The Role of Tricuspid Valve Surgery in the Late Management of Tetralogy of Fallot

Abstract

While surgical repair of tetralogy of Fallot (TOF) is generally associated with good early outcomes, late complications affect long-term survival and may require reoperation. Pulmonary regurgitation (PR) and tricuspid regurgitation (TR) may increase the risk of arrhythmias, reduced cardiac function, and sudden death. Tricuspid valve function can be compromised secondarily in the setting of PR or directly as a result of injury or alteration of the valve related to the original TOF repair. This article reviews the etiologic mechanisms, pathophysiological implications, and surgical interventions for TR. Effective management following TOF repair requires consideration of TR to optimize late outcomes.

Repairing the tricuspid valve in congenital heart diseases other than Ebstein’s

“…For both functional and structural problems with the tricuspid valve, annuloplasty techniques are often required, with or without a stabilising prosthetic ring depending on growth considerations, and of course detachment of any tethered structures of the tricuspid valve apparatus has been caught and injured during ventricular septal defect closure. 30,31,41,46,47 In extreme cases, it may be necessary to detach part of the ventricular septal defect patch or recreate a ventricular septal defect, repair the tricuspid valve accordingly, and close the ventricular septal defect with a new patch. When insufficient tissue exists from prior iatrogenic damage to the valve, bicuspidalisation is a useful, reproducible, technically easy, and inexpensive method to restore valve competence.…”

“…When insufficient tissue exists from prior iatrogenic damage to the valve, bicuspidalisation is a useful, reproducible, technically easy, and inexpensive method to restore valve competence. 41,48 The anterior and septal leaflets are brought together by placing a partial annuloplasty purse string suture, thereby compressing the posterior leaflet and forcing leaflet coaptation of a neo-bicuspidised valve (Figs 12, 13). 5,48 Depending on the general condition of the patient and eventual superimposed haemodynamic and structural burdens on the heart after repaired tetralogy of Fallot, such as right ventricular dilatation and/ or right outflow pathology, the risk for reoperation and the result of tricuspid valve repair will vary widely, ranging from a very safe procedure with an excellent result, or a very high-risk procedure (up to 16.7% reported mortality) and unstable valve Figure 13.…”

“…5 repair. 30,31,41,46,47 Follow-up data on the results and durability of tricuspid valve repair after complete correction of tetralogy of Fallot are scarce, 30,31,47 and it is difficult to evaluate whether the indication is for isolated surgery on the tricuspid valve or other cardiac structures. Namely, confounding factors related to right ventricular dimensions and geometry, right outflow functional status with stenosis and/or insufficiency, pulmonary hypertension, and eventual concomitant right bundle branch block or QRS widening may all impact the efficiency and results of surgery on the tricuspid valve.…”

“…When relatively straightforward and reproducible techniques can restore valve competence and improve right-sided haemodynamics without taking unreasonable surgical risks with regard to bleeding, excessive bypass, and/or crossclamp times, the authors support this holistic approach to right heart restoration. 41 Iatrogenic lesions from intravenous pacemaker and defibrillator leads Although epicardial pacing is increasingly being used and advocated for arrhythmia control in patients with congenital heart disease in whom steady somatic growth is a paramount issue, transvenous pacing and defibrillator leads have historically been placed and are increasingly encountered during follow-up, some of which will lead to iatrogenic lesions requiring therapy. Most transvenous leads cross the tricuspid valve and create insufficiency through mechanisms of traction, perforation, tethering, entanglement, fusion, and/or fibrosis.…”

“…In patients with certain forms of tetralogy of Fallot and pulmonary atresia with intact ventricular septum, with or without a small right ventricle and a diminutive tricuspid valve annulus, biventricular strategy may not be indicated or may be hazardous, as antegrade flow to the pulmonary arteries cannot be secured 29 . In tetralogy of Fallot with a diminutive tricuspid valve annulus, the actual valve is often morphologically normal, 41 but pulmonary valve insufficiency or pulmonary hypertension lead to right ventricular failure. In patients with pulmonary atresia with intact ventricular septum, the tricuspid valve is often dysplastic 25 .…”