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We appreciate the opportunity to reply to the letter sent by Dr. d’Udekem and colleagues concerning the article we recently published in JACC.
Although we are grateful for their interest in our work, we would like to address the issues they have raised. First, their statement that “… all patients operated on … showed neither clinical improvement nor regression of ventricular volumes after reoperation … ” is incorrect. As our article clearly stated, most of our symptomatic patients had a significant clinical improvement postoperatively (24% NYHA class ≥ III preoperatively vs. 0% postoperatively, p < 0.001) (1). Unfortunately, this could not be confirmed objectively (the same mean duration of exercise and external workload was achieved both pre- and postoperatively). Furthermore, although the mean right ventricular volume and function did not improve postoperatively, about one-third of our patients did show such improvement as depicted in Figures 1, 2 and 3 of our article (1). Unfortunately, the relatively small number of patients made it impossible to determine which of the many factors analyzed favored such a response. Finally, we disagree with the statement that “the … effect of this [bulky bioprosthesis] … is to further increase the size of the right ventricular cavity” … and impede contraction of the pulmonary infundibulum by virtue of its extensive transannular patching. They are correct that we do enlarge the outflow tract to accommodate as large a prosthesis as possible, but the patch to do this is largely from the annulus distally. Proximal to the annulus, the patch extends into the infundibulum a distance of 10 to 15 mm. We do not believe that a 10 to 15 mm incision below the pulmonary annulus would have an important impact on right ventricular volume and function. We do agree, however, that any incision in the right ventricle should be avoided or minimized as much as possible in order to potentiate maximal postoperative functional recovery.
The issue of pulmonary valve replacement in adults late after repair of tetralogy of Fallot remains a controversial one and we again thank Dr. d’Udekem and colleagues for their interest in our work.
- American College of Cardiology