Pulmonary regurgitation after repaired tetralogy of Fallot: surgical versus percutaneous treatment

Surgical pulmonary valve redo versus transcatheter pulmonary valve replacement for Tetralogy of Fallot patients

OBJECTIVES

To perform a systematic review to compare the efficacy and safety of transcatheter pulmonary valve replacement (TPVR) and surgical pulmonary valve replacement (SPVR) in managing pulmonary valve dysfunction in Tetralogy of Fallot (TOF) patients.

METHODS

This review investigates through three different databases for randomized control trials or observational studies evaluating TOF patients who underwent TPVR or SPVR until November 2024. The outcomes of interest were hemodynamic improvement, reduction in pulmonary regurgitation or stenosis, complications, quality of life, and long-term outcomes.

RESULTS

Four retrospective studies (1919 procedures) were analyzed. TPVR was non-inferior to SPVR, with a comparable safety profile. The durability of bioprosthetic valves was similar between TPVR and SPVR (HR: 0.97, 95% CI: 0.55-1.73; p = 0.93) and was influenced by patients' age at PVR (HR: 0.78 per 10 years from <1 year; 95% CI: 0.63-0.96; p = 0.02) and true inner valve diameter    .

CONCLUSIONS

TPVR is a safe and less-invasive alternative to SPVR with comparable efficacy in reducing pulmonary regurgitation. Complication rates are similar and valve durability is primarily age- and valve size-dependent. Although further research on long term outcomes is needed, TPVR may be integrated into routine practices, offering a viable alternative for high-risk TOF patients.

REGISTRATION

This systematic review was registered on the international prospective register of systematic reviews (PROSPERO; #CRD42024615871).

Pulmonary valve replacement in tetralogy of Fallot - who and how?

BACKGROUND AND AIM

Pulmonary regurgitation is the most common complication in repaired tetralogy of Fallot patients. Severe chronic pulmonary regurgitation can be tolerated for decades, but if not treated, it can progress to symptomatic, irreversible right ventricular dilatation and dysfunction. We investigated clinical associations with pulmonary valve replacement among patients with significative pulmonary regurgitation and how interventional developments can change their management.

METHODS

All adult patients with repaired tetralogy of Fallot who were followed at an adult CHD Clinic at a single centre from 1980 to 2022 were included on their first outpatient visit. Follow-up was estimated from the time of correction surgery until one of the following events occurred first: pulmonary valve replacement, death, loss to follow-up or conclusion of the study.

RESULTS

We included 221 patients (116 males) with a median age of 19 (18-25). At a median age of 33 (10) years old, 114 (51%) patients presented significant pulmonary regurgitation. Among patients with significant pulmonary regurgitation, pulmonary valve replacement was associated with male gender, older age at surgical repair, and longer QRS duration in adulthood. Pulmonary valve replacement was performed in 50 patients, including four transcatheter pulmonary valve implantations, at a median age of 34 (14) years.

CONCLUSION

Pulmonary regurgitation affects a large percentage of tetralogy of Fallot adult patients, requiring a long-term clinical and imaging follow-up. Sex, age at surgical repair and longer QRS are associated with the need of PVR among patients with significative pulmonary regurgitation. Clinical practice and current literature support TPVI as the future gold standard intervention.

Application of Speckle Tracking Echocardiography for Evaluating Ventricular Function after Transcatheter Pulmonary Valve Replacement

Pulmonary regurgitation usually leads to right heart dilatation and eventually right heart dysfunction, which is associated with a poor prognosis. Transcatheter pulmonary valve replacement is a developing treatment for pulmonary valve dysfunction that can take the place of traditional surgery and make up for the shortcomings of a large injury. Echocardiography plays a significant role in assessing ventricular function; however, conventional echocardiographic parameters have several limitations. Speckle tracking echocardiography has been regarded as a more accurate tool for quantifying cardiac function than conventional echocardiography. Therefore, the aim of this review was to summarize the application of speckle tracking echocardiography for evaluating right and left ventricular functions in patients after transcatheter pulmonary valve replacement.

First experience with real-time magnetic resonance imaging-based investigation of respiratory influence on cardiac function in pediatric congenital heart disease patients with chronic right ventricular volume overload

BACKGROUND

Congenital heart disease (CHD) is often associated with chronic right ventricular (RV) volume overload. Real-time magnetic resonance imaging (MRI) enables the analysis of cardiac function during free breathing.

OBJECTIVE

To evaluate the influence of respiration in pediatric patients with CHD and chronic RV volume overload.

METHODS AND MATERIALS

RV volume overload patients (n=6) and controls (n=6) were recruited for cardiac real-time MRI at 1.5 tesla during free breathing. Breathing curves from regions of interest reflecting the position of the diaphragm served for binning images in four different tidal volume classes, each in inspiration and expiration. Tidal volumes were estimated from these curves by data previously obtained by magnetic resonance-compatible spirometry. Ventricular volumes indexed to body surface area and Frank-Starling relationships referenced to the typical tidal volume indexed to body height (TTVi) were compared.

RESULTS

Indexed RV end-diastolic volume (RV-EDVi) and indexed RV stroke volume (RV-SVi) increased during inspiration (RV-EDVi/TTVi: RV load: + 16 ± 4%; controls: + 22 ± 13%; RV-SVi/TTVi: RV load: + 21 ± 6%; controls: + 35 ± 17%; non-significant for comparison). The increase in RV ejection fraction during inspiration was significantly lower in RV load patients (RV load: + 1.1 ± 2.2%; controls: + 6.1 ± 1.5%; P=0.01). The Frank-Starling relationship of the RV provided a significantly reduced slope estimate in RV load patients (inspiration: RV load: 0.75 ± 0.11; controls: 0.92 ± 0.02; P=0.02).

CONCLUSION

In pediatric patients with CHD and chronic RV volume overload, cardiac real-time MRI during free breathing in combination with respiratory-based binning indicates an impaired Frank-Starling relationship of the RV.

PR and QRS interval changes after transcatheter pulmonary valve replacement in children

BACKGROUND

Changes in PR intervals after transcatheter pulmonary valve replacement (TCPVR) have not been thoroughly evaluated in children. This study evaluated the changes in PR and QRS intervals six months after TCPVR in children with congenital heart disease.

RESULTS

This study included 41 patients who underwent TCPVR from 2010 to 2022. ECG of patients was reviewed before and six months after TCPVR, and the PR and QRS intervals were reported. Right ventricular systolic pressure (RVSP) was retrieved indirectly from echocardiography and compared pre- and 6-months after TPVR. The median age was 13 years (25th-75th percentiles: 11-16), and 61% were males. The preoperative diagnosis was tetralogy of Fallot (n = 29, 71%), transposition of great vessels (n = 4, 10%), common arterial trunk (n = 3, 7%), pulmonary valve stenosis (n = 3, 7%) and pulmonary atresia (n = 2, 5%). The Melody valve was used in 30 patients, and Edwards Sapien was used in 11 patients. RVSP was significantly reduced six months after the procedure (pre-RVSP 40 (30-55) mmHg vs. post-RVSP 25 (20-35) mmHg; P < 0.001). The PR interval was 142 (132-174) msec before TPVR and 146 (132-168) msec post-TCPVR (P = 0.442). Post-TPVR PR was positively related to the pre-PR (β: 0.79 (0.66-0.93), P < 0.001) and inversely related to the right ventricular outflow tract size (- 1.48 (- 2.76 to - 0.21), P = 0.023). The pre-TPVR QRS was 130 (102-146) msec, and the post-TPVR QRS was 136 (106-144) msec (P = 0.668).

CONCLUSIONS

In children undergoing TCPVR, the PR and QRS intervals did not change significantly during a 6-month follow-up.

Right ventricular echocardiographic remodeling after pulmonary valve replacement in repaired Tetralogy of Fallot

BACKGROUND

Many patients with repaired tetralogy of Fallot require reoperation in the medium to long-term for residual pulmonary valve regurgitation. Best timing for pulmonary valve replacement remains controversial. A balance needs to be found between protecting the patients from permanent right ventricular damage and insertion of a prosthetic valve with its inherent issues. In the current study we sought to investigate the right and left ventricular functional recovery following valve replacement in our tertiary care institution.

RESULTS

In a retrospective cross-sectional study patients with history of total correction of tetralogy of Fallot who had undergone pulmonary valve replacement due to severe pulmonary regurgitation between 2003-2018 were evaluated for post intervention right and left ventricular functional recovery. Clinical and full echocardiographic data before and after the surgery were recorded and compared. There was statistically significant improvement in RV size and function post pulmonary valve replacement. There was no statistically significant improvement in left ventricular systolic function. Twenty percent of patient had persisting severe right ventricular enlargement at least twelve months post-surgery. No patient had fully normalized right ventricular size and function in follow-up.

CONCLUSIONS

Pulmonary valve replacement leads to improvement in right ventricular size and function in patients with repaired tetralogy of Fallot. However normalization of functional parameters did not occur and the majority of the patients have residual right and left ventricular dysfunction following redo valve replacement surgery.

First hybrid implantations of novel Salus-Valves in patients with severe pulmonary regurgitation: A case series

With the increasing age of patients after right ventricular outflow tract (RVOT) reconstruction, progressive pulmonary valve (PV) dysfunction can result in different degrees of right heart insufficiency, and PV replacement is frequently needed during follow-up. The traditional redo thoracotomy is difficult and associated with higher risks when compared to transcatheter implantations. Herein, we report the advantages and describe the outcomes of the first hybrid implantations of the novel Salus-Valves (Balance Medical, Beijing, China) from the sub-xiphoid approach in five patients (mean age of 22.6 years) with severe pulmonary regurgitation (PR) after RVOT reconstruction.