HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kenneth G. Warner Patrick K. H. O’Brien Douglas D. Payne Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Warner, K. G. Articles by Payne, D. D. Search for Related Content PubMed PubMed Citation Articles by Warner, K. G. Articles by Payne, D. D. Related Collections Congenital - cyanotic

Ann Thorac Surg 2003;76:1066-1071
© 2003 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Expanding the indications for pulmonary valve replacement after repair of tetralogy of fallot

^a Divisions of Cardiothoracic Surgery, Tufts-New England Medical Center and Boston Floating Hospital, Tufts University School of Medicine, Boston, Massachusetts, USA
^b division of Pediatric Cardiology, Tufts-New England Medical Center and Boston Floating Hospital, Tufts University School of Medicine, Boston, Massachusetts, USA

Accepted for publication April 17, 2003.

^* Address reprint requests to Dr Warner, Division of Cardiothoracic Surgery, New England Medical Center, Box 266, 750 Washington St, Boston, MA 02111, USA
e-mail: kwarner{at}tufts-nemc.org

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: Insertion of a competent pulmonary valve has been advocated to reduce right ventricular volume overload associated with pulmonary regurgitation (PR) after repair of tetralogy of Fallot. However the indications, proper timing, and long-term benefits of restoring pulmonary valve function remain controversial.

METHODS: Thirty-six patients (aged 15.2 ± 9.2 years) underwent pulmonary valve implantation (31 homografts, 5 heterografts) 12.2 ± 6.9 years after tetralogy repair. Additional surgical procedures included pulmonary artery augmentation (n = 14), closure of septal defects (n = 10), and cryoablation and endocardial resection of ventricular tachycardia (n = 2).

RESULTS: All patients have had clinical improvement in their exercise capacity. Preoperative and postoperative bicycle ergometry tests in 6 patients demonstrated significant improvement in the percent of predicted peak workload (68.5% ± 19.8% to 80.7% ± 17.4%, p < 0.015). One midterm death occurred in a 38-year-old patient with a history of ventricular tachycardia who died suddenly 2 years after pulmonary valve insertion. Postoperative echocardiographic measurements were available in 34 patients at a mean follow-up of 5 years. There was a 30% reduction in right ventricular end-diastolic diameter indexed to body surface area after surgery (30.1 ± 10.2 to 18.6 ± 6.0 mm/m², p < 0.0001). Two patients required conduit replacements at 1 and 9 years postoperatively.

CONCLUSIONS: Timely insertion of a competent pulmonary valve in children, adolescents, and young adults with significant PR after tetralogy of Fallot repair results in subjective and objective improvement in exercise capacity and is associated with reduction in right ventricle size.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Progressive right ventricular volume overload from longstanding pulmonary regurgitation (PR) commonly occurs after surgical repair of tetralogy of Fallot [1, 2]. The resultant dilation and stretching of the right ventricle has several deleterious effects including exercise limitation [1, 3–5], right and left ventricular dysfunction [1, 2, 6], electrocardiographic abnormalities [7, 8], and perhaps most important, the development of life-threatening atrial and ventricular arrhythmias [8, 9].

In an effort to halt the progression of right ventricular volume overload, insertion of a competent pulmonary valve has been increasingly performed in recent years in symptomatic patients [10–22]. In a previous report we demonstrated that insertion of homografts in the pulmonary position successfully decreased right ventricular volume overload in patients with PR after tetralogy of Fallot repair [12]. The long-term effects of restoring pulmonary valve competency in this patient population are unknown. Homografts placed in children and adolescents have limited durability due to the development of allograft degeneration. The uncertain longevity of valve substitutes, including homografts and heterografts, mandates close surveillance of these patients. The purpose of this study was to examine our midterm results of a surgical strategy to restore pulmonary valve function in patients with progressive right ventricular enlargement.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patient selection
This is a retrospective analysis of 36 patients undergoing pulmonary valve replacement in our institution for progressive PR after repair of tetralogy of Fallot. All patients had significant PR associated with one or more of the following criteria: (1) symptoms of diminished exercise stamina; (2) echocardiographic evidence of progressive right ventricular dilatation; (3) diminished exercise performance on a formal exercise tolerance test; or (4) symptomatic ventricular arrhythmias. Twenty-seven patients were symptomatic including 4 patients (mean age 32 years) who presented with life-threatening ventricular arrhythmias. Sustained ventricular tachycardia (VT) was documented during preoperative electrophysiologic testing in each of these 4 patients. Patient demographics for the entire study are shown in Table 1.

Cardiac catheterization data
Preoperative cardiac catheterization was performed in all patients to assess hemodynamic data and to determine the presence and the degree of pulmonary artery stenoses. Four patients underwent preoperative balloon dilatations of discrete pulmonary artery stenoses. Postoperative cardiac catheterization was performed selectively in 14 patients at a mean interval of 41.4 months. Preoperative and postoperative catheterization data are shown in Table 3.

Statistical analysis
Data are reported as mean ± SD. Continuous data were analyzed using paired and unpaired Student t tests and ² analysis was used to assess data expressed as percentages. Statistical significance was considered achieved at a p value less than 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
There was no operative mortality. Four patients sustained minor postoperative complications. There was 1 death. A 36-year-old man developed progressive PR with New York Heart Association (NYHA) class III symptoms associated with biventricular failure. He presented with a ventricular fibrillatory arrest. Preoperative electrophysiologic testing demonstrated inducible VT. Pulmonary valve replacement was performed with a bovine pericardial valve and the right pulmonary artery was augmented with a pericardial patch. Postoperative stimulation revealed noninducible ventricular tachycardia. He was treated with multiple medications for persistent right-sided congestive therapy and coumadin for chronic deep vein thrombosis. He died suddenly 2 years later. An autopsy was not performed.

The remaining 35 patients have all reported symptomatic improvement at a mean follow-up of 80.6 ± 40.3 months (range 6 to 152). The vast majority of the patients are in functional NYHA class I (Fig 1).

View larger version (26K): [in this window] [in a new window]   Fig 1. The patients are grouped according to their New York Heart Association classification status before (n = 36) and after (n = 35) surgery. The majority of patients were in class II before surgery. Virtually all patients were in class I after surgery at a mean follow-up of 81 months. (Preop = preoperative; Postop = postoperative.)

Echocardiographic measurements
Postoperative echocardiographic measurements were available in 34 patients at a mean follow-up of 59.5 ± 6.5 months. There was a significant reduction in RVEDD after pulmonary valve insertion (30.1 ± 10.2 to 18.6 ± 6.0 mm/m², p < 0.0001). Measurements of RVEDD decreased in 30 patients after surgery and increased in 4 patients (Fig 2). Moderate conduit regurgitation had developed in 2 of the 4 patients with increased RVEDD after surgery.

View larger version (21K): [in this window] [in a new window]   Fig 2. Two-dimensional echocardiographic measurements of right ventricular end diastolic dimension (RVEDD) indexed to body surface area (BSA) are shown before and after surgery at a mean follow-up (F/U) of 60 months (n = 34). There was a significant (p < 0.0001) decline in RVEDD/BSA in 30 patients (solid lines). Small increases in RVEDD/BSA were identified in 4 patients (dashed lines). (Pre-Op = preoperative.)

View larger version (40K): [in this window] [in a new window]   Fig 3. The patients were stratified according to the type of valve and the echocardiographic assessment of postoperative pulmonary regurgitation (PR). Group 1 patients (shaded bars; n = 25) had either none or mild PR. Group 2 patients (open bars; n = 9) had moderate or severe PR. Although there was a higher percentage of group 2 patients who received an aortic homograft, there was no statistical difference for the three types of valves and the degree of PR (p = not significant).

View larger version (30K): [in this window] [in a new window]   Fig 4. Echocardiographic measurements of the severity of postoperative pulmonary valve obstruction were graded as none or mild (solid bars; n = 23), moderate (open bars; n = 7), and severe (hatched bars; n = 3; see text for definitions). The amount of obstruction was similar for all three valve types.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The results from this study suggests that the early benefits of restoring pulmonary valve competency in patients with significant PR after tetralogy of Fallot repair are sustained for as long as 11 years after surgery. That was demonstrated by subjective reports of clinical improvement in nearly all of the symptomatic patients and by objective measurements of exercise endurance in the subgroup of patients who had preoperative and postoperative bicycle ergometry. The subjective and objective improvement in exercise performance was associated with a significant reduction in right ventricular end diastolic dimension.

Previous studies have also demonstrated diminution in right ventricular size after pulmonary valve insertion using other imaging techniques including chest roentgenograpy [10, 11, 14], magnetic resonance imaging [19, 20], and radionuclide imaging [10]. Echocardiographic measurements of right ventricular dimensions have been shown to be a reliable and consistent technique for assessing right ventricular dilatation [11–14]. The validity of echocardiographic assessment of right ventricular size has been confirmed in a recent study that demonstrated a strong correlation between echocardiographic measurements of RVEDD and magnetic resonance imaging derived quantification of RVEDV [26]. The magnitude of the change in right ventricular measurements after surgery in the current investigation is very similar to the findings noted in other studies [12, 14, 19] and demonstrates that the early salutary effects of PVR persists at a mean follow-up of 5 and a half years .

Although a consistent reduction in right ventricular size was noted in the majority of our patients, a reverse trend in right ventricular dimension was documented in 4 patients (Fig 2). The clinical significance of the small rise in this subgroup of patients is unclear as 3 of the 4 patients remain asymptomatic. The development of allograft regurgitation in 2 of these patients suggests that recurrent PR may have played a role in the persistence of right ventricular volume overload. The hemodynamic importance of the regurgitant load imposed by recurrent PR was also revealed by the smaller reduction in RVEDD in the group 2 patients in comparison with the group 1 patients (Table 4). It is important to realize however that despite the progression of PR in the group 2 patients, RVEDD remained significantly smaller when compared with the preoperative measurements in the majority of these patients. This finding suggests that the hemodynamic burden associated with a regurgitant allograft may be better tolerated than PR created by a patulous and aneursymal outflow tract patch.

Although recurrent PR occurred in 25% of our patients the most common mode of conduit failure in this series was obstruction and not regurgitation of the allograft. Severe conduit obstruction requiring early reoperation and subsequently stent placement developed in two adult-size aortic homografts implanted in the same patient. The experience with this particular patient and the finding that allograft regurgitation appeared to be more prevalent in aortic homografts in our series (Fig 3) suggests that pulmonary allografts may be more durable and the preferred valve substitute for restoring pulmonary valve competency in children and adolescents [13–15, 19].

In the current series pericardial heterografts were implanted in 5 adults. Although there has been a considerable experience with this particular bioprosthesis placed in the aortic position [27] there are limited data on the durability of the Carpentier-Edwards Perimount valve as a pulmonary substitute. Based on a previous report assessing long-term follow-up of porcine heterografts [11] efforts were made to implant a large prosthesis as possible (25 to 29 mm). Although our initial experience with the pericardial tissue valve is favorable, long-term durability of this particular bioprosthetic pericardial valve in the pulmonary position awaits additional follow-up.

The only death occurred in the oldest patient in the series. Significant NYHA class III symptoms persisted in this patient despite satisfactory heterograft valve function. Other authors have also reported disappointing results in inserting a pulmonary valve in older patients [14, 16, 22], suggesting that prolonged exposure to severe PR may produce irreversible myocardial damage. The mean age at pulmonary valve insertion in our series was 15 years and is similar to recent reports from other centers [13–15, 19]. The excellent overall results documented in these studies and in our current experience suggest that significant reduction in the right ventricular dilatation occurs during childhood and adolescence in response to ventricular unloading. Conversely the beneficial effects of pulmonary valve implantation may be limited in adults as evidenced by suboptimal results in patients operated on during the fourth and fifth decades [16]. Although the proper timing for pulmonary valve insertion needs to be individualized and cannot be determined from the data provided in this series, we recommend that surgery should be strongly considered in patients with significant PR and right ventricular dilation before the third decade.

The observation that the mean age of the 4 patients in our series who presented with life-threatening arrhythmias was 32 years also illustrates the deleterious longstanding effects of right ventricular volume load on the development of ventricular arrhythmias [8, 9, 18]. Of note is that the single death occurred in the only patient in the series who did not receive either ablative therapy or an implantable cardiac defibrillator for inducible VT documented on preoperative provocative testing. Although the number of patients with symptomatic tachyarrhythmias is relatively small in our series, the excellent overall survival supports an aggressive surgical approach by unloading the right ventricle and treating symptomatic patients with either surgical or catheter ablation for identifiable arrhythmogenic sources [18]. In patients with symptomatic ventricular arrhythmias in whom a discrete electrical focus is not present, postoperative placement of an implantable cardiac defibrillator is warranted after pulmonary valve insertion [28].

The results from previous investigations and the current study suggests that timing of pulmonary valve insertion is critical in reducing right ventricular size, preserving myocardial function, and preventing the development of ventricular and atrial arrhythmias. Since the development of conduit regurgitation was associated with larger preoperative RVEDD measurements (Table 4), optimization of conduit durability mandates surgery before marked right ventricular dilatation occurs. The appropriate threshold for surgical intervention based on right ventricular enlargement cannot be established from the data in this study. However insertion of a competent pulmonary valve is strongly considered for both symptomatic and asymptomatic patients when progressive right ventricular enlargement is documented by serial echocardiograms.

Some authors have advocated that the development of tricuspid regurgitation is an indication for pulmonary valve replacement for patients with significant PR after tetralogy of Fallot repair [17]. However, in the setting of significant PR, the additional volume load associated with tricuspid regurgitation may lead to rapid deterioration in right ventricular function that may not be reversible after valve replacement. In order to optimize right ventricular unloading it has been our policy to perform pulmonary valve implantation before the onset of significant tricuspid regurgitation [12].

In summary all patients with documented PR after tetralogy of Fallot repair require close surveillance and appropriate surgical intervention. The results of this midterm analysis support an integrative surgical approach to unloading the right ventricle in patients with repaired tetralogy of Fallot. The use of a variety of surgical techniques including insertion of a competent pulmonary valve, resection of aneursymal outflow tract patches, closure of residual septal defects, and augmentation of stenotic pulmonary arteries is advocated to achieve optimal results. Patients who present with symptomatic ventricular arrhythmias should undergo provocative electrophysiolgic testing. Intraoperative endocardial mapping with cryoablation or insertion of an implantable cardiac defibrillator is advocated for those patients with sustained VT on provocative testing. In order to effectively reduce right ventricular enlargement and to prevent the onset of ventricular arrhythmias we recommend surgical intervention in both symptomatic and asymptomatic patients with severe PR before the third decade of life.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Singh G.K., Greenberg S.B., Yap Y.S., Delany D.P., Keeton B.R., Monro J.L. Right ventricular function and exercise performance late after primary repair of tetralogy of Fallot with the transannular patch in infancy. Am J Cardiol 1998;81:1378-1382.[Medline]
2. Schamberger M.S., Hurwitz R.A. Course of right and left ventricular function in patients with pulmonary insufficiency after repair of tetralogy of Fallot. Pediatr Cardiol 2000;21:244-248.[Medline]
3. Rowe S.A., Zahka K.G., Manolio T.A., Horneffer P.J., Kidd L. Lung function and pulmonary regurgitation limit exercise capacity in postoperative tetralogy of Fallot. J Am Coll Cardiol 1991;17:461-466.[Abstract]
4. Yetman A.T., Lee K., Hamilton R., Morrow W.R., McCrindle B.W. Exercise capacity after repair of tetralogy of Fallot in infancy. Am J Cardiol 2001;87:1021-1023.[Medline]
5. Carvalho J.S., Shinebourne E.A., Busst C., Rigby M.L., Redington A.N. Exercise capacity after complete repair of tetralogy of Fallot: deleterious effects of residual pulmonary regurgitation. Br Heart J 1992;67:470-473.[Abstract/Free Full Text]
6. Kondo C, Nakazawa M, Kusakabe K, Momma K. Left ventricular dysfunction on exercise long term after total repair of tetralogy of Fallot. Circulation 1995;(Suppl 2):250–5
7. Helbing W.A., Roest A.A.W., Niezen R.A., et al. ECG predictors of ventricular arrhythmias and biventricular size and wall mass in tetraolgy of Fallot with pulmonary regurgitation. Heart 2002;88:515-520.[Abstract/Free Full Text]
8. Gatzoulis M.A., Balaji S., Webber S.A., et al. Risk factors for arrhythmia and sudden death late after repair of tetralogy of Fallot: a multicentre study. Lancet 2000;356:975-981.[Medline]
9. Harrison D.A., Harris L., Siu S.C., et al. Sustained ventricular tachycardia in adult patients late after repair of tetraolgy of Fallot. J Am Coll Cardiol 1997;30:1368-1373.[Abstract]
10. Bove E.L., Kavey R.-E.W., Byrum C.J., Sondheimer H.M., Blackman M.S., Thomas F.D. Improved right ventricular function following late pulmonary valve replacement for residual pulmonary insufficiency or stenosis. J Thorac Cardiovasc Surg 1985;90:50-55.[Abstract]
11. Ilbawi M.N., Idriss F.S., DeLeon S.Y., et al. Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair: surgical implications. J Thorac Cardovasc Surg 1987;93:36-44.[Abstract]
12. Warner K.G., Anderson J.E., Fulton D.R., Payne D.D., Geggel R.L., Marx G.R. Restoration of the pulmonary valve reduces right ventricular volume overload after previous repair of tetralogy of Fallot. Circulation 1993;88:189-197.
13. d’Udekem Y, Rubay J, Shango-Lody P, et al. Late homograft valve insertion after transannular patch repair of tetralogy of Fallot. J Heart Valve Dis 1998:450–4
14. Conte S., Jashari R., Eyskens B., Gewillig M., Dumoulin M., Daenen W. Homograft valve insertion for pulmonary regurgitation late after valveless repair of right ventricular outflow tract obstruction. Eur J Cardiothorac Surg 1999;15:143-149.[Abstract/Free Full Text]
15. Eyskens B., Reybrouck T., Bogaert J., et al. Homograft insertion for pulmonary regurgitation after repair of tetralogy of Fallot improves cardiorespiratory exercise performance. Am J Cardiol 2000;85:221-225.[Medline]
16. Therrien J., Siu S.C., McLaughlin P.R., et al. Pulmonary valve replacement in adults late after repair of tetralogy of Fallot: are we operating too late ?. J Am Coll Cardiol 2000;36:1670-1675.[Abstract/Free Full Text]
17. Discigil B., Dearani J.A., Puga F.J., et al. Late pulmonary valve replacement after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2001;121:344-351.
18. Therrien J., Siu S.C., Harris L., et al. Impact of pulmonary valve replacement on arrhythmia propensity later after repair of tetralogy of Fallot. Circulation 2001;103:2489-2494.[Abstract/Free Full Text]
19. Hazekamp M.G., Kurvers M.M.J., Schoof P.H., et al. Pulmonary valve insertion late after repair of Fallot’s tetralogy. Eur J Cardiothorac Surg 2001;19:667-670.[Abstract/Free Full Text]
20. Vliegen H.W., van Straten A., de Roos A., et al. Magnetic resonance imaging to assess the hemodynamic effects of pulmonary valve replacement in adults late after repair of tetralogy of Fallot. Circulation 2002;106:1703-1707.[Abstract/Free Full Text]
21. Kanter K.R., Budde J.M., Parks J., et al. One hundred pulmonary valve replacements in children after relief of right ventricular outflow tract obstruction. Ann Thorac Surg 2002;73:1801-1807.[Abstract/Free Full Text]
22. deRuijter F.T.H., Weenink I., Hitchcock F.J., Meijboom E.J., Bennink G.B.W.E. Right ventricular dysfunction and pulmonary valve replacement after correction of tetralogy of Fallot. Ann Thorac Surg 2002;73:1794-1800.[Abstract/Free Full Text]
23. Marx G.R., Hicks R.W., Allen H.D., Goldberg S.J. Noninvasive assessment of hemodynamic responses to exercise in pulmonary regurgitation after operations to correct pulmonary outflow obstruction. Am J Cardiol 1988;61:595-601.[Medline]
24. Rhodes J., Dave A., Pulling M.C., et al. Effect of pulmonary artery stenoses on the cardiopulmonary response to exercise following repair of tetralogy of Fallot. Am J Cardiol 1998;81:1217-1219.[Medline]
25. Wasserman K., Hansen J.E., Sue D.Y., Whipp B.J., Casaburi R. Principles of exercise testing and interpretation. Malvern, PA: Lea and Febiger, 1994.
26. Wei L, Davlouros P, Gibson D, et al. Assessment of pulmonary regurgitation in adults with repaired tetralogy of Fallot-comparison between Doppler echocardiography and MRI. Circulation 2001;(Suppl 17):431–2
27. Frater R.W., Furlong P., Cosgrove D.M., et al. Long-term durability, and patient functional status of the Carpentier-Edwards Perimount pericardial bioprosthesis in the aortic position. J Heart Valve Dis 1998;7:48-53.[Medline]
28. Saul J.P., Blaufox A.D. Arrhythmia management after repair of tetralogy of Fallot: preventing sudden death. In: Gatzoulis M.A., Murphy D.J., eds. The adult with tetralogy of Fallot. Armonk, NY: Futura, 2001:61-80.

This article has been cited by other articles:

				L. Adamson, H. A. Vohra, and M. P. Haw Does pulmonary valve replacement post repair of tetralogy of Fallot improve right ventricular function? Interactive CardioVascular and Thoracic Surgery, September 1, 2009; 9(3): 520 - 527. [Abstract] [Full Text] [PDF]

				K. V Huehnergarth, M. Gurvitz, K. K Stout, and C. M Otto Repaired tetralogy of Fallot in the adult: monitoring and management Heart, December 1, 2008; 94(12): 1663 - 1669. [Full Text] [PDF]

				A. Frigiola, V. Tsang, C. Bull, L. Coats, S. Khambadkone, G. Derrick, B. Mist, F. Walker, C. van Doorn, P. Bonhoeffer, et al. Biventricular Response After Pulmonary Valve Replacement for Right Ventricular Outflow Tract Dysfunction: Is Age a Predictor of Outcome? Circulation, September 30, 2008; 118(14_suppl_1): S182 - S190. [Abstract] [Full Text] [PDF]

				A. C. Fiore, M. Rodefeld, M. Turrentine, P. Vijay, T. Reynolds, J. Standeven, K. Hill, J. Bost, D. Carpenter, C. Tobin, et al. Pulmonary Valve Replacement: A Comparison of Three Biological Valves Ann. Thorac. Surg., May 1, 2008; 85(5): 1712 - 1718. [Abstract] [Full Text] [PDF]

				J. Nordmeyer, L. Coats, P. Lurz, T.-Y. Lee, G. Derrick, P. Rees, S. Cullen, A. M. Taylor, S. Khambadkone, and P. Bonhoeffer Percutaneous pulmonary valve-in-valve implantation: a successful treatment concept for early device failure Eur. Heart J., March 3, 2008; (2008) ehn073v1. [Abstract] [Full Text] [PDF]

				A L Knauth, K Gauvreau, A J Powell, M J Landzberg, E P Walsh, J E Lock, P J d. Nido, and T Geva Ventricular size and function assessed by cardiac MRI predict major adverse clinical outcomes late after tetralogy of Fallot repair Heart, February 1, 2008; 94(2): 211 - 216. [Abstract] [Full Text] [PDF]

				F. J. Meijboom, J. W. Roos-Hesselink, J. S. McGhie, S. E.C. Spitaels, R. T. van Domburg, L. M.W.J. Utens, M. L. Simoons, and A. J.J.C. Bogers Consequences of a selective approach toward pulmonary valve replacement in adult patients with tetralogy of Fallot and pulmonary regurgitation J. Thorac. Cardiovasc. Surg., January 1, 2008; 135(1): 50 - 55. [Abstract] [Full Text] [PDF]

				A. Gengsakul, L. Harris, T. J. Bradley, G. D. Webb, W. G. Williams, S. C. Siu, N. Merchant, and B. W. McCrindle The impact of pulmonary valve replacement after tetralogy of Fallot repair: a matched comparison Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 462 - 468. [Abstract] [Full Text] [PDF]

				O. Ghez, V. T. Tsang, A. Frigiola, L. Coats, A. Taylor, C. Van Doorn, P. Bonhoeffer, and M. De Leval Right ventricular outflow tract reconstruction for pulmonary regurgitation after repair of tetralogy of Fallot.: Preliminary results Eur. J. Cardiothorac. Surg., April 1, 2007; 31(4): 654 - 658. [Abstract] [Full Text] [PDF]

				A. Dodge-Khatami, E. V. Buchel, W. Knirsch, A. Kadner, V. Rousson, H. H. Dave, U. Bauersfeld, and R. Pretre Brain natriuretic peptide and magnetic resonance imaging in tetralogy with right ventricular dilatation. Ann. Thorac. Surg., September 1, 2006; 82(3): 983 - 988. [Abstract] [Full Text] [PDF]

				E. R. V. Buechel, H. H. Dave, C. J. Kellenberger, A. Dodge-Khatami, R. Pretre, F. Berger, and U. Bauersfeld Remodelling of the right ventricle after early pulmonary valve replacement in children with repaired tetralogy of Fallot: assessment by cardiovascular magnetic resonance Eur. Heart J., December 2, 2005; 26(24): 2721 - 2727. [Abstract] [Full Text] [PDF]

				E. E. van der Wall and B. J.M. Mulder Pulmonary valve replacement in patients with tetralogy of Fallot and pulmonary regurgitation: early surgery similar to optimal timing of surgery? Eur. Heart J., December 2, 2005; 26(24): 2614 - 2615. [Full Text] [PDF]

				S. Khambadkone, L. Coats, A. Taylor, Y. Boudjemline, G. Derrick, V. Tsang, J. Cooper, V. Muthurangu, S. R. Hegde, R. S. Razavi, et al. Percutaneous Pulmonary Valve Implantation in Humans: Results in 59 Consecutive Patients Circulation, August 23, 2005; 112(8): 1189 - 1197. [Abstract] [Full Text] [PDF]

				C. A. Warnes The Adult With Congenital Heart Disease: Born To Be Bad? J. Am. Coll. Cardiol., July 5, 2005; 46(1): 1 - 8. [Abstract] [Full Text] [PDF]

				J. A. Quintessenza, J. P. Jacobs, V. O. Morell, J. M. Giroud, and R. J. Boucek Initial Experience With a Bicuspid Polytetrafluoroethylene Pulmonary Valve in 41 Children and Adults: A New Option For Right Ventricular Outflow Tract Reconstruction Ann. Thorac. Surg., March 1, 2005; 79(3): 924 - 931. [Abstract] [Full Text] [PDF]

				T. P. Graham Jr The year in congenital heart disease J. Am. Coll. Cardiol., June 2, 2004; 43(11): 2132 - 2141. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kenneth G. Warner Patrick K. H. O’Brien Douglas D. Payne Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Warner, K. G. Articles by Payne, D. D. Search for Related Content PubMed PubMed Citation Articles by Warner, K. G. Articles by Payne, D. D. Related Collections Congenital - cyanotic