Long-Term Fate of the Truncal Valve. Gellis L, Binney G, Alshawabkeh L, Lu M, Landzberg MJ, Mayer JE, Mullen MP, Valente AM, Sleeper LA, Brown DW.J Am Heart Assoc. 2020 Nov 17;9(22):e019104. doi: 10.1161/JAHA.120.019104. Epub 2020 Nov 9.PMID: 33161813
Take Home Points:
- Long-term rates of truncal valve intervention are significant – by 20 years post-operative period, a quarter of patients with truncus arteriosus underwent truncal valve intervention (repair or replacement).
- Moderate or greater initial truncal valve dysfunction and single coronary ostium were associated with subsequent need for truncal valve intervention.
- Larger truncal valve root z-score is associated with significant truncal valve regurgitation and may identify a subset of patients at risk for truncal valve dysfunction over time.
Commentary from Dr. Manoj Gupta (New York, USA), section editor of Pediatric & Fetal Cardiology Journal Watch: This is a retrospective chart review study from 1985 to 2016 at Boston Children’s Hospital, and a total of 244 patients underwent initial TA repair at BCH.
Of these patients, 170 met the criteria for analysis. Overall, 9% (n=15/170) of patients underwent concomitant truncal valve surgery at time of initial repair. Two thirds (n=10/15) of these patients had a quadricuspid valve. Eleven patients had greater than mild preoperative truncal valve regurgitation, and the remaining 4 patients had moderate or severe truncal valve stenosis. Three patients also had concomitant left coronary artery intervention: unroofing, translocation, and removal of fibrous tissue at the ostium. Of the patients with moderate or greater initial regurgitation, 15 (79%) had a quadricuspid valve.
Overall, 123 patients (83%) underwent at least one surgical or catheter-based intervention during follow-up. Freedom from any surgical reintervention at 1, 5, 10, and 20 years was 90.0%, 50.0%, 21.0%, and 6.0%.
Quadricuspid truncal valve (n=45/140) and concomitant truncal valve surgery at initial repair (n=11/148) were univariate risk factors for truncal valve intervention, a truncal root z-score of ≥5 had a significantly higher odds of developing moderate or greater truncal valve regurgitation
During follow-up, 30 patients (20%) had at least one surgical intervention on the truncal valve, 24 of whom were from the group without concomitant truncal valve surgery (first intervention on the truncal valve occurred subsequently during follow-up) (Figure 1). Among those with only subsequent truncal intervention, 16 underwent repair first and 8 underwent replacement without prior repair. Of note, those who underwent replacement were older (median age, 18.3 [range, 1.1–23.0] years versus 8.3 [range, 2.3–16.8] years; P=0.04) and with larger aortic root size at time of replacement.
Four patients had >1 valve repair, and 3 patients went on to have a second valve replacement during follow-up. Of the 11 long-term survivors with concomitant truncal valve surgery at initial repair, 6 went on to have truncal valve reintervention during follow-up.
During follow-up, 10 patients (7%) underwent truncal root reduction (2 at time of surgery for conduit exchange without truncal valve intervention, 4 at time of truncal valve replacement, and 4 at time of truncal valve re- pair). No patients experienced aortic dissection.