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The Effects of Pulmonary Valve Replacement for Severe Pulmonary Regurgitation on Exercise Capacity and Cardiac Function

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Abstract

Patients may develop hemodynamic abnormalities after right ventricular outflow tract (RVOT) repair. Re-intervention timing remains a dilemma. This study evaluates exercise capacity and RV function before and after intervention using age-related comparisons. Twenty-six patients with severe pulmonary regurgitation (PR) after initial repair scheduled for pulmonary valve replacement (PVR) were enrolled. Metabolic treadmill testing (EST) and MRI were obtained before and after surgery. EST results were compared with matched controls. Preoperative exercise time and peak oxygen consumption (VO2 max) were significantly diminished compared with controls but were not significantly different postoperatively. The patients were then split into age-related cohorts. When comparing pre-PVR and post-PVR exercise time and VO2 max among themselves, neither cohort showed significant differences. However, patients younger than 25 years had better postoperative results, an age-related difference not seen in the controls. Preoperative MRI showed significantly dilated RV, PR, and low normal function. After PVR, the right to left ventricular end-diastolic volume ratio (RVEDV:LVEDV) and pulmonary artery regurgitant fraction (RF) significantly decreased. There was no change in ventricular ejection fractions (EF). Severe PR, decreased RVEF, and RV dilation can significantly diminish exercise capacity. PVR improves RVEDV:LVEDV and RF, but not EF. Younger patients had better exercise capacity that was maintained postoperatively. This age-related difference was not seen in the controls, indicating that earlier intervention may preserve exercise capacity. Serial ESTs in patients with severe PR following RVOT repair may identify deteriorating exercise capacity as an early indicator for the need for PVR.

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References

  1. Ammash NM, Dearani JA, Burkhart HM, Connolly HM (2007) Pulmonary regurgitation after tetralogy of Fallot repair: clinical features, sequelae, and timing of pulmonary valve replacement. Congenit Heart Dis 2:386–403

    Article  PubMed  Google Scholar 

  2. Carvalho JS, Shinebourne EA, Busst C, Rigby ML, Redington AN (1992) Exercise capacity after complete repair of tetralogy of Fallot: deleterious effects of residual pulmonary regurgitation. Br Heart J 67:470–473

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Davlouros PA, Kilner PJ, Hornung TS, Li W, Francis JM, Moon JC, Smith GC, Tat T, Pennell DJ, Gatzoulis MA (2002) Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction. J Am Coll Cardiol 40:2044–2052

    Article  PubMed  Google Scholar 

  4. Discigil B, Dearani JA, Puga FJ, Schaff HV, Hagler DJ, Warnes CA, Danielson GK (2001) Late pulmonary valve replacement after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 121:344–351

    Article  CAS  PubMed  Google Scholar 

  5. Frigiola A, Tsang V, Bull C, Coats L, Khambadkone S, Derrick G, Mist B, Walker F, van Doorn C, Bonhoeffer P, Taylor AM (2008) Biventricular response after pulmonary valve replacement for right ventricular outflow tract dysfunction: is age a predictor of outcome? Circulation 118:S182–S190

    Article  PubMed  Google Scholar 

  6. Gatzoulis MA, Balaji S, Webber SA, Siu SC, Hokanson JS, Poile C, Rosenthal M, Nakazawa M, Moller JH, Gillette PC, Webb GD, Redington AN (2000) Risk factors for arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: a multicenter study. Lancet 356:975–981

    Article  CAS  PubMed  Google Scholar 

  7. Gengsakul A, Harris L, Bradley TJ, Webb GD, Williams WG, Siu SC, Merchant N, McCrindle BW (2007) The impact of pulmonary valve replacement after tetralogy of Fallot repair: a matched comparison. Eur J Cardiothorac Surg 32:462–468

    Article  PubMed  Google Scholar 

  8. Gerestein CG, Takkenberg JJ, Oei FB, Cromme-Dijkhuis AH, Spitaels SE, van Herwerden LA, Steyerberg EW, Bogers AJ (2001) Right ventricular outflow tract reconstruction with an allograft conduit. Ann Thorac Surg 71:911–917

    Article  CAS  PubMed  Google Scholar 

  9. Geva T (2006) Indications and timing of pulmonary valve replacement after tetralogy of Fallot repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 9:11–22

    Article  Google Scholar 

  10. Ghez O, Tsang VT, Frigiola A, Coats L, Taylor A, Van Doorn C, Bonhoeffer P, De Leval M (2007) Right ventricular outflow tract reconstruction for pulmonary regurgitation after repair of tetralogy of Fallot. Preliminary results. Eur J Cardiothorac Surg 31:654–658

    Article  PubMed  Google Scholar 

  11. Giardini A, Specchia S, Coutsoumbas G, Donti A, Formigari R, Fattori R, Oppido G, Gargiulo G, Piccio FM (2006) Impact of pulmonary regurgitation and right ventricular dysfunction on oxygen uptake recovery kinetics in repaired tetralogy of Fallot. Eur J Heart Fail 8:736–743

    Article  PubMed  Google Scholar 

  12. Graham TP Jr (2002) Management of pulmonary regurgitation after tetralogy of Fallot repair. Curr Cardiol Rep 4:63–67

    Article  PubMed  Google Scholar 

  13. Harrison DA, Harris L, Siu SC, MacLoghlin CJ, Connelly MS, Webb GD, Downar E, McLaughlin PR, Williams WG (1997) Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot. J Am Coll Cardiol 30:1368–1373

    Article  CAS  PubMed  Google Scholar 

  14. Hazekamp MG, Kurvers MM, Schoof PH, Vliegen HW, Mulder BM, Roest AA, Ottenkamp J, Dion RA (2001) Pulmonary valve insertion late after repair of Fallot’s tetralogy. Eur J Cardiothorac Surg 19:667–670

    Article  CAS  PubMed  Google Scholar 

  15. Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY, Shim WS, Choi EY, Lee SY, Baek JS (2012) Outcomes of Pulmonary Valve Replacement in 170 Patients with Chronic Pulmonary Regurgitation After Relief of Right Ventricular Outflow Tract Obstruction. JACC 60:1005–1014

    Article  PubMed  Google Scholar 

  16. Lim C, Lee JY, Kim WH, Kim SC, Song JY, Kim SJ, Choh JH, Kim CW (2004) Early replacement of pulmonary valve after repair of tetralogy: is it really beneficial? Eur J Cardiothorac Surg 25:728–734

    Article  PubMed  Google Scholar 

  17. Mahon AD, Marjerrison AD, Lee JD, Woodruff ME, Hanna LE (2010) Evaluating the prediction of maximal heart rate in children and adolescents. Res Q Exerc Sport 81:466–471

    Article  PubMed  Google Scholar 

  18. Mohammadi S, Belli E, Martinovic I, Houyel L, Capderou A, Petit J, Planché C, Serraf A (2005) Surgery for right ventricle to pulmonary artery conduit obstruction: risk factors for further reoperation. Eur J Cardiothorac Surg 28:217–222

    Article  PubMed  Google Scholar 

  19. Oechslin EN, Harrison DA, Harris L, Downar E, Webb GC, Siu SC, Williams WG (1999) Reoperation in adults with repair of tetralogy of Fallot: indications and outcomes. J Thorac Cardiovasc Surg 118:245–251

    Article  CAS  PubMed  Google Scholar 

  20. Oosterhof T, van Straten A, Vliegen HW, Meijboom FJ, van Dijk AP, Spijkerboer AM, Bouma BJ, Zwinderman AH, Hazekamp MG, de Roos A, Mulder BJ (2007) Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance. Circulation 116:545–551

    Article  PubMed  Google Scholar 

  21. Roest AA, Helbing WA, Kunz P, van den Aardweg JG, Lamb HJ, Vliegen HW, van der Wall EE, de Roos A (2002) Exercise MR imaging in the assessment of pulmonary regurgitation and biventricular function in patients after tetralogy of Fallot repair. Radiology 223:204–211

    Article  PubMed  Google Scholar 

  22. Schamberger MS, Hurwitz RA (2000) Course of right and left ventricular function in patients with pulmonary insufficiency after repair of tetralogy of Fallot. Pediatr Cardiol 21:244–248

    Article  CAS  PubMed  Google Scholar 

  23. Sterrett LE, Ebenroth ES, Query C, Ho JG, Montgomery GS, Hurwitz RA, Baye F, Schamberger MS (2014) Why exercise capacity does not improve after pulmonary valve replacement. Pediatr Cardiol 35:1395–1402

    Article  PubMed  Google Scholar 

  24. Therrien J, Siu SC, McLaughlin PR, Liu PP, Williams WG, Webb GD (2000) Pulmonary valve replacement in adults late after repair of tetralogy of Fallot: are we operating too late? J Am Coll Cardiol 36:1670–1675

    Article  CAS  PubMed  Google Scholar 

  25. Therrien J, Siu SC, Harris L, Dore A, Niwa K, Janousek J, Williams WG, Webb G, Gatzoulis MA (2001) Impact of pulmonary valve replacement on arrhythmia propensity late after repair of tetralogy of Fallot. Circulation 103:2489–2494

    Article  CAS  PubMed  Google Scholar 

  26. Therrien J, Provost Y, Merchant N, Williams W, Colman J, Webb G (2005) Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair. Am J Cardiol 95:779–782

    Article  PubMed  Google Scholar 

  27. Tsang FHF, Li X, Cheung YF, Chau KT, Cheng LC (2010) Pulmonary valve replacement after surgical repair of tetralogy of Fallot. Hong Kong Med J 16:26–30

    CAS  PubMed  Google Scholar 

  28. Valsangiacomo Buechel ER, Dave HH, Kellenberger CJ, Dodge-Khatami A, Pretre R, Berger F, Bauersfield U (2005) Remodeling of the right ventricle after early pulmonary valve replacement in children with repaired tetralogy of Fallot: assessment by cardiovascular magnetic resonance. Eur Heart J 26:2721–2727

    Article  Google Scholar 

  29. van Straten A, Vliegen HW, Hazekamp MG, Bax JJ, Schoof PH, Ottenkamp J, van der Wall EE, de Roos A (2004) Right ventricular function after pulmonary valve replacement in patients with tetralogy of Fallot. Radiology 233:824–829

    Article  PubMed  Google Scholar 

  30. Vliegen HW, van Straten A, de Roos A, Roest AA, Schoof PH, Zwinderman AH, Ottenkamp J, van der Wall EE, Hazekamp MG (2002) Magnetic resonance imaging to assess the hemodynamic effects of pulmonary valve replacement in adults late after repair of tetralogy of Fallot. Circulation 106:1703–1707

    Article  PubMed  Google Scholar 

  31. Warner KG, O’Brien PK, Rhodes J, Kaur A, Robinson DA, Payne DD (2003) Expanding the indications for pulmonary valve replacement after repair of tetralogy of fallot. Ann Thorac Surg 76:1066–1071

    Article  PubMed  Google Scholar 

  32. Wessel HU, Paul MH (1999) Exercise studies in tetralogy of Fallot: a review. Pediatr Cardiol 20:39–47

    Article  CAS  PubMed  Google Scholar 

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standard

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Authors and Affiliations

  1. Section of Cardiology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, 699 Riley Hospital Drive, RR 127, Indianapolis, IN, 46202, USA

    Jason G. Ho, Marcus S. Schamberger, Roger A. Hurwitz, Tiffanie R. Johnson, Lauren E. Sterrett & Eric S. Ebenroth

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  1. Jason G. Ho
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  2. Marcus S. Schamberger
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  3. Roger A. Hurwitz
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  4. Tiffanie R. Johnson
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  6. Eric S. Ebenroth
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Correspondence to Jason G. Ho.

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Ho, J.G., Schamberger, M.S., Hurwitz, R.A. et al. The Effects of Pulmonary Valve Replacement for Severe Pulmonary Regurgitation on Exercise Capacity and Cardiac Function. Pediatr Cardiol 36, 1194–1203 (2015). https://doi.org/10.1007/s00246-015-1143-3

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  • DOI: https://doi.org/10.1007/s00246-015-1143-3

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