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Canadian Journal of Cardiology

Pulmonary Valve Procedures Late After Repair of Tetralogy of Fallot: Current Perspectives and Contemporary Approaches to Management

      Abstract

      Few topics in adult congenital heart disease have approached the level of scrutiny bestowed on pulmonary valve replacement (PVR) strategies late after tetralogy of Fallot (TOF) repair. Despite the successes of primary surgery for TOF, there is a growing group of adults with residual right ventricular outflow tract and pulmonary valve dysfunction. Patients with residual chronic pulmonic regurgitation as a consequence of earlier surgery can later develop symptoms of exercise intolerance and complications including heart failure, tachyarrhythmias, and sudden cardiac death. Optimal timing of PVR has sparked debate, which has catalyzed increasing research efforts over the past decade. Although performance of PVR in the absence of symptoms is currently on the basis of the rationale that achievement of complete reverse remodelling is highly desirable, whether this approach results in improvement in patient outcomes in the long-term has yet to be shown. Surgical PVR and percutaneous pulmonary valve intervention are different techniques with specific advantages and disadvantages that require careful consideration for each individual patient, alongside the need for requisite reinterventions over the course of a patient's lifetime. Criteria pertaining to referral strategies are ever being refined as newer technologies for percutaneous therapies continue to evolve. In this article we review the literature surrounding the indications for, the optimal timing of, and the approaches to pulmonary valve procedures in adults with previously repaired TOF.

      Résumé

      Nous avons abordé quelques thèmes sur la cardiopathie congénitale chez l'adulte en ce qui concerne le niveau d'examen accordé aux stratégies de remplacement valvulaire pulmonaire (RVP) bien après la correction de la tétralogie de Fallot (TF). En dépit de la réussite de l'intervention chirurgicale primaire de la TF, de plus en plus d'adultes montrent un dysfonctionnement résiduel de la chambre de chasse du ventricule droit et de la valve pulmonaire. Les patients atteints de régurgitation pulmonaire résiduelle à long terme en raison de l'intervention chirurgicale antérieure peuvent plus tard présenter des symptômes d'intolérance à l'effort et des complications, y compris l'insuffisance cardiaque, les tachyarythmies et la mort cardiaque subite. La controverse entourant le moment optimal du RVP a permis d'accélérer les efforts de recherche au cours de la dernière décennie. Bien que la performance du RVP en l'absence de symptômes repose actuellement sur le principe que la réalisation du remodelage inverse complet est grandement souhaitable, il reste à démontrer si cette approche se traduit par l'amélioration des résultats cliniques à long terme chez les patients. La chirurgie de RVP et l'intervention par voie percutanée de la valve pulmonaire sont des techniques différentes ayant des avantages et des inconvénients propres à chacune qui exigent un examen minutieux de chacun des patients parallèlement à la nécessité des réinterventions requises au cours de la vie du patient. Les critères liés aux stratégies d'orientation sont peaufinés au fur et à mesure que les nouvelles technologies de traitement par voie percutanée évoluent. Dans le présent article, nous passons en revue la littérature relative aux indications, au moment optimal et aux approches chirurgicales en matière d'interventions de la valve pulmonaire chez les adultes ayant déjà subi une correction de la TF.
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