Interact CardioVasc Thorac Surg 2009;9:520-527. doi:10.1510/icvts.2009.211011
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Congenital |
Does pulmonary valve replacement post repair of tetralogy of Fallot improve right ventricular function?
Louise Adamson,
Hunaid A. Vohra and
Marcus P. Haw*
Department of Cardiothoracic Surgery, Southampton General Hospital, Southampton, UK
Received 4 May 2009;
received in revised form 4 June 2009;
accepted 12 June 2009
*Corresponding author. Department of Paediatric Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Road, Southampton, UK. Tel.: +44 2380 777222; fax: +44 2380 794526.
E-mail address: Marcus.Haw{at}suht.swest.nhs.uk (M.P. Haw).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether pulmonary valve replacement (PVR) after repair of tetralogy of Fallot improved outcomes including right ventricular (RV) function. Altogether 730 relevant papers were identified using the below mentioned search, 19 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that PVR after tetralogy of Fallot repair has been shown to improve RV function and to offer symptomatic benefit. Several retrospective reviews report consistent reductions in RV end diastolic and systolic volumes and improvement in RV stroke volume, with one study also finding improvement in left ventricular stroke volume. PVR in this population appears to result in improved clinical outcome and can be performed with low mortality.
Key Words: Pulmonary valve replacement; Tetralogy of Fallot; Cardiac surgery; Right ventricular function; Evidence based medicine; Review
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
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2. Clinical scenario
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A 16-year-old boy is referred to your clinic by the paediatric cardiologists. He had previously undergone repair of tetralogy of Fallot aged 8 and is now noticing symptoms of reduced exercise tolerance. A recent echocardiogram revealed a dilated right ventricle and moderate pulmonary valve regurgitation. The cardiologist has just attended a national conference and has heard that in some cases timely pulmonary valve replacement (PVR) in Fallot patients can improve right ventricular (RV) dimensions and function resulting in improved symptoms. He wonders whether this patient would benefit from PVR. You discuss the case with your consultant who asks you to check the literature.
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3. Three-part question
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In [patients who have undergone repair of tetralogy of Fallot] does [pulmonary valve replacement] result in improvement in [outcome]?
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4. Search strategy
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Medline 1950 to May 2009 using the OvidSP interface. [Pulmonary regurgitation.mp OR pulmonary valve.mp OR exp pulmonary valve/] AND [tetralogy.mp OR fallot$.mp OR exp tetralogy of fallot/] AND [exp Thoracic surgery/OR exp Surgical Procedures, Operative/OR Thoracic surgery.mp OR cardiac surgery.mp OR replacement.mp]. In addition, the reference lists of all relevant papers were searched.
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5. Search outcome
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A total of 730 relevant papers were found from which 19 papers were selected as representing the best evidence on this topic (Table 1).
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6. Comments
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Nineteen clinical studies were found in 1070 patients. The studies reviewed the operative outcomes in patients with previous complete repair of tetralogy of Fallot undergoing PVR.
In a retrospective study by Discigil et al. [2], 42 patients underwent late PVR a mean of 10.8 years after complete repair of tetralogy of Fallot. They found a significant improvement in functional class and in RV function as well as effective control of arrhythmias and concluded that PVR can be performed with low mortality.
In a multicentre study, Graham et al. [3] reviewed 93 adult patients undergoing PVR after TOF repair with regard to mortality, RV size, function, ability index, clinical heart failure status and arrhythmia. They reported two deaths at 6 and 12 months after PVR, and no improvement in arrhythmia occurrence. Systolic RV function increased in only 36% which was not statistically significant. They did, however, demonstrate decreased RV size on echocardiogram following PVR as well as improved ability index and heart failure status.
Frigiola et al. [4] investigated 36 patients undergoing either PVR or percutaneous pulmonary valve implantation (PPVI) and found significant improvement in RV end diastolic volume (EDV), RV end systolic volume (ESV) and RV effective stroke volume. They also reported a significant increase in LV effective stroke volume following both types of procedure, concluding that this may be the parameter to judge procedural benefit.
Gengsakul et al. [5] performed a matched cohort study to investigate the impact of PVR on Fallot patients. They found that symptoms and functional status improved after late PVR. They reported a reduction in both pulmonary and tricuspid valve regurgitation as well as in RV size and function, however, found no significant reduction in arrhythmias although they comment that there were no sudden deaths in the PVR group. Hooft van Huysduynen et al. [6] studied cardiac magnetic resonance images and pre- and postoperative electrocardiograms on 30 Fallot patients undergoing PVR. They found reductions in RV EDV and in T-wave amplitude and area, concluding that PVR in Fallot patients with dilated right ventricles has a beneficial effect on electrocardiographic indices of repolarisation heterogeneity.
Doughan et al. [7] and van Huysduynen et al. [8] both studied groups of Fallot patients undergoing PVR with regard to RV EDV and QRS duration, finding that both were reduced postoperatively. In a study by Therrien et al. [9] reviewing 70 patients undergoing PVR late after Fallot repair, QRS duration was found to be unchanged in the study group but significantly prolonged in a comparable group of Fallot patients who had not undergone PVR. They also reported a decreased incidence of ventricular and atrial arrhythmias postoperatively.
In a cohort of 25 tetralogy of Fallot patients undergoing PVR, van Straten et al. [10] performed cardiac magnetic resonance imaging to investigate RV EDV and ejection fraction and incidence of recurrent pulmonary regurgitation. They found that RV function improves rapidly after PVR in these patients but that recurrence of pulmonary regurgitation following surgery appears to reduce recovery of systolic function.
Eyskens et al. [11] performed a matched cohort study to investigate cardiopulmonary exercise performance in PVR patients with previous Fallot repair. They concluded that aerobic capacity substantially improves after PVR as did Warner et al. [12] in their unmatched study. In a similar group of patients, Lim et al. [13] found a reduction in cardiothoracic ratio and a marked symptomatic improvement after PVR and concluded that this can be performed with low mortality and morbidity.
Cesnjevar et al. [14] investigated RV size and function after PVR in a group of long-term survivors of Fallot repair, finding a reduction in RV pressure and size postoperatively and an improvement in function with low mortality. Borowski et al. [15] reported a reduction in RV dilatation index and low mortality in their smaller study of Fallot patients undergoing PVR.
Henkens et al. [16] in their study of 27 adult Fallot patients demonstrated that PVR resulted in reduced RV ESV and improved RV ejection fraction, as did Therrien et al. [17], Kleinveld et al. [18] and Buechel et al. [19] in their similar studies of adult and paediatric patients. In a cohort study of 16 Fallot patients undergoing PVR, van Straten et al. [20] compared pre- and postoperative RV systolic and diastolic function with results from eight healthy subjects. They found a significant improvement in indexed RV ESV. They report that RV early filling volume and early filling volume/volume of atrial contraction ratio only significantly improved 22 months after PVR, at which point these parameters were not significantly different from the healthy subjects. They concluded that PVR results in late recovery of diastolic function and speculate that the more rapid improvement in systolic performance is a result of volume unloading after PVR whereas improvement in diastolic function requires long-term remodelling.
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7. Clinical bottom line
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PVR after tetralogy of Fallot repair has been shown to improve RV function and to offer symptomatic benefit. Several retrospective reviews report consistent reductions in RV end diastolic and systolic volumes and improvement in RV stroke volume, with one study also finding improvement in left ventricular stroke volume. PVR in this population appears to result in improved clinical outcome and can be performed with low mortality.
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References
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Abstract
1. Introduction