Pulmonary valve replacement after operative repair of tetralogy of Fallot: meta-analysis and meta-regression of 3,118 patients from 48 studies

J Am Coll Cardiol. 2013 Dec 10;62(23):2227-43. doi: 10.1016/j.jacc.2013.04.107. Epub 2013 Sep 28.


Because the real benefit of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot who develop pulmonary insufficiency remains unclear, it is necessary to analyze the evidence published around the world. We performed a systematic review of studies that reported data about the effect of PVR in patients with repaired tetralogy of Fallot that developed pulmonary insufficiency, until December 2012. The variables chosen to represent the benefit were both right ventricular (RV) and left ventricular measures, QRS duration, and functional class. The principal summary measures were difference in means with 95% confidence interval and p values (considered statistically significant when p < 0.05). The differences in means were combined across studies with the weighted DerSimonian-Laird random effects model. Meta-analysis, sensitivity analysis, and meta-regression were completed with the software Comprehensive Meta-Analysis (version 2, Biostat, Inc., Englewood, New Jersey). Forty-eight studies involving 3,118 patients met the eligibility criteria. The pooled 30-day mortality was 0.87% (47 studies; 27 of 3,100 patients); the pooled 5-year mortality was 2.2% (24 studies; 49 of 2,231 patients); the pooled 5-year re-PVR was 4.9% (15 studies; 88 of 1,798 patients). The results of this meta-analysis demonstrate that after PVR: 1) the RV experiences improvement of its volumes and function; 2) the left ventricle experiences improvement of its function; 3) QRS duration decreases; 4) symptoms improve; 5) pre-operative RV geometry modulates the effect of PVR; and 6) there is important heterogeneity of the effects among the studies, and few publication biases. In conclusion, PVR seems to be a positive approach in the analyzed scenario.

Keywords: LV; LVEDV; LVEF; LVESV; MRI; NYHA; New York Heart Association; PRF; PVR; RV; RVEDV; RVEF; RVESV; TOF; left ventricle/ventricular; left ventricular ejection fraction; left ventricular end-diastolic volume; left ventricular end-systolic volume; magnetic resonance imaging; meta-analysis; pulmonary regurgitation fraction; pulmonary valve insufficiency; pulmonary valve replacement; right ventricle/ventricular; right ventricular ejection fraction; right ventricular end-diastolic volume; right ventricular end-systolic volume; tetralogy of Fallot.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Cardiac Surgical Procedures / adverse effects*
  • Heart Conduction System / physiopathology*
  • Heart Valve Prosthesis Implantation* / mortality
  • Humans
  • Pulmonary Valve Insufficiency / etiology*
  • Pulmonary Valve Insufficiency / mortality
  • Pulmonary Valve Insufficiency / physiopathology
  • Pulmonary Valve Insufficiency / surgery*
  • Stroke Volume
  • Tetralogy of Fallot / complications
  • Tetralogy of Fallot / surgery*
  • Treatment Outcome
  • Ventricular Function, Left*
  • Ventricular Function, Right*