title: Clinical outcomes of surgical pulmonary valve replacement after repair of tetralogy of Fallot and potential prognostic value of preoperative cardiopulmonary exercise testing.
abstract: BACKGROUND
  Indications for surgical pulmonary valve replacement (PVR) after repair of tetralogy of Fallot have recently been broadened to include asymptomatic patients.
  
  
  RESULTS
  The outcomes of PVR in adults after repair of tetralogy of Fallot at a single tertiary center were retrospectively studied. Preoperative cardiopulmonary exercise testing was included. Mortality was the primary outcome measure. In total, 221 PVRs were performed in 220 patients (130 male patients; median age, 32 years; range, 16-64 years). Homografts were used in 117 patients, xenografts in 103 patients, and a mechanical valve in 1 patient. Early (30-day) mortality was 2%. Overall survival was 97% at 1 year, 96% at 3 years, and 92% at 10 years. Survival after PVR in the later era (2005-2010; n=156) was significantly better compared with survival in the earlier era (1993-2004; n=65; 99% versus 94% at 1 year and 98% versus 92% at 3 years, respectively; P=0.019). Earlier era patients were more symptomatic preoperatively (P=0.036) with a lower preoperative peak oxygen consumption (peak Vo₂; P<0.001). Freedom from redo surgical or transcatheter PVR was 98% at 5 years and 96% at 10 years for the whole cohort. Peak Vo₂, E/CO2 slope (ratio of minute ventilation to carbon dioxide production), and heart rate reserve during cardiopulmonary exercise testing predicted risk of early mortality when analyzed with logistic regression analysis; peak Vo₂ emerged as the strongest predictor on multivariable analysis (odds ratio, 0.65 per 1 mL·kg⁻¹·min⁻¹; P=0.041).
  
  
  CONCLUSIONS
  PVR after repair of tetralogy of Fallot has a low and improving mortality, with a low need for reintervention. Preoperative cardiopulmonary exercise testing predicts surgical outcome and should therefore be included in the routine assessment of these patients.
authors.affiliation: Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.).
authors.forename: Sonya V
authors.initials: SV
authors.lastname: Babu-Narayan
authors.forename: Gerhard-Paul
authors.initials: GP
authors.lastname: Diller
authors.forename: Radu R
authors.initials: RR
authors.lastname: Gheta
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Bastin
authors.forename: Theodoros
authors.initials: T
authors.lastname: Karonis
authors.forename: Wei
authors.initials: W
authors.lastname: Li
authors.forename: Dudley J
authors.initials: DJ
authors.lastname: Pennell
authors.forename: Hideki
authors.initials: H
authors.lastname: Uemura
authors.forename: Babulal
authors.initials: B
authors.lastname: Sethia
authors.forename: Michael A
authors.initials: MA
authors.lastname: Gatzoulis
authors.forename: Darryl F
authors.initials: DF
authors.lastname: Shore
mesh_terms: D000293:Adolescent; D000328:Adult; D058070:Asymptomatic Diseases; D005080:Exercise Test; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011300:Preoperative Care; D011379:Prognosis; D011665:Pulmonary Valve Insufficiency / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D012086:Reoperation / Q000401:mortality; D012189:Retrospective Studies; D013771:Tetralogy of Fallot / Q000401:mortality* / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
keywords: exercise test; heart defects, congenital; surgery; survival; tetralogy of Fallot