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The timing of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (TOF) and significant pulmonary regurgitation (PR) remains controversial. The AHA/ACC guidelines for Adult Congenital Heart Disease released in 2008 provided non-quantitative recommendations for PVR, although recent studies advocate PVR before indexed right ventricular end diastolic volume (RVEDVi) exceeds 160 ml/m2. We sought to determine whether the published ACC/AHA guidelines significantly affected the clinical or imaging characteristics of patients undergoing PVR.
We conducted a retrospective cohort study evaluating all patients seen at our adult congenital heart disease center (age≥18 years) with TOF who underwent PVR between 1/1/1999 and 6/1/2012. Variables based on prior studies and the AHA/ACC guidelines were defined prior to data acquisition and assessed immediately prior to PVR.
Of 59 patients with TOF who had a PVR at our institution, 35 (59%) were before the release of the guidelines and 24 (41%) were after. All patients had a transthoracic echo upon presentation, and 49 of the 59 patients had a pre-operative cardiac MRI (CMR). All patients had moderate or severe PR. Median time to PVR from initial visit at our institution by log rank-test was significantly higher in the pre-guideline group (p= 0.005). Mean pre-operative right ventricular ejection fraction by CMR was significantly higher in patients who had a PVR after the guidelines (47% vs. 41%, p =0.03), as was pre-operative right ventricular function by echocardiography (p=0.01). However, pre-operative mean RVEDVi was not significantly different between the pre and post guideline groups (194 ml/m2 vs. 175 ml/m2, p=0.24).
Patients with repaired TOF and significant PR who underwent PVR after the release of the ACC/AHA guidelines had a shorter time to surgery and better right ventricular function by TTE and CMR but no significant difference in degree of right ventricular dilation. Although the guidelines may have had a beneficial impact on time to referral, the absence of quantitative recommendations may explain the lack of reduction in RVEDVi in the post-guideline group.
Poster Sessions, Expo North
Monday, March 11, 2013, 9:45 a.m.-10:30 a.m.
Session Title: Congenital Cardiology Solutions: Adult Congenital Heart Disease
Abstract Category: 12. Congenital Cardiology Solutions: Adult
Presentation Number: 1292-130
- 2013 American College of Cardiology Foundation