Abstract

Objective: Pulmonary regurgitation after valveless repair of right ventricular outflow tract obstruction (RVOTO) results in progressive right ventricular (RV) failure in an increasing number of patients. We reviewed our 8-year-experience with pulmonary valve insertion (PVI) in such cases to evaluate the indications for this procedure and its benefits.

Methods: From 1989 to 1997, 44 patients (37 with tetralogy of Fallot and 7 with pulmonary stenosis) aged from 3 to 42 years underwent PVI with pulmonary homograft late after (median 13 years) valveless repair of RVOTO (transannular patch: 34; pulmonary valvulotomy ± infundibular patch: 10). Preoperatively, all patients had cardiomegaly, severe pulmonary regurgitation, significant to severe RV dilatation and dysfunction, reduced exercise tolerance, and were in NYHA class II (n = 38) or III (n = 6). Ten patients had ventricular arrhythmias.

Results: There was one early death, due to air embolism, and one late death, due to ventricular arrhythmia. After a mean follow-up of 43 ± 25 months, most survivors (n = 36) had improved exercise tolerance and RV function, and are currently in NYHA class I with good homograft function. Mean RV end-diastolic diameter and CT ratio decreased from 40 ± 8 to 27 ± 8 (p < 0.01), and from 0.62 ± 0.07 to 0.53 ± 0.04 (p < 0.01), respectively. One patient underwent heart trasplant, 3 patients are still in treatment for RV failure and 5 for arrhythmias.

Conclusion: Homograft PVI is safe and usually provides considerable hemodynamic and clinical improvement with good long-term results. This procedure should be undertaken early in symptomatic patients, before severe RV failure and ventricular arrhythmias ensue.