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Does position of prosthetic valve affect durability of prosthetic valve in pulmonary position in tetralogy of Fallot patients?: Focused on the angle between prosthetic valve and main pulmonary artery
Yujin Kwak, Jae Gun Kwak, Sungkyu Cho, Woong-Han Kim.
Seoul National University Hospital, Seoul, Korea, Republic of.

Background Many patients require pulmonary valve replacement (PVR) later after repair of tetralogy of Fallot (TOF) due to residual pulmonary regurgitation (PR) or stenosis (PS). The objective was to evaluate the factors affecting the durability of the bio-prosthetic pulmonary valve, especially, focusing on the angle of implantation as well as age, valve size or materials of prosthesis.Methods Between January 2001 and May 2020, 58 patients with TOF underwent redo PVR after total repair due to prosthetic valve failure (PS ≥ 3.5m/s or PR ≥ moderate grade). We finally reviewed 36 patients with good images for measuring implantation angle on CT, MRI or angiography. We defined angle of implantation as shown in the figure.Results The baseline characteristics of the preoperative patients are summarized in Table 1. The follow-up was completed in 94.4% of patients. Table 2 shows the operative details. Right ventricular end diastolic volume index decreased from an average 154.846.4 to 123.929.5 ml/m2 (p=0.009) after redo PVR on MRI data. Implantation angle was the significant risk factor for prosthetic valvular failure before 10 years after first PVR. According to the implantation angle, prosthetic valvular failure occurred more rapidly when the valve angle was smaller than 30 degrees or bigger than 45 degrees.Conclusions The risk of early prosthetic valvular failure was relatively lower when the implantation angle was between 30 and 45 degrees. We should be careful to implant a prosthetic valve with an adequate angle to keep a laminar flow in the pulmonary position for better durability.

Baseline characteristics of preoperative patients
VariableValue
Bwt. at TOF repair (kg)9.73.7
Bwt. at first PVR (kg)33.314.0
Age at TOF repair (months)13.4 (IQR, 8.4-22.3)
Age at first PVR (years)10.1 (IQR, 8.4-12.2)
NYHA ≤ II31
NYHA ≥ III5
Atrial flutter3
Ventricular tachycardia2


Operative details
VariableValue
Mean follow-up duration after 1st PVR (years)15.62.5
Mean interval from 1st PVR to 2nd PVR (years)10.13.6
Operative mortality
Irreversible RV dysfunction (n)2
Mean size of prosthesis (mm)25 (IQR, 23-25)
Materials of prosthesis
Pericardial valve (n)24
Porciine valve (n)12



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