Valve-sparing repair (VSR) of tetralogy of Fallot (TOF) tends to result in higher
residual right ventricular outflow tract (RVOT) gradients. We evaluated the progression
and clinical implications of RVOT gradients following VSR of TOF. Demographic, clinical,
and operative data were retrospectively collected from consecutive TOF patients who
underwent VSR at our institution between 01/2010 and 06/2021. RVOT gradient, pulmonary
valve annulus (PVA) diameter and Boston Z-scores were recorded from serial echocardiograms.
Data are presented as median and interquartile range or number and percentage. A total
of 156 children (boys 92, 59%) underwent VSR at 6.5 (4.9-8.4) months of age and 6.6
kg (5.6- 7.7) weight. There was 1 (0.6%) operative mortality. The remaining 155 patients
were followed for 69.4 months (4-106.2). RVOT gradient was 2.4m/s (1.7-2.9) at discharge.
It transiently increased, then declined and stabilized during follow-up. PVA Z-score
was -1.7 (-3.1 to 0.5) at discharge and ‘grew’ to -0.8 (-1.7 to 0.4) at last follow-up.
Freedom from RVOT re-intervention was 97%, 94% and 91% at 1, 5 and 10-year follow-up.
Among 67 (43%) patients with PVA Z-score < -2, a similar RVOT gradient pattern was
observed and freedom from RVOT re-intervention was 97%, 95% and 95% at 1, 5 and 8-year
follow-up. Following VSR of TOF, RVOT gradients transiently increase and then fall
as PVA growth catches up, resulting in durable intermediate outcomes. Patients with
PVA Z-score < -2 demonstrated a similar pattern of hemodynamics in the RVOT and excellent
freedom from reintervention.
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Graphical Abstract
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Article info
Publication history
Published online: December 22, 2022
Publication stage
In Press Journal Pre-ProofFootnotes
Conflicts of Interest: None
Funding: The National Heart Lung and Blood Institute of the National Institutes of Health partially support O.T. by grant F30HL154324 and S.R.K. by grant R03HL154301.
Ethics Approval: The Institutional Review Board of Children's Hospital Los Angeles approved this study (CHLA-21-00275) on October 21, 2021, and waived the requirement for patient consent.
Meeting Presentation: This work was presented as a podium presentation at the 48th Annual Meeting of the Western Thoracic Surgical Association, June 22-25, 2022.
Clinical Trial Registry Number: Not applicable
Read at the 48th Annual Meeting of the Western Thoracic Surgical Association, June 22 - 25, 2022, Koloa, Hawaii. This manuscript was handled by Associate Editor, Dr. Robert D.B. Jaquiss.
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© 2022 Elsevier Inc. All rights reserved.
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- Commentary: The Many Shades of Gradient After Repair of Tetralogy of FallotSeminars in Thoracic and Cardiovascular Surgery
- PreviewWe continue to refine the management of tetralogy of Fallot (TOF) decades after initial surgical treatment was first described in the 1950s. The focus has shifted from relief of gradient and cyanosis to long-term health of the right ventricle. Pertinent to right ventricular health is afterload and preload conditions on the right ventricle and the duration of adverse loading condition. An expert consensus document produced by the American Association of Thoracic Surgery outlined patient selection and follow-up after valve sparing repair.
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