Right Ventricular Remodeling After Pulmonary Valve Replacement: Early Gains, Late Losses

• Published in: The Annals of thoracic surgery Vol. 99; no. 2; pp. 660 - 666
• Main Authors: Hallbergson, Anna, MD, PhD, Gauvreau, Kimberlee, ScD, Powell, Andrew J., MD, Geva, Tal, MD
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.02.2015
• Subjects: Adolescent; Adult; Cardiac Surgical Procedures; Cardiothoracic Surgery; Child; Child, Preschool; Cross-Sectional Studies; Female; Heart Valve Prosthesis Implantation; Humans; Infant; Longitudinal Studies; Male; Pulmonary Valve - surgery; Retrospective Studies; Surgery; Tetralogy of Fallot - surgery; Time Factors; Ventricular Function, Right; Ventricular Remodeling; Young Adult; EF; ESVi; PR; pulmonary regurgitation; ejection fraction; RV; CMR; LV; TOF; cardiovascular magnetic resonance; pulmonary valve replacement; right ventricle or right ventricular; tetralogy of Fallot; PVR; RVOT; right ventricular outflow tract; left ventricle or left ventricular; tricuspid regurgitation; EDVi; end-diastolic volume index; TR; 20; end-systolic volume index
• ISSN: 0003-4975; 1552-6259
• DOI: 10.1016/j.athoracsur.2014.09.015

Background Although early results of pulmonary valve replacement (PVR) after tetralogy of Fallot repair have been described, information about late postoperative ventricular size and function is lacking. This study was designed to characterize right ventricular (RV) remodeling up to 10 years after PVR. Methods Retrospective analysis was conducted of cardiovascular magnetic resonance (CMR) data from 2002 to 2011 in 101 patients (244 studies) who underwent PVR and had one or more post-PVR CMR studies at five post-PVR time intervals up to 10 years. Results Compared with pre-PVR values, in the 0- to 1-year post-PVR group, pulmonary regurgitation (PR) fraction decreased from 49 ± 11% to 3 ± 2% ( p < 0.001), RV end-diastolic volume index (EDVi) decreased by 39% ( p < 0.001), RV end-systolic volume index (ESVi) decreased by 33% ( p  < 0.001), and RV ejection fraction (EF) decreased from 48 ± 8% to 44 ± 8% ( p  = 0.01). These values remained unchanged through the sixth post-PVR year. However, by 7 to 10 years after PVR (n = 15), RVEDVi and RVESVi were significantly increased and had returned to 84% and 104% of pre-PVR volumes, respectively, and RV EF had declined further. Increasing RV EDVi correlated with increasing grades of PR ( r s  = 0.36, p < 0.001), tricuspid regurgitation ( r s  = 0.33, p  < 0.001), and RV pressure ( r s  = 0.32, p  = 0.03). Conclusions In this cohort, early reduction in RV size showed a gradual return toward preoperative values by 7 to 10 years after PVR. The late adverse RV remodeling was associated with increased RV volume and pressure loads. These findings highlight the palliative nature of PVR and the importance of continued surveillance.