Comer Children's Hospital, University of Chicago, Chicago, Illinois, USA.
Advocate Children's Hospital, Advocate Children's Heart Institute, Oak Lawn, Illinois, USA.
J Card Surg. 2022 Dec;37(12):5144-5152. doi: 10.1111/jocs.17156. Epub 2022 Nov 15.
Tetralogy of Fallot (TOF) repair is a frequent procedure, and although valve-sparing (VS) repair is preferred, determining which patients can successfully undergo this operation remains controversial. We sought to identify parameters to determine a selective, accurate indication for VS repair.
We reviewed 71 patients (82%) undergoing VS repair. We analyzed hemodynamic data, intraoperative reports, and follow-up echocardiography results to identify acceptable indications. Patients requiring pulmonary valve (PV) reintervention versus no reintervention were compared.
PV annulus size at repair was z-score of -2.0 (-5.3, 1.3). Approximately half (51%) had a z-score less than -2. Cox regression results showed this was not a risk factor for reintervention (p = .59). Overall, 1-, 3-, 5-, and 10-year freedom from PV reintervention rates were 95.8%, 92.8%, 91% and 77.8%, respectively. Residual pulmonary stenosis (PS) at initial repair was relatively higher in the reintervention group compared with no reintervention group (40 [28, 51] mmHg vs. 30 [22, 37] mmHg; p = .08). For patients with residual PS, pressure gradient (PG) was consistent over time across both groups (PV reintervention: -3 [-15, 8] mmHg vs. no reintervention: 0 [-9, 8] mmHg). The risk of PV reintervention is 3.7-fold higher when the PG from intraoperative TEE is greater than 45 mmHg (p = .04).
Our review of the midterm outcomes of expanded indication for VS suggests intraoperative decision to convert to transannular patch is warranted if intraoperative postprocedure TEE PG is greater than 45 mmHg or RV pressure is higher than half of systemic pressure to prevent reintervention.
法洛四联症（TOF）修复是一种常见的手术，虽然保留瓣膜（VS）修复是首选，但确定哪些患者可以成功进行这种手术仍然存在争议。我们试图确定参数，以确定 VS 修复的选择性、准确指征。
我们回顾了 71 例（82%）接受 VS 修复的患者。我们分析了血流动力学数据、术中报告和随访超声心动图结果，以确定可接受的指征。比较了需要肺动脉瓣（PV）再次干预与无需再次干预的患者。
修复时 PV 瓣环大小为 z 分数-2.0（-5.3，1.3）。大约一半（51%）的 z 分数小于-2. Cox 回归结果显示，这不是再次干预的危险因素（p=0.59）。总体而言，1 年、3 年、5 年和 10 年免于 PV 再次干预的累积率分别为 95.8%、92.8%、91%和 77.8%。初次修复时残留的肺动脉瓣狭窄（PS）在再次干预组中相对较高，与无再次干预组相比（40[28，51]mmHg 比 30[22，37]mmHg；p=0.08）。对于有残余 PS 的患者，两组之间的 PG 随时间推移保持一致（PV 再次干预：-3[-15，8]mmHg 比无再次干预：0[-9，8]mmHg）。当术中 TEE 的 PG 大于 45mmHg 时，PV 再次干预的风险增加 3.7 倍（p=0.04）。
我们对扩大 VS 适应证的中期结果进行的回顾表明，如果术中术后 TEE PG 大于 45mmHg 或 RV 压力高于体循环压力的一半，应考虑行跨瓣环补片以避免再次干预。
