Long-Term Outcomes After Pulmonary Valve Repair for Regurgitation Secondary to Prior Intervention

D. K. Ragheb¹, Y. Zhang², A. Jaggi², S. Maskatia², G. Adamson³, G. Lui², E. Martin², M. Ma², F. Hanley³, D. McElhinney^2
1Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio ²Stanford University, Stanford, California ³Stanford University, Palo Alto, California

Purpose: Pulmonary valve (PV) replacement (PVR) is commonly used to treat regurgitation secondary to prior repair of congenital heart disease. However, prosthetic valve degeneration ultimately requires reintervention. Another therapeutic option is PV repair (PVr), but long-term durability is unknown. Our purpose was to compare long-term outcomes of PVr and PVR.

Methods: The inception cohort comprised all patients who underwent PVr for chronic regurgitation in 2018 or earlier to ensure a minimum potential follow-up duration of 5 years. A control cohort comprised patients who underwent surgical PVR during the same time frame and for the same indications. PVr for secondary PR after prior surgery or balloon valvuloplasty was first performed at our center in 2010, and the surgical technique can be found described in prior reports. PV Z-score after repair, immediate postoperative RVOT gradient and PR, time-related outcomes including freedom from RVOT reintervention, freedom from moderate or greater PR, and freedom from a maximum Doppler gradient ≥36mmHg were compared between PVr and PVR groups. Data are presented as number (%) or median (25th, 75th percentiles). Data were compared between groups with the Wilcoxon rank sum test or Fisher’s exact test as appropriate. Time-related outcomes were compared between groups with log-rank test.

Results: The study included 33 and 151 patients who underwent PVr and PVR, respectively. Diagnostic, historical, procedural, and early and long-term outcomes can be found in Table 1. Estimated freedom from reintervention 5 and 10 years after discharge was 97% (80,100) and 89% (69,96) after PVr and 96% (92,99) and 79% (67,87) after PVR. On univariable Cox regression analysis, there was no significant difference in freedom from reintervention between PVr and PVR patients. However, when the analysis was limited to patients < 21 years, freedom from reintervention was significantly longer in the PVr group. Similarly, on Cox regression analysis with adjustment for age or weight at the time of surgery, and on multivariable Cox regression, PVr was associated with significantly longer time to reintervention than PVR. Freedom from PR, RVOT obstruction, and either regurgitation or obstruction did not differ between PVr and PVR patients overall, but freedom from these hemodynamic outcomes was significantly longer for PVr patients when analysis was limited to patients < 21 years (Figure 1). As with reintervention, freedom from valve dysfunction was significantly longer after PVr than after PVR on Cox regression analysis adjusted for age or weight, and on multivariable Cox regression.

Conclusion: In this cohort, long-term durability of PVr was superior to PVR in patients < 21. PVr may be especially beneficial in younger patients, who are likely to require earlier and more interventions over time due to replacement valve degeneration, and indeed, these patients saw the most encouraging benefit in this cohort.

Identify the source of the funding for this research project: NA