A new pulmonary valve cusp plasty technique markedly decreases transannular patch rate and improves midterm outcomes of tetralogy of Fallot repair

Objectives: To assess the operative and mid-term outcome of a very aggressive pulmonary annulus preservation strategy and pulmonary valve leaflet plasty technique which achieved 95% freedom of transannular patch (TAP) in complete tetralogy repair.

Methods: From August 2006 through May 2010, 139 consecutive patients underwent repair of tetralogy of Fallot at a median age of 6.5 months, with median weight 7.2kg. None of the patients had a prior shunt. A total of 132 patients (95%) had pulmonary valve annulus-sparing procedures, predominantly through a transatrial and transpulmonary approach (n=120%, 86.3%). Special techniques included generous pulmonary supra-valve patch, bicuspid pulmonary leaflets plasty, or augmentation to maximally preserve pulmonary annulus. All the patients who survived were followed up closely.

Results: Only seven (5.0%) patients had a TAP. Among them, five (71.4%) had doubly committed subarterial defect. None of the tricuspid pulmonary valves need TAP. Preoperative size of pulmonary annulus<-6 is associated with TAP (p<0.001). A total of 12 (13.7%) patients needed repump to do either a ventriculotomy and patch the incision or a TAP to relieve residual stenosis. One patient needed a third pump run to do a TAP. The operative mortality was 0.7%, and there was one late death due to hemoptysis. The pulmonary regurgitation of non-TAP patients was less than mild in 105 (79.5%) and mild to moderate in 27 (20.5%) patients. Three patients had peak gradient greater than 50mmHg across the right ventricle and pulmonary artery at 1-month follow-up, but the gradient dropped to less than 50mmHg in two patients at 6-month follow-up. One patient had a persistent 50-55mmHg gradient across pulmonary valve and he is under close follow-up.

Conclusions: Excellent outcome can be achieved even with 95% freedom of TAP in complete repair of tetralogy. The function of most patients' pulmonary valve was well preserved.