Restrictive enlargement of the pulmonary annulus at repair of tetralogy of Fallot: a comparative 10-year follow-up study

Eur J Cardiothorac Surg. 2017 Dec 1;52(6):1149-1154. doi: 10.1093/ejcts/ezx143.


Objectives: Since 1996, our centre performs restrictive enlargement of the pulmonary annulus at surgical repair of tetralogy of Fallot. A transannular patch is only used if the z-score of the pulmonary annulus is smaller than -2. We sought to determine whether this strategy reduces pulmonary insufficiency (PI) and reoperation rate compared to a nationwide contemporary cohort that has not been operated using a uniform strategy.

Methods: Eighty-seven tetralogy of Fallot patients were included in the study (Group 1). One hundred sixty-seven tetralogy of Fallot patients from the Competence Network for Congenital Heart Disease served as controls (Group 2). Clinical, echocardiographic, electrocardiogram, cardiovascular magnetic resonance and outcome data were analysed.

Results: Follow-up time since repair was not different between groups [12.9 (7.8-18.8) vs 13.1 (5.2-16.9) years, P = 0.96] while transannular patch rate was significantly lower in Group 1 (32.2% vs 64.7%, P < 0.001). Ten-year freedom from reoperation for PI was significantly higher in our cohort (98% vs 92%, P = 0.01). Multivariable analysis identified restrictive enlargement as the only predictor for no need of reoperation [hazard ratio 0.4 (95% confidence interval 0.24-0.84), P < 0.01]. In Group 1, cardiovascular magnetic resonance-derived volumes were smaller (indexed end-diastolic volume: 103 ± 24 vs 123 ± 31 ml/m2, P < 0.001; indexed end-systolic volume: 53 ± 19 vs 59 ± 20 ml/m2, P = 0.04) and regurgitation fraction was lower (21 ± 14 vs 31 ± 17%, P < 0.001).

Conclusions: Restrictive enlargement of the pulmonary annulus reduces PI and limits the amount of right ventricular dilatation at intermediate-term follow-up. The need for reoperation to alleviate PI is significantly lower compared to a contemporary cohort. Restrictive enlargement strategy has a stronger influence on freedom from reoperation than the use of a transannular patch.

Clinical trial registration: WHO Main ID: DRKS00010087. URL:

Keywords: Pulmonary insufficiency; Restrictive enlargement; Tetralogy of Fallot; Transannular patch.

MeSH terms

  • Child, Preschool
  • Echocardiography
  • Electrocardiography
  • Female
  • Follow-Up Studies
  • Forecasting*
  • Humans
  • Infant
  • Magnetic Resonance Imaging, Cine
  • Male
  • Prospective Studies
  • Pulmonary Valve / diagnostic imaging
  • Pulmonary Valve / surgery*
  • Pulmonary Valve Insufficiency / diagnosis*
  • Pulmonary Valve Insufficiency / etiology
  • Pulmonary Valve Insufficiency / surgery
  • Reoperation
  • Tetralogy of Fallot / complications
  • Tetralogy of Fallot / diagnosis
  • Tetralogy of Fallot / surgery*
  • Time Factors
  • Treatment Outcome