Division of Cardiology and Cardiovascular Surgery, Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto, Ontario, Canada.
Int J Cardiol. 2012 Oct 18;160(3):165-70. doi: 10.1016/j.ijcard.2011.04.007. Epub 2011 May 12.
Adverse ventricular-ventricular interactions have been recognized in those with repaired tetralogy of Fallot (TOF) and severe pulmonary regurgitation.
We aimed to examine the impact of pulmonary valve replacement (PVR) on the left heart late after TOF repair.
Left ventricular (LV) volumes and ejection fractions (EF) were analyzed in adults with severe pulmonary regurgitation after TOF repair with cardiac magnetic resonance imaging (CMR) before and after PVR. Thirty-nine patients (median age 33[20-65] years) were reviewed. Post-PVR, LVEF improved significantly in the entire cohort (50 ± 9%→54 ± 7%, p<0.001) and in those with moderately impaired (defined as LVEF ≤ 45%) preoperative LVEF (38 ± 5%→47 ± 6%, p<0.0001), but was not statistically different in those with relatively preserved (defined as LVEF >45%) preoperative LVEF. By multivariate linear regression analysis to evaluate independent CMR predictors of improved LVEF post-PVR for the entire cohort, the only CMR variable to emerge was preoperative LVEF (p=0.012, regression coefficient -0.54, SE 0.13). Whereas PVR resulted in increased LV filling in patients with relatively preserved preoperative LVEF reflected by an increase in LV end-diastolic volumes (77 ± 10→82 ± 16 mL/m(2), p=0.05), LV end-systolic volumes decreased after PVR in patients with impaired preoperative LVEF (65 ± 12→54 ± 10 mL/m(2), p=0.001) but LV end-diastolic volumes were not significantly changed.
When LVEF is decreased after TOF repair, PVR appears to have a salutary effect on postoperative LVEF, thereby supporting the concept of recovery of adverse right-left heart interactions. Mechanisms of left heart improvement post-PVR differ depending on degree of preoperative LV systolic dysfunction.
已认识到在法洛四联症（TOF）修复术后伴严重肺动脉瓣反流（PR）的患者中存在有害的心室-心室相互作用。
我们旨在检查 TOF 修复术后行肺动脉瓣置换（PVR）对左心的远期影响。
应用心脏磁共振成像（CMR），在 TOF 修复术后伴严重 PR 的患者中分析左心室（LV）容量和射血分数（EF），并在 PVR 前后进行评估。共回顾 39 例患者（中位年龄 33[20-65]岁）。PVR 后，整个队列的 LVEF 显著改善（50 ± 9%→54 ± 7%，p<0.001），术前 LVEF 中度受损（定义为 LVEF ≤ 45%）的患者（38 ± 5%→47 ± 6%，p<0.0001），但术前 LVEF 相对保留（定义为 LVEF >45%）的患者中无统计学差异。通过多元线性回归分析评估整个队列中 PVR 后 LVEF 改善的独立 CMR 预测因子，唯一出现的 CMR 变量是术前 LVEF（p=0.012，回归系数 -0.54，SE 0.13）。尽管 PVR 导致术前 LVEF 相对保留的患者的 LV 充盈增加（LV 舒张末期容积从 77 ± 10→82 ± 16 mL/m²，p=0.05），但术前 LVEF 受损的患者的 LV 收缩末期容积在 PVR 后下降（65 ± 12→54 ± 10 mL/m²，p=0.001），但 LV 舒张末期容积无明显变化。
当 TOF 修复后 LVEF 降低时，PVR 似乎对术后 LVEF 具有有益的作用，从而支持不良右-左心相互作用恢复的概念。PVR 后左心改善的机制取决于术前 LV 收缩功能障碍的程度。
