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Ann Thorac Surg 2005;80:1615-1621
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Early Insertion of a Pulmonary Valve for Chronic Regurgitation Helps Restoration of Ventricular Dimensions

^a Division of Congenital Cardiac Surgery, University Children's Hospital Zurich, Zurich, Switzerland
^b Department of Cardiology, University Children's Hospital Zurich, Zurich, Switzerland
^c Department of Biostatistics, University of Zurich, Zurich, Switzerland

Accepted for publication April 21, 2005.

^_* Address correspondence to Dr Dave, Division of Congenital Cardiac Surgery, University Children's Hospital (Kinderspital Zurich), Steinwiesstrasse 75, CH-8032, Zurich, Switzerland (Email: hitendu.dave{at}kispi.unizh.ch; hitendu{at}hotmail.com).

Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.

	Abstract

Top Abstract Introduction Material and Methods Results Comment Discussion Footnotes Acknowledgments References

 
BACKGROUND: This study assesses the results of early insertion of a pulmonary valve for chronic pulmonary regurgitation based on right ventricular volume measurements.

METHODS: Valved conduits were prospectively inserted in 39 patients (aged 14 to 39 years) when the right ventricular (RV) end-diastolic volume index on magnetic resonance imaging (MRI) exceeded 150 mL/m². Changes in morphology and function of the RV were prospectively analyzed by an MRI at 6 months postoperatively (available in 21 patients).

RESULTS: There were no early or late deaths. All conduits showed good function at a median 15 month follow-up. Postoperative RV end-systolic and end-diastolic volumes showed a significant positive correlation (p = 0.005 and p < 0.0001), while postoperative left ventricular (LV) ejection fraction showed a significant negative correlation (p = 0.03) with preoperative RV end-diastolic volume index. Seven patients who achieved normal RV end-diastolic volume index ( 100 mL/m²) (group 1) when compared with 14 remaining patients (group 2) showed that they differed significantly with respect to their preoperative RV end-diastolic volume index (170.3 ± 21.1 vs 203.6 ± 35.6; p = 0.02) and postoperative LV ejection fraction (59.9 ± 4.2 vs 54 ± 7%, p = 0.03).

CONCLUSIONS: Our results show that the improvement in ventricular dimensions and functions directly correlates with the timing of pulmonary valve insertion. Early insertion leads to normalization and late insertion leads only to improvement. These observations, along with a low morbidity for these reoperations, justify earlier reintervention in cases of chronic pulmonary regurgitation. A RV end-diastolic volume index of 150 mL/m² seems to be a practical cutoff value to prescribe pulmonary valve insertion.

	Introduction

Top Abstract Introduction Material and Methods Results Comment Discussion Footnotes Acknowledgments References

 
Though many studies of surgically corrected patients with tetralogy of Fallot (TOF) have demonstrated excellent long-term results [1], there continues to exist a constant late hazard in their survival [2]. The mode of late attrition is often sudden (due to cardiac causes) and is most often attributed to ventricular tachyarrhythmias [2]. Out of the various risk factors responsible for terminal tachyarrhythmias, such as late age at repair and transventricular approach for ventricular septal defect closure [3, 4], chronic severe pulmonary regurgitation (PR) [5] and right ventricular (RV) dilatation have been the focus of intense study recently, and have appeared as significant independent risk factors [6]. Treatment of PR with pulmonary valve replacement (PVR) has been pursued for many years [7–9]. However, because most of these patients continue to be asymptomatic until severe ventricular dysfunction sets in, optimal timing for PVR has not been clearly established [10]. Magnetic resonance imaging (MRI) allows precise and reliable volumetric analysis in addition to providing a three-dimensional geometry of the heart, and has therefore emerged as a modality of choice in the decision making process for PVR [11]. Based on a prospective analysis of these findings and their reversibility on a population with a spectrum of ventricular dilatations, we aimed at defining objective guidelines for the precise timing of PVR.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment Discussion Footnotes Acknowledgments References

 
Between August 2002 and December 2004, 39 patients aged 14 to 39 years and weighing 17 to 101 kg, were prospectively enrolled in an MRI analysis of ventricular morphology and function. The demographic and operative data of the patients are shown in Table 1.

Surgical Technique
Cardiopulmonary bypass was instituted through cannulation of the right external iliac artery and vein. The distal limb of the external iliac artery was perfused by a small catheter off-shooting from the arterial perfusion cannula. The tip of the cannula was positioned in the right atrium to obtain collapse of the heart prior to sternotomy. The venous drainage was assisted by a low level vacuum. A minimum dissection strategy was employed to separate the mediastinal mass from the sternum by fully opening the right pleura and freeing the heart away from underneath the left hemisternum. The right ventricular outflow tract (RVOT) was opened vertically, the pulmonary bifurcation was identified, and the main pulmonary artery was completely transected a few millimeters above the bifurcation. The flabby transannular patch or the degenerated homograft was completely excised. In case of aneurysmal dilatation of the RV infundibulum, a longitudinal strip of RV free wall was excised. In some cases of major discrepancy between the sizes of the RV opening and that of the conduit, a reduction of the RV opening was performed by tightening a circumferential Prolene (Ethicon, Somerville, NJ) stitch (similar to the de Vega annuloplasty of the tricuspid valve) [14]. A homograft or bovine jugular vein graft was prepared according to usual protocol and was inserted on the pulmonary bifurcation and then on the RV with a continuous Prolene suture (Ethicon) (Fig 1). In addition to short-term antiplatelet therapy with acetylsalicylic acid, 5 mg/kg per day for 3 months postoperatively, angiotensin converting enzyme inhibitors were given for a variable period of time (usually 1 to 3 months) until adequate recovery of the ventricular function had occurred.

View larger version (116K): [in this window] [in a new window]   Fig 1. Postoperative three-dimensional magnetic resonance imaging picture in a patient who received a 20 mm bovine jugular vein graft and bifurcation plasty, 14 years after correction of tetralogy of Fallot.

Outcome of Interest
Primarily, a correlation analysis of the outcomes (as continuous variables) with respect to the preoperative RVEDVI was performed. Secondarily, taking postoperative RVEDVI of less than or equal to 100 mL/m² as a desirable outcome (to demonstrate normalization of RV) based on published reports [15], patients who achieved normal RVEDVI were categorized as group 1 and the remaining patients as group 2.

Statistical Methods
Continuous variables have been presented as mean ± standard deviations (M ± SD), median or range as appropriate. When the variables were analyzed continuously, Pearsons correlation was calculated. Comparison between groups 1 and 2 with respect to various continuous outcomes was carried out using two sample t tests (SPSS 2001, version 11.5.1; SPSS Inc, Chicago, IL). Change in New York Heart Association (NYHA) class after operation (for all patients) was tested using a sign test. The p values 0.05 or less were considered as statistically significant.

	Results

Top Abstract Introduction Material and Methods Results Comment Discussion Footnotes Acknowledgments References

 
All 39 patients survived the operation. There was no perioperative or late morbidity and mortality. Freedom from conduit-related reintervention was 100% at a median follow-up of 15 (13.1 ± 7.1) (range, 1 to 28.5) months. Since 21 out of the 39 enrolled patients have completed both preoperative and postoperative MRI at the time of writing this paper, we will restrict the subsequent analysis to these 21 fully studied patients.

RV Dimensions and Function
When analyzing as a continuous variable, we found a strong and significant positive correlation (p < 0.0001) between the preoperative RVEDVI and its value at 6 months after surgery (Fig 2). Correspondingly, the postoperative right ventricular end-systolic volume index (RVESVI) showed a significant positive correlation (p = 0.005) with the preoperative RVEDVI (Fig 2). The right ventricular ejection fraction did not show any correlation with preoperative RVEDVI.

View larger version (13K): [in this window] [in a new window]   Fig 2. Correlation graph between preoperative RVEDVI and postoperative right ventricular dimensions: RVESVI (above) and RVEDVI (below). (RVEDVI = right ventricular end-diastolic volume index; RVESVI = right ventricular end-systolic volume index.)

View larger version (12K): [in this window] [in a new window]   Fig 3. Correlation graph between preoperative RVEDVI and postoperative LVEF (above) and the change in LVEF (below) after PVR. (LVEF = left ventricular ejection fraction; PVR = pulmonary valve replacement; RVEDVI = right ventricular end-diastolic volume index.)

View larger version (13K): [in this window] [in a new window]   Fig 4. Correlation graph between preoperative RVEDVI and postoperative QRS duration. (RVEDVI = right ventricular end-diastolic volume index.)

	Comment

Top Abstract Introduction Material and Methods Results Comment Discussion Footnotes Acknowledgments References

Since the early days of repair for TOF, a great deal of literature [16, 17] has been published which state that chronic PR after repair of TOF is well-tolerated. However, it has now become evident that a late survival hazard persists even decades after repair for TOF. As high as a third to a half of these late deaths are due to cardiac causes, most probably sudden deaths attributable to ventricular arrhythmias [1, 18]. While right ventriculotomy is described as one of the possible causes for occurrence of late ventricular arrhythmias [19], it is the chronic PR and consequent RV dilatation after transannular enlargement of the RVOT that have been increasingly implicated for the occurrence of ventricular arrhythmias. Various groups [20, 21] have recognized the adverse influence of chronic PR after repair of TOF, and documented improved RV function, functional class, and incidence of arrhythmias after PVR [7–9]. Using clinical and echocardiographic criteria, the Mayo clinic reported [8] an incidence of 7% sudden deaths in spite of PVR (all of them associated with severe RV dilatation) and a 44% incidence of late, persistent, moderate to severe RV dilatation. Hence, though a broad consensus on PVR for chronic PR exists, the issue of its optimal timing is yet to be resolved. It is believed that when RV dysfunction results in clinical symptoms, it is already too late [10]. A majority of our patients who reached or surpassed our criteria for PVR, including those with severely dilated RV, reported themselves to be in a good validity class.

Echocardiographic measurement for RV evaluation is considered undependable for various reasons [9, 10]. The MRI, on the other hand, allows three-dimensional volumetric measurement of the RV, thus lending greater reliability to its use as a criterion for PVR. In addition, it helps in estimating the regurgitant fraction through the pulmonary valve and flow distribution to both the lungs [12, 22]. In our experience, these measurements have not only helped in decision making for PVR, but also helped in surgical planning by depicting the proximity of the heart to the undersurface of the sternum, the extent of aneurysmal dilatation of the RVOT, and the site and type of obstruction in the branch pulmonary arteries.

We believe that timely PVR not only results in smaller RV dimensions, but even results in better filling of the LV, probably by restoring the septal shift toward the right side. These changes result in improved LVEF in patients operated upon early (group 1). These findings support our strategy of early PVR, thus eliminating one of the important substrates underlying ventricular arrhythmogenicity and exercise intolerance seen late in these patients.

The shorter postoperative QRS duration in our aggressively treated cohort of patients should mean better mechanoelectrical interaction, and hence a lower propensity to malignant ventricular arrhythmias [20]. We have not been able to document any correlation of ventricular arrhythmias or impairment in exercise capacity in patients who reported late for PVR, probably because of very small numbers.

We set a value of 150 mL/m² for deciding on PVR, based on results obtained in MRI-based studies in adults in similar situations [11, 23]. While the presented evidence clearly favors early PVR, availability of suitable valved conduits as well as safety and durability of surgery, are important elements to justify such a strategy. Our technique of conduit insertion on a beating heart is quick, safe, easily reproducible, and carries minimal morbidity and tendential zero mortality. The industrialization of some xenografts has meant that they are always available off the shelf in various sizes [14]. This development has definitely given an impetus to following an aggressive approach for PVR.

Limitations of This Study
The number of patients enrolled is not large enough to demonstrate strong evidence in terms of improvement of biventricular dynamics, even though the correlations were strong and significant. The improvement in RV dimension and function was also influenced by additional resection of the akinetic and fibrotic anterior wall. This factor was difficult to integrate in our analysis, even though the study had been conducted prospectively. Resection was performed in the massively dilated RV, and therefore should have demonstrated a false positive remodeling response in selected patients. This confounding phenomenon was still not sufficient to demonstrate a trend toward normalization of ventricular dimensions in the more dilated hearts, and thus should be a further argument to set a low threshold for PVR in these patients.

In patients with chronic PR, early PVR based on MRI volumetry results in significantly improved RV dimensions and function, as well as better LV function, in comparison with patients who undergo late insertion of a valved conduit. Considering that a long lasting valved conduit with a potential for growth is not yet available, larger experience with such an approach would help to establish precise criteria for valved conduit insertion, which ensure that it is done neither too late nor too early. A longer follow-up with this aggressive approach would let us know if better preservation of ventricular dynamics translates into a decrease in late attrition of patients corrected for TOF.

	Discussion

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DR JOSEPH DEARANI (Rochester, MN): Doctor Pairolero, Dr Murray, members and guests. Today, the challenge for practicing cardiologists and surgeons is the timing of operation to replace the pulmonary valve for pulmonary regurgitation and the choice of prosthesis. Tomorrow, the challenge will be the timing of percutaneous intervention to replace the pulmonary valve. Current literature supports earlier and earlier pulmonary valve replacement, with the ultimate aim of reducing the late incidence of arrhythmias and cardiac-related death, which is often related to progressive significant right ventricular dilatation.

Doctor Dave and his colleagues have presented information with an aggressive approach at even earlier pulmonary valve replacement for pulmonary regurgitation. The controversy with this report is whether operation is being advised too early.

Strengths of their review include excellent early results with low morbidity and mortality. Importantly, the authors routinely use preoperative MRI examination, which provides accurate, objective information about right ventricular size and function. This has been a great limitation of echocardiography.

The authors advise pulmonary valve replacement without symptoms and only moderate right ventricular dilatation, a right ventricular end-diastolic volume index of 150 mL/m². I believe this number should serve as a guide, a "magic number," that will remind clinicians that close follow-up is warranted and pulmonary valve replacement is on the horizon. This point should be emphasized since symptoms are often not present until the right ventricle is markedly dilated.

While follow-up in this review is short, the authors were able to show a significant reduction in right ventricular size, even in patients with a right ventricular end-diastolic volume index of up to approximately 200 mL. Longer follow-up is required to examine the durability and late events related to pulmonary prostheses and conduits used in this review. Our operative experience with pulmonary valve replacement now exceeds 1,200. We strongly agree with the use of preoperative MRI to determine right ventricular dimensions and ejection fraction. This test is the key that aids us with timing of operation or intervention.

In the asymptomatic patient with isolated pulmonary regurgitation, we generally advise pulmonary valve replacement when the right ventricular end-diastolic volume index is somewhere between 175 and 200. We believe the recommendation for earlier pulmonary valve replacement must be carefully balanced with the expected early mortality and the durability of the chosen prosthesis. Although the early mortality is generally low in this patient group, there is an incremental increase when there have been multiple prior operations or when associated cardiac abnormalities require repair. I have three questions for Dr Dave.

Could you comment on the role of percutaneous pulmonary valve replacement in the setting of a markedly dilated right ventricular outflow tract and main pulmonary artery? Should these particular patients continue to be managed with surgery even after percutaneous valve replacement has become common practice?

Number two, could you comment on your use of adjunctive antiarrhythmia procedures when atrial or ventricular tachyarrhythmias are present preoperatively?

Finally, a conduit was used in all of your patients. Most surgeons would probably do isolated pulmonary valve replacement and avoid a conduit in this situation. Could you comment on your choice of prosthesis?

I will close by emphasizing that we surgeons need to be more involved with percutaneous valve replacement. This particular group of patients with isolated pulmonary regurgitation is the most attractive for this technology. We understand the anatomical issues and potential problems better than anyone else.

I thank the authors for providing me with the manuscript in advance and I thank the Society for the privilege of discussing this important paper.

DR DAVE: Thank you Dr Dearani, for the kind comments. Percutaneous pulmonary valve insertion is an evolving therapy and we do not know, as yet, what size of valves will be ultimately possible to be implanted percutaneously. However, in those patients which come with severely dilated right ventricular outflow tracts and main pulmonary arteries, there is the presence of old akinetic material which we consider important to be removed, and hence in those subset of patients we would still consider surgery. However, it is only the future evolution of percutaneous valve techniques that will tell us whether a few of the subset of patients are still suitable for that type of therapy.

As far as antiarrhythmic surgery is concerned, when we profess early insertion of a pulmonary valve we would imagine that we would find hardly any patients who have significant arrhythmias to be treated. Unfortunately, or fortunately, we have no experience with this type of therapy.

As far as the choice of prosthesis is concerned, we believe in a philosophy that all these conduits are basically dead tubes with valves, and there is a significant amount of difference with regards to the preparation, with regards to the washing, and the techniques involved in implantations that play a significant role in the longevity of these conduits. So our philosophy at present based on our own experience, is that we would prefer to have a pulmonary homograft if we have one available, but we would rather prefer to save them for the Ross procedures where it seems to be more important. If not, then we consider the aortic homograft or the newer evaluated bovine jugular vein grafts to be similar.

Thank you very much.

	Acknowledgments

Top Abstract Introduction Material and Methods Results Comment Discussion Footnotes Acknowledgments References

 
We thank Dr Christian Kellenberger for his assistance in performing the MRI. We thank our colleagues at the Department of Cardiology for their help in echocardiographic assessment and we also thank Sabine Baessler, the medical trainee, for her help in data collection.

	Footnotes

Top Abstract Introduction Material and Methods Results Comment Discussion Footnotes Acknowledgments References

 
^_* The first two authors contributed equally to this paper.

	References

Top Abstract Introduction Material and Methods Results Comment Discussion Footnotes Acknowledgments References

 

1. Murphy JG, Gersh BJ, Mair DD, et al. Long-term outcome in patients undergoing surgical repair of tetralogy of Fallot N Engl J Med 1993;329:593-599.[Abstract/Free Full Text]
2. Harrison DA, Harris L, Siu SC, et al. Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot J Am Coll Cardiol 1997;30:1368-1373.[Abstract]
3. Chandar JS, Wolff GS, Garson A Jr, et al. Ventricular arrhythmias in postoperative tetralogy of Fallot. Am J Cardiol 19901;65:655–61..
4. Sullivan ID, Presbitero P, Gooch VM, Aruta E, Deanfield JE. Is ventricular arrhythmia in repaired tetralogy of Fallot an effect of operation or a consequence of the course of the disease? A prospective study Br Heart J 1987;58:40-44.[Abstract/Free Full Text]
5. Zahka KG, Horneffer PJ, Rowe SA, et al. Long-term valvular function after total repair of tetralogy of Fallot. Relation to ventricular arrhythmias Circulation 1988;78:III14-III19.
6. Kavey RE, Thomas FD, Byrum CJ, Blackman MS, Sondheimer HM, Bove EL. Ventricular arrhythmias and biventricular dysfunction after repair of tetralogy of Fallot J Am Coll Cardiol 1984;4:126-131.[Abstract]
7. Bove EL, Kavey RE, Byrum CJ, Sondheimer HM, Blackman MS, Thomas FD. Improved right ventricular function following late pulmonary valve replacement for residual pulmonary insufficiency or stenosis J Thorac Cardiovasc Surg 1985;90:50-55.[Abstract]
8. Discigil B, Dearani JA, Puga FJ, et al. Late pulmonary valve replacement after repair of tetralogy of Fallot J Thorac Cardiovasc Surg 2001;121:344-351.
9. Hazekamp MG, Kurvers MM, Schoof PH, et al. Pulmonary valve insertion late after repair of Fallot's tetralogy Eur J Cardiothorac Surg 2001;19:667-670.[Abstract/Free Full Text]
10. Therrien J, Siu SC, McLaughlin PR, Liu PP, Williams WG, Webb GD. Pulmonary valve replacement in adults late after repair of tetralogy of fallotare we operating too late?. J Am Coll Cardiol 2000;36:1670-1675.[Abstract/Free Full Text]
11. Vliegen HW, 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]
12. Rebergen SA, Chin JG, Ottenkamp J, van der Wall EE, de Roos A. Pulmonary regurgitation in the late postoperative follow-up of tetralogy of Fallot. Volumetric quantitation by nuclear magnetic resonance velocity mapping Circulation 1993;88:2257-2266.[Abstract/Free Full Text]
13. Pelc NJ, Herfkens RJ, Shimakawa A, Enzmann DR. Phase contrast cine magnetic resonance imaging Magn Reson Q 1991;7:229-254.[Medline]
14. Dave HH, Kadner A, Berger F, et al. Early results of the bovine jugular vein graft used for reconstruction of the right ventricular outflow tract Ann Thorac Surg 2005;79:618-624.[Abstract/Free Full Text]
15. Lorenz CH. The range of normal values of cardiovascular structures in infants, children, and adolescents measured by magnetic resonance imaging Pediatr Cardiol 2000;21:37-46.[Medline]
16. Jones EL, Conti CR, Neill CA, Gott VL, Brawley RK, Haller Jr JA. Long-term evaluation of tetralogy patients with pulmonary valvular insufficiency resulting from outflow-patch correction across the pulmonic annulus Circulation 1973;48(suppl 1):III11-III18.
17. Fuster V, McGoon DC, Kennedy MA, Ritter DG, Kirklin JW. Long-term evaluation (12 to 22 years) of open heart surgery for tetralogy of Fallot Am J Cardiol 1980;46:635-642.[Medline]
18. Nollert G, Fischlein T, Bouterwek S, Bohmer C, Klinner W, Reichart B. Long-term survival in patients with repair of tetralogy of Fallot36-year follow-up of 490 survivors of the first year after surgical repair. J Am Coll Cardiol 1997;30:1374-1383.[Abstract]
19. Dietl CA, Cazzaniga ME, Dubner SJ, Perez-Balino NA, Torres AR, Favaloro RG. Life-threatening arrhythmias and RV dysfunction after surgical repair of tetralogy of Fallot. Comparison between transventricular and transatrial approaches Circulation 1994;90(Pt 2):II7-II12.
20. Gatzoulis MA, Till JA, Somerville J, Redington AN. Mechanoelectrical interaction in tetralogy of Fallot. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death Circulation 1995;92:231-237.[Abstract/Free Full Text]
21. Carvalho JS, Shinebourne EA, Busst C, Rigby ML, Redington AN. Exercise capacity after complete repair of tetralogy of Fallotdeleterious effects of residual pulmonary regurgitation. Br Heart J 1992;67:470-473.[Abstract/Free Full Text]
22. Helbing WA, de Roos A. Clinical applications of cardiac magnetic resonance imaging after repair of tetralogy of Fallot Pediatr Cardiol 2000;21:70-79(Review).[Medline]
23. Therrien J, Provost Y, Merchant N, Williams W, Colman J, Webb G. Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair Am J Cardiol 2005;95:779-782.[Medline]

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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): Hitendu Hasmukhlal Dave Ali Dodge-Khatami Alexander Kadner René Prêtre Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dave, H. H. Articles by Prêtre, R. Search for Related Content PubMed PubMed Citation Articles by Dave, H. H. Articles by Prêtre, R. Related Collections Congenital - cyanotic