CONGENITAL – Original Submission|Articles in Press

Characterization of Favorable Right Ventricular Dimensions for Optimal Reverse Remodeling following Pulmonary Valve Replacement

Published:February 23, 2023DOI:

      Structured Abstract


      : We sought to couple current cardiac magnetic resonance (CMR) thresholds of right ventricular (RV) size and function with longitudinal trajectories of RV recovery, after pulmonary valve replacement (PVR). We aimed to identify optimal timing of PVR and couple CMR-based metrics with contemporaneous echocardiographic metrics.


      : From 6/2002 to 1/2019, 174 patients with severe pulmonary regurgitation and peak RV outflow tract gradient <30 mmHg underwent PVR at Cleveland Clinic. Mean age was 35±16 years and 60 (34%) had concomitant tricuspid valve surgery. RV end diastolic area index (RVEDAi) and function metrics were measured by offline image review on preoperative and 794 postoperative echocardiograms. Contemporaneous RV end diastolic volume index (RVEDVi) was assessed on CMR and correlated to RVEDAi. Multiphase nonlinear mixed-effects models were used to analyze the longitudinal change in RV size and function after PVR.


      : RVEDAi was correlated with RVEDVi (P<.0001, r=.59). RVEDAi decreased slowly over 10 years following PVR. An inflection point at 24 cm2/m2 was noted at 1 year post-PVR and was associated with failure of RV reverse remodelling and RVEDVi ≥ 150 ml/m2. Compared to patients with preoperative RVEDVi ≥ 150 mL/m2, patients with RVEDVi < 150 mL/m2 had accelerated recovery of longitudinal trajectories of RV size and function metrics on echocardiograms.


      : Reverse remodeling of RV following PVR is an ongoing process. Current accepted threshold values for PVR are associated with greatest RV recovery, suggesting that earlier PVR is warranted. Echocardiography can potentially be utilized in lieu of CMR for surveillance and interventional triage.

      Graphical abstract



      CMR (Cardiac magnetic resonance), FAC (Fractional area change), MPI (Myocardial performance index), PVR (Pulmonary valve replacement), RV (Right ventricular), RVEDAi (Right ventricular end diastolic area index), RVEDVi (Right ventricular end diastolic volume index), RVOT (Right ventricular outflow tract), TAPSE (Tricuspid annular plane systolic excursion), TV (Tricuspid valve)
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      Linked Article

      • Commentary: Imaging Surveillance of Pulmonary Regurgitation: Is Echo Good Enough?
        Seminars in Thoracic and Cardiovascular Surgery
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          As congenital heart disease patients continue to live longer, the goal moves from simply survival to adulthood, to being physically active as an adult doing the activities they love. Advances in medical and surgical management have enabled such a paradigm shift, and for patients with tetralogy of Fallot, excellent late survival and good quality of life is expected. However, good quality of life for these patients often involves pulmonary valve replacement (PVR) at some point down the road. Part of this refinement in care has been optimizing timing PVR in patients who have previously undergone complete repair.
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