Preserving the pulmonary valve during early repair of tetralogy of Fallot: Anatomic substrates and surgical strategies

Objective: To describe the anatomy of the PV in tetralogy of Fallot (TOF) and to define the influence of PV anatomy on the development of surgical techniques for PV preservation during early repair. Methods: The PV was evaluated in 79 anatomic specimens of patients with TOF who had not undergone surgery for repair, and in 82 patients who underwent early TOF repair at our institution. New surgical techniques for PV preservation during early repair are described. Results: The PV in TOF was predominantly bicuspid (n = 118 of 160; 73.7%), less frequently tricuspid (n = 28 of 160; 17.5%), and seldom unicuspid (n = 14 of 160; 8.8%). In 82 cases (51.3%), the PV cusps were normal; in 78 cases (48.7%), they were thickened and dysplastic. Preservation of the PV was possible in 46 of 82 (56%) consecutive patients during TOF repair in our more recent experience, either using balloon dilation alone (18 of 46; 39%) or in association with other PV plasty procedures (28 of 46; 61%). Most bicuspid and tricuspid valves were salvageable, but unicuspid valves were not suitable. After a median follow-up time of 2.8 years (range, 0.5-6.8 years), the degree of PV regurgitation continued to be zero or mild in 40 patients (86%), and moderate in 6 (14%). Conclusions: The majority of patients with TOF (>90%) have a bicuspid or tricuspid PV, which is the most favorable surgical anatomy for preserving the PV, independent of the degree of leaflet dysplasia. The recent introduction of more-complex PV plasty techniques, such as delamination plasty, allowed us to further extend the applicability of PV-preservation techniques.