Original article
Cardiovascular
Tetralogy of Fallot: Results of a Pulmonary Valve-Sparing Strategy

Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.
https://doi.org/10.1016/j.athoracsur.2005.04.016Get rights and content

Background

Our surgical strategy for repair of tetralogy of Fallot has focused on preserving the pulmonary valve. The purpose of this review was to identify pulmonary valve characteristics that mark the limits of this strategy.

Methods

From 1997 through 2004, 102 consecutive patients underwent repair of tetralogy of Fallot at a median age of 5.9 months. Twenty-five patients had a prior shunt. Eighty-two patients (80%) had pulmonary valve-sparing procedures, predominantly through a transatrial and transpulmonary approach (n = 52). Twenty patients had a transannular patch (20%). Intraoperative measurements included the pulmonary valve annulus size and the postoperative pressure ratio between the right and left ventricles.

Results

Eighty of 85 (94%) patients with z-score greater than −4 had a pulmonary valve-sparing procedure compared with 2 of 17 patients (12%) with pulmonary valve annulus z-scores less than −4 (p < 0.0001). All patients with a tricuspid pulmonary valve (n = 26) had a pulmonary valve-sparing procedure compared with 56 of 76 (74%) patients with a bicuspid pulmonary valve (p = 0.0016). Five patients with initial pulmonary valve-sparing operations required reoperation for residual stenoses; 4 pulmonary valve-sparing right ventricular outflow tract resections and 1 transannular patch. The only death occurred after reoperation elsewhere. Three of 9 patients (33%) who had a postoperative pressure ratio between the right and left ventricles greater than 0.7 after their initial pulmonary valve-sparing procedure required reoperation compared with 2 of 73 with postoperative pressure ratio between the right and left ventricles less than 0.7 (3%; p = 0.008). Fifteen of 25 patients (60%) with prior shunts had pulmonary valve-sparing procedures.

Conclusions

A pulmonary valve-sparing approach to the repair of tetralogy of Fallot was applied successfully in 80% of patients. Significant markers for success were a measured pulmonary annulus z-score of −4 or larger, a tricuspid pulmonary valve, and a postoperative pressure ratio between the right and left ventricles less than 0.7.

Section snippets

Patients and Methods

Institutional review board approval was obtained for this study.

All patients undergoing repair of TOF between January 1997 and July 2004 at our institution were identified from our computerized patient database. Patients with prior complete repair, TOF with pulmonary atresia, TOF with absent pulmonary valve, and TOF with atrioventricular canal defects were excluded.

Reparative techniques were similar for all patients and included aorto–bicaval cardiopulmonary bypass with moderate hypothermia

Results

There were 102 patients with TOF with pulmonary stenosis repaired during the study period. There were no perioperative deaths. One infant who required reoperation died after surgical revision at another hospital 5 months after the initial procedure. Twenty-five patients had prior systemic-to-pulmonary artery shunts (25%) at a median age of 36 days and a mean weight of 3.5 ± 2.0 kg. There were no deaths among the patients who had a shunt, although 1 patient had a cardiac arrest after a shunt

Comment

This series of patients with TOF with pulmonary stenosis demonstrates that an aggressive approach to subvalvar and supravalvar obstruction with pulmonary valvuloplasty can lead to a very low rate of transannular patching. The pulmonary valve salvage rate of 80% may indeed be an underestimate owing to our experience with the monocusp valve insertion during the first 15 months of this study period. The effort to salvage the pulmonary valve was perhaps less aggressive with the thought of

References (31)

Cited by (151)

View all citing articles on Scopus
View full text