Outcome of Pulmonary Valve Repair in Patients with Tetralogy of Fallot Using Different Surgical Methods

Abstract

Objective: To compare the early perioperative, echocardiographic, and clinical outcomes associated with right atrial appendage reconstruction, monocusp reconstruction, and pulmonary valve preservation in children undergoing complete surgical repair of Tetralogy of Fallot (TOF). Methodology: This prospective non-randomized comparative cohort study was conducted at The Children's Hospital & University of Child Health, Lahore, between 1 January 2025 and 30 June 2025. A total of 150 consecutive children undergoing complete repair of Tetralogy of Fallot were enrolled and allocated into three equal groups according to the pulmonary valve management strategy selected intraoperatively by the operating surgeon: right atrial appendage reconstruction (n=50), monocusp reconstruction (n=50), and pulmonary valve preservation (n=50). Patients were followed for 30 days after surgery. The primary outcome was postoperative pulmonary valve function, while secondary outcomes included operative characteristics, postoperative recovery, echocardiographic findings, complications, and short-term clinical outcomes. Results: The mean age of the study population was 6.9 ± 3.2 years, and 60% were male. Baseline demographic and clinical characteristics were comparable across the three groups. Pulmonary valve preservation was associated with significantly shorter operative time (197 ± 24 min), aortic cross-clamp time (85 ± 11 min), and cardiopulmonary bypass time (128 ± 16 min) compared with right atrial appendage and monocusp reconstruction (all p<0.05). Patients in the pulmonary valve preservation group also demonstrated shorter durations of mechanical ventilation, intensive care unit stay, hospital stay, and lower inotropic requirements (all p<0.05). Postoperative echocardiography showed a higher proportion of mild pulmonary insufficiency, significantly greater tricuspid annular plane systolic excursion (TAPSE), lower postoperative RVOT gradients, and higher left ventricular ejection fraction in the pulmonary valve preservation group. After adjustment for potential confounders, pulmonary valve preservation remained independently associated with shorter ICU stay, shorter hospital stay, improved right ventricular systolic function, lower RVOT gradients, and a reduced likelihood of reintervention within 30 days. Conclusion: In this prospective non-randomized comparative cohort study, pulmonary valve preservation was associated with more favourable early perioperative recovery, postoperative right ventricular function, and pulmonary valve competence compared with right atrial appendage reconstruction and monocusp reconstruction.