International Journal of Cardiology 121 (2007) 123 – 124 www.elsevier.com/locate/ijcard Letter to the Editor Preoperative determinants of recovery time in adult Fallot patients after late pulmonary valve replacement Ivo R. Henkens, Alexander van Straten, Mark G. Hazekamp, Martin J. Schalij, Albert de Roos, Ernst E. van der Wall, Hubert W. Vliegen⁎ Departments of Cardiology, Radiology and Thoracic Surgery, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands Received 28 July 2006; accepted 4 August 2006 Available online 28 November 2006 Keywords: Adult congenital Heart disease; Tetralogy of Fallot; Pulmonary valve; Valve surgery; Recovery time 1. Introduction Tetralogy of Fallot is the most common type of cyanotic heart disease. Surgical correction at an early age offers good long-term results [1]. Pulmonary valve disease and right ventricular outflow tract size determine right ventricular function, and prognosis [2]. Success of pulmonary valve replacement has led to a debate regarding its optimal timing [3–5]. Recovery time, defined as time between pulmonary valve replacement and return to work or school, should be an important part of this discussion. 2. Patients and methods 2.1. Patients Records of 23 consecutively operated adult Fallot patients (15 male) of normal intelligence, working or in school before pulmonary valve replacement, were reviewed, and patients were interviewed regarding their recovery time. Concomitant interventions were necessary in 9 patients: right ventricular infundibulum resection (1), tricuspid valve annuloplasty (5), and residual ventricular septal defect closure (3). 2.2. Methods Evaluated preoperative parameters were: gender, age, presence of symptoms (New York Heart Association func⁎ Corresponding author. Tel.: +31 71 526 2448; fax: +31 72 526 6809. E-mail address: H.W.Vliegen@lumc.nl (H.W. Vliegen). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.08.055 tional class ≥ 2, n = 14), necessity for concomitant surgical intervention(s), QRS duration, and right ventricular volumes and function (assessed by magnetic resonance imaging). Also assessed were: age at total correction (range 0.4– 11.9 years), history of palliative intervention (n = 8) and use of a transannular patch (n = 10), and time since total correction (range 15.4–40.2 years). Cardiac magnetic resonance (CMR) was performed as previously described [4]. Right ventricular end-diastolic and end-systolic volume, pulmonary regurgitation severity, right ventricular ejection fraction, and restrictive right ventricular function (defined as end-diastolic pulmonary forward flow) were evaluated. Data evaluation was performed with SPSS (bivariate correlation analysis, Mann–Whitney test, and linear regression analysis). A p value of b0.05 was considered statistically significant. 3. Results All patients fully recovered. Median recovery time was 14.1 weeks (range 5–43 weeks). After 3 and 6 months 15 (65%) and 21 (91%) patients, respectively, had fully recovered. In one patient with a protracted recovery time elective balloon dilatation was necessary to relieve a residual right pulmonary artery stenosis. Recovery time was not associated with gender, presence of symptoms, need for concomitant surgery, history of palliative surgery, use of a transannular patch, or restrictive right ventricular function. QRS duration, right ventricular end-diastolic and end-systolic volume, right ventricular ejection fraction, and severity of pulmonary regurgitation 124 I.R. Henkens et al. / International Journal of Cardiology 121 (2007) 123–124 non-symptomatic patients is biased, correction for presence of symptoms did not change the age-effect. Given the excellent survival after pulmonary valve replacement, expected recovery time is the next most important parameter from a patient's point of view [6]. Since re-intervention indications were given careful consideration it was unexpected that two mildly symptomatic patients experienced a substantially protracted recovery time. Ideally, eligible patients would nowadays benefit from percutaneous valve implantation [7]. 5. Conclusion Fig. 1. Recovery time after pulmonary valve replacement in patients in NYHA class b2 as compared to patients in NYHA class ≥2. + =patient with residual right pulmonary artery stenosis. were not associated with recovery time either. Recovery time was only associated with age at total correction (r = 0.49, p b 0.05), time between total correction and pulmonary valve replacement (r = 0.58, p b 0.01), and patient age at the time of pulmonary valve replacement (r = 0.64, p b 0.01). Multivariate regression analysis was not allowed due to substantial collinearity, rendering age at pulmonary valve replacement the best predictor for recovery time (Fig. 1). 4. Discussion The fact that recovery time was not associated with presence of symptoms or decreased right ventricular function may come as a surprise. However, all patients were active in school or work, regardless of symptoms and, as reported before, right ventricular function improved in all patients [4]. Although it may be debated that comparing symptomatic and The majority of adult Fallot patients recover within reasonable time after pulmonary valve replacement. However, older adult Fallot patients should expect a more prolonged functional recovery time after pulmonary valve replacement, regardless of functional class or right ventricular function. References [1] Daliento L, Mapelli D, Russo G, et al. Health related quality of life in adults with repaired tetralogy of Fallot: psychosocial and cognitive outcomes. Heart 2005;91:213–8. [2] Bouzas B, Kilner PJ, Gatzoulis MA. Pulmonary regurgitation: not a benign lesion. Eur Heart J 2005;26:433–9. [3] Therrien J, Provost Y, Merchant N, Williams W, Colman J, Webb GD. Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair. Am J Cardiol 2005;95:779–82. [4] Vliegen HW, Van Straten A, De Roos A, et al. Magnetic resonance imaging to assess the hemodynamic effects of pulmonary valve replacement in adults late after repair of tetralogy of Fallot. Circulation 2002;106:1703–7. [5] Therrien J, Siu SC, McLaughlin PR, Liu PP, Williams WG, Webb GD. Pulmonary valve replacement in adults late after repair of Tetralogy of Fallot: are we operating too late? J Am Coll Cardiol 2000;36:1670–5. [6] Yemets IM, Williams WG, Webb GD, et al. Pulmonary valve replacement late after repair of tetralogy of Fallot. Ann Thorac Surg 1997;64:526–30. [7] Khambadkone S, Coats L, Taylor, et al. Percutaneous pulmonary valve implantation in humans: results in 59 consecutive patients. Circulation 2005;112:1189–97.