Pulmonary valve replacement in adults late after repair of tetralogy of Fallot: are we operating too late?

BJECTIVES The purpose of this study is to evaluate right ventricular (RV) volume and function after pulmonary valve replacement (PVR) and to address the issue of optimal surgical timing in these patients. BACKGROUND Chronic pulmonary regurgitation (PR) following repair of tetralogy of Fallot (TOF) leads to RV dilation and an increased incidence of sudden cardiac death in adult patients. METHODS We studied 25 consecutive adult patients who underwent PVR for significant PR late after repair of TOF. Radionuclide angiography was performed in all at a mean of 8.2 months (± 8 months) before PVR and repeated at a mean of 28.0 months (± 22.8 months) after the operation. Right ventricular (RV) end-systolic volume (RVESV), RV end-diastolic volume (RVEDV) and RV ejection fraction (RVEF) were measured. RESULTS Mean RVEDV, RVESV and RVEF remained unchanged after PVR (227.1 ml versus 214.9 ml, P = 0.74; 157.4 ml versus 155.4 ml, P = 0.94; 35.6% versus 34.7%, P = 0.78, respectively). Of the 10 patients with RVEF ≥ 0.40 before PVR, 5 patients (50%) maintained a RVEF ≥ 0.40 following PVR, whereas only 2 out of 15 patients (13%) with pre-operative values <0.40 reached an RVEF ≥ 0.40 postoperatively (p < 0.001). CONCLUSIONS Right ventricular recovery following PVR for chronic significant pulmonary regurgitation after repair of TOF may be compromised in the adult population. In order to maintain adequate RV contractility, pulmonary valve implant in these patients should be considered before RV function deteriorates.