Postoperative Pulmonary Regurgitation Research Articles

The Nakata index and McGoon ratio: correlation with the severity of pulmonary regurgitation after the repair of paediatric tetralogy of Fallot.

Pulmonary regurgitation is the most common complication after the complete repair of tetralogy of Fallot, and severe pulmonary regurgitation after surgery requires pulmonary valve replacement. In this retrospective observational, cross-sectional study, we included a total of 56 children aged 6 years or younger who underwent complete repair of TOF at Shahid Rajaei Cardiovascular Medical and Research Center in Tehran, Iran. Preoperative dual-source computed tomography was used to measure the McGoon ratio and Nakata index. The patients were divided into two groups based on the severity of postoperative pulmonary regurgitation, as estimated by trans-thoracic echocardiography: the severe pulmonary regurgitation group and the non-severe pulmonary regurgitation group. The McGoon ratio and Nakata index were then compared between the two groups. When comparing the two groups, we found that the corrected right pulmonary artery diameter, main pulmonary artery diameter, and McGoon ratio in the non-severe pulmonary regurgitation group were higher than in the severe pulmonary regurgitation group. However, none of these differences were statistically significant. Additionally, other variables, including the corrected left pulmonary artery diameter and Nakata index, showed higher measurements in children with severe pulmonary regurgitation, but again, the differences were not statistically significant. This study indicates that pulmonary arteries diameter, Nakata index, and McGoon ratio were not significantly correlated with the severity of pulmonary regurgitation after the complete repair of tetralogy of Fallot.

Outlet Ventricular Septal Defect: Impact of Surgery on the Late Aortic and Pulmonary Valve Functions

This study retrospectively evaluated long-term post-operative aortic and pulmonary valve functions in outlet ventricular septal defects. We evaluated aortic regurgitation and pulmonary regurgitation using pre- and post-operative echocardiograms. Overall, 158 patients who underwent intracardiac repair due to outlet ventricular septal defects with aortic valve deformity or congestive heart failure were included. The median follow-up period was 7years (interquartile range: 0-17years), without deaths or pacemaker implantations. The age, weight, ventricular septal defect size, and mild aortic regurgitation at surgery were factors associated with post-operative residual aortic regurgitation. Mild pulmonary regurgitation was observed in 12%, 30%, and 40% of patients 5, 10, and 15years after surgery, respectively. There were no significant differences in age and weight at which surgery was performed between patients with mild pulmonary regurgitation and those with less than mild pulmonary regurgitation. However, the number of sutures across the pulmonary valve was associated with post-operative pulmonary regurgitation (P < 0.01). As some patients with mild pre-operative aortic regurgitation may not improve even after surgery, early surgical intervention is necessary when aortic regurgitation appears. Some patients may develop post-operative pulmonary regurgitation in the long term, suggesting the need for careful follow-up.

Computed tomography for evaluating right ventricle and pulmonary artery in pediatric tetralogy of Fallot: correlation with post-operative pulmonary regurgitation

Pulmonary regurgitation (PR) is the most common complication after tetralogy of Fallot (TOF) surgical repair, and long-term PR might result in cardiovascular events. The aim of this study was to assess the influence of pre-operative right ventricle (RV) and pulmonary artery (PA) parameters assessed by dual-source computed tomography on post-operative PR. A total of 41 TOF patients who underwent trans-valve surgical repair were retrospectively recruited. The RV and PA parameters evaluated by pre-operative DSCT were compared between the PR and non-PR groups. Our result revealed that the PA parameters (McGoon ratio, Nakata index, and LPA diameter) and RV parameters (RV length diameter and RV short diameter) all showed significant differences between the two groups (all p < 0.05). There was a significant correlation between PR and LPA diameter (r = 0.361), McGoon ratio (r = 0.413), and Nakata index (r = 0.482). Receiver operating characteristic analysis also revealed a moderate sensitivity and specificity of LPA (66.33%; 82.60%), McGoon ratio (83.33%, 56.52%), and Nakata index (83.33%; 60.87%) for predicting the occurrence of PR. This study indicated that these pre-operative indices calculated by DSCT are associated with post-operative PR and that these pre-operative PA and RV parameters may serve as novel predictors of the risk of PR.

Long-term results of pulmonary valve annular enlargement with valve repair in tetralogy of Fallot.

We adopted an operative technique of pulmonary valve (PV) annular enlargement with valve repair in tetralogy of Fallot (TOF) correction to reduce postoperative pulmonary regurgitation (PR) 16 years ago. Here, we have evaluated the long-term results. Between April 2000 and August 2005, 43 patients (26 men) with tetralogy of Fallot with pulmonary stenosis underwent PV annular enlargement with valve repair. The median age and body weight at the time of surgery were 14 months and 10.2 kg, respectively. There was no operative mortality. Mean postoperative PR grade at discharge was 0.93 ± 0.40 (none or trivial in 10 patients, mild in 27 patients, mild to moderate in 5 patients and moderate in 1 patient), and the mean postoperative pressure gradient across PV was 13.0 ± 10.9 mmHg. The mean follow-up duration was 131.9 ± 42.9 months. During follow-up, 1 reoperation was performed for residual ventricular septal defect. The mean PR grade at the last follow-up echocardiography was 1.59 ± 0.60 (mild in 17 patients, mild to moderate in 8 patients, moderate in 14 patients, moderate to severe in 1 patient and severe in 3 patients), and the mean pressure gradient was 22.7 ± 9.9 mmHg. We have compared the incidence of moderate or more PR with the incidence of patients who underwent simple transannular patch enlargement through propensity score matching. The PV repair group had a lower incidence of moderate or more PR compared with the simple transannular patch group (40% vs 68%, P = 0.04). PV annular enlargement with valve repair has reasonable long-term results and yields a lower long-term incidence of significant PR compared with the simple transannular patch enlargement technique.

Annulus-Sparing Tetralogy of Fallot Repair: Low Risk and Benefits to Right Ventricular Geometry

Annulus-sparing repair of tetralogy of Fallot (TOF) carries a potential increased risk of reoperation for restenosis and unproven benefits on right ventricular (RV) geometry. Primary TOF repairs (n= 434) between 2000 and 2012 were studied using risk-adjusted parametric techniques. Progression of cardiac dimensions was analyzed using repeated measures regression using reports of all 2,103 echocardiograms undertaken throughout the study period, to a maximum follow-up of 13.7 years. Repair was at a mean age of 180 days: AS approach in 296 (68%) patients; and transannular patch in 138 (32%). Intraoperative revisions (for residual stenosis) were required in 135 patients (29%). There have been 4 deaths (survival 99%). Surgical reoperation for recurrent right ventricular outflow tract stenosis was occasionally required in both groups at comparable rates (transannular patch, 5 of 136 [4%]; annulus-sparing repair, 14 of 296 [5%]; p= 0.83). Larger increases in RV end-diastolic dimensions were evident in transannular patch patients versus annulus-sparing repair patients (p < 0.0001). Other risks for RV dilation included worse grade of postoperative pulmonary regurgitation, larger right ventricular end-diastolic dimension at the time of diagnosis, and higher operative weight (all p < 0.0001). Factors associated with successful annulus-sparing repair included (1) pulmonary annulus greater than 7 mm, right ventricular end-diastolic dimension greater than 1.2 cm, and tricuspid annulus greater than 1.4 cm (all preoperatively); and (2) right ventricular outflow tract diameter greater than 10 mm and right ventricular systolic pressure less than 50 mm Hg (both intraoperatively after repair). Pursuit of annulus-sparing repair strategies can lower the use of transannular patch to approximately 30% with low risk of reoperation for the patient. Annulus-sparing repair is associated with significantly reduced long-term RV dilation. Pulmonary valve enlargement to approximately 10 mm and right ventricular systolic pressure less than 50 mm Hg during annulus-sparing repair are associated with low risk of recurrent stenosis.

An audit of surgical repair of Tetralogy of Fallot in an African tertiary care centre

Background: For patients undergoing Tetralogy of Fallot (TOF) repair at institutions in sub-Saharan Africa, data on type of surgical repair, operative mortality and important determinants of outcome such as age at operation and development of pulmonary regurgitation (PR) post-repair is scanty. Objective: To describe the outcomes of children diagnosed with TOF who underwent surgical repair at our center with emphasis on post-operative PR. Methods: This was a retrospective cohort study undertaken from 1 January 1994 to 31 December 2003 at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). The descriptive analysis of the clinical audit was done in 2010. Results: Fifty four (75%) patients were operated upon: 50 (92.5%) had complete repair and 4 (7.4%) had a palliative procedure in the form of a Blalock-Taussig (B-T) shunt. The median age for corrective surgery was 39.5 months. Twenty out of 50 (40%) patients had simple repair, 10 (20%) had repair which included pulmonary valvotomy, 15 (30%) had a transannular patch (TAP) repair with or without monocusp and 5 (10%) had conduit insertion. An evaluation of severe PR among all the repair groups in the immediate post-operative period ( 5 years), severe PR was documented in 3 (30%) patients with pulmonary valvotomy, 8 (53%) who had TAP repair, 2 (10%) patients with simple repair including 1 (20%) patient with a xenograft conduit. One out of 50 (2%) surgically corrected patients who had a complex anatomy died in the immediate post-operative period. Twenty eight out of 50 (56%) patients who had complete correction were lost to follow-up. Conclusion: Surgical correction occurs much later in infancy and childhood compared to developed countries. Severe PR is a serious complication strongly associated with all types of surgical repair of TOF and these patients require lifelong follow-up. Despite the small sample size, the operative mortality compares favourably to fi rst world centers.

Transcatheter Pulmonary Valve Replacement Reduces Tricuspid Regurgitation in Patients With Right Ventricular Volume/Pressure Overload

BackgroundTricuspid regurgitation (TR) is a common and important comorbidity in patients with postoperative right ventricular outflow tract (RVOT) obstruction or pulmonary regurgitation (PR). Transcatheter pulmonary valve replacement (TPVR) has become a useful tool in the management of postoperative RVOT obstruction and PR, but it is unknown whether relief of the right ventricular volume and/or pressure overload by TPVR will have a beneficial effect on TR, as is often seen with surgical pulmonary valve replacement. ObjectivesThis study sought to assess the prevalence of and factors associated with significant TR in patients undergoing TPVR for RVOT obstruction or PR. MethodsData were combined from 3 prospective multicenter trials of patients referred for TPVR. Follow-up data through 5 years post-implantation were analyzed. ResultsOf 300 patients studied, 77 (25.6%) had moderate or severe TR at baseline. After TPVR, TR severity was improved in 65% of those patients, and more than one-half had mild TR or less TR at discharge. Of 13 patients with severe TR pre-implantation, only 1 had severe TR at 1-year follow-up and beyond. Moderate or severe baseline TR was associated with shorter freedom from RVOT reintervention after TPVR. ConclusionsIn this prospective multicenter study of post-operative patients with RVOT obstruction and/or PR, TR was common. In patients with significant baseline TR, TPVR resulted in clinically relevant acute reductions in TR that persisted over at least 5 years of follow-up. These observations support the application of TPVR therapy in patients with RVOT obstruction or PR who are anatomically suitable, even in the setting of significant concomitant TR.

Individualised prediction of pulmonary homograft durability in tetralogy of Fallot

BackgroundIn patients with repaired tetralogy of Fallot (rTOF), multiple reoperations or percutaneous interventions after pulmonary valve replacement (PVR) may be necessary due to limited homograft durability. However, data to guide...

Pulmonary Annulus Growth After the Modified Blalock-Taussig Shunt in Tetralogy of Fallot

In tetralogy of Fallot (TOF), it is well known that postoperative pulmonary regurgitation reduces right ventricular function during long-term follow-up. Complete repair without a transannular patch should help avoid pulmonary regurgitation. Recently, primary complete repair has been preferred to the staged repair with use of a Blalock-Taussig shunt (BTS) even in neonates or small infants; however, little has been reported about the influence of a BTS on pulmonary annular growth. We examined 40 patients with TOF or double-outlet right ventricle with pulmonary stenosis. Twenty-one patients received a BTS before complete repair, whereas 19 patients underwent primary complete repair. Pulmonary annular size was measured by echocardiography before BTS, complete repair, or both, and ventricular volume was measured by cardiac catheterization. There were no significant differences in complete repair age or body size between the groups. Pulmonary annulus sizes in the BTS group were smaller than those in the primary repair group (Z score, -5.1 ± 2.5 vs -3.7 ± 1.8). After the BTS, significant annular growth (Z score, -2.8 ± 2.1) was observed (p = 0.0028), with a significant increase in left ventricular end-diastolic volume (p = 0.015). When patients with severe pulmonary stenosis (Z score > -7.0) were excluded, pulmonary annular preservation at complete repair was achieved in 64.7% (11/17) of the BTS group and 36.8% (7/19) of the primary repair group (p = 0.088). The BTS increased the pulmonary annular size and the left ventricular volume during the 6 months before complete repair, resulting in preservation of the pulmonary valve function.

Long-term outcome of correction of tetralogy of Fallot in 56 adult patients

Background Although most patients with tetralogy of Fallot undergo radical repair during infancy and childhood, patients that remain undiagnosed and untreated until adulthood can still be treated. This study aimed to evaluate long-term outcomes of adult patients with tetralogy of Fallot who were treated surgically, and to determine the predictors of postoperative pulmonary regurgitation. Methods Fifty-six adult patients underwent complete surgical repair. Forty-three patients (76.8%) required a transannular patch. Systolic, diastolic, and mean pressure in the main pulmonary artery were measured after repair. Results The early mortality rate was 3.6%. The 16-year survival rate was (84.4±11.5)%. Late echocardiography revealed 41 patients with transannular patch who had pulmonary regurgitation, consisting of mild pulmonary regurgitation in 28 patients, moderate in eight, and severe regurgitation in five patients. In addition, there was right ventricular outflow tract stenosis in nine patients, moderate/severe tricuspid valve regurgitation in seven, and residual ventricular septal defect in five. Logistic regression analysis demonstrated that the mean pulmonary pressure measured just after repair predicted late pulmonary regurgitation. Conclusions The long-term survival of surgically treated adult patients with tetralogy of Fallot is acceptable. The mean pressure &gt;20 mmHg in the main pulmonary artery measured right after surgical repair may be a feasible reference to time the reconstruction of the pulmonary valve.

Abstract 19356: Pulmonary Valve Replacement Can be Delayed in Repaired Tetralogy of Fallot Patients with Preserved RVEF

BACKGROUND Surgical pulmonary valve replacement (PVR) is common in repaired Tetrology of Fallot. PVR is indicated for right ventricle (RV) remodeling. Previous studies have found that RV size normalization is rare in larger RVs that exceed RV end-diastolic volume (RVEDV) 160 mL/m2. METHODS A retrospective chart review was conducted in patients &gt; 18 years who had PVR at our institution from 2000-2011. Demographic and clinical data, pre and post-operative MRI, and ECG, were collected. RESULTS 19 patients were included. Average age was 24.9 years (range 18-44y). Average age at PVR was 20.3 years (range 12-40y). Only 2 patients had a pre-operative RVEDV &lt; 160 mL/m2, with one patient whose RVEDV normalized ( 160 mL/m2 normalized RVEDV following PVR. All 4 patients without significant post-operative pulmonary regurgitation and preserved RVEF normalized. All had pre-operative RVEDVs &gt; 160 mL/m2, with three &gt;190 mL/m2. Table 1 shows, overall RV volume and function improved significantly following PVR while QRS duration remained unchanged by paired t-test. CONCLUSION In contrast to prior studies, delaying PVR in patients with preserved RVEF may be a reasonable management strategy. Our findings suggest that in patients with preserved RVEF, PVR can be delayed until the RVEDV reaches 190mL/m2. In patients with preserved RVEF, PVR with RVEDV &lt; 160 mL/m2 may not be warranted.

Transpulmonary arterial repair of type 1 ventricular septal defect will induce pulmonary regurgitation: Appraisal of subpulmonic approach

A transpulmonary arterial approach to repair type I ventricular septal defect is the standard. However, the possible adverse effect on the pulmonary valve by this technique has not been investigated. A retrospective study reviewing type I ventricular septal defect repair from January 1991 to May 2010 was conducted. Of the 142 cases, the ventricular septal defect was repaired via the transpulmonary arterial route in 77 patients (54.2%, PA group) and via the subpulmonic route in 65 patients (45.8%, SP group). All patients received serial annual transthoracic color Doppler echocardiographic evaluation of pulmonary valve function. The age at operation ranged from 1.2 to 272 months (median, 35.0 months; mean, 50.4 months). The mean follow-up period was 96.2 months (range, 2-234 months). Between the PA and SP groups, there was no significant difference in age, body weight, ventricular septal defect size, left to right shunt amount, mean pulmonary arterial pressure, and preoperative pulmonary stenosis or regurgitation. Postoperatively, there was no significant difference in the ejection fraction or incidence of residual ventricular septal defect, right bundle branch block, and pulmonary stenosis. However, the incidence of postoperative pulmonary regurgitation of more than moderate and the total scale of postoperative pulmonary regurgitation were both significantly higher in the PA group (16.9% vs 4.6% and 1.7 ± 0.1 vs 1.4 ± 0.1, P=.031 and .019, respectively). Although the transpulmonary arterial approach for type I ventricular septal defect repair has been advocated for decades, considering the adverse effect on pulmonary valve competency, the subpulmonic approach may be an alternative.

Correction of tetralogy of Fallot in an adult using a stented bioprosthetic valved conduit

A 55-year-old man with tetralogy of Fallot successfully underwent correction using a valved conduit. He was diagnosed as having congenital heart disease during childhood, but no surgical intervention was performed. Cyanosis and dyspnea on effort had progressed gradually. Catheterization showed a left ventricular end diastolic volume of 126 ml, and the pulmonary arteries had sufficient diameters. To prevent postoperative pulmonary regurgitation, we planned to use a bioprosthetic valved conduit for right ventricular outflow tract reconstruction. At 4.5 years after the operation he is in New York Heart Association functional class I. The catheterization performed 1.5 years after the surgery showed no pressure gradient between the right ventricle and the pulmonary artery. Thus, total correction of tetralogy of Fallot in an adult can be achieved safely, and the use of a bioprosthetic stented valved conduit can be beneficial.

Double-barrel Damus–Kaye–Stansel operation is better than end-to-side Damus–Kaye–Stansel operation for preserving the pulmonary valve function: The importance of preserving the shape of the pulmonary sinus

The Damus-Kaye-Stansel operation sometimes results in deteriorating semilunar valve insufficiency. We verified the semilunar valve function after the Damus-Kaye-Stansel operation and compared the end-to-side Damus-Kaye-Stansel with the double-barrel Damus-Kaye-Stansel. Forty-seven patients who underwent the Damus-Kaye-Stansel operation between June 1993 and August 2008 were retrospectively reviewed. Any patient who underwent a Norwood-type operation was excluded. The median age at operation was 19 months (range, 0-276 months). Forty-five patients were Fontan candidates. Thirty-nine patients underwent pulmonary artery banding before the Damus-Kaye-Stansel operation. Twenty-two patients had undergone an arch repair previously. The semilunar valve function was evaluated by echocardiography. Thirteen patients underwent the end-to-side Damus-Kaye-Stansel operation, and 34 patients underwent the double-barrel Damus-Kaye-Stansel operation. The mean follow-up period was 71 ± 50 months (range, 1-188 months). Although there were 4 deaths, no death was related to the Damus-Kaye-Stansel procedure. Two of the patients with early death could not undergo a postoperative evaluation of the semilunar valves. The semilunar valve regurgitation mildly deteriorated in 7 patients (pulmonary regurgitation in 5 patients and aortic regurgitation in 2 patients). Pulmonary regurgitation deteriorated from none to mild in 1 patient, none to trivial in 2 patients, and trivial to mild in 2 patients. Both deteriorations in aortic regurgitation ranged from none to trivial. Semilunar valve regurgitation did not affect patients' circulatory condition. The end-to-side Damus-Kaye-Stansel operation more frequently caused a deterioration in pulmonary regurgitation than the double-barrel Damus-Kaye-Stansel operation (4/11 vs 1/34, P = .001). No surgical intervention for a systemic ventricular outflow obstruction was observed in the follow-up period. The double-barrel Damus-Kaye-Stansel operation was found to be superior to the end-to-side Damus-Kaye-Stansel operation for the prevention of postoperative pulmonary regurgitation.

Synergistic interaction between right ventricular mechanical dyssynchrony and pulmonary regurgitation determines early outcome following tetralogy of Fallot repair☆

The ability of the right ventricle to tolerate acute pulmonary regurgitation (PR) following tetralogy of Fallot (TOF) repair is variable and the mechanisms that underlie this are not completely understood. We hypothesise that dyssynchronous wall mechanics affects the RV tolerance to postoperative PR with adverse effect on early surgical outcome. Twenty-four TOFs (mean age 19.5+/-15.5 months) undergoing elective repair were prospectively recruited. Ventricular wall mechanics was studied by tissue Doppler echocardiography following induction (preop) and postoperative day one (POD1) and compared with a control group (10 VSD/AVSD). Segmental dyssynchrony, defined as out-of-phase peak myocardial contraction, was determined at the base, mid, apical segments of the septum, RV and LV free walls and scored by the total number of affected segments. PR was graded from absent to severe and RV dimension was quantified by end-diastolic area index (RVEDAI). Cardiac index (CI) was measured by pulse contour cardiac output analysis. Outcome measures were CI, mixed venous oxygen saturation (SvO2), lactate, and duration of ventilation and critical care stay. Preoperatively, biventricular free-wall motion was synchronous in both groups. Following surgery, TOF developed RV-septal dyssynchrony (>2 segments in 11 (46%) vs none in control, p=0.01), while the LV free wall remained normal in both groups. RV-septal dyssynchrony correlated with the ventilation time (rho=0.69, p=0.003), critical care stay (rho=0.58, p=0.02) in the presence of PR (n=16), but not with other outcome measures. The relationships between dyssynchrony and early outcome were not seen when PR was absent. In the presence of PR, median RVEDAI was greater with higher dyssynchrony score (>3 segments; p=0.009). The degree of PR did not affect critical care/ventilation time or RVEDAI. The presence of transannular patch (p=0.007) or at least moderate PR (p=0.01) was associated with a more severe dyssynchrony. Dyssynchronous RV-septal wall mechanics occurs early after Fallot repair. The magnitude of dyssynchrony appears to interact synergistically with pulmonary regurgitation to influence RV dimension and early outcome.

Evaluation of postoperative pulmonary regurgitation after surgical repair of tetralogy of Fallot: Comparison between Doppler echocardiography and MR velocity mapping

Evaluation of postoperative pulmonary regurgitation after surgical repair of tetralogy of Fallot: Comparison between Doppler echocardiography and MR velocity mapping

1064 Evaluation of postoperative pulmonary regurgitation after surgical repair of tetralogy of Fallot: comparison between Doppler-echocardiography and MR velocity mapping

Background Pulmonary regurgitation is a common finding in patients after correction of tetralogy of Fallot (TOF). Right ventricular impairment and even ventricular arrhythmia have been ascribed to pulmonary valve insufficiency (PI), which is therefore an important issue in follow-up examinations.

Restrictive enlargement of the pulmonary annulus at surgical repair of tetralogy of Fallot: 10-year experience with a uniform surgical strategy

Retrospective data suggest that a wide pulmonary annulus after Fallot repair aggravates pulmonary regurgitation. Therefore, since 1997, in our institution transannular patch enlargement was only intended for patients with a native pulmonary annulus z-score less than -4. If transannular patching was needed, enlargement was aimed to diameters within the range of a z-score of -2. We sought to determine whether this strategy of restrictive enlargement of the pulmonary annulus was adequate to reduce transannular patch rate and to limit pulmonary annulus width without increased right ventricular pressure load. Two-hundred-and-sixteen Fallot patients were retrospectively analysed. Ninety-eight patients underwent repair between 1997 and 2006 adhering to our uniform strategy (Group 1). One hundred and eighteen patients were operated between 1977 and 1996 without a uniform strategy (Group 2). Transannular patch rate, native and postoperative pulmonary annulus z-score, postoperative right ventricular outflow tract velocity on echocardiography and early reoperation rate for right ventricular outflow tract obstruction were analysed in both groups. Compared to Group 2, patients in Group 1 were younger at repair, transannular patch rate was significantly reduced (32 vs 68%, p<0.0001) and postoperative pulmonary annulus diameters were smaller (z-score -2.1+/-1.5 vs 0.0+/-3.1, p<0.0001). However, no difference in right ventricular outflow tract velocity (2.4+/-0.8 vs 2.2+/-0.8m/s; p=NS) or the incidence of early reoperation for right ventricular outflow tract obstruction was found between the groups (3/98 vs 1/118; p=NS). Restrictive enlargement of the pulmonary annulus at Fallot repair lowers transannular patch rate, limits the postoperative width of the pulmonary annulus but does not result in increased right ventricular pressure load or reoperation rate for residual right ventricular outflow tract obstruction. A limitation of postoperative pulmonary regurgitation can be expected when the extent of pulmonary annulus enlargement at repair is limited.

Evaluation of postoperative pulmonary regurgitation after surgical repair of tetralogy of Fallot: comparison between Doppler echocardiography and MR velocity mapping

Pulmonary regurgitation is a common finding in patients after correction of tetralogy of Fallot (TOF). Right ventricular impairment and even ventricular arrhythmia have been ascribed to pulmonary valve insufficiency (PI), which is therefore an important issue in follow-up examinations. To compare PI measured by echocardiography (ECHO) with data provided by cardiac MRI (CMR). We studied 54 selected patients (18 female; median age 14.0 years, range 3.8-53.4 years) after surgical correction of TOF. To quantify pulmonary regurgitant fraction (PRF) by CMR, flow velocity mapping was performed. On Doppler ECHO, length, width and localization of regurgitant flow was measured. The severity of PI was categorized as mild, moderate or severe and compared to the data obtained by CMR. On CMR the mean PRF was 29.2 +/- 13.4%. Patients with a transannular patch had a significantly higher PRF (39.9 +/- 11.6%) than patients with an intact annular ring (23.6 +/- 11.4%). Differentiation by Doppler ECHO between the categories mild, moderate and severe PI was confirmed by significant differences in PRF measured by CMR (mild vs. moderate P < 0.04; moderate vs. severe P < 0.014; mild vs. severe P < 0.001). Furthermore, PRF correlated with right ventricular end diastolic volume index (r = 0.45, P < 0.01) and right ventricular end systolic volume index (r = 0.39, P < 0.01). Doppler ECHO can estimate the severity of PI after repair of TOF with acceptable results compared to CMR flow measurement. In univariate analysis there is only a weak influence of PRF on right ventricular volume.

Early and mid-term results of pulmonary valve reconstruction in surgical repair of tetralogy of Fallot; comparison with other techniques of right ventricular outflow reconstruction

Purpose : The purpose of this study is to determine whether the new pulmonary valve reconstruction technique prevents short-term postoperative pulmonary regurgitation and improves early and mid-term clinical outcome. Methods : We reviewed postoperative echocardiographic variables and chest X-ray films from 31 patients who had undergone valve reconstruction(pulmonary valve reconstruction group : PVR) for the repair of TOF between April 2000 and August 2004. We compared the clinical data of these patients with those from 47 patients who had right ventricular outflow tract reconstruction with a monocusp valve(monocusp ventricular outflow patch group : MVOP) and 22 patients who had a transannular patch repair without a monocusp valve(transannular patch group : TAP). Results : In the PVR group, 25 patients(81 percent) had trivial or mild pulmonary regurgitation in their early post operative echocardiogram. Only 12 patients(26 percent) in the MVOP group had mild pulmonary regurgitation; and no patient in the TAP group had it. Pulmonary valve function was good in 96 percent of the PVR group, 36 percent of the MVOP group, and none in the TAP group in early post-operative echocardiogram. Follow-up echocardiogram(1, 2, 3, 4 years later) of the MVOP and TAP groups showed moderate pulmonary regurgitation and severely decreased valve function in almost all cases. However, in the PVR group 54 percent(16/28), 50 percent(14/28), 37 percent(9/24), and 31 percent(5/16) of the patients had trivial or mild pulmonary regurgitation 1, 2, 3 and 4 years after operation, respectively. The valve function remained good in 80 percent(24/30), 64 percent(18/28), 57 percent(12/21), and 31 percent(5/16) of the patients 1, 2, 3 and 4 years after operation respectively. Conclusion : Pulmonary valve reconstruction is effective in reducing pulmonary regurgitation and right ventricular dilatation in the repair of TOF, even though regurgitation increases with time. Further study is needed to determine long-term results. (Korean J Pediatr 2006;49:635-642)