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Letters to the Editor

Reply to Kestelli et al.

^a Department of Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 9, 24105 Kiel, Germany
^b Department of Thoracic and Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 7, 24105 Kiel, Germany

Received 17 February 2009; accepted 18 February 2009.

^_* Corresponding author. Tel.: +49 431 597 1728; fax: +49 431 597 1828. (Email: uebing{at}pedcard.uni-kiel.de).

Key Words: Tetralogy of Fallot • Surgical repair • Pulmonary annulus diameter • Pulmonary regurgitation

We thank Dr Kestelli et al. [1] for their comments on our study [2]. We fully agree with the point that surgical repair of tetralogy of Fallot (ToF) should aim nowadays at limiting the damage to the right ventricular outflow tract (RVOT) and pulmonary regurgitation (PR). Therefore, we proposed a valve-sparing surgical strategy that aims to use transannular patches (TAP) only in patients with a very small pulmonary annulus (z score 4) and to enlarge the pulmonary annulus to low normal values (z score in the range of –2) in case a TAP is deemed necessary [2]. We presented that this strategy is feasible resulting in a marked reduction in TAP rate and without an increase in right ventricular (RV) pressure.

We admit that our threshold for using a TAP is high (pulmonary annulus z score 4) but could demonstrate that a pulmonary valve-sparing approach is possible in patients with a z score of –4 or larger as long as the repair also consists of inspection of the valve and commissurotomy. Accordingly, the incidence of commissurotomy was higher adhering to the valve-sparing strategy as opposed to a historic cohort of patients operated before this strategy was implemented.

We also agree that it is necessary to carefully apply the diagnostic criteria of ToF when conducting a study on these patients. We therefore reported comprehensively on all patients with this diagnosis who underwent repair in the period from 1997 to 2006. Only patients with double outlet right ventricle, pulmonary atresia and absent pulmonary valve and those in whom Fallot repair consisted of pulmonary valve replacement (PVR) were excluded. Patients were not excluded from the study on the basis of the preoperative pulmonary annulus size as suggested by Kestelli et al. since it was intended to investigate a surgical strategy applied to Fallot patients with the full spectrum of RVOT and pulmonary valve anatomy.

We take issue with Kestelli et al. on the subject of the incidence of PVR in our two groups. By study design, no patient received PVR as part of surgical repair. However, the incidence of PVR for residual PR was higher in our historic cohort (group 2; see Table 1 of the manuscript) [2]. This result might relate to a higher incidence of PR in this group. However, the longer follow-up period of these patients might also explain this difference. Further follow-up studies are necessary to confirm that restrictive RVOT repair truly limits the incidence and severity of PR.

We fully agree that any postoperative RVOT obstruction might decrease when RV hypertrophy regresses with time. This has to be considered when judging the immediate postoperative result. The University of Alabama group showed a decrease in right-to-left ventricular (RV/LV) pressure-ratio with time after Fallot repair [3]. Nollert et al. found no association between a RV/LV-pressure-ratio of 0.7 and early or late survival [4]. Hirsch et al. found that a RV/LV-pressure-ratio >0.7 is a risk factor for reoperation after neonatal repair [5]. We therefore accept an RV/LV-pressure-ratio of up to 0.7 immediately after RVOT reconstruction before deciding to insert a TAP.

References

1. Kestelli M, Tulukoglu E, Yurekli I, Gurbuz A. Think twice while inserting a transannular patch. Eur J Cardiothorac Surg 2009;35:1113.[Free Full Text]
2. Voges I, Fischer G, Scheewe J, Schumacher M, Babu-Narayan SV, Jung O, Kramer HH, Uebing A. Restrictive enlargement of the pulmonary annulus at surgical repair of tetralogy of Fallot: 10-year experience with a uniform surgical strategy. Eur J Cardiothorac Surg 2008;34:1041-1045.[Abstract/Free Full Text]
3. Katz NM, Blackstone EH, Kirklin JW, Pacifico AD, Bargeron Jr. LM. Late survival and symptoms after repair of tetralogy of Fallot. Circulation 1982;65:403-410.[Abstract/Free Full Text]
4. Nollert G, Fischlein T, Bouterwek S, Bohmer C, Klinner W, Reichart B. Long-term survival in patients with repair of tetralogy of Fallot: 36-year follow-up of 490 survivors of the first year after surgical repair. J Am Coll Cardiol 1997;30:1374-1383.[Abstract]
5. Hirsch JC, Mosca RS, Bove EL. Complete repair of tetralogy of Fallot in the neonate: results in the modern era. Ann Surg 2000;232:508-514.[CrossRef][Medline]

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				I. Voges, J. Scheewe, H.-H. Kramer, and A. Uebing Reply to Kestelli et al. Eur. J. Cardiothorac. Surg., June 1, 2009; 35(6): 1113 - 1113. [Full Text] [PDF]

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