Background : Transannular patch repair of tetralogy of Fallot leads to pulmonary
insufficiency and progressive right ventricular dilatation. Whether this phenomenon is
detrimental to the patients or not is still controversial because these patients are not very
symptomatic. At 30 years, their rate of reoperation does not exceed 10% and no more
than 6% died of sudden death due to ventricular arythmias. We studied the impact of late
homograft valvulation on the regression of the right ventricular volumes in symptomatic
patients.
Patients and methods : From July 1992 to August 1996, 15 consecutive patients aged 4
to 24 years were operated at a mean of 12.6 ± 6.8 years after a transannular patch repair
of tetralogy of Fallot. They all complained of exertional dyspnea and fatigue. Syncopes were
reported in 6 patients and 4 patients had presented sustained episodes of ventricular
tachycardia. Fourteen had a pulmonary regurgitation grade 3 or 4 and one had a mixed
stenosis and insufficiency. All patients had a dilated right ventricle. At reoperation, no
patients presented a major aneurysm. The patch was resected and the right ventricular
outflow tract was reconstructed with a cryopreserved pulmonary homograft. Right
ventricular volumes were studied before, 10 days, and more than 30 days after the
procedure.
Results : There was no operative death. One patient who had a concomitant patch repair of
a hypoplastic left pulmonary artery needed an ECMO support for 8 days. After a median
follow-up of 25 months (range: 3 - 54 months) all but one patient are in NYHA class I. The
end-diastolic diameter of the right ventricle decreased from a mean of 36 ± 9 mm before
the reoperation to a mean of 28 ± 7 mm at 10 days and a mean of 31 ± 6 mm at more than
30 days after the reoperation (not significant). The ratio between the end-diastolic diameter
of the right and the left ventricle decreased from a mean of 0.94 ± 0.3 to a mean of 0.74
± 0.3 at the 10th postoperative day and a mean of 0.74 ± 0.2 after more than 30 days
(p < 0.01).
Conclusion : An increasing number of patients who had a transannular patch repair of
tetralogy of Fallot will need a reoperation for symptomatic long-term pulmonary
regurgitation. Homograft valvulation of the right ventricular outflow tract of these patients
induce regression of their right ventricular dilatation and lead to their functional recovery.