Congenital: Pulmonary Valve
Secondary repair of incompetent pulmonary valves after previous surgery or intervention: Patient selection and outcomes

https://doi.org/10.1016/j.jtcvs.2019.06.110Get rights and content
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Abstract

Objectives

Pulmonary valve (PV) regurgitation (PR) is common after intervention for a hypoplastic right ventricular outflow tract. Secondary PV repair is an alternative to replacement (PVR), but selection criteria are not established. We sought to elucidate preoperative variables associated with successful PV repair and to compare outcomes between repair and PVR.

Methods

Patients who underwent surgery for secondary PR from 2010 to 2017 by a single surgeon were studied. The PV annulus and leaflets were measured on the preoperative echocardiogram and magnetic resonance images, and the primary predictor variable was leaflet area indexed to ideal PV annulus area (iPLA) by magnetic resonance imaging. PV repair and PVR groups were compared using multivariable logistic regression, and with a conditional inference tree. Freedom from PV dysfunction and from reintervention were assessed with Kaplan–Meier survival analyses.

Results

Of 85 patients, 31 (36%) underwent PV repair. By multivariable analysis, longer PV total leaflet length (cm/m2) (β = 3.00, standard error [SE] = 0.82, P < .001), larger PV z score (β = 1.34, SE = 0.39, P = .001), and larger iPLA (β = 8.13, SE = 2.62, P = .002) were associated with repair. iPLA of 0.90 or greater was 91% sensitive and 83% specific for achieving PV repair. At a median of 4.1 years follow-up, there was greater freedom from significant PR in the PV repair group (log rank P = .008).

Conclusions

Patients with an iPLA >0.9, and those with an iPLA between 0.7 and 0.9 with a PV annulus z score >0 should be considered for a native PV repair. At midterm follow-up, patients with a PV repair were not more likely to develop PR or to require reintervention when compared with patients undergoing PVR.

Graphical abstract

iPLA is the total pulmonary valve leaflet area divided by the ideal pulmonary valve annulus area (z score of 0). In this study, measures of PV leaflet tissue such as iPLA were associated with achieving native secondary PV repair. Over the follow-up period of this study, PV repair outcomes compared favorably to PVR. PR, Pulmonary regurgitation; PV, pulmonary valve; iPLA, indexed pulmonary valve leaflet area; PVR, pulmonary valve replacement.

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Key Words

pulmonary valve
valve repair
tetralogy of Fallot
magnetic resonance imaging
echocardiography
outcomes

Abbreviations and Acronyms

BSA
body surface area
iPLA
indexed pulmonary valve leaflet area
MRI
magnetic resonance imaging
PR
pulmonary valve regurgitation
PS
pulmonary stenosis
PV
pulmonary valve
PVR
pulmonary valve replacement
ROC
receiver operating characteristic
RVOT
right ventricular outflow tract
TAP
transannular patch
TEE
transesophageal echocardiogram
TOF
tetralogy of Fallot
TTE
transthoracic echocardiogram

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