Right Ventricular Remodeling After Pulmonary Valve Replacement: Early Gains, Late Losses

Abstract

Although early results of pulmonary valve replacement (PVR) after tetralogy of Fallot repair have been described, information about late postoperative ventricular size and function is lacking. This study was designed to characterize right ventricular (RV) remodeling up to 10 years after PVR. Retrospective analysis was conducted of cardiovascular magnetic resonance (CMR) data from 2002 to 2011 in 101 patients (244 studies) who underwent PVR and had one or more post-PVR CMR studies at five post-PVR time intervals up to 10 years. Compared with pre-PVR values, in the 0- to 1-year post-PVR group, pulmonary regurgitation (PR) fraction decreased from 49 ± 11% to 3 ± 2% (p < 0.001), RV end-diastolic volume index (EDVi) decreased by 39% (p < 0.001), RV end-systolic volume index (ESVi) decreased by 33% (p < 0.001), and RV ejection fraction (EF) decreased from 48 ± 8% to 44 ± 8% (p = 0.01). These values remained unchanged through the sixth post-PVR year. However, by 7 to 10 years after PVR (n = 15), RVEDVi and RVESVi were significantly increased and had returned to 84% and 104% of pre-PVR volumes, respectively, and RV EF had declined further. Increasing RV EDVi correlated with increasing grades of PR (rs = 0.36, p < 0.001), tricuspid regurgitation (rs = 0.33, p < 0.001), and RV pressure (rs = 0.32, p = 0.03). In this cohort, early reduction in RV size showed a gradual return toward preoperative values by 7 to 10 years after PVR. The late adverse RV remodeling was associated with increased RV volume and pressure loads. These findings highlight the palliative nature of PVR and the importance of continued surveillance.