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Title RISK-BENEFIT RATIO MAY NOT JUSTIFY A FURTHER DECREASE IN THRESHOLD FOR PULMONARY VALVE REPLACEMENT LATE AFTER TETRALOGY OF FALLOT REPAIR: AN EXPERIENCE WITH 2579 PATIENTS |
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Type Free Paper Session 3 |
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Theme ACC Asia & SCS 32nd Annual Scientific Meeting |
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Topic Non-Invasive Cardiac Imaging, Echocardiography, Nuclear Cardiology / Adult Congenital Heart Disease / Cardiac Surgery |
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Main Author Perryn Ng1 |
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Presenting Author Perryn Ng1 |
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Co-Author Ting Ting Low1 Susan L Roche2 Edward J Hickey2 |
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Department / Institution / Country National University Heart Centre, Singapore / National University Health System / Singapore1 Cardiology / Toronto General Hospital / Canada2 |
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Objective(s) Recommended thresholds for pulmonary valve replacement (PVR) in asymptomatic patients after tetralogy of Fallot (TOF) repair are continually decreasing. We studied the natural history versus outcomes after PVR in various categories of indexed right ventricular end-diastolic volume (RVEDVi). |
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Material and Method Acquisition of all repeated measure datapoints and cross-sectional review in 2579 patients (born 1924 - 2011), including 7553 echos, 2579 MRI scans and all interventional data. Analysis was via parametric competing risks techniques and time-related regressions adjusted for repeated measures. |
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Result(s) Survival was 95%, 81% and 73% at age 20, 40 and 60 years respectively. Freedom from PVR (N=516, mean age 25 years) was 87%, 66% and 45% at 20, 40 and 60 years. Overall, survival after PVR was 98%, 95% and 87% at 1, 10 and 20 years. PVR-free survival in all 345 patients with MRI RVEDVi > 150 was 95% at 15 years. Comparative survival showed no survival advantage with PVR versus natural history for RVEDVi 150-160, 160-170, 170-180; these categories had excellent PVR-free survival approaching 100% at 10 years. Patients with RVEDVi > 200 had late survival decrements with PVR or without. PVR resulted in a large and significant reduction in RVEDVi (mean 40 ml/m2, P<.0001), after which RVEDVi remained stable (P=.10). Patients with RVEDVi 150-160, 160-170 or 170-180 had similar reductions in RVEDVi after PVR to comparable levels. 35% of children transitioning to adult care had RVEDVi > 150 ml/m2 |
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Conclusion Lowering the RVEDVi threshold for PVR does not appear to offer a clear survival advantage and offers small differences (if any) to RV geometry, potential procedure-related morbidity and endocarditis risk and would mean intervening on many teenagers with repaired TOF who could otherwise anticipate intervention in later life. |