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Patients with tetralogy of Fallot (TOF) following complete repair and pulmonic stenosis (PS) after surgical valvotomy often develop significant pulmonic regurgitation (PR) that eventually requires valve replacement (PVR). Though several criteria exist for the timing of PVR in TOF, it is less clear when to intervene in valvotomy patients and whether TOF recommendations can be applied.
We compared the clinical characteristics, electrocardiograms, imaging studies and invasive hemodynamics of 109 patients (34 PS and 75 TOF) newly referred to a large congenital heart disease clinic for evaluation of PR between 2005 and 2011. Patients with prior PVR or conduit implantation and those with > mild right ventricular outflow narrowing were excluded. Valvular regurgitation was graded echocardiographically from 1 (mild) to 4 (severe). ECG analysis was limited to nonpaced tracings.
The two cohorts were similar in terms of baseline demographics and comorbidities as well as presenting NYHA function class. Time interval from surgery to referral was longer in valvotomy patients (37±10 vs. 32±11 years, p=0.022) and degree of PR was greater by echocardiography (3.2±0.9 vs. 2.4 ±1.6, p=0.004). ECG showed considerably greater QRS width in TOF (150±28 vs. 114±27ms, p<0.001). Echo pulmonary valve gradient was greater for TOF (14±8 vs. 8±3 mm Hg, p<0.001). MRI Right ventricular (RV) ejection fraction (41±11 vs. 49±8%, p=0.001) and left ventricular (LV) ejection fraction (52±10 vs. 59±7%, p=0.002) were considerably lower in TOF. Invasive hemodynamics revealed similar pulmonary artery pressure, right atrial pressure and cardiac index for both groups. 22.1% of the TOF cohort required pacemaker or ICD implantation compared to 2.8% of the valvotomy patients (p=0.011).
Though presenting later than TOF after classic repair, PS valvotomy patients have greater degrees of regurgitation. RV/LV function and QRS width appear less affected, suggesting changes in TOF patients that go beyond the effects of PR. This suggests a need for disease-specific guidelines for intervention in PS valvotomy patients.
Poster Sessions, Expo North
Sunday, March 10, 2013, 9:45 a.m.-10:30 a.m.
Session Title: Congenital Cardiology Solutions: Valvular Disease in the Adult
Abstract Category: 12. Congenital Cardiology Solutions: Adult
Presentation Number: 1202-118
- 2013 American College of Cardiology Foundation