Impact of additional tricuspid valve annuloplasty in TOF patients undergoing pulmonary valve replacement

Many patients with tetralogy of Fallot (TOF) who underwent surgical correction of their congenital cardiac malformation during infancy develop right ventricular dysfunction and exercise intolerance in the long term. The right ventricle (RV) dilates due to the development of severe pulmonary regurgitation (and secondary tricuspid insufficiency). To reduce RV dilation and improve exercise tolerance pulmonary valve replacement (PVR) is the common therapeutic strategy. Whether concomitant tricuspid valve repair (TVR) is beneficial in these pure volume-overload conditions is still unknown.

Twenty-eight adults who received surgical PVR were included in the study and perioperative data including operative records, postoperative course and echocardiography before and after surgery was analyzed retrospectively.

Mean age of the patients was 41.1±13.5 years and PVR with Carpentier Edwards Perimount bioprostheses was performed 32.0±9.5 years after initial cardiac surgery. Preoperative echocardiography revealed moderate RV dilation in 60.7% of the patients and severe pulmonary valve regurgitation in 82.3%. Ten patients underwent additional TVR. Indication was purely based on annular dilation (>40 mm), independent from the degree of tricuspid insufficiency. Periprocedural data of both groups did not differ significantly. However, ICU stay was significantly increased in patients who underwent additional TVR (P=0.0420) and these patients developed more complications (P=0.0407) while postoperative echography showed the same recovery of the RV function and diameters, independent of concomitant TVR.

In grown-ups with congenital heart disease surgical PVR with or without TVR is a safe procedure with good short-term outcomes. As the RV remodels after volume reduction, indication for concomitant TVR should be restrictive.