title: Expanding the indications for pulmonary valve replacement after repair of tetralogy of fallot.
abstract: BACKGROUND
  Insertion of a competent pulmonary valve has been advocated to reduce right ventricular volume overload associated with pulmonary regurgitation (PR) after repair of tetralogy of Fallot. However the indications, proper timing, and long-term benefits of restoring pulmonary valve function remain controversial.
  
  
  METHODS
  Thirty-six patients (aged 15.2 +/- 9.2 years) underwent pulmonary valve implantation (31 homografts, 5 heterografts) 12.2 +/- 6.9 years after tetralogy repair. Additional surgical procedures included pulmonary artery augmentation (n = 14), closure of septal defects (n = 10), and cryoablation and endocardial resection of ventricular tachycardia (n = 2).
  
  
  RESULTS
  All patients have had clinical improvement in their exercise capacity. Preoperative and postoperative bicycle ergometry tests in 6 patients demonstrated significant improvement in the percent of predicted peak workload (68.5% +/- 19.8% to 80.7% +/- 17.4%, p < 0.015). One midterm death occurred in a 38-year-old patient with a history of ventricular tachycardia who died suddenly 2 years after pulmonary valve insertion. Postoperative echocardiographic measurements were available in 34 patients at a mean follow-up of 5 years. There was a 30% reduction in right ventricular end-diastolic diameter indexed to body surface area after surgery (30.1 +/- 10.2 to 18.6 +/- 6.0 mm/m(2), p < 0.0001). Two patients required conduit replacements at 1 and 9 years postoperatively.
  
  
  CONCLUSIONS
  Timely insertion of a competent pulmonary valve in children, adolescents, and young adults with significant PR after tetralogy of Fallot repair results in subjective and objective improvement in exercise capacity and is associated with reduction in right ventricle size.
authors.affiliation: Division of Cardiothoracic Surgery, Tufts-New England Medical Center and Boston Floating Hospital, Tufts University School of Medicine, Boston, Massachusetts 02111, USA. kwarner@tufts-nemc.org
authors.forename: Kenneth G
authors.initials: KG
authors.lastname: Warner
authors.forename: Patrick K H
authors.initials: PK
authors.lastname: O'Brien
authors.forename: Jonathan
authors.initials: J
authors.lastname: Rhodes
authors.forename: Avnit
authors.initials: A
authors.lastname: Kaur
authors.forename: Davida A
authors.initials: DA
authors.lastname: Robinson
authors.forename: Douglas D
authors.initials: DD
authors.lastname: Payne
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D017079:Exercise Tolerance; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011183:Postoperative Complications; D011664:Pulmonary Valve / Q000601:surgery*; D011665:Pulmonary Valve Insufficiency / Q000601:surgery; D012086:Reoperation; D013771:Tetralogy of Fallot / Q000601:surgery*