Homograft valve insertion for pulmonary regurgitation late after valvelessrepair of right ventricular outflow tract obstruction

Objective: Pulmonary regurgitation after valveless repair of right ventricu lar outflow tract obstruction (RVOTO) results in progressive right ventricu lar (RV) dilatation and dysfunction in an increasing number of patients. Si nce 1989, we have exclusively used cryopreserved homografts to restore pulm onary valve competence in these patients. Our 9-year-experience with pulmon ary valve insertion (PVI) in such cases has been reviewed to evaluate the i ndications for this procedure and its benefits. Methods: From 1989 to 1998, 49 patients (original diagnosis: tetralogy of Fallot in 42 patients and pu lmonary stenosis in seven) aged from 3 to 42 years (mean 18 +/- 9 years) un derwent PVI with homografts late (mean 13 +/- 7 years) after valveless repa ir of RVOTO (transannular patch, n = 38; pulmonary valvulotomy therefore ta u chi infundibular patch, n = Il). Preoperatively, all patients had severe pulmonary regurgitation, cardiomegaly, significant to severe RV dilatation and dysfunction, fatigue, reduced exercise tolerance, and were in NYHA clas s II (n = 43) or III (n = 6). Ten patients had ventricular arrhythmia. Resu lts: There was one early death, due to air embolism, and one late death, du e to ventricular arrhythmia. All survivors but one, who subsequently underw ent heart transplant, had symptomatic improvement after homograft insertion . The mean RV end-diastolic diameter decreased from 38 +/- 9 to 26 +/- 8 mm (P < 0.01), and cardiothoracic ratio decreased from 0.62 +/- 0.07 to 0.54 +/- 0.04 (P < 0.01). Good late homograft function was the rule, with all th e survivors being free of reoperation for valve failure. At a mean follow-u p of 42 +/- 28 months, 41 patients (87% of the survivors) were in New York Heart Association (NYHA) class I and six in class II. Within this group thr ee patients are still in treatment for RV failure and five for ventricular arrhythmias. In these patients, the average interval between RVOTO repair a nd PVI was significantly longer than in the others (18 +/- 7 vs. 12 +/- 6 y ears, P < 0.01). Conclusion: Homograft PVI is safe and provides clinical im provement with a significant reduction in RV volume overload and excellent mid-term results in most patients with severe PR late after RVOTO repair. T his procedure should be undertaken early in symptomatic patients, before se vere RV failure and ventricular arrhythmias ensue. (C) 1999 Elsevier Scienc e B.V. All rights reserved.