Transannular patch repair of tetralogy of Fallot with or without monocusp valve reconstruction: a meta-analysis

Background Tetralogy of Fallot (TOF) is one of the most common cyanotic congenital heart diseases. Pulmonary regurgitation is the most common and severe comorbidity after transannular patch (TAP) repair of TOF patients. It has not been confirmed whether a TAP repair with monocusp valve reconstruction would benefit TOF patients in perioperative period compared to those without monocusp valve reconstruction. The purpose of the study is to review and analyze all clinical studies that have compared perioperative outcomes of TOF patients undergoing TAP repair with or without monocusp valve reconstruction and conduct a preferable surgery. Methods Eligible studies were identified by searching the electronic databases. The year of publication of studies was restricted from 2000 till present. The primary outcome was perioperative mortality, and secondary outcomes included cardiopulmonary bypass time, aortic cross-clamp time, ventilation duration, ICU length of stay, hospital length of stay, perioperative right ventricular outflow tract (RVOT) pressure gradient, and moderate or severe pulmonary regurgitation (PR). The meta-analysis and forest plots were drawn using Review Manager 5.3. Statistically significant was considered when p-value ≤ 0.05. Results Eight studies were included which consisted of 8 retrospective cohort study and 2 randomized controlled trial. The 10 studies formed a pool of 526 TOF patients in total, in which are 300 undergoing TAP repair with monocusp valve reconstruction (monocusp group) compared to 226 undergoing TAP repair without monocusp valve reconstruction (non-monocusp group). It demonstrated no significant differences between two groups in perioperative mortality (OR = 0.69, 95% CI 0.20–2.41, p = 0.58). It demonstrated significant differences in perioperative cardiopulmonary bypass time (minute, 95% CI 17.93–28.42, p < 0.00001), mean length of ICU stay (day, 95% CI − 2.11–0.76, p < 0.0001), and the degree of perioperative PR (OR = 0.03, 95% CI 0.010.12, p < 0.00001). Significant differences were not found in other secondary outcomes. Conclusion Transannular patch repair with monocusp valve reconstruction have significant advantages on decreasing length of ICU stay and reducing degree of PR for TOF patients. Large, multicenter, randomized, prospective studies which focuse on perioperative outcomes and postoperative differences based on long-term follow-up between TAP repair with and without monocusp valve reconstruction are needed.

Applicability and Durability of Valve-Sparing Tetralogy of Fallot Repair

Background: Although valve-sparing repair remains ideal for patients with tetralogy of Fallot, the durability of valve-sparing repair and which patients may have been better served with a transannular patch remain unclear. Methods: Retrospective review was performed of tetralogy of Fallot operations at our institution from January 2008 to December 2018. Standard demographic data were collected, including echocardiographic parameters, operative details, and clinical outcomes. Statistical analysis was performed comparing the transannular patch and valve-sparing repair groups. Results: Sixty-seven patients underwent tetralogy of Fallot repair with a median age of 4.5 (3.2-6.0) months and weight of 5.8 (5.2, 6.7) kg. Seventeen (25%) patients underwent transannular patch repair and 50 (75%) patients underwent valve-sparing repair. There was no difference in age or weight between patients who underwent a transannular patch repair and those who underwent a valve-sparing repair. At last follow-up (median 42 months), there was a trend of a higher peak pulmonary valve/right ventricular outflow tract gradient ( P = .06) in the valve-sparing group, but no difference in the pulmonary valve annulus z-scores. Additionally, the pulmonary valve z-scores in the valve-sparing group decreased from −2.3 ± 1.0 on predischarge echocardiogram of to −1.2 ± 1.6 on last follow-up, with the peak gradient on predischarge 23 (0-37) mm Hg remaining stable on last follow-up at 18 (0-29) mm Hg. There was one reoperation: pulmonary valve replacement six years after a transannular patch. Conclusions: Obtaining a postrepair pulmonary valve z-score of −2 yields satisfactory, stable valve-sparing repair with pulmonary valve growth, acceptable gradients, minimal regurgitation, and high freedom from reintervention during follow-up.

Surgical Outcome of Right Ventricular Outflow Tract Reconstruction Using Bicuspid Pulmonary Valve in Tetralogy of Fallot Repair: A Single Centre Experience

Background: Tetralogy of Fallot (TOF) is one of the most common congenital cardiac defect. In patients with small PV annulus, it has to be augmented to certain diameter by cutting annulus. In these cases, transannular patch is used free PR is inevitable. Free PR with transannular patch ultimately leads to RV dilatation, dysfunction, arrhythmia and failure with time. Monocuspid reconstruction of PV is commonly practiced in many centers but its long-term outcome is poor though it helps to achieve a less stormy ICU course. Modified monocusp or bicuspid PV reconstruction is a good choice where 0.1mm PTFE patch is used. Objectives: We are presenting the results of bicuspid PV reconstruction using a 0.1mm PTFE patch as a method of RVOT reconstruction in repair of TOF with transannular patch. Methods: A total, 42 patients diagnosed as TOF were treated from January 2016 to October 2020. Age range 18 months to 35 years, weighing 10 kg to 70 kg. 38 patients had TOF, 4 had DORV with PS. The transannular patch was followed by implantation of a 0.1-mm PTFE modified monocusp valve using posterior fixation. Results: Among total patients 28 were male and 14 were female. Mean age 9.58±5.6 yrs. Bypass time was 187±31 min, cross-clamp time 123.63±25.42 min. Out of 42 patients, PR gradient was trivial in 7(16.67%), mild in 31(73.1%), moderate in 4(9.52%) patients. First, a follow-up echocardiogram revealed no significant deterioration of PR gradient. ICU stay was 89±32.6 hours and mean hospital stay 11.48±2.1 days. Conclusion: Initial results using a transannular patch with a modified monocusp valve to repair the outflow tract in cases of Tetralogy of Fallot were excellent. There were only a slight pressure gradient and mild regurgitation in most of the cases. DS (Child) H J 2020; 36(2): 114-119

Native Pulmonary Valve Restoration Late Following Transannular Patch Repair of Tetralogy of Fallot

We present a surgical case of native pulmonary valve (PV) restoration in a 16-year-old boy with a previous history of transannular patch repair of tetralogy of Fallot in infancy. The PV was restored by approximation of split anterior commissure in the presence of developed and pliable leaflets well preserved after initial surgery. Postoperative echocardiogram showed a competent valve with peak velocity of 2.8 m/s. At six-week follow-up, the patient remained well, and echocardiogram demonstrated a competent PV with decreased velocity of 2.1 m/s across it. We encourage a mindful preservation of PV leaflets whenever it is possible at time of initial repair to implement this relatively easy operation to restore PV function later in life.

Value of pulmonary annulus index in predicting transannular patch in tetralogy of Fallot repair

Objective: It is very important to accurately assess the transannular patch (TAP) in the surgical treatment of tetralogy of Fallot（TOF）. Methods: 130 patients who were diagnosed with TOF and underwent TOF repair. 112 cases were included in this study. They were divided into TAP group and no TAP group; the values of pulmonary annulus and aortic annulus were measured. GA ratio, PAI, PAAI, the pulmonary annulus Z-score and main pulmonary artery (MPA) Z-score were calculated to do statistically analyze. Results: A total of 112 patients were included in the study.62 cases (55.8%) did not transannular patch, 50 cases (44.2%) undergoing transannular patch. The pulmonary annulus Z-score, main pulmonary artery Z-score and PAI in TAP group were smaller than those in no TAP group (P < 0.05). ROC analysis showed that when the cutoff value of pulmonary annulus at -1.98 ,the area under curve (AUC) was 0.88, the sensitivity was 80%, the specificity was 71%; when the cut-off value of PAI at 0.53 ,AUC was 0.85, the sensitivity was 75%, the specificity was 80%; when the cutoff value of GA ratio at 0.55 ,AUC was 0.85, the sensitivity was 76%, and the specificity was 80%. The area under the PAAI curve (AUC) was 0.85, the sensitivity was 76%, and the specificity was 79%. Conclusion: The predictive effect of pulmonary annulus index as a simple and effective predictor of TAP in TOF radical operation is the same as that of pulmonary annulus Z-score.

Predictors of Transannular Patch Enlargement in Tetralogy of Fallot Repair; a Single Center Experience

Introduction: Tetralogy of Fallot (ToF) accounts for 5% to 10% of all congenital heart diseases (CHD) and is the commonest cyanotic heart disease beyond the neonatal period. Surgical repair is directed at relieving the right ventricular outflow tract obstruction (RVOTO) and has evolved over time from the frequent use of transannular patch enlargement (TAPE) of the pulmonary valve annulus (PVA), to the more recent trend of conservation of the PVA using valve-sparing surgical techniques. This is latter technique is preferred to avoid serious and progressive complications associated with TAPE. The decision on TAPE is primarily base on the PVA z-score which is subject to variability across different surgeons and centers; as such, other parameters have been proposed and some determined to be better predictors of TAPE in ToF surgeries. Aim: To determine the predictors of transannular patch enlargement in ToF surgeries in a CHD specialist center. Methods: This was a retrospective analysis of all patient with ToF who presented at a major CHD center - the Sri Sathya Sai Sanjeevani Hospital (SSSSH), in Raipur India between July 2018 to April 2019. Parameters sought and obtained included patients’ demographics, anthropometry and echocardiographic parameters. The z-scores and other derivable variables were calculated and entered into a data base. Analysis using SPSS was done. Descriptive statistics was used to represent continuous variables in means, medians and ranges while categorical variables were represented in bar chats. Analysis of variance was done among group means. Results: There were 135 patients with age range from 7months to 199 months, with more males 89 (65.9%). TAPE was done in 36(26.7%). The aortic valve diameter (18.3 Vs 20mm, p=0.037), Pulmonary valve diameter (10.1 vs 12.0mm, P=0.003), and pulmonary valve Z-score (-2.48 vs -1.47, p=0.011) were significantly smaller for the group that received TAPE. Univariate analysis of the great artery ratio (PVA/AoV) did not significantly predict TAPE use. However, a GA ratio of < 0.54 was significantly associated with a higher likelihood of having TAPE, odds ratio 2.37(CI: 1.47 to 3.9). Multivariate logistic for use of TAPE in TOF explained 15% (R2) of the variance seen in the use of TAPE and correctly predicted 70.8% of the children with TOF who received TAPE. The area under curve for predictability of who received TAPE was 65% (95% CI 53.5% to 76.6. Conclusion: The PVA diameter, Aortic valve diameter and PVA z-score are predictors of TAPE. A GA ratio < 0.54 increases the likelihood of TAPE. Clinical parameters are not useful as determinants of TAPE.

Echocardiographic comparison between pulmonary valve preservation and transannular patch techniques in children with repaired Tetralogy of Fallot

Funding Acknowledgements Type of funding sources: None. INTRODUCTION Many centers have recently adopted pulmonary valve (PV) preservation procedures to prevent the detrimental long-term effects of chronic pulmonary regurgitation after tetralogy of Fallot (ToF) repair. PURPOSE The aim of our study was to investigate pulmonary valve (PV) and right ventricular function by echocardiography in paediatric patients with repaired Tetralogy of Fallot (ToF), comparing PV preservation surgical strategies to standard transannular patch (TAP) repair. METHODS All patients undergoing transatrial-transpulmonary repair for ToF at our institution between January 2007 and May 2020 were reviewed retrospectively. Patients were divided into 2 main groups, according to the different techniques used: patients undergoing a PV preservation strategy and patients undergoing TAP repair. All patients underwent standard echo-Doppler study including RV end-diastolic area (RVEDA), end-systolic area (RVESA), fractional area change (FAC) and TAPSE; PR was assessed by Color Doppler, continuous-wave (CW) Doppler and derived parameters such as pressure half time (PHT) and pulmonary regurgitation (PR) index. By speckle tracking we measured also, in a subgroup of patients, right atrial strain (RAS), RV and left ventricle (LV) global longitudinal strain (RVGLS, LVGLS) and their time to peak (TTP) values. RESULTS Overall, 82 patients underwent a successful PV preservation strategy while 34 underwent a standard TAP repair. At index surgery, BSA (0.31 ± 0.1 m2, P = 0.3), age (4.8 ± 0.3 months, P = 0.5) and preoperative PV Z-score (-3.20 ± 0.1, P = 0.1) did not different between groups. Five-year actuarial freedom from moderate/severe PV regurgitation was significantly higher in the PV preservation group compared to the TAP (61.3% [95% CI: 48-73%] vs 25.9% [95% CI: 12-43%], respectively; p = 0.02). After adjusting for age, gender, BSA, and type of PV, the use of a TAP was still significantly associated with an increased risk for PV regurgitation at follow up (HR: 1.85, 95% CI: 1.09, 3.15; p = 0.02). At a mean follow-up of 6.9 ± 0.3 years, patients undergoing PV preservation showed an increased right ventricular fractional area change (46.9 ± 0.8% vs 42.5 ± 1.7%, P &lt; 0.001) and tricuspid annular plane systolic excursion (TAPSE) z-score (-3.36 ± 0.3% vs -4.7 ± 0.4%, P = 0.005), while maintaining better PV competence in terms of pulmonary regurgitation index (87.9 ± 1.2% vs 82.7 ± 2.4%, P = 0.02). At speckle tracking subanalysis, patients undergoing PV preservation (n= 23), compared to the TAP group (n = 13) showed also higher values of RAS (37.5 ± 6.0% vs 29.3 ± 8.2% , P &lt; 0.006), shorter right TTP (319 ± 39ms vs 357.5 ± 45.2 ms, P &lt; 0.01) and higher values of LVGLS (-20,6 ± 4,2% vs -17.5 ± 3.0, P &lt; 0.03). CONCLUSIONS Surgical repair of ToF with PV preservation provides excellent outcomes in terms of PV competence and right ventricular function and should be advocated whenever possible. Abstract Figure. Degree of pulmonary regurgitation