Congenital Heart Disease
Outcomes of Pulmonary Valve Replacement in
170 Patients With Chronic Pulmonary Regurgitation
After Relief of Right Ventricular Outﬂow Tract Obstruction
Implications for Optimal Timing of Pulmonary Valve Replacement
Cheul Lee, MD,* Yang Min Kim, MD,† Chang-Ha Lee, MD,* Jae Gun Kwak, MD,*
Chun Soo Park, MD,* Jin Young Song, MD,‡ Woo-Sup Shim, MD,‡ Eun Young Choi, MD,‡
Sang Yun Lee, MD,‡ Jae Suk Baek, MD‡
The objectives of this study were to evaluate outcomes of pulmonary valve replacement (PVR) in patients with
chronic pulmonary regurgitation (PR) and to better deﬁne the optimal timing of PVR.
Although PVR is effective in reducing right ventricular (RV) volume overload in patients with chronic PR, the opti-
mal timing of PVR is not well deﬁned.
A total of 170 patients who underwent PVR between January 1998 and March 2011 for chronic PR were retro-
spectively analyzed. To deﬁne the optimal timing of PVR, pre-operative and post-operative cardiac magnetic res-
onance imaging (MRI) data (n ϭ 67) were analyzed.
The median age at the time of PVR was 16.7 years. Follow-up completeness was 95%, and the median
follow-up duration was 5.9 years. Overall and event-free survival at 10 years was 98% and 70%, respectively.
Post-operative MRI showed signiﬁcant reduction in RV volumes and signiﬁcant improvement in biventricular
function. Receiver-operating characteristic curve analysis revealed a cutoff value of 168 ml/m
normalization of RV end-diastolic volume index (EDVI) and 80 ml/m
for RV end-systolic volume index (ESVI).
Cutoff values for optimal outcome (normalized RV volumes and function) were 163 ml/m
for RV EDVI and
for RV ESVI. Higher pre-operative RV ESVI was identiﬁed as a sole independent risk factor for subopti-
Midterm outcomes of PVR in patients with chronic PR were acceptable. PVR should be considered before RV
EDVI exceeds 163 ml/m
or RV ESVI exceeds 80 ml/m
, with more attention to RV ESVI. (J Am Coll Cardiol
2012;60:1005–14) © 2012 by the American College of Cardiology Foundation
Relief of right ventricular (RV) outﬂow tract obstruction in
tetralogy of Fallot or similar physiology often results in
pulmonary regurgitation (PR). The resultant chronic vol-
ume overload can lead to RV dilation, biventricular dysfunc-
tion, heart failure symptoms, arrhythmias, and sudden death
(1–5). Pulmonary valve replacement (PVR) can lead to
improvement in functional class and a substantial decrease
or normalization of RV volumes (6,7). Other potential
beneﬁts of PVR are improvement in exercise capacity (8)
and decrease in QRS duration (9). However, beneﬁts of
PVR have to be weighed against the risks of this procedure.
See page 1015
Although operative mortality of PVR is low (6), post-
operative morbidities are not negligible (10) and patients are
exposed to the risk of repeat PVR (11–13). PVR is indicated
when patients become symptomatic or at risk for life-
threatening arrhythmias (14). For asymptomatic patients,
there have been debates regarding the optimal timing of
PVR (15–19). Magnetic resonance imaging (MRI) is a gold
standard for evaluating RV volumes and function (20), and
these MRI parameters can be used to decide the indications
for PVR. Many studies dealing with changes in MRI
parameters after PVR have been reported (7–9,21–26).
However, most of them have a limitation of small patient
From the *Department of Thoracic and Cardiovascular Surgery, Cardiovascular
Center, Sejong General Hospital, Bucheon, Republic of Korea; †Department of
Radiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of
Korea; and the ‡Department of Pediatric Cardiology, Cardiovascular Center, Sejong
General Hospital, Bucheon, Republic of Korea. All authors have reported that they
have no relationships relevant to the contents of this paper to disclose.
Manuscript received December 8, 2011; revised manuscript received February 28,
2012, accepted March 29, 2012.
Journal of the American College of Cardiology Vol. 60, No. 11, 2012
© 2012 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00
Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.03.077