ECHO ROUNDS: Percutaneous Balloon Valvuloplasty for Pulmonic Stenosis: The Role of Multimodality Imaging

Patients with tetralogy of Fallot (TOF) following complete repair and pulmonic stenosis (PS) after surgical valvotomy often develop significant pulmonic regurgitation (PR), eventually requiring valve replacement (PVR). Though criteria exist for the timing of PVR in TOF, it remains less clear when to intervene in valvotomy patients and whether TOF recommendations can be applied. Our aim was to compare the structural and functional sequelae of valvotomy for pulmonic stenosis (PS) with complete repair for tetralogy of Fallot (TOF). We compared the clinical characteristics, electrocardiograms, echocardiograms, cardiac MRI and invasive hemodynamics of 109 adults (34 PS and 75 TOF) newly referred to a congenital heart disease center for evaluation of PR between 2005 and 2012. Both cohorts were similar in terms of baseline demographics and presenting NYHA function class. Valvotomy patients had a slightly greater degree of PR by echo, though it was similar by cardiac MRI. ECG QRS width was greater in TOF (114±27 vs. 150±28 ms, p<0.001). MRI right ventricular ejection fraction (49±8 vs. 41±11%, p=0.001) and left ventricular ejection fraction (59±7 vs. 52±10%, p=0.002) were lower in TOF. Pacemaker or defibrillator implantation was significantly higher in TOF (3% vs. 23%, p=0.011). In conclusion, patients post-valvotomy and complete repair present with similar degrees of PR and symptom severity. Biventricular systolic function and ECG QRS width appear less affected, suggesting morphologic changes in TOF and its repair that extend beyond the effects of PR. These findings suggest the need for developing disease-specific guidelines for patients with PR post-valvotomy.

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