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Evolution of Pulmonary Valve Management During Repair of Tetralogy of Fallot: A 14-year Experience |
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| Institution: | 1. Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri;2. Washington University School of Medicine, St Louis, Missouri;3. Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St Louis Children’s Hospital, St Louis, Missouri;4. Section of Pediatric Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis Children’s Hospital, St Louis, Missouri;1. Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Massachusetts;2. Division of Cardiac Surgery, University of British Columbia, Vancouver, British Columbia;3. Marshall School of Medicine, Huntington, West Virginia;1. Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts;2. Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts;3. Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts;4. Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;5. Department of Surgery, Harvard Medical School, Boston, Massachusetts;1. Department of Cardiothoracic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia;1. Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida;2. Department of Surgery, University of Southern California, Los Angeles, California;3. Department of Surgery and Pediatrics, Children’s Hospital of Georgia, Augusta University, Augusta, Georgia;4. Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia;5. The Society of Thoracic Surgeons Research Center, Chicago, Illinois;6. Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina;7. Department of Pediatrics, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, Michigan;8. Cardiac Center, Children''s Hospital of Philadelphia, Philadelphia, Pennsylvania;9. Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia;10. Division of Cardiovascular Surgery, Mayo Clinic-Children’s Minnesota Cardiovascular Collaborative, Minneapolis, Minnesota;11. Department of Cardiovascular Surgery, Boston Children''s Hospital, Harvard Medical School, Boston, Massachusetts;12. Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;13. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;1. Department of Thoracic and Cardiovascular Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea |
| Abstract: | BackgroundThe optimal repair strategy for tetralogy of Fallot remains controversial. This report presents a 14-year evolution of management of the pulmonary valve (PV) from transannular patch to valve-sparing repair to neovalve creation using living right atrial appendage tissue.MethodsA retrospective review of 172 consecutive patients undergoing complete repair for TOF between January 2007 and June 2021 was performed. Clinical and follow-up data were analyzed by repair group. Neopulmonary valve (NPV) creation using right atrial appendage tissue was introduced in 2019. Failure of valve-sparing repair was defined as needing reintervention for recurrent right ventricular outflow tract obstruction (RVOTO).ResultsMedian age and weight at repair were 4.9 months and 6 kg, respectively. Median preoperative PV size and z-score were 6.4 mm (5.2-8.3 mm) and ?3.2 (?4.1 to ?2.1), respectively. Patients who underwent valve-sparing repair had larger PV size and z-score compared with patients who underwent transannular patch procedures (8 mm vs 5.6 mm; ?2.1 vs ?3.2; both P < .001). There were no hospital mortalities. Overall follow-up was 44 months. At last follow-up, 10% of patients who underwent valve-sparing repair had repeat intervention for recurrent RVOTO. Patients who had failed valve-sparing repair had significantly lower PV z-scores (?2.6 vs ?1.9; P = .01). An NPV was used in 8 patients with a median PV z-score of ?4 (?4.7 to ?3.9). At 6 months, 6 patients (75%) had mild or trivial pulmonary insufficiency after NPV placement.ConclusionsRepair of tetralogy of Fallot is a safe operation with excellent outcomes. Valve-sparing repair avoids right ventricular dilation but may fail for RVOTO at a PV z-score <?2. NPV creation offers an alternative option in patients with a small PV. |
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