Persistent end-diastolic forward flow after pulmonary valve replacement in patients with repaired tetralogy of Fallot

Abstract

OBJECTIVES The clinical significance of persistent end-diastolic forward flow (EDFF) after pulmonary valve replacement (PVR) remains unclear in patients with repaired tetralogy of Fallot. This study aimed to identify the characteristics of these patients and the impact of persistent EDFF on outcomes. METHODS Of 46 consecutive patients who underwent PVR for moderate to severe pulmonary regurgitation between 2003 and 2019, 23 (50%) did not show EDFF before PVR [group (−)]. In the remaining 23 patients with EDFF before PVR, EDFF was diminished after PVR in 13 (28%) [group (+, −)] and persisted in 10 (22%) [group (+, +)]. The following variables were compared between these 3 groups: (i) preoperative right ventricular (RV) and right atrial volumes measured by magnetic resonance imaging, haemodynamic parameters measured by cardiac catheterization and the degree of RV myocardial fibrosis measured by RV biopsy obtained at PVR and (ii) the post-PVR course, development of atrial arrhythmia and need for intervention. RESULTS A high RV end-diastolic pressure, a greater right atrial volume index and a greater RV end-systolic volume index before PVR and a high degree of RV fibrosis were significantly associated with persistent EDFF 1 year after PVR. Persistent EDFF was a significant risk factor for postoperative atrial tachyarrhythmia, and catheter ablation and pacemaker implantation were required more frequently in these patients. CONCLUSIONS Persistent EDFF after PVR could predict a worse prognosis, especially an increased risk of arrhythmia. Close follow-up is required in patients with persistent EDFF for early detection of arrhythmia and prompt reintervention if necessary. Clinical trial registration number Institutional review board of Osaka University Hospital, number 16105

End‐Diastolic Forward Flow and Restrictive Physiology in Repaired Tetralogy of Fallot: A Systematic Review and Meta‐Analysis

“…A total of 552 citations were identified, of which 83 publications were potentially relevant and retrieved as full text. Forty‐five reports 5 , 6 , 7 , 8 , 11 , 12 , 13 , 14 , 15 , 16 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 of 42 individual studies fulfilled our eligibility criteria (Figure 1 ). Characteristics of each study and its participants are shown in Table 1 .…”

“… 12 This dilatation‐related phenotype has been linked to severe PR, 16 fibrosis, 45 accelerated RV enlargement, 54 and increased risk of adverse outcomes. 56 Corroborating these observations, Lee et al 39 demonstrated that EDFF was associated with improved exercise tolerance (peak oxygen consumption) in patients with RVEDVi <170 mL/m², but not in those with RVEDVi ≥170 mL/m².…”

“…In addition, the relevance of EDFF for risk stratification for common procedures in rToF, such as placement of implantable cardioverter‐defibrillator and pulmonary valve replacement, should be investigated. 66 , 67 As an example of the latter, Tominaga et al 56 showed that EDFF may disappear after pulmonary valve replacement but signals worse prognosis when it persists. It might be important to interpret this in conjunction with RV size, as patients with smaller RVs (<170 mL/m²) have not consistently shown an effect of persistent EDFF on the risk of arrhythmias.…”

Risk factors for atrial arrhythmia recurrence after atrial arrhythmia surgery with pulmonary valve replacement

“…Asymptomatic patients underwent PVR when the right ventricular end-diastolic volume index and right ventricular end-systolic volume index (RVESVI) approached 150 mL/m 2 and 80 mL/m 2 , respectively, as assessed by cardiac magnetic resonance imaging (MRI) or cardiac computed tomography (CT). 5 , 9 , 12 , 13 Of these 74 patients, 22 underwent concomitant atrial arrhythmia surgery (18 patients with TOF and 4 patients with pulmonary atresia with ventricular septal defect; mean age at PVR, 39 years; Table 1 ) before PVR (maze [+] group) due to a history of atrial arrhythmia. The other 52 patients without histories of atrial arrhythmia before PVR did not undergo arrhythmia surgeries (maze [–] group).…”

End-diastolic forward flow in repaired tetralogy of Fallot: Mid-term outcomes from a single center

“…End-diastolic forward flow (EDFF) in the main pulmonary artery, resulting from diastolic RV stiffness ( 4 ), is regarded as a manifestation of RV restrictive physiology in many studies ( 2 , 7 , 8 ). More and more attention has been paid to this phenomenon in rTOF patients ( 8 , 9 ), whereas the risk factors of EDFF are not clear, which mostly focus on preoperative physiological state and surgical procedures, such as transannular patch (TAP) ( 6 ). Studies of the association between TAP and EDFF have yielded divergent results.…”