Dorobantu DM, Sharabiani MTA, Taliotis D, Parry AJ, Tulloh RMR, Bentham JR, Caputo M, van Doorn C, Stoica SC.Eur J Cardiothorac Surg. 2020 Oct 1;58(4):825-831. doi: 10.1093/ejcts/ezaa069.PMID: 32187367
Dorobantu DM, Sharabiani MTA, Taliotis D, Parry AJ, Tulloh RMR, Bentham JR, Caputo M, van Doorn C, Stoica SC.Eur J Cardiothorac Surg. 2020 Oct 1;58(4):873. doi: 10.1093/ejcts/ezaa190.PMID: 32688385 No abstract available.
Commentary from Dr. Frederic Jacques (Quebec City, Quebec, Canada), congenital heart surgery section editor of Journal Watch: Dorobantu et al. published a study in the European Journal of Cardiothoracic Surgery trying to answer the question: Does age at the time of the first pulmonary valve replacement (PVR) among repaired tetralogy of Fallot (ToF) patients impact the long-term outcomes?[1] More specifically, it addresses survival. In this national registry-based multicentric retrospective study, the authors included all (707) ToF patients aged 15 or older who had to have PVR in the UK. They set to determine an age at which patients were more likely to survive both the procedure and in the long-term. They used a Cox regression model as well as CART (classification and regression tree analysis) to identify the optimal cut-off age. Both methods identified 35 years old as their cut-off, with older patients experiencing a 5.6-fold increased risk of dying at 10 years after PVR compared to the younger patients. Said differently, patients under 35 years of age at first PVR had a 10-year mortality of 1.3% compared to 10.4% for those between 35 and 50 years. Older patients required more tricuspid repair or replacement (15% vs. 6%) and arrhythmia surgery (18% vs. 6%) compared to the younger patients. The association of tricuspid valve surgery was linked to a worse survival in those between 35 and 50 years old, but not for the younger patients. Both age groups had worse survival than the general UK population, but the mortality excess was less for those with PVR under 35 (0.9%) compared to the 35-50 age group (7.7%).
Significance: Current guidelines for PVR among ToF patients do not take age into account in setting the surgical indication and timing but they likely should include guidance on this point. This study raises the question: Should we operate on patients earlier to achieve better long-term outcome?
Comment: With this type of registry, surgical indication criteria are not strongly defined, but one can reasonably assume most patients were treated with current Western standards. The most important strength of this study is that it is based on the mandatory inclusion of all the congenital patients from one country: no patient is missed. This likely results in catching subclinical right-sided damage that have not reach clinical significance. The reader is well aware that both residual regurgitation and stenosis are linked to myocardial damage, impact on exercise tolerance and even survival. Current guidelines recommend PVR when either volume or pressure overload had resulted in clinical signs and symptoms. So far, the literature has shown repercussion of PVR on RV volume and symptoms, but clear survival benefit is still to be demonstrated. Recent findings suggest that most of the hemodynamic recovery is seen immediately after surgery. This supports the idea that once right ventricular damage has been severe enough and long-standing, it might not be reversible. This also favors earlier intervention, since relieving the burden on the right ventricle earlier may prevent other comorbidities from developing. This study shows that older patients had more tricuspid regurgitation and arrhythmias. Obviously, a spectrum of subclinical myocardial damage occurs in the background before reaching to other clinically significant lesions. It is not known what portion of this damage is reversible. The authors suggest that current guidelines should be revisited not only based on hemodynamic parameters and symptoms, but that age should be accounted for in order to achieve a survival that approaches the general population as closely as possible. Will the paradigm shift from reacting to hemodynamic complications to preventing them?
