Long-term follow-up after pulmonary valve replacement in repaired tetralogy of Fallot

Surgical pulmonary valve replacement (PVR) in previously repaired tetralogy of Fallot (TOF) is frequently required. There are few data in large series of patients with long-term follow-up. Our aim was to review our 40-year experience with PVR after TOF repair and to evaluate prognostic factors for reintervention and death. Between 1973 and 2012, 278 patients with repaired TOF (53% men; 31.4 ± 16.4 years) underwent first PVR 24 ± 13 years after TOF repair. Three or more previous operations were performed in 17% of the patients, and 42% were in New York Heart Association (NYHA) class III/IV. PVR types included porcine (n = 211), pericardial (n = 37), homograft (n = 27), and mechanical (n = 3). Early mortality was 1.4%. Mean follow-up was 7.3 ± 6.8 years (maximum, 34 years). Overall survival at 5, 10, and 15 years was 93%, 83%, and 80% compared with 99%, 97%, and 95% in a gender- and age-matched US population, p <0.001. Independent risk factors for death were older age at complete repair (hazards ratio [HR] 1.2, p = 0.012), ≥ 3 previous cardiac operations (HR 1.9, p = 0.019), NYHA class III/IV at PVR (HR 2.7, p = 0.019), and large body surface area at PVR (HR 1.9, p <0.001). Reintervention after initial PVR occurred in 25 patients. Overall 5, 10, and 15 years freedom from pulmonary valve reintervention was 97%, 85%, and 75%, respectively. Multivariate analysis demonstrated older age at PVR to be protective from reintervention (HR 0.7, p <0.001). In conclusion, PVR is a safe operation with a low rate of reintervention in repaired TOF. The total number of cardiac operations, surgical timing, and the NYHA classification before PVR are important prognostic factors.