Pulmonary valve insertion late after repair of Fallot's tetralogy

Objectives: To analyze the results of pulmonary valve insertion late after initial repair of Fallot's tetralogy. Pulmonary insufficiency (PI) after co rrection of Fallot's tetralogy is usually well tolerated in the short term, but is associated with symptomatic right ventricular dilatation and an inc reased risk of ventricular arrhythmias over longer periods of time. Methods : From 1993 to July 2000, 51 patients were reoperated for PI at a mean age of 25.7 +/- 11.9 years. The mean age at initial repair was 6.4 +/- 7.2 year s. Patients with a conduit inserted at initial operation, with absent pulmo nary valve syndrome or with a more than moderate ventricular septal defect at reoperation were excluded from the study. A cryopreserved pulmonary (96% ) or aortic (4%) homograft was implanted in the orthotopic position with th e use of cardiopulmonary bypass 19.3 +/- 9.1 years (2.7-40.3 years) after i nitial correction. Preoperative symptoms (New York Heart Association, NYHA class), degree of PI (echo-Doppler, MRI), right ventricular dimensions (MRI ) and QRS duration were compared to findings at last follow-up. Results: Fo llow-up is complete and had a mean duration of 1.7 +/- 1.4 years. Hospital mortality was 2%. No serious morbidity occurred. Severe PI was present preo peratively in all patients. At last follow-up echo-Doppler studies showed P I to be absent or trivial in 96% and mild in 4% of patients. In 13 patients MRI studies were performed both pre- and postoperatively: in this group PI was reduced from a mean of 48 to 4%. After 6 months NYHA capacity class ha d improved significantly from 2.3 +/- 0.6 to 1.4 +/- 0.5. After 1 year end- diastolic and end-systolic right ventricular volumes were reduced significa ntly. Right ventricular ejection fraction and QRS duration remained unchang ed. Conclusions: PI late after correction of Fallot's tetralogy may lead to serious symptomatic right ventricle dilatation. After pulmonary homograft insertion right ventricular dimensions decrease rapidly and functional impr ovement is observed in almost all patients. (C) 2001 Elsevier Science B.V. All rights reserved.