dimension, right ventricular to pulmonary artery gradient, and valve size. Follow-up was longer in the homograft cohort (porcine, 20 ± 27 months; pericardial, 42 ± 21; homograft, 49 ± 40; p < 0.01).
All three prostheses significantly reduce chronic pulmonary regurgitation, but late insufficiency was higher with homografts. Right ventricular dimension was significantly reduced in the stented but not the allograft cohorts. Late valve dysfunction was highest with homografts (54%), followed by porcine (19%) and pericardial valves (5.5%; p < 0.05. Functional class and mild to moderate tricuspid insufficiency significantly improved with pulmonary valve replacement. Early and late mortality was 3.6% and 1.2%, respectively.
All three prostheses performed similarly for 3 years. Pulmonary regurgitation developed more frequently in homografts albeit at a longer duration of follow-up.
Right ventricular restrictive physiology in repaired tetralogy of Fallot is associated with smaller respiratory variability
2008, International Journal of Cardiology
Long-term outcomes of patients with repaired tetralogy of Fallot (TOF) are known to be related with right ventricular (RV) volume overload, severity of pulmonary insufficiency (PI) and the type of outflow repair. Right ventricular restrictive physiology (RVRP) has also been reported to interfere with several factors influencing the late result in repaired TOF patients. However, the mechanism and physiology of this unique myocardial property in the chronically overloaded right ventricle are not yet clearly understood.
We investigated 43 patients after repair of TOF to assess the relationships among biventricular diastolic function, volume characteristics, and influence of respiratory effort. The patients were classified into 3 groups; 15 patients with RVRP and significant PI (RP group, 35%), 19 without RVRP in the presence of significant PI (NR + PI group, 44%), and 9 without RP or significant PI (NR − PI group, 21%). Doppler spectrals obtained by echocardiography from systemic and pulmonary veins, main pulmonary artery (MPA), and both ventricular inlets, and biventricular diastolic function were compared according to the respiratory cycle.
The RP group revealed higher pulmonary venous systolic/diastolic flow ratio (S/D ratio) and the NR + PI group showed larger velocity-time integral (VTI) ratio of total regurgitant/antegrade flow at the MPA and more respiratory variability in the systemic vein.
RP is associated with less volume overload of the RV and smaller respiratory variability is also associated with the restrictive RV. The diastolic function and volume status of the RV may influence the diastolic properties of the left heart.
Quantitative Assessment of Pulmonary Insufficiency by Doppler Echocardiography in Patients with Adult Congenital Heart Disease
2008, Journal of the American Society of Echocardiography
We determined the utility of continuous wave (CW) Doppler for quantification of pulmonary insufficiency (PI) confirmed by pulmonary angiography in patients with postoperative adult congenital heart disease. A total of 41 patients with PI were divided into two groups on the basis of PI severity by pulmonary angiography: group A (n = 27) with severe PI and group B (n = 14) with mild or moderate PI. Nine patients in group A had pulmonic valve replacement and reverted to mild PI after surgery. Their pre- and postoperative data were compared. All underwent a two-dimensional/Doppler study with interrogation of the PI jet for jet width by color Doppler and peak flow velocity, deceleration time (DT), pressure half-time (PHT), diastolic period (DP), and PI flow time (FT) by CW Doppler. The no-flow time (NFT), NFT/FT ratio, and NFT/DP fraction were calculated. Group A had a larger right ventricle (4.1 ± 0.9 vs. 3.5 ± 0.6 cm, P = .033), higher PI peak velocity (2.1 ± 0.5 vs. 1.7 ± 0.5 m/s, P = .04), shorter DT (261 ± 61 vs. 317 ± 83 ms, P = .018) and PHT (76 ± 29 vs. 132 ± 53, P < .0001), longer NFT (146 ± 66 vs. 40 ± 42 ms, P < .0001), and higher ratios of NFT/FT (46% ± 27% vs. 13% ± 14%, P < .0001) and NFT/DP (29% ± 13% vs. 10% ± 9%, P < .0001). The PHT and DT lengthened, and the NFT shortened in patients who underwent pulmonic valve replacement (all P < .05). By binary logistic regression, NFT and PHT were the best predictors for severe PI. An NFT of 80 ms had 84% sensitivity and 93% specificity, and a PHT of 100 ms had 93% sensitivity and 93% specificity for identifying angiographically severe PI. CW Doppler accurately distinguishes severe from lesser degrees of PI in patients with postoperative adult congenital heart disease.

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: Presented in part at the Nineteenth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 17–19, 1983.

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Pulmonary Valve Replacement for Regurgitation after Repair of Tetralogy of Fallot

Abstract

J Thorac Cardiovasc Surg

Am J Med

Am J Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Lancet