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

BackgroundAdverse ventricular-ventricular interactions have been recognized in those with repaired tetralogy of Fallot (TOF) and severe pulmonary regurgitation.ObjectiveWe aimed to examine the impact of pulmonary valve replacement (PVR) on the left heart late after TOF repair.Methods and resultsLeft 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. By multivariate 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/m2, p = 0.05), LV end-systolic volumes decreased after PVR in patients with impaired preoperative LVEF (65 ± 12 → 54 ± 10 mL/m2, p = 0.001) but LV end-diastolic volumes were not significantly changed.ConclusionWhen 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.