Right ventricular dysfunction and the role of pulmonary valve replacement after correction of tetralogy of Fallot.

BACKGROUND

Correction of tetralogy of Fallot (ToF) often leads to pulmonary regurgitation, sometimes warranting pulmonary valve replacement (PVR), for which the indications and timing to achieve optimal results are not yet clear. This retrospective study describes follow-up and reinterventions in our ToF population.

METHODS

Review of all consecutive patients operated for ToF between 1977 and 2000. Included are date and type of repair, Doppler echocardiography (2D-echo), ECGs, re-operations and physical condition.

RESULTS

Total repair was performed in 270 patients, mean age 1.9±2.5 years, 82 were excluded because of follow-up abroad. Right ventriculotomy was used in 92%, transatrial VSD closure in 8%, while 69% received a transannular outflow patch. Pulmonary atresia required a pulmonary graft in 13 (8%) patients. Overall 20-year survival was 88%. Last follow-up: ECG showed RBBB in 67% (QRS complex 129±29.3 msec). RVOT aneurysms were detected in 16%. 2D-echo demonstrated mild pulmonary insufficiency (PI) in 40%, severe in 31%, dilated RV in 76%, both increasing with post-repair age. In 39%, RV dimensions were equal or even exceeded LV dimensions, 45% showed tricuspid insufficiency and the RA was enlarged in 14%. Reintervention was necessary in 39/185 patients, this included angioplasty for residual stenosis and PVR (22/19 homografts, six patients in PA group) at a mean age of 11.2 years after correction. In seven patients, the RV returned to normal dimensions and symptoms disappeared, but in three severe dysfunction developed. Eleven others still have RV dilatation and/or PI. In total, 75% were free of reintervention in the first ten years. The right atrial approach diminishes severe RV dilatation and prolonged QRS duration (p=0.001 and 0.007). Early correction reduces the risk of re-operation (p=0.011).

CONCLUSIONS

Severe RV dilatation (39%) and PI (31%) secondary to outflow tract repair in ToF are frequently occurring sequels developing slowly over time. Timing of PVR remains controversial, still best guided by the clinical condition.