Determinants of Late Survival and Reoperation Following Bioprosthetic Pulmonary Valve Replacement in Adults with Repaired Tetralogy of Fallot
Ishan K Shah, Joseph A. Dearani, Richard C. Daly, *Sameh M. Said, Alberto Pochettino, Heidi M. Connolly, Ammash M. Naser, Roxann B. Pike, Hartzell V. Schaff
Mayo Clinic, Rochester, MN
Objectives: Pulmonary valve replacement (PVR) following complete repair of Tetralogy of Fallot (TOF) is a commonly performed adult congenital operation. Data regarding risk factors for reoperation, late survival, and the ideal bioprosthesis is lacking. We examined risk factors and late survival for bioprosthetic porcine vs. pericardial PVR.
Methods: From January 1993 to December 2015, 247 adult patients with TOF underwent bioprosthetic PVR. Concomitant procedures included ASD/PFO closure (n=89), tricuspid valve repair (n=71), atrial arrhythmia surgery (n=46), ventricular arrhythmia surgery (n=43), VSD closure (n=17) and others (n=19). Mean age at operation was 39.7 ± 13.3 years (maximum 83 years) and 126 (51%) were males. Indication for PVR was pulmonary regurgitation (PR) in 220, pulmonary stenosis (PS) in 8 and both PR/ PS in 19. The most common presenting symptoms were exercise intolerance (n=175; 71%), palpitations (n=80; 32%) and right-sided heart failure (n=38; 15%). Preoperative MRI was performed in 72 patients with a mean RVEDVI of 164.11 ± 1 .15 ml/m2 and RVEF of 42.09 ± 8.46 %.
Results: Repeat sternotomy was employed in all patients, and average period of cardiopulmonary bypass was 83.72 ± 56.0 min. 205 (83%) had a porcine valve, while 42(17%) had pericardial. Operative mortality was 1.6% (n=4), and median follow-up was 5.1 years (maximum, 21.5years). Overall survival at 5, 10 and 15 years was 94.3%, 85.8% and 82.2%, respectively, and this was significantly lower than an age-matched population (p<0.001) (figure 1). Older age at the time of PVR (HR=1.06[1.03-1.08], p<0.001), elevated preoperative pulmonary valve gradient (HR=1.03[1.01-1.05], p=0.001), higher right atrial pressure (HR=1.18[1.07-1.30], p<0.001) and higher right ventricular systolic pressure (HR=1.02[1.00-1.03], p=0.048) were risk factors for late mortality. There was no correlation between bioprosthetic valve type, size, or indexed size and late survival. The only concomitant procedure that was a risk factor for late survival was VSD repair (HR=4.38[1.74-11.01], p<0.001). Reoperation was required in 7 pts, while transcatheter valve-in-valve was performed in two. Freedom from reoperation at 5, 10 and 15 years was 99.5%, 96.5% and 86.7%, respectively. Median time to reoperation was 10.6 years (maximum, 16.1 years). There was no clear correlation between bioprosthetic valve type and subsequent need for reoperation.
Conclusion: Pulmonary valve replacement in adults with repaired TOF can be performed with low early mortality and excellent freedom from reoperation. Late survival is however reduced when compared to an age-matched population, especially in those with a concomitant VSD repair.
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