Abstract
Background
There is no systematic evidence review of the long-term results of surgical pulmonary
valve replacement (PVR) dedicated to adults with repaired tetralogy of Fallot (rTOF)
and pulmonary regurgitation.
Methods
Our primary objective was to determine whether PVR reduced long-term mortality in
adults with rTOF compared with conservative therapy. Secondary objectives were to
determine the postoperative incidence rate of death, the changes in functional capacity
and in right ventricular (RV) volumes and ejection fraction after PVR, and the postoperative
incidence rate of sustained ventricular arrhythmias. A systematic search of multiple
databases for studies was conducted without limits.
Results
No eligible randomized controlled trial or cohort study compared outcomes of PVR and
conservative therapy in adults with rTOF. We selected 10 cohort studies (total 657
patients) reporting secondary outcomes. After PVR, the pooled incidence rate of death
was 1% per year (95% confidence interval [CI] 0-1% per year) and the pooled incidence
rate of sustained ventricular arrhythmias was 1% per year (95% CI 1%-2% per year).
PVR improved symptoms (odds ratio for postoperative New York Heart Association functional
class > II 0.08, 95% CI 0.03-0.24). Indexed RV end-diastolic (−61.29 mL/m2, −43.64 to −78.94 mL/m2) and end-systolic (−37.20 mL/m2, −25.58 to −48.82 mL/m2) volumes decreased after PVR, but RV ejection fraction did not change (0.19%, −2.36%
to 2.74%). The effect of PVR on RV volumes remained constant regardless of functional
status.
Conclusion
Studies comparing PVR and conservative therapy exclusively in adults with rTOF are
lacking. After PVR, the incidence rates of death and ventricular tachycardia are both
1 per 100 patient-years. Pooled analyses demonstrated an improved functional status
and a reduction in RV volumes.
Résumé
Contexte
Il n’existe aucune revue systématique des résultats à long terme du remplacement valvulaire
pulmonaire (RVP) chirurgical chez les adultes ayant une tétralogie de Fallot réparée
(TFr) et présentant une régurgitation pulmonaire.
Méthodologie
Notre objectif premier était de déterminer si le RVP réduisait la mortalité à long
terme chez les adultes ayant une TFr par rapport à un traitement conservateur. Nos
objectifs secondaires étaient de déterminer le taux d’incidence postopératoire de
décès, les variations de la capacité fonctionnelle ainsi que des volumes et de la
fraction d’éjection ventriculaires droits (VD) après le RVP, et le taux d’incidence
postopératoire des arythmies ventriculaires soutenues. Nous avons effectué une recherche
systématique sans restriction dans plusieurs bases de données afin de trouver des
études pertinentes.
Résultats
Aucune étude comparative avec répartition aléatoire ni étude de cohorte admissible
comparant les résultats du RVP et ceux du traitement conservateur chez des adultes
ayant une TFr n’a été relevée. Nous avons retenu 10 études de cohorte (657 patients
au total) les critères d’évaluation secondaires. Après le RVP, le taux d’incidence
groupé de décès s’établissait à 1% par année (intervalle de confiance [IC] à 95%:
de 0 à 1% par année), et le taux d’incidence groupé des arythmies ventriculaires soutenues
s’établissait à 1% par année (IC à 95%: de 1 à 2% par année). Le RVP a atténué les
symptômes: le rapport de cotes pour une classe fonctionnelle de la New York Heart
Association de II ou plus après l’intervention s’établissant à 0,08 (IC à 95 %: de
0,03 à 0,24). Le volume télédiastolique VD (–61,29 mL/m2, de –43,64 à –78,94 mL/m2) et le volume tétlésystolique VD (–37,20 mL/m2, de –25,58 à –48,82 mL/m2) ont diminué après le RVP, mais la fraction d’éjection VD n’a pas changé (0,19 %,
de –2,36 % à 2,74 %). L’effet du RVP sur les volumes VD est demeuré constant, sans
égard à la capacité fonctionnelle.
Conclusion
Il n’existe aucune étude comparant le RVP et le traitement conservateur exclusivement
chez des adultes ayant une TFr. Après le RVP, les taux d’incidence de décès et de
tachycardie ventriculaire étaient tous deux de 1 par 100 patients-années. Les résultats
des analyses groupées montrent une amélioration de la capacité fonctionnelle et une
diminution des volumes VD.
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Article info
Publication history
Published online: August 29, 2019
Accepted:
August 16,
2019
Received:
June 17,
2019
Footnotes
See page 1781 for the list of members of the Writing Committee of the 2019 Update of the Canadian Cardiovascular Society Guidelines for the Management of Adults With Congenital Heart Disease.
See editorial by Vonder Muhll, pages 1620--1622 of this issue.
See page 1782 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Timing and Results of Pulmonary Valve Replacement for Pulmonary Regurgitation in Repaired Tetralogy of Fallot: A Challenge for Evidence-Based MedicineCanadian Journal of CardiologyVol. 35Issue 12
- PreviewThere are now more adults than children with repaired tetralogy of Fallot (rTOF).1 Operative repair includes relief of pulmonary stenosis, which comes at the expense of pulmonary regurgitation. Despite development of valve-preserving surgical techniques at the time of primary repair, postoperative pulmonary regurgitation remains the most important clinical problem for adults with rTOF. Although pulmonary regurgitation can be well tolerated with a long asymptomatic period, it is associated with right ventricular dilation and dysfunction, exercise intolerance, and increased risk of ventricular arrhythmias and sudden cardiac death.
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