Abstract 18833: Annulus Preservation Strategy Improves Late Outcomes in Tetralogy of Fallot: An Anatomical Equivalency Study
Introduction: Late outcome of repaired TOF is driven by the impact of residual lesions. We shifted strategy from liberal transannular patch (TAP) use to aggressive valve and annulus preservation (AP) hypothesizing that for equivalent anatomy, AP would leave a mixed stenosis regurgitation lesion that would lead to a healthier right ventricle (RV).
Methods: Between 1996 and 2002, 185 children underwent TOF repair (median age 7.7 m). A regression equation for predicting annulus preservation, in the AP group, was derived from preoperative anatomic parameters and applied to all. Patients were identified (n=107) that could have had either AP or TAP on the basis of anatomical equivalency (subgroup validation with propensity matching) with 52 having a TAP and 55 having AP. These are the primary study group.
Results: Cardiac MRI at mean age 13.1±2.3 yrs (TAP n=28, AP n=23) showed AP was associated with significantly lower indexed RV end diastolic vol (AP: 120±29; TAP: 181±35 mL - Fig. 1), RV end systolic vol (AP: 57±23; TAP: 95±25 mL), RV stroke volume (AP: 64±15; TAP: 86±15 mL), MPA regurgitant fraction (AP: 28±11; TAP: 45±9 %), all p<0.0001, and LV mass (AP: 46±6; TAP: 54±8 gm/m2); p=0.001). Echo RVOT gradient was no different (AP 31 Vs TAP 25 mmHg (p=ns). MRI LVEF (AP: 57±4; TAP: 55±4 %; P=0.031) and RVEF (AP: 54±7; TAP: 48±6 %; p=0.004) was higher after AP. Freedom from surgical reintervention at 15 years was 89.3% (TAP) and 71.7% (AP , P=0.048) (Fig.2) with early reoperation for RVOTO predominating in AP and late pulmonary valve replacement most frequent in TAP. VO2 max for all AP vs TAP was higher in AP (p<0.05).
Conclusion: This is the first long-term follow-up study demonstrating that, for equivalent anatomy, an aggressive AP strategy leads to a lower reoperative incidence, less pulmonary insufficiency, smaller indexed RV volumes and better LV function as compared to a standard TAP. Surgical strategy directly impacts ventricular health and should be reflected in practice.
- Tetralogy of Fallot
- Congenital heart surgery
- Congenital heart disease
- Ventricular function
- Pediatric cardiology
Author Disclosures: P. Pondorfer: None. T. Yun: None. M. Cheung: None. D. Ashburn: None. C. Manlhiot: None. B. McCrindle: None. L. Mertens: None. L. Grosse-Wortmann: None. A. Redington: None. G. Van Arsdell: None.
- © 2014 by American Heart Association, Inc.