Impact of pulmonary valve replacement in tetralogy of Fallot with pulmonary regurgitation: a comparison of intervention and nonintervention

Background: The timing and indicators for surgical pulmonary valve replacement (PVR) in patients with pulmonary regurgitation (PR) after repair of tetralogy of Fallot (ToF) are controversial. In this study we tested the hypothesis that delaying PVR in patients with ToF and severe PR would lead to short-term progressive deterioration in right ventricular/left ventricular (RV/LV) dimensions or function. We compared PVR-treated patients with matched untreated patients who were eligible for PVR based on hemodynamic status.

Methods: A current cohort of 87 patients with ToF and free PR serial cardiovascular magnetic resonance (CMR) assessments at a median interval of 1.8 years (interquartile range [IQR], 1.4-2.1) were identified. During this interval, 51 patients had surgical PVR and 36 patients were managed conservatively. Twenty-five patients from each group were matched for comparison using propensity score matching (PSM). RV and LV measurements were assessed by CMR at rest at follow-up.

Results: There was no significant deterioration in RV or LV measurements in the matched untreated patients over a median of 1.8 years. "Normalization" of right ventricular end-diastolic volume (RVEDV) and end systolic volume (ESV) after PVR occurred in the majority of patients during the study period, and no absolute ceiling beyond which the right ventricle did not normalize could be discerned. In a group of treated patients who were not matchable because of severe baseline characteristics, there was a significant improvement in resting cardiac output (CO) after PVR (from 2.9 to 3.3 L/min/m(2); p = 0.001).

Conclusions: Our data indicate that patients with intermediate RV dilatation and severe PR are at low risk for significant progression in the short term, which can guide the interval for CMR imaging and advise the timing for future PVR.