Evolution of Pulmonary Valve Management During Repair of Tetralogy of Fallot: A 14-year Experience

Residual Pulmonary Valve Disease Following Repair of Tetralogy of Fallot-Is Stenosis Better Than Regurgitation?

BackgroundResidual pulmonary valve disease (PVD) including pulmonary stenosis (PS), pulmonary regurgitation (PR), or both remains a known complication following repair of Tetralogy of Fallot (TOF). We sought to clarify prevalence, progression, and prognostic impact of residual PVD.MethodsWe identified consecutive patients who underwent repair of TOF at our institution between January 2004 and July 2023. Based on echocardiographic measurements following repair, residual PVD was defined: nonsevere PVD (PS < 25 mm Hg; PR Collapse

Key Words

• annulus-sparing repair
• pulmonary valve
• tetralogy of Fallot
• transannular patch

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Affiliation(s)

Maria von Stumm Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine, Munich, Germany Division of Congenital and Paediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany European Kids Heart Centre, Munich, Germany
Gregory Heger Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine, Munich, Germany European Kids Heart Centre, Munich, Germany
Julia Danner Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
Zahra Alalawi Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine, Munich, Germany Division of Congenital and Paediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany European Kids Heart Centre, Munich, Germany
Cordula Wolf Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany DZHK (German Centre for Cardiovascular Research), Munich, Germany
Katarzyna Gendera Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
Stanimir Georgiev Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
Peter Ewert Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
Jürgen Hörer Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine, Munich, Germany Division of Congenital and Paediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany European Kids Heart Centre, Munich, Germany
Julie Cleuziou Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine, Munich, Germany Division of Congenital and Paediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany European Kids Heart Centre, Munich, Germany

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Predictors of Success Following Valve-Sparing Repair of Tetralogy of Fallot

Objective: We aim to report predictors of success following valve-sparing repair (VSR) for Tetralogy of Fallot (TOF). Methods: We performed a single-institution retrospective review of 70 patients who underwent VSR for TOF from 2007 to 2021. Risk factors for moderate to severe pulmonary insufficiency (PI) and surgical or catheter intervention for right ventricular outflow tract (RVOT) obstruction were analyzed. Results: During a median follow-up time of 6 years (range 1 month to 17 years), 5/70 (7%) patients required surgical or catheter intervention for isolated RVOT obstruction, 8/70 (11%) had moderate or severe PI, and 3/70 (4%) had a combined outcome of RVOT obstruction and PI. Patients who required reintervention had smaller pulmonary valve (PV) z-score (-2.8 vs -1.7, P < .01), were more likely to have isolated infundibular patching (75% vs 31%, P = .02), and had smaller PV z-score at the end of the procedure (-1.4 vs -1.0, P = .03). Patients with significant PI were more likely to have intraoperative valvotomy via Hegar dilation (36% vs 13%, P = .04). The strongest independent predictors of RVOT obstruction and/or PI were preoperative cyanotic episodes (odds ratio 6.0, 95%CI: 1.6-22, P = .01) and valvotomy via Hegar dilation (odds ratio 4.6, 95%CI: 1.0-21, P = .04). Conclusions: Valve-sparing repair of TOF is less likely to be successful if reliant on isolated infundibular patching or not achieving at least a z-score of -1 at the PV at the completion of the procedure. Repairs using blind dilation destabilize the valve and lead to long-term valve incompetence.

Right ventricular outlet tract reconstruction for tetralogy of Fallot: systematic review and network meta-analysis

OBJECTIVES

Concerns persist regarding pulmonary regurgitation after transannular patch repair (TAP) for tetralogy of Fallot. Despite the introduction of various architectural preservation techniques, the optimal strategy remains controversial. Our goal was to compare different right ventricular outlet tract reconstruction techniques.

METHODS

PubMed, EMBASE and Cochrane Central were searched through March 2024 to identify comparative studies on right ventricular outlet tract reconstruction techniques (PROSPERO ID: CRD42024519404). The primary outcome was mid-term pulmonary regurgitation, with secondary outcomes including postoperative mortality, postoperative pulmonary regurgitation, length of intensive care unit stays, postoperative right ventricular outlet tract pressure gradient and mid-term mortality. We performed a network meta-analysis to compare outcomes among TAP, valve-repairing (VR), TAP with neo-valve creation (TAPN) and valve-sparing (VS).

RESULTS

Two randomized controlled studies and 32 observational studies were identified with 8890 patients. TAP carried a higher risk of mid-term pulmonary regurgitation compared to TAPN [hazard ratio, 0.53; 95% confidence interval (CI) (0.33; 0.85)] and VS [hazard ratio, 0.27; 95% CI (0.19; 0.39)], with no significant difference compared to VR. VS was also associated with reduced postoperative mortality compared to TAP [risk ratio, 0.31; 95% CI (0.18; 0.56)], in addition to reduced ventilation time. TAP also carried an increased risk of postoperative pulmonary regurgitation compared to the other groups. The groups were comparable in terms of length of intensive care unit stay, right ventricular outlet tract pressure gradient and mid-term mortality.

CONCLUSIONS

VR was associated with a reduced risk of postoperative pulmonary regurgitation, whereas TAPN was associated with reduced risks of both postoperative and mid-term pulmonary regurgitation.

Comparing clinical and echocardiographic outcomes following valve-sparing versus transannular patch repair of tetralogy of Fallot: a systematic review and meta-analysis

OBJECTIVES

Transannular patch (TAP) repair of tetralogy of Fallot (ToF)relieves right ventricular tract obstruction but may lead to pulmonary regurgitation. Valve-sparing (VS) procedures can avoid this situation, but there is a potential for residual pulmonary stenosis. Our goal was to evaluate clinical and echocardiographic outcomes of TAP and VS repair for ToF.

METHODS

A systematic search of the PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials and Web of Science databases was carried out to identify articles comparing conventional TAP repair and VS repair for ToF. Random-effects models were used to perform meta-analyses of the clinical and echocardiographic outcomes.

RESULTS

Forty studies were included in this meta-analysis with data on 11 723 participants (TAP: 6171; VS: 5045). Participants who underwent a VS procedure experienced a significantly lower cardiopulmonary bypass time [mean difference (MD): -14.97; 95% confidence interval (CI): -22.54, -7.41], shorter ventilation duration (MD: -15.33; 95% CI: -30.20, -0.46) and shorter lengths of both intensive care unit (ICU) (MD: -0.67; 95% CI: -1.29, -0.06) and hospital stays (MD: -2.30; 95% CI: [-4.08, -0.52). There was also a lower risk of mortality [risk ratio: 0.40; 95% CI: (0.27, 0.60) and pulmonary regurgitation [risk ratio: 0.35; 95% CI: (0.26, 0.46)] associated with the VS group. Most other clinical and echocardiographic outcomes were comparable in the 2 groups.

CONCLUSIONS

This meta-analysis confirms the well-established increased risk of pulmonary insufficiency following TAP repair while also demonstrating that VS repairs are associated with several improved clinical outcomes. Continued research can identify the criteria for adopting a VS approach as opposed to a traditional TAP repair.

Contemporary Patterns of Care in Tetralogy of Fallot: Analysis of The Society of Thoracic Surgeons Data

BACKGROUND

Against the background of earlier studies, recent patterns in surgical management of tetralogy of Fallot (TOF) were assessed.

METHODS

A retrospective review of The Society of Thoracic Surgeons (STS) Congenital Database (2010-2020) was performed on patients aged <18 years with TOF or pulmonary stenosis and primary procedure TOF surgical repair or palliation. Procedural frequencies were examined by epoch. Demographics, clinical variables, and outcomes were compared between the initial palliation and primary repair groups. Among those operated on at 0 to 60 days of age, variation in palliation rates across hospitals was assessed.

RESULTS

The 12,157 operations included 11,307 repairs (93.0%) and 850 palliations (7.0%); 68.5% of all palliations were modified Blalock-Taussig-Thomas shunts. Of 1105 operations on neonates, 45.4% (502) were palliations. Among neonates, palliations declined from 49.0% (331 of 675) in epoch 1 (2010-2015) to 39.8% (171 of 430) in epoch 2 (2016-2020; P = .0026). Overall, the most prevalent repair technique (5196 of 11,307; 46.0%) was ventriculotomy with transanular patch, which was also used in 520 of 894 (58.2%) of repairs after previous cardiac operations. Patients undergoing initial palliation demonstrated more preoperative STS risk factors (50.1% vs 24.3% respectively; P < .0001) and more major morbidity and mortality than patients undergoing primary repair (21.2% vs 7.46%; P < .0001). In the 0- to 60-day age group, risk factor-adjusted palliation rates across centers varied considerably, with 32 of 99 centers performing significantly more or significantly fewer palliations than predicted on the basis of their case mix.

CONCLUSIONS

Surgical palliation rates have decreased across all age groups despite increasing prevalence of risk factors. Ventriculotomy with transanular patch remains the most prevalent repair type. The considerable center-level variation in rates of palliation was not completely explained by case mix.

Traumatic Hemomediastinum and Hemothorax in a Patient With Totally Corrected Tetralogy of Fallot

An 18-year-old Japanese youth was transferred to our emergency department because of a traffic accident. He had a past history of total correction for tetralogy of Fallot as an infant. Chest computed tomography revealed hemomediastinum and hemothorax. In an emergency operation, massive bleeding from the mediastinum was observed. Bleeding arose from the torn Blalock-Taussig shunt and right subclavian artery. Hemostasis was achieved by clipping the shunt and suturing the subclavian artery. This is a rare case of a patient with hemomediastinum caused by torn Blalock-Taussig shunt after a high-impact accident who survived it by operation.

Creation of a Neo-Mitral Valve With Right Atrial Appendage Tissue in an Infant

Mitral valve replacement in neonates and infants is a challenging operation with few good options. Neo-mitral valve reconstruction with right atrial appendage (RAA) may overcome some of the limitations of existing options.