Pediatric Cardiology

, Volume 37, Issue 5, pp 818–825 | Cite as

Aiming to Preserve Pulmonary Valve Function in Tetralogy of Fallot Repair: Comparing a New Approach to Traditional Management

  • Danielle Gottlieb Sen
  • Marc Najjar
  • Betul Yimaz
  • Stéphanie M. Levasseur
  • Bindu Kalessan
  • Jan M. Quaegebeur
  • Emile A. BachaEmail author
Original Article


Pulmonary valve (PV) incompetence following transannular patch (TAP) repair of tetralogy of Fallot (TOF) results in long-term morbidity and mortality. Valve-sparing repairs have recently gained recognition; however, they may be associated with residual pulmonary stenosis (PS) in patients with small PV z scores. We sought to determine whether a repair that increases the PV annulus and augments the valve leaflet with a biomaterial would result in annular growth and in longer duration of valve competence compared with TAP. Eighty patients (median age 136 days, range 4–350) who underwent surgical repair of TOF between 2010 and 2014 were included in the study. Patients were divided into three groups based on the PV intervention: balloon dilation/valvotomy (n = 29), valve-sparing transannular repair (VSTAR) (n = 19) and TAP (n = 32). Intraoperative, early postoperative and midterm follow-up echocardiographic data (median 19 months, range 1–59) were obtained. The primary outcomes were the presence and severity of pulmonary regurgitation and/or PS. Compared with TAP, VSTAR patients demonstrated significantly less severe PR with 100 % freedom of severe PR immediately post-op (vs. 0 % in TAP), 60 % at 6 months and 20 % at 20 months. There were no differences in PS between VSTAR and TAP at follow-up. A subgroup analysis of the VSTAR group was performed. PV z scores were calculated and fit to a random effects model. Patient data fit the model closely, predicting a reproducible increase in valve annulus size over time. With better short-term and comparable midterm results, VSTAR may be appropriate for TOF repair in patients with small PV that would conventionally require a TAP.


Tetralogy of Fallot Pulmonary valve Valve-sparing repair Transannular patch repair 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Anagnostopoulos P, Azakie A, Natarajan S et al (2007) Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot. J Thorac Cardiovasc Surg 133(3):640–647CrossRefPubMedGoogle Scholar
  2. 2.
    Attanawanich S, Ngodgnamthaweesuk M (2012) Pulmonary cusp augmentation in repair of tetralogy of Fallot. Asian Cardiovasc Thorac Ann 21(1):9–13CrossRefGoogle Scholar
  3. 3.
    Bacha E (2012) Valve-sparing options in tetralogy of Fallot surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 15(1):24–26. doi: 10.1053/j.pcsu.2012.01.006 CrossRefPubMedGoogle Scholar
  4. 4.
    Bautista-Hernandez V, Cardenas I, Martinez-Bendayan I et al (2013) Valve-sparing tetralogy of Fallot repair with intraoperative dilation of the pulmonary valve. Pediatr Cardiol 34:918–923CrossRefPubMedGoogle Scholar
  5. 5.
    Brown JW, Ruzmetov M, Vijay P et al (2007) Right ventricular outflow tract reconstruction with a polytetrafluoroethylene monocusp valve: a twelve-year experience. J Thorac Cardiovasc Surg 133:1336–1343CrossRefPubMedGoogle Scholar
  6. 6.
    Geva T (2013) Indications for pulmonary valve replacement in repaired tetralogy of Fallot: the quest continues. Circulation 128:1855–1857CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Horton KD, Meece RW, Hill JC (2009) Assessment of the right ventricle by echocardiography: a primer for cardiac sonographers. J Am Soc Echocardiogr 22:776–792CrossRefPubMedGoogle Scholar
  8. 8.
    Hua Z, Li S, Wang L et al (2011) A new pulmonary valve cusp plasty technique markedly decreases transannular patch rate and improves midterm outcomes of tetralogy of Fallot repair. Eur J Cardiothorac Surg 40:1221–1226PubMedGoogle Scholar
  9. 9.
    Ito H, Ota N, Murata M et al (2013) Technical modification enabling pulmonary valve-sparing repair of a severely hypoplastic pulmonary annulus in patients with tetralogy of Fallot. Interact Cardiovasc Thorac Surg 16:802–807CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Latus H, Gummel K, Rupp S et al (2013) Beneficial effects of residual right ventricular outflow tract obstruction on right ventricular volume and function in patients after repair of tetralogy of Fallot. Pediatr Cardiol 34(2):424–430CrossRefPubMedGoogle Scholar
  11. 11.
    Murphy JG, Gersh BJ, Mair DD et al (1993) Long-term outcome in patients undergoing surgical repair of tetralogy of Fallot. N Engl J Med 329(9):593–599CrossRefPubMedGoogle Scholar
  12. 12.
    Nath DS, Nussbaum DP, Yurko C, Ragab OM et al (2010) Pulmonary homograft monocusp reconstruction of the right ventricular outflow tract: outcomes to the intermediate term. Ann Thorac Surg 90(1):42–49. doi: 10.1016/j.athoracsur.2010.03.045 CrossRefPubMedGoogle Scholar
  13. 13.
    Sasson L, Houri S, Raucher Sternfeld A et al (2013) Right ventricular outflow tract strategies for repair of tetralogy of Fallot: effect of monocusp valve reconstruction. Eur J Cardiothorac Surg 43(4):743–751. doi: 10.1093/ejcts/ezs479 CrossRefPubMedGoogle Scholar
  14. 14.
    Stewart R, Backer C, Young L et al (2005) Tetralogy of Fallot: results of a pulmonary valve-sparing strategy. Ann Thorac Surg 80:1431–1439CrossRefPubMedGoogle Scholar
  15. 15.
    Sung S, Kim S, Woo JS et al (2003) Pulmonic valve annular enlargement with valve repair in tetralogy of Fallot. Ann Thorac Surg 75:303–305CrossRefPubMedGoogle Scholar
  16. 16.
    Valente AM, Gauvreau K, Assenza G et al (2014) Contemporary predictors of death and sustained ventricular tachycardia in patients with repaired tetralogy of Fallot enrolled in the INDICATOR cohort. Heart 100(3):247–253CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Danielle Gottlieb Sen
    • 1
    • 2
  • Marc Najjar
    • 1
  • Betul Yimaz
    • 3
    • 4
  • Stéphanie M. Levasseur
    • 1
  • Bindu Kalessan
    • 1
  • Jan M. Quaegebeur
    • 1
  • Emile A. Bacha
    • 1
    Email author
  1. 1.Pediatric Cardiac Surgery, Morgan Stanley Children’s Hospital of New York-PresbyterianColumbia UniversityNew YorkUSA
  2. 2.Pediatric Cardiac SurgeryNew Orleans Children’s HospitalNew OrleansUSA
  3. 3.Pediatric Cardiology, Morgan Stanley Children’s Hospital of New York-PresbyterianColumbia UniversityNew YorkUSA
  4. 4.Pediatric CardiologyTexas Children’s HospitalHoustonUSA

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