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Canadian Journal of Cardiology

Pulmonary Valve Replacement for Pulmonary Regurgitation in Adults With Tetralogy of Fallot: A Meta-analysis—A Report for the Writing Committee of the 2019 Update of the Canadian Cardiovascular Society Guidelines for the Management of Adults With Congenital Heart Disease

Published:August 29, 2019DOI:https://doi.org/10.1016/j.cjca.2019.08.031

      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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