The impact of a bicuspid pulmonary valve in the aortic position after arterial switch for transposition of the great arteries on neoaortic root dimension and function: a propensity score matched analysis.

OBJECTIVES: This study investigated the effect of a bicuspid pulmonary valve on neoaortic root morphology, function, and the clinical outcomes of early survivors after the arterial switch operation using propensity score matching. METHODS: From 1997 to 2018, a total of 442 patients underwent the arterial switch operation for transposition of the great arteries. After exclusion of patients who underwent a staged repair, were repaired beyond 1 year of age, died before discharge and who lacked echocardiographic data at discharge, propensity score matching was used for analysis. RESULTS: Among 352 eligible patients, 18 patients (5.1%) had a bicuspid pulmonary valve. After propensity score matching (1:4), 15 patients with bicuspid valve (bicuspid group) and 60 patients with tricuspid valve (tricuspid group) were enrolled. The median follow-up duration was 9.9 years (4 months∼22.3 years). All-cause reoperation-free survival at 10 years was 93.3% in the bicuspid group and 87.0% in the tricuspid group (P = 0.839), and reoperation for neoaortic valve or root was required in 2 patients in the bicuspid group and 1 in the tricuspid group without intergroup difference. The z-score of the neoaortic annulus did not change in either group, although there was an increasing tendency in the z-score of the neoaortic sinus without intergroup difference (P = 0.690). Deterioration in neoaortic valve function was more prominent in the bicuspid group (p = 0.028). CONCLUSIONS: The neoaortic sinus might outgrow the norm regardless of the number of neoaortic valve cusps, whereas the neoaortic annulus remained unchanged. Deterioration of valve function was more prominent in the bicuspid group, which suggests that a bicuspid valve might play a significant role in deterioration of neoaortic valve function, without an additional effect on root pathology.

Surgical treatment of tetralogy of Fallot in symptomatic neonates and young infants.

OBJECTIVES: Optimal management of tetralogy of Fallot in symptomatic neonates and young infants remains controversial. METHODS: A retrospective review of 53 patients (26 male) with symptomatic tetralogy of Fallot who underwent primary repair (group 1, n = 22) or initial palliation (group 2, n = 31) within 2 months (60 days) after birth between 2005 and 2018 was performed. Subsequent repairs were performed in 29 patients at postpalliation 7.1 months in group 2 except for 2 interstage mortalities. Optimal early outcome was defined as no significant pulmonary stenosis or significant pulmonary regurgitation, and no reintervention within 12 months after repair. RESULTS: In group 2, median Z-score of the pulmonary valve annulus and McGoon ratio increased after palliation from -3.52 to -2.95 (P = .074) and from 1.31 to 1.93 (P < .001), respectively. Pulmonary annulus preservation at repair and optimal early outcome were achieved in 38 patients (17/22, 77%, group 1; 21/29, 72%, group 2) and 26 patients (12/22, 55%, group 1; 14/29, 48%, group 2), respectively. On logistic regression analysis, initial Z-score of the pulmonary valve annulus was the only predictor of annulus preservation at repair (odds ratio, 1.715, P = .0204) and optimal early outcome (odds ratio, 1.583, P = .0259). The annulus preservation probability curve according to the initial postnatal Z-score of the pulmonary valve annulus of all patients with repair (n = 51) showed an annulus preservation probability less than 70% in 3 patients (3/22) in group 1 and greater than 85% in 8 patients (8/29) in group 2, signifying that the alternative strategy might have been beneficial for each subset. CONCLUSIONS: The surgical strategy for symptomatic tetralogy of Fallot should be individualized according to the initial size of the pulmonary valve annulus.