Jonathan W. Cramer, MD, Salil Ginde, MD, Garick D. Hill, MD, Scott B. Cohen, MD, Peter J. Bartz, MD, James S. Tweddell, MD, and Michael G. Earing, MD Departments of Pediatrics, Division of Cardiology, Internal Medicine, Division of Adult Cardiovascular Medicine, and Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
Background. Chronic pulmonary regurgitation after tetralogy of Fallot repair often leads to progressive right ventricle dilation, dysfunction, and frequently, pulmonary valve replacement. For those with significant tricuspid regurgitation at the time of pulmonary valve replacement, it is unknown whether concomitant tricuspid valve repair improves postoperative outcomes. Methods. This is a retrospective review of patients after tetralogy of Fallot repair who underwent pulmonary valve replacement between 1999 and 2012. Preoperative and postoperative echocardiograms were assessed for tricuspid regurgitation (vena contracta) and right ventricular size and function (Tomtec software). Results. Sixty-two patients underwent pulmonary valve replacement. Thirty-six (58%) had greater than or equal to moderate tricuspid regurgitation on preoperative echocardiogram. Significant predictors were not identified. Of the 36, 18 (50%) underwent concomitant tricuspid valve repair at the time of pulmonary valve replacement. After
surgery, there was a significant reduction in the degree of tricuspid regurgitation (p < 0.001) and measures of right ventricular size (p < 0.05) in both cohorts. Between surgical groups, there was no statistical difference in the grade of tricuspid regurgitation (p [ 0.47) or measures of right ventricular size (p > 0.4) at 6-month follow-up. Conclusions. Tricuspid regurgitation is a common finding in repaired tetralogy of Fallot, although risk factors for its development remain unclear. After pulmonary valve replacement with or without tricuspid valve repair there is significant improvement in the degree of tricuspid regurgitation and right ventricular size. Finally, 6 months after pulmonary valve replacement there were no statistical differences between those patients undergoing concomitant tricuspid valve repair and those undergoing pulmonary valve replacements alone.
N
supportive structure or damage to the leaflets and subvalvular apparatus at the time of repair. Previous studies have indicated that as many as 13% to 41% of patients with repaired TOF undergoing PVR will undergo a concomitant tricuspid valve repair (TVR) for tricuspid regurgitation [5–9]. However, it is unknown whether concomitant TVR at the time of PVR improves RV size, tricuspid valve (TV) annular size, or TV function when compared with PVR alone. The goals of our study were the following: (1) to evaluate for risk factors in the development of greater than or equal to moderate tricuspid regurgitation in patients with repaired TOF; and (2) to compare the outcomes (RV size, RV function, and TV function) of TOF patients with greater than or equal to moderate tricuspid regurgitation who underwent PVR with and without TVR.
umerous studies now show excellent long-term survival after surgical repair of tetralogy of Fallot (TOF) [1, 2]. Given the initial surgical repair often involves disruption of the pulmonary valve (PV), severe pulmonary regurgitation is a common late finding. The right ventricular volume overload from chronic severe pulmonary regurgitation can result in progressive right ventricle (RV) dilation, RV dysfunction, arrhythmias, and sudden cardiac death [3]. Because of this, pulmonary valve replacement (PVR) is now the most common cause for late reoperation in TOF patients and is often indicated in an attempt to prevent many of these long-term complications [4]. Tricuspid regurgitation is also a common long-term complication in patients with repaired TOF [5]. Progressive RV dilation due to severe pulmonary regurgitation can lead to tricuspid annular dilation and “functional tricuspid regurgitation,” which may accelerate RV volume overloading and dilation. Other common causes for tricuspid regurgitation after TOF repair include intrinsic abnormalities of the tricuspid valve leaflets and its
(Ann Thorac Surg 2015;99:899–904) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods After receiving Institutional Review Board approval, we identified those patients greater than 16 years of age with
Accepted for publication Sept 23, 2014. Address correspondence to Dr Earing, Children’s Hospital of Wisconsin, 9000 W Wisconsin Ave, MS 713, Milwaukee, WI 53226; e-mail: mearing@ chw.org.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Dr Tweddell discloses a financial relationship with CorMatrix.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.09.086
CONGENITAL HEART
Tricuspid Repair at Pulmonary Valve Replacement Does Not Alter Outcomes in Tetralogy of Fallot
CONGENITAL HEART
900
CRAMER ET AL TRICUSPID REPAIR AT PULMONARY REPLACEMENT
a history of TOF who underwent reintervention consisting of PVR between the years 1999 and 2012 at our institution. Those with additional significant congenital heart disease, such as atrioventricular canal or pulmonary atresia with ventricular septal defect, were excluded from this study. Surgical repair was performed by 1 of 5 congenital heart surgeons from within our institution. The cohort was then divided into those patients who underwent PVR alone and those patients who underwent PVR with concurrent TVR. The decision to perform TVR at the time of PVR was largely based on referring cardiologist and surgeon preference at the time of PVR. Descriptive data obtained from chart review included the patients’ date of birth, date of original TOF repair, date of PVR, date of last follow-up, sex, prior palliative procedures, type of pulmonary valve disruption, and any additional procedures done at the time of PVR. Echocardiograms prior to PVR and 6 months postoperative were individually reviewed and used to assess pulmonary and tricuspid valve function, as well as RV size and function. Both pulmonary and tricuspid regurgitation were scored on a scale from 0 to 3 (0, none; 1, mild; 2, moderate; 3, severe). The degree of pulmonary regurgitation was quantified on a scale of 0 to 3 (0, none; 1, mild; 2, moderate; 3, severe). The degree of tricuspid regurgitation was graded based on the vena contracta diameter of the tricuspid regurgitant jet in the standard apical 4-chamber window. A vena contracta diameter of greater than 6 mm was classified as severe, a diameter of 4 to 6 mm was classified as moderate, and a diameter of less than 4 was mild [10–12]. The TV annulus was measured in the standard apical 4-chamber view. Software from Tomtec Imaging Systems (Munich, Germany), was used to obtain three-dimensional RV area and volumes in both end-diastole and end-systole (RVEDV and RVESV). These volumes were then used to obtain an RV ejection fraction [13]. In patients with significant tricuspid regurgitation, we compared the postoperative echocardiographic parameters of those receiving PVR alone to those patients who underwent PVR with concomitant TVR. Univariate and multivariable analysis were performed to assess for potential risk factors for the development of significant preoperative tricuspid regurgitation (defined as moderate regurgitation) using the c2 test for categoric variables and Wilcoxon rank sum or t test for continuous variables. Multivariable analysis was performed using logistic regression. Data are expressed as mean standard deviation or median with range as appropriate. A p value less than 0.05 was considered statistically significant.
Results Baseline Characteristics There were 62 patients identified from within our surgical database with a history TOF who had undergone PVR replacement from 1999 to 2012. The patient characteristics are shown in Table 1. The majority of the patients were male (36, 58%). The median age at the time of original
Ann Thorac Surg 2015;99:899–904
Table 1. Patient Characteristics (n ¼ 62) Variable Male Prior palliative shunt(s) Blalock-Tausig Watterson Potts Age at TOF repair (y) Type of initial repair Transannular patch Valvotomy Age at PVR (y) Interval Time Type of PVR Bioprosthetic valve Conduit Moderate TR Concomitant procedures TV repair Ring annuloplasty De Vega repair Other/combination Maze procedure Early postop deaths Late postop deaths
N
%
36 21 16 6 1 2.9
(58%) (34%)
[1d–21.7y]
50 12 28.8 25.5
(81%) (19%) [16–67] [15–52]
57 5 36
(92%) (8%) (58%)
18 11 4 3 12 0 1
(29%) (61%) (22%) (17%) (19%) (0%) (1.6%)
d ¼ days; postop ¼ postoperative; replacement; TOF ¼ tetralogy of Fallot; tation; y ¼ years.
PVR ¼ pulmonary valve TR ¼ tricuspid regurgi-
TOF repair was 2.9 years (1 day to 21.7 years). At the time of original TOF repair, 21 patients (34%) had undergone a prior palliative shunt, with a Blalock-Taussig (BT) shunt being most common. Two patients had undergone both a BT shunt and a Waterston shunt. At the time of original repair, the majority of patients underwent right ventricular outflow tract reconstruction using a transannular patch (50, 81%). The remaining patients (12, 19%) underwent outflow tract reconstruction using surgical pulmonary valvotomy with preservation of the annulus. At the time of PVR, the median age was 28.8 years (range 16 to 67 years). Average length of follow-up from original repair was 25.5 years (range 15 to 52 years). For the 62 patients in the cohort, 42 underwent pulmonary valve replacement with a heterograft (either stented bioprosthetic valves or porcine valved conduits) and 20 had replacement with homograft pulmonary valves. Indications for PVR included symptomatic right heart failure, severe pulmonary valve regurgitation, right ventricular dilation, and reduced right ventricular function. Patients who underwent PVR for the primary indications of severe residual pulmonary stenosis or right ventricular outflow tract obstruction were excluded from the study. However, of the 62 patients in the study cohort, 57 had no significant RV outflow tract obstruction by preoperative echocardiogram, 4 patients had mild residual RV outflow tract obstruction (peak echocardiographic gradient of 20 to 40 mm Hg), and 1 patient had moderate residual RV outflow tract obstruction (peak gradient 40 to 60 mm Hg). No
Ann Thorac Surg 2015;99:899–904
CRAMER ET AL TRICUSPID REPAIR AT PULMONARY REPLACEMENT
901
Table 2. Risk Factor Assessment for Significant ( Moderate) Tricuspid Regurgitation at the Time of Pulmonary Valve Replacement Moderate TR (n ¼ 36)
Characteristic
14 4.8 35.1 30.3 30.3 166.3 76.2 0.542
(39%) ( 4.9) ( 13.7) ( 11.0) ( 3.1) ( 61.1) ( 36.8) ( 0.119)
7 3.6 29.0 25.4 30.2 175.2 81.1 0.5650
p Value
(27%) ( 4.3) ( 12.4) ( 9.2) ( 4.2) ( 57.0) ( 29.9) ( 0.113)
0.42 0.28 0.07 0.06 0.57 0.56 0.56 0.82
Preop ¼ preoperative; PVR ¼ pulmonary valve replacement; RVEDV ¼ right ventricle end-diastolic volume; RVEF ¼ right ventricle ejection fraction; RVESV ¼ right ventricle end-systolic volume; TOF ¼ tetralogy of Fallot; TR ¼ tricuspid regurgitation; TV ¼ tricuspid valve; y ¼ years.
patient had severe RV outflow tract stenosis preoperatively. Of the 62 patients who underwent PVR, 36 patients (58%) had significant tricuspid regurgitation at the time of PVR.
Predictors of Significant Tricuspid Regurgitation To identify risk factors for significant tricuspid regurgitation at time of PVR, we compared the 36 patients with significant tricuspid regurgitation to those without (n ¼ 26). By univariate analysis there was a trend for patients with significant tricuspid regurgitation to be older (35 versus 29 years, p ¼ 0.06) and to have a longer length of follow-up (35.1 13.7 years vs 29.0 12.4 years, p ¼ 0.07) at the time of PVR. However, these factors did not reach statistical significance (Table 2). Other variables analyzed included the presence of a palliative shunt prior to TOF repair and age at TOF repair. Echocardiographic variables analyzed included preoperative assessments of TV annulus diameter, RV end diastolic volume, RV end systolic volume, and RV ejection fraction.
Effect of PVR Alone Versus PVR With Concurrent TV Repair After PVR there were no early deaths and no deaths at 6-month follow-up. The preoperative and postoperative
echocardiographic characteristics for the 36 patients with significant tricuspid regurgitation at the time of PVR and for the 26 patients without tricuspid regurgitation are summarized in Table 3. Echocardiographic variables assessed prior to and after PVR included grade of pulmonary and tricuspid regurgitation, TV annulus diameter, RV end diastolic volume, RV end systolic volume, RV end diastolic area, RV end systolic area, and RV ejection fraction. For patients in both cohorts there was statistically significant improvement in the pulmonary regurgitation grade, TV annular diameter, grade of tricuspid regurgitation, and measures of right ventricular volume and area after PVR (Table 3). There was no significant association between type of pulmonary valve replacement (heterograft versus homograft) and grade of pulmonary valve regurgitation at 6-month follow-up. To further evaluate the impact of PVR alone versus PVR with concurrent TVR, we further divided the 36 patients with significant tricuspid regurgitation at the time of PVR into those who underwent PVR alone (18 [50%]) and those who underwent concurrent TVR (18 (50%)). For those patients who underwent TVR, 11 patients underwent ring annuloplasty, 4 underwent De Vega stitch annuloplasty, and 3 patients underwent some
Table 3. Preoperative and Postoperative Echocardiographic Measures of Those Patients Undergoing Pulmonary Valve Replacement Alone and Those Patients Undergoing Pulmonary Valve Replacement With Concurrent Tricuspid Valve Repair PVR Alone (n ¼ 18) Variable PR gradea TR gradea TV annular (cm) RVEDV (mL) RVESV (mL) RVEDA (cm2) RVESA (cm2) RVEF a
Preop 3.0 2.2 29.5 157.3 73.2 36.2 25.1 0.523
0 0.4 4 60 45 12 8.6 0.11
PVR With TVR (n ¼ 18)
6-Months Postop
p Value
Background. Chronic pulmonary regurgitation after tetralogy of Fallot repair often leads to progressive right ventricle dilation, dysfunction, and frequently, pulmonary valve replacement. For those with significant tricuspid regurgitation at the time of pulmonary valve replacement, it is unknown whether concomitant tricuspid valve repair improves postoperative outcomes. Methods. This is a retrospective review of patients after tetralogy of Fallot repair who underwent pulmonary valve replacement between 1999 and 2012. Preoperative and postoperative echocardiograms were assessed for tricuspid regurgitation (vena contracta) and right ventricular size and function (Tomtec software). Results. Sixty-two patients underwent pulmonary valve replacement. Thirty-six (58%) had greater than or equal to moderate tricuspid regurgitation on preoperative echocardiogram. Significant predictors were not identified. Of the 36, 18 (50%) underwent concomitant tricuspid valve repair at the time of pulmonary valve replacement. After
surgery, there was a significant reduction in the degree of tricuspid regurgitation (p < 0.001) and measures of right ventricular size (p < 0.05) in both cohorts. Between surgical groups, there was no statistical difference in the grade of tricuspid regurgitation (p [ 0.47) or measures of right ventricular size (p > 0.4) at 6-month follow-up. Conclusions. Tricuspid regurgitation is a common finding in repaired tetralogy of Fallot, although risk factors for its development remain unclear. After pulmonary valve replacement with or without tricuspid valve repair there is significant improvement in the degree of tricuspid regurgitation and right ventricular size. Finally, 6 months after pulmonary valve replacement there were no statistical differences between those patients undergoing concomitant tricuspid valve repair and those undergoing pulmonary valve replacements alone.
N
supportive structure or damage to the leaflets and subvalvular apparatus at the time of repair. Previous studies have indicated that as many as 13% to 41% of patients with repaired TOF undergoing PVR will undergo a concomitant tricuspid valve repair (TVR) for tricuspid regurgitation [5–9]. However, it is unknown whether concomitant TVR at the time of PVR improves RV size, tricuspid valve (TV) annular size, or TV function when compared with PVR alone. The goals of our study were the following: (1) to evaluate for risk factors in the development of greater than or equal to moderate tricuspid regurgitation in patients with repaired TOF; and (2) to compare the outcomes (RV size, RV function, and TV function) of TOF patients with greater than or equal to moderate tricuspid regurgitation who underwent PVR with and without TVR.
umerous studies now show excellent long-term survival after surgical repair of tetralogy of Fallot (TOF) [1, 2]. Given the initial surgical repair often involves disruption of the pulmonary valve (PV), severe pulmonary regurgitation is a common late finding. The right ventricular volume overload from chronic severe pulmonary regurgitation can result in progressive right ventricle (RV) dilation, RV dysfunction, arrhythmias, and sudden cardiac death [3]. Because of this, pulmonary valve replacement (PVR) is now the most common cause for late reoperation in TOF patients and is often indicated in an attempt to prevent many of these long-term complications [4]. Tricuspid regurgitation is also a common long-term complication in patients with repaired TOF [5]. Progressive RV dilation due to severe pulmonary regurgitation can lead to tricuspid annular dilation and “functional tricuspid regurgitation,” which may accelerate RV volume overloading and dilation. Other common causes for tricuspid regurgitation after TOF repair include intrinsic abnormalities of the tricuspid valve leaflets and its
(Ann Thorac Surg 2015;99:899–904) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods After receiving Institutional Review Board approval, we identified those patients greater than 16 years of age with
Accepted for publication Sept 23, 2014. Address correspondence to Dr Earing, Children’s Hospital of Wisconsin, 9000 W Wisconsin Ave, MS 713, Milwaukee, WI 53226; e-mail: mearing@ chw.org.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Dr Tweddell discloses a financial relationship with CorMatrix.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.09.086
CONGENITAL HEART
Tricuspid Repair at Pulmonary Valve Replacement Does Not Alter Outcomes in Tetralogy of Fallot
CONGENITAL HEART
900
CRAMER ET AL TRICUSPID REPAIR AT PULMONARY REPLACEMENT
a history of TOF who underwent reintervention consisting of PVR between the years 1999 and 2012 at our institution. Those with additional significant congenital heart disease, such as atrioventricular canal or pulmonary atresia with ventricular septal defect, were excluded from this study. Surgical repair was performed by 1 of 5 congenital heart surgeons from within our institution. The cohort was then divided into those patients who underwent PVR alone and those patients who underwent PVR with concurrent TVR. The decision to perform TVR at the time of PVR was largely based on referring cardiologist and surgeon preference at the time of PVR. Descriptive data obtained from chart review included the patients’ date of birth, date of original TOF repair, date of PVR, date of last follow-up, sex, prior palliative procedures, type of pulmonary valve disruption, and any additional procedures done at the time of PVR. Echocardiograms prior to PVR and 6 months postoperative were individually reviewed and used to assess pulmonary and tricuspid valve function, as well as RV size and function. Both pulmonary and tricuspid regurgitation were scored on a scale from 0 to 3 (0, none; 1, mild; 2, moderate; 3, severe). The degree of pulmonary regurgitation was quantified on a scale of 0 to 3 (0, none; 1, mild; 2, moderate; 3, severe). The degree of tricuspid regurgitation was graded based on the vena contracta diameter of the tricuspid regurgitant jet in the standard apical 4-chamber window. A vena contracta diameter of greater than 6 mm was classified as severe, a diameter of 4 to 6 mm was classified as moderate, and a diameter of less than 4 was mild [10–12]. The TV annulus was measured in the standard apical 4-chamber view. Software from Tomtec Imaging Systems (Munich, Germany), was used to obtain three-dimensional RV area and volumes in both end-diastole and end-systole (RVEDV and RVESV). These volumes were then used to obtain an RV ejection fraction [13]. In patients with significant tricuspid regurgitation, we compared the postoperative echocardiographic parameters of those receiving PVR alone to those patients who underwent PVR with concomitant TVR. Univariate and multivariable analysis were performed to assess for potential risk factors for the development of significant preoperative tricuspid regurgitation (defined as moderate regurgitation) using the c2 test for categoric variables and Wilcoxon rank sum or t test for continuous variables. Multivariable analysis was performed using logistic regression. Data are expressed as mean standard deviation or median with range as appropriate. A p value less than 0.05 was considered statistically significant.
Results Baseline Characteristics There were 62 patients identified from within our surgical database with a history TOF who had undergone PVR replacement from 1999 to 2012. The patient characteristics are shown in Table 1. The majority of the patients were male (36, 58%). The median age at the time of original
Ann Thorac Surg 2015;99:899–904
Table 1. Patient Characteristics (n ¼ 62) Variable Male Prior palliative shunt(s) Blalock-Tausig Watterson Potts Age at TOF repair (y) Type of initial repair Transannular patch Valvotomy Age at PVR (y) Interval Time Type of PVR Bioprosthetic valve Conduit Moderate TR Concomitant procedures TV repair Ring annuloplasty De Vega repair Other/combination Maze procedure Early postop deaths Late postop deaths
N
%
36 21 16 6 1 2.9
(58%) (34%)
[1d–21.7y]
50 12 28.8 25.5
(81%) (19%) [16–67] [15–52]
57 5 36
(92%) (8%) (58%)
18 11 4 3 12 0 1
(29%) (61%) (22%) (17%) (19%) (0%) (1.6%)
d ¼ days; postop ¼ postoperative; replacement; TOF ¼ tetralogy of Fallot; tation; y ¼ years.
PVR ¼ pulmonary valve TR ¼ tricuspid regurgi-
TOF repair was 2.9 years (1 day to 21.7 years). At the time of original TOF repair, 21 patients (34%) had undergone a prior palliative shunt, with a Blalock-Taussig (BT) shunt being most common. Two patients had undergone both a BT shunt and a Waterston shunt. At the time of original repair, the majority of patients underwent right ventricular outflow tract reconstruction using a transannular patch (50, 81%). The remaining patients (12, 19%) underwent outflow tract reconstruction using surgical pulmonary valvotomy with preservation of the annulus. At the time of PVR, the median age was 28.8 years (range 16 to 67 years). Average length of follow-up from original repair was 25.5 years (range 15 to 52 years). For the 62 patients in the cohort, 42 underwent pulmonary valve replacement with a heterograft (either stented bioprosthetic valves or porcine valved conduits) and 20 had replacement with homograft pulmonary valves. Indications for PVR included symptomatic right heart failure, severe pulmonary valve regurgitation, right ventricular dilation, and reduced right ventricular function. Patients who underwent PVR for the primary indications of severe residual pulmonary stenosis or right ventricular outflow tract obstruction were excluded from the study. However, of the 62 patients in the study cohort, 57 had no significant RV outflow tract obstruction by preoperative echocardiogram, 4 patients had mild residual RV outflow tract obstruction (peak echocardiographic gradient of 20 to 40 mm Hg), and 1 patient had moderate residual RV outflow tract obstruction (peak gradient 40 to 60 mm Hg). No
Ann Thorac Surg 2015;99:899–904
CRAMER ET AL TRICUSPID REPAIR AT PULMONARY REPLACEMENT
901
Table 2. Risk Factor Assessment for Significant ( Moderate) Tricuspid Regurgitation at the Time of Pulmonary Valve Replacement Moderate TR (n ¼ 36)
Characteristic
14 4.8 35.1 30.3 30.3 166.3 76.2 0.542
(39%) ( 4.9) ( 13.7) ( 11.0) ( 3.1) ( 61.1) ( 36.8) ( 0.119)
7 3.6 29.0 25.4 30.2 175.2 81.1 0.5650
p Value
(27%) ( 4.3) ( 12.4) ( 9.2) ( 4.2) ( 57.0) ( 29.9) ( 0.113)
0.42 0.28 0.07 0.06 0.57 0.56 0.56 0.82
Preop ¼ preoperative; PVR ¼ pulmonary valve replacement; RVEDV ¼ right ventricle end-diastolic volume; RVEF ¼ right ventricle ejection fraction; RVESV ¼ right ventricle end-systolic volume; TOF ¼ tetralogy of Fallot; TR ¼ tricuspid regurgitation; TV ¼ tricuspid valve; y ¼ years.
patient had severe RV outflow tract stenosis preoperatively. Of the 62 patients who underwent PVR, 36 patients (58%) had significant tricuspid regurgitation at the time of PVR.
Predictors of Significant Tricuspid Regurgitation To identify risk factors for significant tricuspid regurgitation at time of PVR, we compared the 36 patients with significant tricuspid regurgitation to those without (n ¼ 26). By univariate analysis there was a trend for patients with significant tricuspid regurgitation to be older (35 versus 29 years, p ¼ 0.06) and to have a longer length of follow-up (35.1 13.7 years vs 29.0 12.4 years, p ¼ 0.07) at the time of PVR. However, these factors did not reach statistical significance (Table 2). Other variables analyzed included the presence of a palliative shunt prior to TOF repair and age at TOF repair. Echocardiographic variables analyzed included preoperative assessments of TV annulus diameter, RV end diastolic volume, RV end systolic volume, and RV ejection fraction.
Effect of PVR Alone Versus PVR With Concurrent TV Repair After PVR there were no early deaths and no deaths at 6-month follow-up. The preoperative and postoperative
echocardiographic characteristics for the 36 patients with significant tricuspid regurgitation at the time of PVR and for the 26 patients without tricuspid regurgitation are summarized in Table 3. Echocardiographic variables assessed prior to and after PVR included grade of pulmonary and tricuspid regurgitation, TV annulus diameter, RV end diastolic volume, RV end systolic volume, RV end diastolic area, RV end systolic area, and RV ejection fraction. For patients in both cohorts there was statistically significant improvement in the pulmonary regurgitation grade, TV annular diameter, grade of tricuspid regurgitation, and measures of right ventricular volume and area after PVR (Table 3). There was no significant association between type of pulmonary valve replacement (heterograft versus homograft) and grade of pulmonary valve regurgitation at 6-month follow-up. To further evaluate the impact of PVR alone versus PVR with concurrent TVR, we further divided the 36 patients with significant tricuspid regurgitation at the time of PVR into those who underwent PVR alone (18 [50%]) and those who underwent concurrent TVR (18 (50%)). For those patients who underwent TVR, 11 patients underwent ring annuloplasty, 4 underwent De Vega stitch annuloplasty, and 3 patients underwent some
Table 3. Preoperative and Postoperative Echocardiographic Measures of Those Patients Undergoing Pulmonary Valve Replacement Alone and Those Patients Undergoing Pulmonary Valve Replacement With Concurrent Tricuspid Valve Repair PVR Alone (n ¼ 18) Variable PR gradea TR gradea TV annular (cm) RVEDV (mL) RVESV (mL) RVEDA (cm2) RVESA (cm2) RVEF a
Preop 3.0 2.2 29.5 157.3 73.2 36.2 25.1 0.523
0 0.4 4 60 45 12 8.6 0.11
PVR With TVR (n ¼ 18)
6-Months Postop
p Value
