Gregory T Adamson1, Doff B McElhinney2, George Lui3, Alison K Meadows4, Joseph Rigdon5, Frank L Hanley6, Shiraz A Maskatia7. 1. Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif. Electronic address: gregadamson@stanford.edu. 2. Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif; Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif. 3. Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif; Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif. 4. Department of Cardiology, Kaiser San Francisco Medical Center, San Francisco, Calif. 5. Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, Calif. 6. Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif. 7. Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif.
Abstract
OBJECTIVES: Pulmonary valve (PV) regurgitation (PR) is common after intervention for a hypoplastic right ventricular outflow tract. Secondary PV repair is an alternative to replacement (PVR), but selection criteria are not established. We sought to elucidate preoperative variables associated with successful PV repair and to compare outcomes between repair and PVR. METHODS: Patients who underwent surgery for secondary PR from 2010 to 2017 by a single surgeon were studied. The PV annulus and leaflets were measured on the preoperative echocardiogram and magnetic resonance images, and the primary predictor variable was leaflet area indexed to ideal PV annulus area (iPLA) by magnetic resonance imaging. PV repair and PVR groups were compared using multivariable logistic regression, and with a conditional inference tree. Freedom from PV dysfunction and from reintervention were assessed with Kaplan-Meier survival analyses. RESULTS: Of 85 patients, 31 (36%) underwent PV repair. By multivariable analysis, longer PV total leaflet length (cm/m2) (β = 3.00, standard error [SE] = 0.82, P < .001), larger PV z score (β = 1.34, SE = 0.39, P = .001), and larger iPLA (β = 8.13, SE = 2.62, P = .002) were associated with repair. iPLA of 0.90 or greater was 91% sensitive and 83% specific for achieving PV repair. At a median of 4.1 years follow-up, there was greater freedom from significant PR in the PV repair group (log rank P = .008). CONCLUSIONS: Patients with an iPLA >0.9, and those with an iPLA between 0.7 and 0.9 with a PV annulus z score >0 should be considered for a native PV repair. At midterm follow-up, patients with a PV repair were not more likely to develop PR or to require reintervention when compared with patients undergoing PVR.
OBJECTIVES:Pulmonary valve (PV) regurgitation (PR) is common after intervention for a hypoplastic right ventricular outflow tract. Secondary PV repair is an alternative to replacement (PVR), but selection criteria are not established. We sought to elucidate preoperative variables associated with successful PV repair and to compare outcomes between repair and PVR. METHODS:Patients who underwent surgery for secondary PR from 2010 to 2017 by a single surgeon were studied. The PV annulus and leaflets were measured on the preoperative echocardiogram and magnetic resonance images, and the primary predictor variable was leaflet area indexed to ideal PV annulus area (iPLA) by magnetic resonance imaging. PV repair and PVR groups were compared using multivariable logistic regression, and with a conditional inference tree. Freedom from PV dysfunction and from reintervention were assessed with Kaplan-Meier survival analyses. RESULTS: Of 85 patients, 31 (36%) underwent PV repair. By multivariable analysis, longer PV total leaflet length (cm/m2) (β = 3.00, standard error [SE] = 0.82, P < .001), larger PV z score (β = 1.34, SE = 0.39, P = .001), and larger iPLA (β = 8.13, SE = 2.62, P = .002) were associated with repair. iPLA of 0.90 or greater was 91% sensitive and 83% specific for achieving PV repair. At a median of 4.1 years follow-up, there was greater freedom from significant PR in the PV repair group (log rank P = .008). CONCLUSIONS:Patients with an iPLA >0.9, and those with an iPLA between 0.7 and 0.9 with a PV annulus z score >0 should be considered for a native PV repair. At midterm follow-up, patients with a PV repair were not more likely to develop PR or to require reintervention when compared with patients undergoing PVR.