Immediate and Midterm Cardiac Remodeling After Surgical Pulmonary Valve Replacement in Adults With Repaired Tetralogy of Fallot: A Prospective Cardiovascular Magnetic Resonance and Clinical Study

Ee Ling Heng, Michael A Gatzoulis, Anselm Uebing, Babulal Sethia, Hideki Uemura, Gillian C Smith, Gerhard-Paul Diller, Karen P McCarthy, Siew Yen Ho, Wei Li, Piers Wright, Veronica Spadotto, Philip J Kilner, Paul Oldershaw, Dudley J Pennell, Darryl F Shore, Sonya V Babu-Narayan, Ee Ling Heng, Michael A Gatzoulis, Anselm Uebing, Babulal Sethia, Hideki Uemura, Gillian C Smith, Gerhard-Paul Diller, Karen P McCarthy, Siew Yen Ho, Wei Li, Piers Wright, Veronica Spadotto, Philip J Kilner, Paul Oldershaw, Dudley J Pennell, Darryl F Shore, Sonya V Babu-Narayan

Abstract

Background: Pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot provides symptomatic benefit and right ventricular (RV) volume reduction. However, data on the rate of ventricular structural and functional adaptation are scarce. We aimed to assess immediate and midterm post-PVR changes and predictors of reverse remoeling.

Methods: Fifty-seven patients with repaired tetralogy of Fallot (age ≥16 y; mean age, 35.8±10.1 y; 38 male) undergoing PVR were prospectively recruited for cardiovascular magnetic resonance performed before PVR (pPVR), immediately after PVR (median, 6 d), and midterm after PVR (mPVR; median, 3 y).

Results: There were immediate and midterm reductions in indexed RV end-diastolic volumes and RV end-systolic volumes (RVESVi) (indexed RV end-diastolic volume pPVR versus immediately after PVR versus mPVR, 156.1±41.9 versus 104.9±28.4 versus 104.2±34.4 mL/m2; RVESVi pPVR versus immediately after PVR versus mPVR, 74.9±26.2 versus 57.4±22.7 versus 50.5±21.7 mL/m2; P<0.01). Normal postoperative diastolic and systolic RV volumes (the primary end point) achieved in 70% of patients were predicted by a preoperative indexed RV end-diastolic volume ≤158 mL/m2 and RVESVi ≤82 mL/m2. RVESVi showed a progressive decrease from baseline to immediate to midterm follow-up, indicating ongoing intrinsic RV functional improvement after PVR. Left ventricular ejection fraction improved (pPVR versus mPVR, 59.4±7.6% versus 61.9±6.8%; P<0.01), and right atrial reverse remodeling occurred (pPVR versus mPVR, 15.2±3.4 versus 13.8±3.6 cm2/m2; P<0.01). Larger preoperative RV outflow tract scar was associated with a smaller improvement in post-PVR RV/left ventricular ejection fraction. RV ejection fraction and peak oxygen uptake predicted mortality (P=0.03) over a median of 9.5 years of follow-up.

Conclusions: Significant right heart structural reverse remodeling takes place immediately after PVR, followed by a continuing process of further biological remodeling manifested by further reduction in RVESVi. PVR before RVESVi reaches 82 mL/m2 confers optimal chances of normalization of RV function.

Keywords: magnetic resonance imaging; pulmonary valve; tetralogy of Fallot; ventricular remodeling.

© 2017 The Authors.

Figures

Figure 1.
Figure 1.
Right heart cardiovascular magnetic resonance (CMR) parameters. Study time points: red, before pulmonary valve replacement (PVR); yellow, immediately after PVR within 14 days; green, at midterm follow-up after PVR. cRVEF indicates corrected right ventricular ejection fraction; RAAi, indexed right atrial area; RVEDVi, indexed right ventricular end-diastolic volume; RVEF, right ventricular ejection fraction; RVESVi, indexed right ventricular end-systolic volume; and RVOT akin., linear length of akinetic right ventricular outflow tract.
Figure 2.
Figure 2.
Receiver-operating characteristic curves illustrating threshold value. (A) Pre–pulmonary valve replacement (PVR) indexed right ventricular end-diastolic volume (RVEDVi) of 158 mL/m2 for normalization of RVEDVi and (B) pre-PVR indexed right ventricular end-systolic volume (RVESVi) of 82 mL/m2 for normalization of RVESVi. The 95% confidence intervals (CIs) for area under the curve (AUC) are given.

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