Minimally Invasive Pulmonary Valve Replacement Following Tetralogy of Fallot Repair
Joseph Nellis1, Steven Thornton, Jr2, Nicolas Drysdale2, Andrew Vekstein1, Joseph Turek1
1Duke University, Durham, NC, USA, 2Duke University School of Medicine, Durham, NC, USA
BACKGROUND: Pulmonary insufficiency is a well-documented complication following Tetralogy of Fallot (ToF) repair. Traditionally, pulmonary insufficiency following ToF primary repair is addressed through re-do median sternotomy (MS). Patients often need multiple pulmonary valve replacements (PVR) throughout their life, and the temporary setbacks associated with each MS including sternal precautions is inescapable. Percutaneous strategies exist but present their own risks including coronary compression associated with stent-in-stent constructs, stent fracture, and infective endocarditis. We compare outcomes for ToF patients undergoing PVR through a 5cm left anterior mini incision (LAMI) and MS at a single institution.
METHODS: Retrospective review of patients undergoing PVR for pulmonary insufficiency following ToF repair through either MS or LAMI at single institution between 7/1/2016 and 12/31/2019. Continuous variables reported as median (IQR) and compared using Mann-Whitney U non-parametric analysis.
RESULTS: Twenty four patients were included in the study; 12 patients underwent PVR through a MS and LAMI respectively. Median age at presentation was 14.5 and 16 years old (p-value 0.62) with associated BMIs of 23.7 and 20.9 (p-value 0.64). Patients undergoing LAMI experienced a median bypass time of 156 minutes (135-166) and operative time of 320 minutes (292-380), while those undergoing MS experienced bypass times of 118 minutes (71-136) and operative times of 291 minutes (230-318)(p-values 0.04 and 0.09 respectively). One patient was converted from a LAMI to a hemi-sternotomy due to dense adhesions. No differences were observed in blood products required, postoperative length of stay, patient reported pain, morphine equivalents required, or complications at most recent follow-up.
CONCLUSIONS: PVR following primary ToF repair through a 5cm LAMI is associated with a longer bypass time, although otherwise does not appear to be inferior to MS across key endpoints including blood product requirements, length of stay, patient report pain, and complications. LAMI is a safe alternative to MS for patients with history of ToF undergoing PVR who would like to avoid sternal precautions.