Surgical Pulmonary Valve Replacement In Paediatric Patients With Repaired Tetralogy Of Fallot:Outcomes In The Current Era

Objective:Pulmonary valve replacement(PVR)is the surgical choice to treat pulmonary regurgitation(PR)after anatomical repair of tetralogy of Fallot(TOF).Despite numerous investigations on timing,indications,techniques,and results of PVR in adults,large gaps in knowledge persist on how to manage paediatric patients with PR.The research is aimed to report outcomes of current practice(2014.10-2017.12)of PVR in patients with repaired TOF,emphasizing results of paediatric patients.Methods:A retrospective research of all patients with severe pulmonary regurgitation after TOF repair who underwent PVR from Oct 2014 to Dec 2017 was conducted.All the patients were evaluated by cardiovascular magnetic resonance and cardiopulmonary exercise test.The medical records and imaging results were analyzed.The clinical composite endpoint including death,sustained ventricular tachycardia,atrial arrythmia or heart failure.The hemodynamic endpoint was whether preoperative abnormal RV(RVEF<47%or RVEDVi>114 ml/m2)can be rehabilitated after PVR.Results:From Oct 2014 to Dec 2017,there were 26 consecutive patients with severe pulmonary regurgitation after TOF repair who underwent PVR.It was divided into two groups,including 11 paediatric patients and 15 adult patients.The initial age at TOF repair was llmonthes(2-58 months)vs 114 months(12-516 months),P =0.004.The patients underwent PVR with the age of 15.5±2.4 years vs 34.8±10.2 years,P<0.001;the mean interval from total correction of TOF to PVR was 169.8±30.0 months vs 255.5±106.0 months,P=0.009.The peak oxygen consumption of the preoperative cardiopulmonary exercise in the paediatric groups and the adult groups was 24.8 ±5.4mL/kg/min vs 18.5 ± 3.9mL/kg.min,p = 0.025.There was no other statistical difference between two groups.Valve types included homograft(n=11)and bioprosthetic pulmonary valve(n=15).Concomitant tricuspid annuloplasty was performed in 11 patients,mitral valvuloplasty was performed in 1 patients,branch pulmonary arterioplasty was performed in 1 patients and residual VSD repair was performed was in 3 patients.Follow-up time was 18.3±9.0 months and there was no early or long-term death,and no reoperation after PVR.The CMR review was performed in all patients.RVEDVi and RVESVi were both smaller than preoperative period,and RVEF increased.In addition,there were 1 case of new atrial arrhythmia in the paetiatric group,and 1 case of new ventricular arrhythmia and 1 case of new atrial arrhythmia in adult group.In the paediatric group,only 1(9.1%)and 4(26.7%)of the adult group were satisfied with the postoperative criterion that RVEF≥48%and the RVEDVi≤114ml/m2.Inclusion:Pulmonary valve replacement was safe and effective to cure pulmonary regurgitation and the midterm outcome of paediatric and adult patients were similar.RVEF value increased compared with preoperative period,while RVEDVi decreased.Preoperative abnormal RV(RVEF<47%or RVEDVi>114 ml/m2)can be rehabilitated after PVR in some patients.And majority of patients were free from clinical events after PVR.