LATE HOMOGRAFT VALVE INSERTION AFTER TRANSANNULAR PATCH REPAIR OF TETRALOGY OF FALLOT

Background ann aims of the study: Transannular patch repair of tetralo gy of Fallot leads to pulmonary insufficiency and progressive right ve ntricular dilatation responsible for a decreased exercise capacity. We studied the impact of late homograft insertion on the regression of t he right ventricular volumes in symptomatic patients. Methods: Between July 1992 and August 1996, 15 consecutive patients (age range: 4 to 2 4 years) were operated on at a median of 13 years (range: 3 to 20 year s) after transannular patch repair of tetralogy of Fallot. All patient s complained of exertional dyspnea and fatigue. Syncopes were reported in six patients and four patients had sustained episodes of ventricul ar tachycardia. Fourteen had pulmonary regurgitation grade 3 or 4 and one had an associated stenosis and insufficiency. All patients had a d ilated right ventricle. At reoperation, no patients presented with maj or aneurysm. The patch was resected and the right ventricular outflow tract reconstructed with a cryopreserved pulmonary homograft. Right ve ntricular volumes were studied before the procedure and at the last fo llow up consultation. Results: There was no operative death. One patie nt who had a concomitant patch repair of a hypoplastic left pulmonary artery needed extracorporeal circulatory support for eight days. After a median follow up of 25 months (range: 3 to 54 months) all patients but one are in NYHA class I. There were no late deaths. The mean end-d iastolic diameter of the right ventricle decreased from 36 +/- 9 mm be fore surgery to 31 +/- 6 mm (not significant). The mean ratio between the end-diastolic diameter of the right and the left ventricles decrea sed from 0.94 +/- 0.3 to 0.74 +/- 0.2 (p<0.01). Conclusion: An increas ing number of patients who had transannular patch repair for tetralogy of Fallot will require reoperation for symptomatic long-term pulmonar y regurgitation. Homograft reconstruction of the right ventricular out flow tract of these patients induces regression of their right ventric ular dilatation and leads to their functional recovery.