Impact of pressure load caused by right ventricular outflow tract obstruction on right ventricular volume overload in patients with repaired tetralogy of Fallot

Yoo, Byung Won; Kim, Jung Ok; Kim, Young Jin; Choi, Jae Young; Park, Han Ki; Park, Young Hwan; Sul, Jun Hee

doi:10.1016/j.jtcvs.2011.12.033

Cited by 68 publications

(43 citation statements)

References 23 publications

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“…Rather, patients with AP tend to have residual RVOT obstruction more frequently than patients with TAP, which may lead to less frequent PVI by preventing RV dilatation [8,26]. Therefore, the decision of PVI was made not merely by the presence of severe pulmonary regurgitation.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary Annulus Preservation Lowers the Risk of Late Postoperative Pulmonary Valve Implantation After the Repair of Tetralogy of Fallot

2014

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The long-term benefits of pulmonary annulus preservation in tetralogy of Fallot (ToF) repair in patients with a marginally small pulmonary annulus are controversial. We sought to determine whether pulmonary annulus preservation (AP) is superior to transannular patching (TAP) in lowering the risk of pulmonary valve implantation (PVI) long after the repair of ToF. Of the 255 patients who underwent total correction of ToF during infancy between January 1989 and December 2005, 114 patients (AP group = 57, TAP group = 57) were selected by propensity score matching for various preoperative variables, such as age and body weight at operation, sex, pulmonary artery size, pre-repair palliation, anatomical types of ventricular septal defect, and Z-score of pulmonary valve annulus diameter (PVA-Z). The PVA-Z of the AP and TAP groups were -2.3 ± 1.3 and -2.1 ± 1.3, respectively (p = 0.547). The time to PVI was compared between the two groups. The median follow-up duration was 146 months (AP group: 141 months, TAP group: 147 months; p = 0.191). During the follow-up periods, there were 12 reoperations for the relief of right ventricular outflow tract obstruction (RVOTO), eight PVIs, and three late deaths. While freedom from reoperation for RVOTO was comparable between the two groups (p = 0.182), freedom from PVI at postoperative 15 years was significantly lower in the TAP group than in the AP group (74 and 100 %, p = 0.015). In repairing ToF with marginally small pulmonary valve annulus, AP is associated with a lower risk of late postoperative PVI.

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Section: Discussionmentioning

confidence: 99%

Pulmonary Annulus Preservation Lowers the Risk of Late Postoperative Pulmonary Valve Implantation After the Repair of Tetralogy of Fallot

2014

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“…That an element of residual RVOT obstruction may protect against late RV dilatation is suggested by Yoo et al, 31 who used CMR to assess 190 patients with repaired ToF and found that patients with residual RVOT obstruction (mean gradient, 34.2±10.0 mm Hg) had less RV volume overload and no medium-term deterioration of RV function compared with those with predominant pulmonary regurgitation. Van der Hulst and colleagues 32 also demonstrated that mild residual pulmonary stenosis reduced the need for PVR in 171 patients with ToF repair over a follow-up of 24 years.…”

Section: Discussionmentioning

confidence: 96%

Physiological and Phenotypic Characteristics of Late Survivors of Tetralogy of Fallot Repair Who Are Free From Pulmonary Valve Replacement

et al. 2013

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Background-Pulmonary valve replacement (PVR) after repair of tetralogy of Fallot is commonly required and is burdensome. Detailed anatomic and physiologic characteristics of survivors free from late PVR and with good exercise capacity are not well described in a literature focusing on the indications for PVR. Methods and Results-Survival and freedom from PVR were tracked in 1085 consecutive patients receiving standard tetralogy of Fallot repair in a single institution from 1964 to 2009. Of 152 total deaths, 100 occurred within the first postoperative year. Surviving patients between 10 and 50 years of age had an annual risk of death of 4 (confidence limit, 2.8-5.4) times that of normal contemporaries. To date, 189 patients have undergone secondary PVR at mean age of 20±13 years (36% of those alive at 40 years of age). A random sample of 50 survivors (age, 4-57 years) free from PVR underwent cardiovascular magnetic resonance, echocardiography, and exercise testing. These patients had mildly dilated right ventricles (right ventricular end-diastolic volume=101±26 mL/m 2 ) with good systolic function (right ventricular ejection fraction=59±7%). Most had exercise capacity within normal range (z peak V i o 2 =−0.91±1.3; z V i e/V i co 2 =0.20±1.5). In patients >35 years of age with normal exercise capacity, there was mild residual right ventricular outflow tract obstruction (mean gradient, 24±13 mm Hg), pulmonary annulus diameters <0.5z, and unobstructed branch pulmonary arteries. Conclusions-An important proportion of patients require PVR late after tetralogy of Fallot repair. Patients surviving to 35 years of age without PVR and with a normal exercise capacity may have had a definitive primary repair; their right ventricular outflow tracts are characterized by mild residual obstruction and pulmonary annulus diameter <0.5z.

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“…Previously, surgeons used smaller TAPs and infundibular incisions to limit free regurgitation of the PV. These measures indeed slowed the effect of PI on the RV, 14 but this mere delay in RV dysfunction led eventually to a fate similar to that of patients who developed isolated PI after the TAP. 15 The more fruitful solution, as we have outlined it above, relieves the RVOT stenosis as well as possible and creates a competent PV in patients who really need a TAP.…”

Section: Discussionmentioning

confidence: 98%

Fresh Autologous Pericardium to Reconstruct the Pulmonary Valve at the Annulus When Tetralogy of Fallot Requires a Transannular Patch at Midterm

Pande¹,

Sharma²,

Siddartha³

et al. 2016

Texas Heart Institute Journal

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Tetralogy of Fallot often requires reconstruction of the right ventricular outflow tract with a transannular patch (TAP), but this renders the pulmonary valve incompetent and eventually leads to right ventricular dysfunction.We P ulmonary insufficiency (PI) is an unwarranted side effect of the transannular patch (TAP) used for relieving the right ventricular outflow tract (RVOT) obstruction that is characteristic of tetralogy of Fallot (TOF).1 With time, the presence of PI causes right ventricular (RV) overload and eventually leads to RV dysfunction.2 Attempts to reduce insufficiency at the pulmonary valve (PV)-such as limiting the extent of infundibular incision or using a smaller transannular patch-have met with limited success.3,4 A TAP for RVOT reconstruction relieves its obstruction; but its expansion, especially at the level of the PV, cannot be governed, and this results in free pulmonary regurgitation. The use of a smaller TAP not only fails to relieve the RVOT obstruction efficiently but is unable to curtail the free PI. A procedure that can resolve the problem of PI with relief of RVOT obstruction must fulfill these 2 criteria: 1) limit the expanse of the TAP at the level of the native PV, while enabling it to bulge (and thereby increase the room in the RVOT to relieve obstruction) and 2) provide a competent PV. This study evaluates the efficiency of one such procedure at creating a competent PV complex (that is, a competent PV and a new pulmonary annulus) in TOF patients who need a TAP for relief of RVOT obstruction when undergoing complete intracardiac repair. This procedure was tested at midterm follow-up. Patients and MethodsThis is a retrospective analysis of 70 cases of children who underwent total cardiac repair for TOF

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Impact of pressure load caused by right ventricular outflow tract obstruction on right ventricular volume overload in patients with repaired tetralogy of Fallot

Cited by 68 publications

References 23 publications

Pulmonary Annulus Preservation Lowers the Risk of Late Postoperative Pulmonary Valve Implantation After the Repair of Tetralogy of Fallot

Pulmonary Annulus Preservation Lowers the Risk of Late Postoperative Pulmonary Valve Implantation After the Repair of Tetralogy of Fallot

Physiological and Phenotypic Characteristics of Late Survivors of Tetralogy of Fallot Repair Who Are Free From Pulmonary Valve Replacement

Fresh Autologous Pericardium to Reconstruct the Pulmonary Valve at the Annulus When Tetralogy of Fallot Requires a Transannular Patch at Midterm

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