Investigation of Mid-Term Outcomes of Patients with Tetralogy of Fallot Undergoing Total Correction Surgery and Evaluation of Factors Affecting Reoperation

Öz

Background: This study was conducted to investigate mid-term clinical outcomes in patients with Tetralogy of Fallot (TOF) who underwent complete surgical repair and to evaluate factors associated with the need for pulmonary valve replacement (PVR). Materials and Methods: Of 239 patients who underwent complete repair for TOF between 1992 and 2014, 84 patients with regular outpatient follow-up and available echocardiographic data were retrospectively analyzed. Preoperative demographic and echocardiographic findings, s urgical techniques, postoperative echocardiographic and electrocardiographic data, and cardiac magnetic resonance imaging (MRI) findings i n s elected patients were evaluated. The associations of pulmonary regurgitation (PR), tricuspid regurgitation (TR), tricuspid annular plane systolic excursion (TAPSE), QRS duration, right ventricular outflow tract (RVOT) aneurysm, and residual ventricular septal defect (VSD) with PVR were assessed using univariate and multivariate analyses. Results: The median age at surgery was 1.5 years (1.0-5.0 years), and the median follow-up duration was 5 years (2.0-9.25 years). No mortality was observed during mid-term follow-up. Moderate-to-severe PR developed in 49 patients (58%), while moderate-to-severe TR was observed in 36 patients (43%). The reoperation rate was 28.6% (n=24), and the PVR rate was 12% (n=10). In patients who underwent PVR, cardiac MRI demonstrated marked right ventricular dilatation, increased right ventricular end-systolic volume index (RVESVi), and reduced right ventricular ejection fraction (RVEF) (pulmonary regurgitant fraction: 57.17±30.7%; RVESVi: 91±23.55 mL/m²; RVEF: 40±5.0%; right ventricular end-diastolic volume index [RVEDVi]: 149.5±48 mL/m²). Multivariate analysis identified severe PR as the only independent predictor of PVR (OR 18.18, 95% CI 3.38-97.59, p<0.001).
Conclusions: Residual ventricular septal defect was the most common indication for reoperation following TOF repair. Both pulmonary and tricuspid regurgitation increased significantly after surgery. Severe pulmonary regurgitation was identified as an independent predictor of pulmonary valve replacement. Although QRS duration increased significantly following repair, further studies with larger cohorts and longer follow-up are required to clarify its relationship with malignant arrhythmias. Close surveillance with regular echocardiographic and electrocardiographic assessment, supplemented by cardiac MRI when indicated, is essential for the timely identification o f p atients w ho m ay benefit from reintervention.

Anahtar Kelimeler

• Tetralogy of Fallot
• pulmonary regurgitation
• pulmonary valve replacement
• right ventricular function

Destekleyen Kurum

The author declares that there is no conflict of interest regarding this work.

Proje Numarası

2015-04/32

Etik Beyan

Çalışma için Dokuz Eylül Üniversitesi Girişimsel Olmayan Araştırma Etik Kurulu'ndan onay alınmıştır (karar no: 2015/04-32, tarih: 12.02.2015).

Tam Düzeltme Ameliyatı Yapılmış Fallot Tetralojili Hastaların Orta Dönem Sonuçlarının Araştırılması ve Reoperasyonu Etkileyen Faktörlerin Değerlendirilmesi

Öz

Amaç: Bu çalışma, tam düzeltme ameliyatı uygulanmış Fallot Tetralojisi (FT) tanılı hastalarda orta dönem klinik sonuçları incelemek ve özellikle pulmoner kapak replasmanı (PVR) gereksinimini belirleyen faktörleri değerlendirmek amacıyla gerçekleştirilmiştir.
Materyal ve metod: 1992-2014 yılları arasında FT nedeniyle tam düzeltme cerrahisi uygulanmış 239 hastadan, düzenli poliklinik izlemi ve ekokardiyografik ( EKO) v erileri m evcut o lan 8 4 hasta retrospektif olarak incelenmiştir. Preoperatif demografik ve ekokardiyografik ( EKG) bulgular, c errahi t eknikler, postoperatif EKO/EKG verileri ve seçilmiş olgularda kardiyak  manyetik rezonans (MR) sonuçları değerlendirilmiştir. Pulmoner yetersizlik (PY), triküspit yetersizliği (TY), triküspit anüler düzlem sistolik ekskürsiyonu (TAPSE), QRS süresi, sağ ventrikül çıkım yolu( RVOT) anevrizması ve rezidüel ventriküler septal defekt (VSD) gibi değişkenlerin PVR ile ilişkisi tek değişkenli  ve çok değişkenli analizlerle test edilmiştir.
Bulgular: Ortalama ameliyat yaşı 1,5 yıl (1,0-5,0), ortalama izlem süresi 5 yıl (2,0-9,25)  olup orta dönemde mortalite görülmemiştir. Hastaların 49’unda  (%58) orta-ağır PY, 36’sında (%43) orta-ağır TY gelişmiştir. Reoperasyon oranı %28,6 (n: 24), PVR oranı %12 (n:10) olarak bulunmuştur. PVR yapılan hastalarda MR ölçümleri belirgin sağ ventrikül dilatasyonu, artmış sağ ventrikül sistol sonu volümü (RVESV) ve azalmış sağ ventrikül ejeksiyon fraksiyonu (RVEF)  ile uyumlu bulunmuştur (pulmoner yetmezliğin regürjitasyon fraksiyonu 57,17±30,7 ml/m2; sağ ventrikül end sistolik volümü 91± 23,55 ml/m²; sağ ventrikül EF % 40±5,0; sağ ventrikül end diastolik volümü 149,5±48 ml/m²).Çok değişkenli analizde yalnızca ağır PY’nin PVR için bağımsız risk faktörü olduğu belirlenmiştir (OR, 95%Cl ve p değerleri sırasıyla  18.18,  3.38-97-59, <0.001)
Sonuç: Çalışmamızda FT onarımı sonrası en sık reoperasyon nedeni ventriküler septal defekttir. Operasyon sonrası dönemde hem triküspid, hem de pulmoner yetmezlikte anlamlı artış izlenmiştir. Ağır pulmoner yetersizlik, pulmoner kapak replasmanı gereksiniminin bağımsız belirleyicisi olarak saptanmıştır. Operasyon sonrası QRS süresi uzamıştır, ancak bunun malign aritmiler ile ilişkisi için daha çok ve daha uzun süreli izlem yapılan çalışmaya ihtiyaç vardır. Düzenli ekokardiyografik, elektrokardiyografik v e gerektiğinde k ardiyak M R i le yakın izlenmesi, uygun zamanda yeniden girişim planlanması açısından önemlidir.

Anahtar Kelimeler

• fallot tetralojisi
• pulmoner yetersizlik
• pulmoner kapak replasmanı
• sağ ventrikül fonksiyonu

Destekleyen Kurum

Yazar, bu çalışma ile ilgili herhangi bir çıkar çatışması olmadığını beyan eder.

Proje Numarası

2015-04/32

Etik Beyan

Çalışma için Dokuz Eylül Üniversitesi Girişimsel Olmayan Araştırma Etik Kurulu'ndan onay alınmıştır (karar no: 2015/04-32, tarih: 12.02.2015).

Kaynakça

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