Preserving The Pulmonary Valve During Early Repair Of Tetralogy Of Fallot: Considerations And Factors That May Influence Surgical Approach
Adedotun Adewale, MD MPH1, Emily Pena, PA-C2, Kelci Schulz, DO2, Umar Siddiqi3, Luca Vricella, MD1, Michel Ilbawi, MD2, Chakwi El-Zein, MD2, Luca Vricella, MD1,2, Narutoshi Hibino, MD PHD1,2.
1University of Chicago Hospitals, Chicago, IL, USA, 2Advocate Children’s Heart Institute, Advocate Children’s Hospital, Chicago, IL, USA, 3University of Chicago, Chicago, IL, USA.
Study aim: To identify parameters to expand the indication for valve-sparing repair in tetralogy of Fallot (TOF). Methods: A retrospective chart review of 71 patients who underwent valve-sparing TOF repair (82% of TOF repairs performed). We analyzed the hemodynamic data, intraoperative reports, and follow-up echocardiography results to identify the acceptable indication for a valve-sparing procedure. A comparison of patients requiring pulmonary valve (PV) reintervention (surgical or transcatheter) vs no reintervention was performed.Results: Pulmonary valve annulus size at the time of repair is Z-score of -2.0 (1.32 to -5.34). 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 the time of initial TOF repair was relatively higher in the reintervention group compared with no reintervention group (39.1±40mmHg vs 30.6±30mmHg; P=0.08). For patients with residual PS, there was limited change of the PV pressure gradient (PG) over time across both groups (PV reintervention: -1.67± 20.2mmHg vs no reintervention: -0.59 ± 20.9mmHg). Using a cox regression model, the risk of PV reintervention is 3.7-fold higher when the PG from immediate postoperative echo is greater than 45 mmHg (P=0.04).Conclusion: In our study, about 82% had a TOF valve-sparing procedure compared to 45% reported by the STS database. The change of residual PS over time is limited. Based on our increased experience of valve-sparing TOF repair, intraoperative decision to convert to transannular patch is warranted if intraoperative postprocedure TEE PG is greater than 45 mmHg to prevent reintervention.
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