Biventricular response after pulmonary valve replacement for right ventricular outflow tract dysfunction: is age a predictor of outcome?
BACKGROUND
The timing of pulmonary valve replacement (PVR) for free pulmonary incompetence in patients with congenital heart disease remains a dilemma for clinicians. We wanted to assess the determinants of improvement after PVR for pulmonary regurgitation over a wide range of patient ages and to use any identified predictors to compare clinical outcomes between patient groups.


RESULTS
Seventy-one patients (mean age 22+/-11 years; range, 8.5 to 64.9; 72% tetralogy of Fallot) underwent PVR for severe pulmonary regurgitation. New York Heart Association class improved after PVR (median of 2 to 1, P<0.0001). MRI and cardiopulmonary exercise testing were performed before and 1 year after intervention. After PVR, there was a significant reduction in right ventricular volumes (end diastolic volume 142+/-43 to 91+/-18, end systolic volume 73+/-33 to 43+/-14 mL/m(2), P<0.0001), whereas left ventricular end diastolic volume increased (66+/-12 to 73+/-13 mL/m(2), P<0.0001). Effective cardiac output significantly increased (right ventricular: 3.0+/-0.8 to 3.3+/-0.8 L/min, P=0.013 and left ventricular: 3.0+/-0.6 to 3.4+/-0.7 L/min, P<0.0001). On cardiopulmonary exercise testing, ventilatory response to carbon dioxide production at anaerobic threshold improved from 35.9+/-5.8 to 34.1+/-6.2 (P=0.008). Normalization of ventilatory response to carbon dioxide production was most likely to occur when PVR was performed at an age younger than 17.5 years (P=0.013).


CONCLUSIONS
A relatively aggressive PVR policy (end diastolic volume <150 mL/m(2)) leads to normalization of right ventricular volumes, improvement in biventricular function, and submaximal exercise capacity. Normalization of ventilatory response to carbon dioxide production is most likely to occur when surgery is performed at an age </=17.5 years. This is also associated with a better left ventricular filling and systolic function after surgery.
Frigiola
Alessandra
A
Cardiothoracic Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK. alessandra.frigiola@gmail.com
Tsang
Victor
V
Bull
Catherine
C
Coats
Louise
L
Khambadkone
Sachin
S
Derrick
Graham
G
Mist
Bryan
B
Walker
Fiona
F
van Doorn
Carin
C
Bonhoeffer
Philipp
P
Taylor
Andrew M
AM
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015308:Anaerobic Threshold; D002245:Carbon Dioxide; D002648:Child; D015331:Cohort Studies; D004452:Echocardiography; D005080:Exercise Test; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010807:Physical Endurance; D011184:Postoperative Period; D011379:Prognosis; D011446:Prospective Studies; D011664:Pulmonary Valve / Q000601:surgery*; D011665:Pulmonary Valve Insufficiency / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D012119:Respiration; D013318:Stroke Volume; D016896:Treatment Outcome; D016276:Ventricular Function; D014694:Ventricular Outflow Obstruction / Q000503:physiopathology / Q000601:surgery*
D002245:Carbon Dioxide