The left heart after pulmonary valve replacement in adults late after tetralogy of Fallot repair

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. Methods and 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. Bymultivariate 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. Conclusion: 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. (C) 2011 Elsevier Ireland Ltd. All rights reserved.