| OBJECTIVE:Tetralogy of Fallot is one of the most common cyanotic complex congenital heart diseases,and also with the most satisfactory surgical treatment outcomes.At present,the mortality rate of Tetralogy of Fallot is extremely low,and the long-term survival rate after repair is significantly improved.Due to the application of Tetralogy of Fallot repair technique and use of trans-annular patching,Long-term asymptomatic survival could be achieved in patients with pulmonary regurgitation.When patient's right ventricular enlargement leads to right ventricular dysfunction and symptoms appear.For purpose of correcting right ventricular dysfunction and reverse right ventricular failure,pulmonary valve replacement is required according to the conventional surgical indications.However,there were still some patients with no improvement in postoperative cardiac function after valve replacement,suggesting that the timing of pulmonary valve replacement was late,and heart failure could not be reversed.This study is to investigate the differences between two treatments(medication/surgical treatment)that can be used to correct right ventricular dysfunction,reverse right ventricular failure,and different treatments in patients after tetralogy of Fallot repair.Whether there is a difference in prognosis between patients after different treatments?METHODS:From June 2014 to April 2018,a total of 81 asymptomatic patients with moderate to severe pulmonary regurgitation after tetralogy of Fallot repair in the outpatients of Fuwai Hospital who were eligible for inclusion criteria were included in the cohort study.Forty-one patients were enrolled in the surgical treatment group and underwent pulmonary valve replacement.Forty patients were enrolled in the medication treatment group and treated with digoxin and diuretics.At the time of enrollment,cardiac magnetic resonance(CMR),cardiopulmonary exercise(CPET),transthoracic echocardiography(TTE),electrocardiogram(ECG)and chest X-ray examination were performed.After the enrollment examination,two groups were treated with pulmonary valve replacement and medication,respectively.The above examinations were re-examined six months later.Cardiac function changes were measured before and after treatment,and the incidence of adverse events were recorded.Kaplan-Meier analysis showed whether there was a statistically significant difference in the incidence of advers events between the two groups,and the survival curve of freedom from adverse events was drawn.RESULTS:The mean follow-up time for this cohort was 33.1± 10.0 months.During the follow-up period,in the surgical treatment group,there was no death patient and no patient with heart failure symptoms.One patient underwent pulmonary valve replacement due to valve deterioration during follow-up,31 patients restored normal right ventricular volume index,and 7 patients restored normal right ventricular function.While in the medication treatment group,three patients died,one patient had a heart transplantation,three patients underwent pulmonary valve replacement after onset of heart failure symptoms,and 2 patients had heart failure symptoms.Two patients returned to normal right ventricular volume index,and no patients returned to normal right ventricular function according to the CMR parameters.The incidence of adverse events in the surgical treatment group was significantly lower than that in the medication treatment group(P=0.023).CMR showed that the right ventricular ejection fraction,right ventricular end-diastolic volume index,right ventricular end-systolic volume index,pulmonary regurgitation fraction and left ventricular ejection fraction were significantly higher than those in medication treatment group(P<0.05).The follow-up echocardiographic results showed that the right ventricular end-diastolic diameter and tricuspid regurgitation degree were significantly improved in the surgical group compared with the medication treatment group.CONCLUSION:Medication treatment cannot correct the right ventricular function in asymptomatic patients with pulmonary regurgitation after tetralogy of Fallot repair.Surgical treatment can significantly reduce right ventricular volume index and improve right ventricular function.The comparison of the two groups showed that the right heart function in surgical treatment group was significantly better than that in medication treatment group according to the latest examinations,and the incidence of adverse events in the surgical treatment group was significantly lower than that in medication treatment group.OBJECTIVE:The treatment of tetralogy of Fallot is often accompanied by pulmonary regurgitation.As the patient grows,the degree of pulmonary regurgitation and regurgitant flow volume gradually increase,the long-term right ventricular pre-load volume increases,leading to right ventricular dilatation,right ventricular dysfunction until right heart failure.pulmonary valve replacement(PVR)is the main aspect for correcting this pathophysiology.however,PVR was routinely performed in symptomatic patients regarding the mainstream idea that pulmonary regurgitation in asymptomatic patients is benign.In fact,some symptomatic patients cannot restore the right ventricular function even after the PVR,which means the timing for PVR is too late.This study was to investigate whether PVR in asymptomatic patients can delay or even reverse the progression of right ventricular failure.METHODS:From June 2014 to April 2018,a total of 41 asymptomatic patients(18 males)with moderate to severe pulmonary regurgitation after tetralogy of Fallot repair in the outpatients of Fuwai Hospital were enrolled.PVR was performed after enrolled within one month in this group.After enrollment,cardiac magnetic resonance(CMR),cardiopulmonary exercise(CPET),transthoracic echocardiography(TTE),electrocardiogram(ECG)and chest X-ray examination were performed.Six months later after PVR,the aforementioned examination was re-examined.Cox regression analysis of independent risk factors associated with the normalization of right ventricle size after PVR,Receiver operating characteristic(ROC)curve analysis of each risk factor,using the Youden index to analyze cut-off value of risk factor.RESULTS:The median age of the patients enrolled in this study was 21.00 years(Interquartile range,IQR 17 years).The median age of the repair of tetralogy of Fallot was 2.67 years(IQR 4.00 years),of which 33 patients underwent trans-annular patching.The median interval time from the repair of tetralogy of Fallot to the enrollment was 17.00 years(IQR 6.30 years).The average interval time between cardiac MRI examinations was 17.24±10.22 months.The average follow-up time of this group was 33.76±10.49 months.During the follow-up period,no death and cardiac transplantation was recorded,1 patients underwent redo PVR due to the deterioration of the pulmonary valve.Thirty-one patients restored normal RV size after PVR,7 of them restored normal RV function.All the patients,heart function was maintained in Class I(New York Heart Association classification).Tricuspid valve regurgitation was significantly improved after PVR(2.15±1.27 VS 1.08±0.89,pp=0.000).parameters of cardiac function was significantly improved after PVR(P<0.05).Cox regression analysis of preoperative right ventricular end systolic volume index(RVESVI)was independent risk factors for the normaliTation of right ventricle size after PVR.The cut-off value of preoperative RVESVI analyzed by Yoden index was 120 ml/m2(sensitivity 90.3%,specificity 70%).CONCLUSION:PVR in asymptomatic patients with moderate to severe pulmonary regurgitation after tetralogy of Fallot repair is appropriate and effective in reducing right ventricular size and preserving right ventricular function.a majority of the patients(75.6%)restored normal RV size.The recommended criterion of RV ESVI for PVR is 120 ml/m2.OBJECTIVE:The treatment of tetralogy of Fallot is often accompanied by pulmonary regurgitation.As the patient grows and develops,the circulating blood volume increases,the degree of pulmonary regurgitation and regurgitant flow volume gradually increase.the long-term right ventricular pre-load volume increases,leading to right ventricular dilatation,right ventricular dysfunction until right heart failure.Digoxin and diuretics were routinely used in clinical treatment for chronic heart failure.This study was to investigate whether medication can delay or even reverse the progression of right ventricular failure in asymptomatic patients with moderate to severe pulmonary regurgitation after tetralogy of Fallot repair.METHODS:From June 2014 to April 2018,a total of 40 asymptomatic patients(21 males)with moderate to severe pulmonary regurgitation after tetralogy of Fallot repair in the outpatients of Fuwai Hospital were enrolled.Medication was carried out as scheduled in this group.After enrollment,cardiac magnetic resonance(CMR),cardiopulmonary exercise(CPET),transthoracic echocardiography(TTE),electrocardiogram(ECG)and chest X-ray examination were performed,and conventional drugs such as Digoxin and diuretics were taken.The above examination was re-examined six months later after medication.Cox regression analysis of independent risk factors associated with adverse events,Receiver operating characteristic(ROC)curve analysis of each risk factor,using the Youden index to analyze cut-off value of risk factor.RESULTS:The median age of the patients enrolled in this study was 17.00 years(Interquartile range,IQR 11 years).The median age of the repair of tetralogy of Fallot was 2.00 years(IQR 3.38 years),of which 32 patients underwent trans-annular patching.The median interval time from the repair of tetralogy of Fallot to the enrollment was 13.83 years(IQR 9.34 years).The average interval time between cardiac MRI examinations was 28.36±10.09 months.The average follow-up time of this group was 32.08±9.65 months.During the follow-up period,3 patients died,1 patient underwent cardiac transplantation,3 patients underwent pulmonary valve replacement,and 2 patients developed heart failure symptoms.There was no statistically significant difference between the results of the examinations.Cox regression analysis of arrhythmia and preoperative right ventricular end systolic volume index(RVESVI)were independent risk factors for follow-up adverse events.The cut-off value of preoperative RVESVI analyzed by Yoden index was 150.79 ml/m2(sensitivity 60%,specificity 96.7%).CONCLUSION:Drug therapy cannot delay or reverse the progression of right ventricular failure.Arrhythmia and RVESVI were independent risk factors for adverse events during follow-up in this group. |
PDF Full Text Request