title: The left heart after pulmonary valve replacement in adults late after tetralogy of Fallot repair.
abstract: BACKGROUND
  Adverse ventricular-ventricular interactions have been recognized in those with repaired tetralogy of Fallot (TOF) and severe pulmonary regurgitation.
  
  
  OBJECTIVE
  We aimed to examine the impact of pulmonary valve replacement (PVR) on the left heart late after TOF repair.
  
  
  RESULTS
  Left ventricular (LV) volumes and ejection fractions (EF) were analyzed in adults with severe pulmonary regurgitation after TOF repair with cardiac magnetic resonance imaging (CMR) before and after PVR. Thirty-nine patients (median age 33[20-65] years) were reviewed. Post-PVR, LVEF improved significantly in the entire cohort (50 ± 9%→54 ± 7%, p<0.001) and in those with moderately impaired (defined as LVEF ≤ 45%) preoperative LVEF (38 ± 5%→47 ± 6%, p<0.0001), but was not statistically different in those with relatively preserved (defined as LVEF >45%) preoperative LVEF. By multivariate linear regression analysis to evaluate independent CMR predictors of improved LVEF post-PVR for the entire cohort, the only CMR variable to emerge was preoperative LVEF (p=0.012, regression coefficient -0.54, SE 0.13). Whereas PVR resulted in increased LV filling in patients with relatively preserved preoperative LVEF reflected by an increase in LV end-diastolic volumes (77 ± 10→82 ± 16 mL/m(2), p=0.05), LV end-systolic volumes decreased after PVR in patients with impaired preoperative LVEF (65 ± 12→54 ± 10 mL/m(2), p=0.001) but LV end-diastolic volumes were not significantly changed.
  
  
  CONCLUSIONS
  When LVEF is decreased after TOF repair, PVR appears to have a salutary effect on postoperative LVEF, thereby supporting the concept of recovery of adverse right-left heart interactions. Mechanisms of left heart improvement post-PVR differ depending on degree of preoperative LV systolic dysfunction.
authors.affiliation: Division of Cardiology and Cardiovascular Surgery, Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto, Ontario, Canada.
authors.forename: Daniel
authors.initials: D
authors.lastname: Tobler
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Crean
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Redington
authors.forename: Glen S
authors.initials: GS
authors.lastname: Van Arsdell
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Caldarone
authors.forename: Kumar
authors.initials: K
authors.lastname: Nanthakumar
authors.forename: Dominik
authors.initials: D
authors.lastname: Stambach
authors.forename: Laura
authors.initials: L
authors.lastname: Dos
authors.forename: Bernd J
authors.initials: BJ
authors.lastname: Wintersperger
authors.forename: Erwin N
authors.initials: EN
authors.lastname: Oechslin
authors.forename: Candice K
authors.initials: CK
authors.lastname: Silversides
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Wald
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D011665:Pulmonary Valve Insufficiency / Q000503:physiopathology / Q000601:surgery*; D012189:Retrospective Studies; D013318:Stroke Volume / Q000502:physiology*; D013771:Tetralogy of Fallot / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology*; D055815:Young Adult