Skip to main content
NCBI home page
Interdisciplinary Cardiovascular and Thoracic Surgery logoLink to Interdisciplinary Cardiovascular and Thoracic Surgery
. 2024 Nov 5;39(6):ivae180. doi: 10.1093/icvts/ivae180

Right ventricular outlet tract reconstruction for tetralogy of Fallot: systematic review and network meta-analysis

Akira Yamaguchi 1,#, Tomonari Shimoda 2,#, Hiroo Kinami 3, Jun Yasuhara 4, Hisato Takagi 5, Shinichi Fukuhara 6, Toshiki Kuno 7,8,9,✉
PMCID: PMC11629697  PMID: 39499166

Abstract

OBJECTIVES

Concerns persist regarding pulmonary regurgitation after transannular patch repair (TAP) for tetralogy of Fallot. Despite the introduction of various architectural preservation techniques, the optimal strategy remains controversial. Our goal was to compare different right ventricular outlet tract reconstruction techniques.

METHODS

PubMed, EMBASE and Cochrane Central were searched through March 2024 to identify comparative studies on right ventricular outlet tract reconstruction techniques (PROSPERO ID: CRD42024519404). The primary outcome was mid-term pulmonary regurgitation, with secondary outcomes including postoperative mortality, postoperative pulmonary regurgitation, length of intensive care unit stays, postoperative right ventricular outlet tract pressure gradient and mid-term mortality. We performed a network meta-analysis to compare outcomes among TAP, valve-repairing (VR), TAP with neo-valve creation (TAPN) and valve-sparing (VS).

RESULTS

Two randomized controlled studies and 32 observational studies were identified with 8890 patients. TAP carried a higher risk of mid-term pulmonary regurgitation compared to TAPN [hazard ratio, 0.53; 95% confidence interval (CI) (0.33; 0.85)] and VS [hazard ratio, 0.27; 95% CI (0.19; 0.39)], with no significant difference compared to VR. VS was also associated with reduced postoperative mortality compared to TAP [risk ratio, 0.31; 95% CI (0.18; 0.56)], in addition to reduced ventilation time. TAP also carried an increased risk of postoperative pulmonary regurgitation compared to the other groups. The groups were comparable in terms of length of intensive care unit stay, right ventricular outlet tract pressure gradient and mid-term mortality.

CONCLUSIONS

VR was associated with a reduced risk of postoperative pulmonary regurgitation, whereas TAPN was associated with reduced risks of both postoperative and mid-term pulmonary regurgitation.

Keywords: Tetralogy of Fallot, Network meta-analysis, Right ventricular outlet tract reconstruction

Since Kirklin and colleagues introduced the transannular patch repair (TAP) method, the strategy for right ventricular outlet tract reconstruction (RVOTR) in tetralogy of Fallot (TOF) has been refined over the past decades [1].

Graphical Abstract

graphic file with name ivae180f5.jpg

Open in a new tab

INTRODUCTION

Since Kirklin and colleagues introduced the transannular patch repair (TAP) method, the strategy for right ventricular outlet tract reconstruction (RVOTR) in tetralogy of Fallot (TOF) has been refined over the past decades [1]. TAP is often associated with postoperative pulmonary regurgitation (PR), resulting in heart failure and necessitating reoperations [2]. Despite these challenges, TAP remains the most common technique, accounting for 46% of cases [3]. In an attempt to minimize postoperative PR, various techniques have been developed to better preserve RVOT architecture to improve long-term outcomes [4–8].

The transannular patch with the neo-pulmonary valve creation (TAPN) technique, where a monocusp or other tissues are fashioned to create a ‘neo-valve’ to reduce the PR, has been introduced [4]. Additionally, valve-repairing (VR) techniques have been introduced, where the native pulmonary valve is repaired, often with a transannular incision. Sung et al. [5] described a VR technique involving a transannular incision and division and augmentation of the anterior leaflet of the pulmonary valve with a rectangular patch and a patch placement for transannular incision closure. Valve-sparing (VS) techniques, without a transannular incision, are often performed to preserve long-term pulmonary valve function [6].

Although various techniques are available, most reports are single-centre studies with limited populations. No comprehensive comparative analysis has been conducted among the TAP, VR, TAPN and VS techniques. Currently, the choice of technique depends on the surgeons’ preferences or the institutions’ practices. Therefore, this study is designed to evaluate the clinical outcomes of various surgical techniques for patients with TOF using a network meta-analysis.

MATERIALS AND METHODS

Given the nature of our study, institutional research board or informed written consent for publication was not required.

Eligibility criteria

This network meta-analysis was conducted under the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and was registered on PROSPERO (ID=CRD42024519404) [9]. Inclusion criteria met the following features: (i) randomized controlled or observational studies and (ii) comparative studies for primary RVOTR of TOF repair. Exclusion criteria included (i) studies not comparing the different types of RVOTRs; (ii) studies including patients who underwent right ventricle–pulmonary artery conduit reconstruction or pulmonary valve replacement; or patients with severe concomitant cardiac anomalies including pulmonary atresia, absent pulmonary valve, major aortopulmonary collateral artery or atrioventricular septal defect; and (iii) studies published before 2000.

Search strategies

The studies that met inclusion criteria were identified using a two-level strategy. PubMed, Embase, and Cochrane Central were searched on 4 March 2024. Then, relevant studies were searched manually through references to the identified articles, reviews and commentaries. Search terms were summarized in Supplementary Material, Tables S1–S3. Eligible studies were screened based on title and abstract, followed by full review. Two independent and blinded authors (A.Y. and T.S.) conducted separate reviews, resolving disagreements by consensus, with occasional arbitration by the third reviewer (T.K.). Language limitations were not applied.

Outcomes of interest

Our primary outcome of interest was mid-term occurrence rates of PR. Secondary outcomes of interest were (i) postoperative deaths, (ii) postoperative PR, (iii) postoperative ventilation time, (iv) length of intensive care unit (ICU) stays, (v) postoperative peak right ventricular outlet tract pressure gradient (RVOT-PG) and (vi) mid-term mortality. Table 1 summarized the definitions of each outcome.

Table 1:

Definition of each outcome

Outcomes Definition Pooled variables
Mid-term PR Moderate/severe PR at the end of studies with more than 3 years of follow-up. RR, HR or adjusted HR
Postoperative mortality Event number of 30-day mortality or in-hospital mortality RR
Postoperative PR Moderate/severe PR immediately post-operation during admission by echocardiography RR
Postoperative ventilation time The time patients were on ventilation postoperatively MD
Length of ICU stays The length of ICU stays in days MD
RVOT-PG RVOT pressure gradient was measured postoperatively to examine whether there was any/no residual pressure gradient. In this analysis, we compared the differences of RVOT-PG among the groups, not the changes between the pre- and postoperative gradients in each group. MD
Mid-term deaths More than 1-year follow-up RR, HR or adjusted HR
Open in a new tab

HR: hazard ratio; ICU: intensive care unit; MD: mean difference; PR: pulmonary regurgitation; RR: risk ratio;

RVOT-PG: right ventricular outlet tract pressure gradient.

We conducted a network meta-analysis to compare RVOTR techniques comprising TAP, VR, TAPN and VS.

RVOTR procedures comprised TAP, VR, TAPN and VS techniques, as depicted in Fig. 1, with detailed procedural definitions provided in Table 2. If studies reported a mixed cohort of TAP and TAPN as a single group, cohorts were reclassified based on the predominant technique. Groups were reclassified as TAP if TAP accounted for more than 50%, and TAPN if TAPN accounted for more than 50%. If the proportion was not available, classification followed study definitions.

Figure 1:

Figure 1:

Open in a new tab

Graphical depiction of right ventricular outlet tract reconstruction. (A) Conventional transannular patch repair technique. (B) Valve-repair technique: a transannular incision was made, and the original pulmonary valve was repaired with a patch. Another patch was placed to cover the transannular incision. (C) An example of the valve-sparing technique, mostly entailing main pulmonary artery augmentation, right ventricular outflow tract muscle resection and/or commissurotomy without longitudinal transannular incision. Ao: aorta; MPA: main pulmonary artery; RV: right ventricle.

Table 2:

Definition of the right ventricular outlet tract reconstruction

Definition
TAP A transannular incision was placed from the main pulmonary artery to the right ventricle, completely dividing the original pulmonary annulus.
VR A transannular incision was placed by dividing the pulmonary annulus and anterior leaflet of the pulmonary valve evenly. A rectangular patch was sutured directly to both sides of the divided pulmonary annulus and anterior leaflet to repair the pulmonary valve. Subsequently, the transannular incision was covered by another patch.
TAPN This technique was defined as inserting a neo-pulmonary valve after placing a transannular incision, but it did not involve repairing the original pulmonary valve itself. Specifically, the neo-valve was reconstructed using either of the following techniques: a neo-valve was fashioned as a pocket-like structure attached to the transannular patch or a right atrial appendage was inserted as a neo-valve. Also, this group includes the studies in which the details of neo-valve reconstruction techniques are unknown.
VS This technique spares the original function of the pulmonary valve without completely dividing the original pulmonary annulus.
Open in a new tab

TAP: transannular patch repair; TAPN: transannular patch repair with neo-valve; VR: valve-repairing; VS: valve-sparing.

Assessment of study quality

Study quality was assessed using the revised Cochrane risk of bias tool for randomized trials [10], as well as the risk of bias in non-randomized studies of interventions for observational trials [11].

Statistics

We extracted risk ratios (RRs) for postoperative mortality and postoperative PR, along with RRs or hazard ratios (HRs) for mid-term mortality and mid-term PR from each study. If the studies reported adjusted outcomes including propensity score matched results or adjusted RRs or HRs, they were prioritized and utilized for the analysis. If HRs were not reported but Kaplan–Meier curves were available, the HR was calculated during the entire follow-up period using the ‘HR-calculations spreadsheet’ provided by Tierney and colleagues based on standard statistical methods reported by Palmar and Williamson [12–14]. Mean differences for postoperative ventilation time, length of ICU stays, hospital stays and RVOT-PGs were calculated, converting median and interquartile values to mean ± standard deviation [15, 16].

Analyses were conducted using the ‘netmeta’ package software version 2.8–2 [R Core Team (2023) (R: A Language and Environment for Statistical Computing, R Foundation for Statistical Computing, Vienna, Austria)] [17]. Heterogeneity was quantified using I2 and the Q statistics, which represent the proportion of total variation in study estimates resulting from heterogeneity [18]. The I2 statistic represents the proportion of variability that is not attributable to chance. The Q statistic is the sum of a statistic for heterogeneity and a statistic for inconsistency, which represents the variability of treatment effect between direct and indirect comparisons at the meta-analytic level [19]. Random-effects models were used. Significant heterogeneity was considered to be present when the I2 index was over 50% or the P-value for heterogeneity was <0.05. Significant inconsistency was considered to be present when the P-value was <0.05. Inconsistency was further assessed through forest plots comparing direct evidence and indirect evidence. Procedures were examined using a P-score of 0% to 100%, with higher scores indicating more effective or safer procedures [20]. Funnel plot asymmetry suggesting publication bias was assessed using the Egger linear regression test [21].

Secondary analyses

To address potential heterogeneity in studies in which the TAP arm included both TAP and TAPN, we conducted secondary analyses based on their proportions. Initially, studies that combined TAP and TAPN into a single group were excluded from the sensitivity analysis if either TAP or TAPN accounted for less than 80% of their respective group. Second, a sensitivity analysis excluding all mixed TAP studies was also performed.

RESULTS

Study selection

Thirty-four studies were identified [22–55], including 2 randomized controlled trials [34, 37] and 32 observational studies. Among the 32 observational studies, there were 5 propensity score matched studies (Supplementary Material, Fig. S1) [23, 31, 43, 44, 49].

Study characteristics

Table 3 summarizes the baseline characteristics of the studies (for more details, see Supplementary Material, Table S4). Seven studies were from the United States [24, 40, 44, 45, 48, 54, 55]. There were 3 reports from China [30, 33, 38], Canada [31, 35, 41], India [34, 46, 52] and South Korea [43, 47, 49]. Two studies from Japan [27, 28] and Iran [32, 36] were included. There was 1 report each from the Czech Republic [22], Australia [24], Italy [25], Colombia [26], Taiwan [29], Egypt [36], the Netherlands [39], Turkey [42], Israel [50], Thailand [51] and Saudi Arabia [53]. A total of 3562 patients underwent TAP; 584 patients underwent VR; 906 patients underwent TAPN; and 3838 patients underwent VS. Seven studies included both TAP and TAPN in the TAP arm [28, 31, 33, 35, 38, 41, 55], with proportions detailed in 5 studies (Supplementary Material, Table S4) (For reclassification details, see Supplementary Material, Fig. S2) [28, 35, 38, 41, 55].

Table 3:

Short summary of study characteristics

First Author Gebauer Ishigami Schulte Guariento Guerrero Kobayashi Ono Huang Wu Blais Amirghofran
Year 2023 2023 2023 2022 2022 2022 2022 2022 2021 2021 2021
Country Czech Republic Australia United States Italy Colombia Japan Japan Taiwan China Canada Iran
Periods 1979–2020 1990–2020 2007–2021 2007–2020 2010–2019 1991–2019 1978–2003 2009–2017 2009–2018 1980–2015 2018–2019
Design Retrospective Retrospective, PSM Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective, PSM Retrospective
Comparison (patient, n) TAP (182) vs VR (90) vs VS (645)

  • TAP (722) vs VS (233)

  • PSM cohort TAP (152), VS (152)

 TAP (95) vs TAPN (8) vs VS (71) VS (73) vs TAPN (133) TAP (66) vs VR (63) vs VS (145) VR (123) vs VS (207) TAPN (242: TAP 77, TAPN 165) vs VS (198) TAP (8) vs TAPN (16) TAP (63) vs TAPN (65)

  • TAP (401) vs VS (282)

  • PSM cohort TAP (264), VS (264)

 TAP (10) vs TAPN (21)
First Author Jiang Rawat Ducas Singab Samadi Zhao Mouws Singh Hickey Aydin Kim
Year 2021 2021 2021 2020 2020 2020 2019 2018 2018 2018 2018
Country China India Canada Egypt Iran China Netherlands United States Canada Turkey South Korea
Periods 2012–2017 2016–2017 1981–1996 2012–2019 2011–2018 2016–2017 2000–2015 2005–2016 2000–2012 2010–2015 1996–2011
Design Retrospective Randomized controlled trial Retrospective Retrospective Randomized controlled trial Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective, PSM
Comparison (patient, n) TAP (729) vs VS (944) TAP (15) vs TAPN (15) TAP (126: TAP 81, TAPN 45) vs VS (104) TAPN (377) vs VS (103) TAP (30) vs TAPN (30) TAP (156: TAP 130, TAPN 26) vs VS (81) TAP (120) vs VS (57) TAP (76) vs VR(43) TAP (138: TAP 116, TAPN 22) vs VS (296) TAP (35: TAP 20, VR 15) vs VS (29)

  • TAP (63) vs VR (43)

  • PSM cohort

  • TAP (25), VR (25)
First Author Hofferberth Simon Sayyed Jang Sen Kim Sasson Attanawanich Pande Ismail Anagnostopoulos Stewart
Year 2018 2017 2016 2016 2016 2015 2013 2013 2010 2010 2007 2005
Country United States United States India South Korea United States South Korea Israel Thailand India Saudi Arabia United States United States
Periods 2007–2015 2000–2010 2011–2015 2000–2009 2010–2014 1989–2005 2003–2009 1990–2004 2005–2007 2002–2006 2001–2005 1997–2004
Design Retrospective, PSM Retrospective Retrospective Retrospective Retrospective Retrospective, PSM Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective
Comparison (patient, n)

  • Overall, 162

  • PSM cohort

  • TAP (53), VS (53)

 TAP (48) vs VS (46) TAP (30) vs TAPN (60) TAP (11) vs VR (25) TAP (32) vs VR (19)

  • TAP (183) vs VS (72)

  • PSM cohort TAP (57), VS (57)

 TAP (20) vs VR (74) vs VS (69) TAP (38) vs VR (55) TAP (24) vs VR (16)

  • TAP (48) + TAPN (16) vs VS (19)

  • TAP (48) vs TAPN (16)

 TAP (25) vs VR (18) TAP (20: TAP 13, TAPN 7) vs VS (82)
Open in a new tab

PSM: propensity-score matched; TAP: transannular patch repair; TAPN: transannular patch with neo-pulmonary valve creation; VR: valve-repairing; VS: valve-sparing.

Patient characteristics

The mean age in each study ranged from 3 to 132 months in TAP, 4.6 to 90 months in VR, 3 to 145 months in TAPN and 5 to 36 months in VS, respectively. Most patients underwent primary repair, ranging from 59% to 100% across studies. Median or mean pulmonary valve diameter in z-value ranged from −6.9 to −1.8 in TAP, −3.5 to −1.9 in VR, −4.0 to −1.89 in TAPN and −4.5 to 0.05 in VS.

Procedural information

Indications, procedures and materials for RVOTR are summarized in Supplementary Material, Tables S5 and S6. VR and TAPN were applied in 12 studies [22, 26, 27, 40, 42, 43, 47, 48, 50, 51, 52, 54] and 11 studies [24, 25, 28–30, 32, 34, 36, 37, 46, 53], respectively. Among the studies reporting the TAPN technique, 5 studies fashioned the monocusp method with a pocket-like structure attached to a transannular patch [25, 34, 36, 46, 53], whereas 2 studies inserted a right atrial appendage as a neo-valve [23, 32]; no details were specified in 3 studies [28, 29, 37]. Only 1 study utilized the bi-orifice technique [30].

Pooled outcomes

Primary outcome: mid-term pulmonary regurgitation

Studies reporting more than 3 years of follow-up were included in the analysis of mid-term PR (Supplementary Material, Table S7). TAP carried a significantly higher risk of mid-term PR than TAPN [HR, 0.53; 95% confidence interval (CI) (0.33; 0.85); P < 0.001] and VS [HR, 0.27; 95% CI (0.19; 0.39); P < 0.001] (Fig. 2). In contrast, there was no such difference between VR and TAP.

Figure 2:

Figure 2:

Open in a new tab

Network plot and forest plot for primary outcome. CI: confidence interval; HR: hazard ratio; PR: pulmonary regurgitation; TAP: transannular patch repair; TAPN: transannular patch with neo-pulmonary valve creation; VR: valve-repairing; VS: valve sparing.

Secondary outcomes

Figures 3 and 4 illustrate the network characteristics and forest plots for each secondary outcome.

Figure 3:

Figure 3:

Open in a new tab

Network plots for secondary outcomes. (A) Postoperative mortality; (B) postoperative pulmonary regurgitation; (C) postoperative ventilation time; (D) length of intensive care unit stay; (E) right ventricular outlet tract pressure gradient and (F) mid-term mortality. ICU: intensive care unit; PR: pulmonary regurgitation; RVOT-PG; right ventricular outlet pressure gradient; TAP: transannular patch; TAPN: transannular patch with neo-pulmonary valve creation; VR: valve-repairing; VS: valve sparing.

Figure 4:

Figure 4:

Open in a new tab

Forest plots for secondary outcomes. (A) Postoperative mortality; (B) postoperative pulmonary regurgitation; (C) postoperative ventilation time; (D) length of intensive care unit stay; (E) right ventricular outlet pressure gradient; and (F) mid-term mortality. CI: confidence interval; ICU: intensive care unit; MD: mean difference; PR: pulmonary regurgitation; RR: risk ratio; RVOT-PG: right ventricular outlet pressure gradient; TAP: transannular patch repair; TAPN: transannular patch with neo-pulmonary valve creation; VR: valve-repairing; and VS: valve-sparing.

Postoperative mortality

Postoperative mortality was lower in VS than in TAP [RR, 0.31; 95% CI (0.18; 0.56); P < 0.001] (Supplementary Material, Table S8, Fig. 4A).

Postoperative pulmonary regurgitation

Postoperative PR was significantly higher in TAP compared to all the other groups (Supplementary Material, Table S9, Fig. 4B).

Postoperative ventilation time

Postoperative ventilation time was significantly shorter in VS compared to the other groups. However, we found no such differences for TAPN and VR compared to TAP (Supplementary Material, Table S10, Fig. 4C).

Length of intensive care unit stay

Length of ICU stay was significantly shorter in VS compared to TAP (Supplementary Material, Table S11, Fig. 4D).

Right ventricular outlet tract pressure gradient

There was no significant difference among the techniques (Supplementary Material, Table S12, Fig. 4E).

Mid-term mortality

There were no significant differences among TAP, TAPN and VS (Supplementary Material, Table S13, Fig. 4F). There was no reported mid-term mortality for the VR group.

Heterogeneity and inconsistency

Supplementary Material, Fig. S3 shows the results of direct and indirect estimations. Supplementary Material, Table S14 provides a summary of heterogeneity, inconsistency and P-values from tests assessing disagreement between direct and indirect evidence for each outcome.

Summary of P-scores

P-scores for each outcome among the treatment groups are summarized in Supplementary Material, Fig. S4.

Secondary analyses

Among the 7 studies reporting both TAPN and TAP as the TAP arm [28, 31, 33, 35, 38, 41, 55], proportions of each technique in the TAP arm were available in 5 studies [28, 35, 38, 41, 55]. TAP accounted for more than 80% in 2 studies (Supplementary Material, Table S4) [38, 41]. The remaining 3 studies were pooled for outcomes: primary outcome, postoperative mortality, postoperative PR, RVOT-PG and mid-term mortality [28, 35, 55]. Excluding these 3 studies demonstrated similar outcomes to the main analysis (Supplementary Material, Fig. S5). After excluding 7 studies with mixed TAP arms [28, 31, 33, 38, 41, 55], all the outcomes remained consistent with the main analysis (Supplementary Material, Fig. S6).

Quality assessment

The quality of observational studies is summarized in Supplementary Material, Fig. S7. Among 34 studies, 20 studies were considered to be of low quality [22, 23, 25–36, 43–47, 49, 55]. Publication bias was assessed with funnel plots (Supplementary Material, Fig. S8). Publication bias existed in mid-term PR, length of ICU stays and mid-term mortality.

DISCUSSION

We used our network meta-analysis to comprehensively investigate the comparative outcomes between TAP and various architectural preservation techniques. TAP was associated with higher occurrences of mid-term PR in comparison to VS and TAPN, although it was comparable to VR. We also demonstrated more postoperative deaths and longer postoperative ventilation time with TAP compared to VS. In contrast, we found no between-group differences for mid-term deaths, postoperative RVOT-PG and ICU stays.

Based on the higher postoperative mortality associated with TAP, TAP may be a potential risk factor in the postoperative period compared to VS. This short-term disadvantage of TAP could be attributed to the earlier neonatal operations often associated with the procedure. In our analysis, the mean age of the TAP group in each study ranged from 3 to 132 months, and some studies have included neonatal repair. A recent meta-analysis revealed primary repair in the neonatal period as a risk factor for the TAP procedure, increased mortality and longer ICU stay [56]. Patients with a small pulmonary valve diameter in the z-value (PVD[Z]) have been reported to be more prone to cyanotic spells, potentially leading to TAP at an earlier age. Our study results may coincide with this theory, with patients with TAP preoperatively having a small PVD[Z] ranging from −6.9 to −1.8. Although the criteria of PVD[Z] for VS or TAP remain undefined, some studies suggest PVD[Z] below −2 as indicative of TAP (Supplementary Material, Table S5) and PVD[Z] of −1.7 (range 0 to −4.9) to be a marker for VS [57]. However, the exact proportion of neonatal repair was not available and was beyond the scope of this study. Future studies are warranted to assess the potential association.

Whether to pursue complete neonatal or non-neonatal TOF repair warrants discussion. To date, comparable outcomes have been reported for staged and neonatal primary repair. Despite the high risk associated with Blalock-Tausig shunt procedures, the benefits of staged repair include the potential to enhance the somatic growth of the pulmonary artery and the reduced risk of necessitating TAP [58]. Moreover, the recent development of percutaneous duct stenting could potentially enable a safer execution of staged repairs. A recent study demonstrated favourable mid-term mortality with a stent compared to the Blalock-Taussig shunt, although at the expense of a higher risk of unplanned reinterventions [59].

The findings from our meta-analysis align with previous findings that architectural preservation techniques reduce postoperative PR in comparison to TAP [60]. Our meta-analysis further elucidated this by including the greatest number of studies to date, and we provided a detailed categorization of TAPN techniques for clarity.

Historically, VR and TAPN were introduced with the goal of preventing PR, and our study demonstrated that VR and TAPN reduce postoperative PR compared to TAP. Anagnostopoulos [61] highlighted the benefits of the VR technique in preserving coaptation with native valves. Additionally, attaching the neo-valve to the original valves offers growth potential for the RVOT. However, such a trend was not observed for mid-term PR for VR, whereas TAPN consistently demonstrated a favourable outcome compared to TAP. This result could be attributed to potential variations in neo-valve materials and different factors influencing the mid-term outcomes. Previously, the risk of long-term PR between expanded polytetrafluoroethylene (ePTFE) and pericardial patch for VR was investigated, demonstrating a lower risk of long-term PR with ePTFE [62]. Brown et al. [63] reported a 12-year experience with the ePTFE neo-valve. Although 15% of patients had moderate-to-severe PR at 5 years of follow-up, the rate progressed to 37% at 7 years postoperatively. Conversely, our analysis suggested that TAPN was associated with a lower risk of mid-term PR, although we could not adjust with material types due to the nature of the study. Future studies investigating different materials are warranted to elucidate the long-term occurrences of PR.

Our study revealed that TAPN was associated with a reduced risk of mid-term PR and postoperative PR compared to TAP. Other researchers have suggested reduced postoperative ventilation time, decreased need for inotropic supports and lower pleural effusion volume with TAPN [46, 50, 54, 64]. The neo-valve has been reported to reduce the regurgitation volume and enhance the resilience of the RV function in the early postoperative phase [46, 51, 54, 65].

Postoperative RVOT-PG may predict future reinterventions for recurrent stenosis. Surgeons aim to optimize residual pulmonary stenosis/RVOT stenosis to minimize the risk of severe PR. Although some residual RVOT-PG may delay future reinterventions due to PR, the optimal RVOT-PG is still controversial. Ishigami et al. [23] identified a postoperative peak RVOT-PG ≥ 25 mmHg as a risk factor for RVOT reintervention, with VS independently associated with RVOT reintervention risk. Similarly, there have been some concerns of TAPN methods being associated with restenosis, leading to higher risks of pulmonary valve replacement. Contrary to such concerns, our analysis of RVOT-PG revealed no significant differences among all groups. Most studies in the TAPN and VS groups also successfully achieved RVOT-PG below 25 mmHg in the short term (Supplementary Material, Table S12).

Ultimately, VR was associated with a reduced risk of postoperative PR, and TAPN was associated with reduced risks of both postoperative and mid-term PR. VR and TAPN do not worsen postoperative mortality, postoperative ventilation time, length of ICU stays, RVOT-PG and mid-term mortality compared to TAP. If candidates are not suitable for VS, repairing the pulmonary valve or creating a neo-pulmonary valve is a reasonable option.

Limitations

Our study has some limitations. The nature of retrospective studies resulting in unadjusted outcomes and unmeasured confounders and differences in era and perioperative management practices may have impacted our outcomes. Although we defined study eligibility to be after publication year 2000, this study still has inherent study biases due the factors mentioned above. Additionally, our study included patients spanning a wide range of ages. The disparity in follow-up duration across the studies could influence mid-term outcomes. Pulmonary annulus diameter was not adjusted among groups, potentially impacting PR results. Furthermore, substantial variability in materials for RVOTR and variety of TAPN techniques may have influenced mid-term results. Lastly, the identical categorization of TAP and TAPN presents a challenge. Although efforts were made to reclassify them based on the proportion of TAP or TAPN, this factor still potentially influenced our results.

CONCLUSION

Our study demonstrated that architectural preservation techniques, including VS, TAPN and VR, were associated with a reduced risk of postoperative PR compared to TAP. This trend persisted in the mid-term for TAPN and VS. VS, VR and TAPN may serve as reliable alternatives to TAP, offering additional benefits. These findings could aid in decision making for RVOTR for primary TOF repair.

Supplementary Material

ivae180_Supplementary_Data
ivae180_supplementary_data.zip (1.7MB, zip)

Acknowledgements

None.

Glossary

ABBREVIATIONS

CI

Confidence interval

ePTFE

Expanded polytetrafluoroethylene

HR

Hazard ratio

ICU

Intensive care unit

PR

Pulmonary regurgitation

RR

Risk ratio

RVOT-PG

Right ventricular outlet tract pressure gradient

RVOTR

Right ventricular outlet tract reconstruction

TAP

Transannular patch repair

TAPN

Transannular patch with neo-pulmonary valve creation

TOF

Tetralogy of Fallot

VR

Valve-repairing

VS

Valve-sparing

Contributor Information

Akira Yamaguchi, Division of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan.

Tomonari Shimoda, Department of Medicine, Ibaraki Prefectural University of Health Sciences, Ami, Ibaraki, Japan.

Hiroo Kinami, Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, CA, USA.

Jun Yasuhara, Department of Cardiology, The Royal Children’s Hospital, Melbourne, VIC, Australia.

Hisato Takagi, Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan.

Shinichi Fukuhara, Department of Cardiothoracic Surgery, University of Michigan, Ann Arbor, MI, USA.

Toshiki Kuno, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, NY, USA; Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

SUPPLEMENTARY MATERIAL

Supplementary material is available at EJCTS online.

Funding

None.

Conflicts of interest: none declared.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author contributions

Akira Yamaguchi: Conceptualization; Data curation; Formal analysis; Methodology; Writing—original draft; Writing—review & editing. Tomonari Shimoda: Conceptualization; Formal analysis; Writing—original draft; Writing—review & editing. Hiroo Kinami: Writing—review & editing. Jun Yasuhara: Writing—review & editing. Hisato Takagi: Writing—review & editing. Shinichi Fukuhara: Writing—review & editing. Toshiki Kuno: Writing—review & editing.

Reviewer information

Interdisciplinary CardioVascular and Thoracic Surgery thanks Daouda Amadou, Pankaj Garg and the other anonymous reviewers for their contributions to the peer review process of this article.

REFERENCES

  • 1. Shimoda T, Mathis BJ, Kato H, Matsubara M, Suzuki Y, Suetsugu F. et al. Architecture matters: tissue preservation strategies for tetralogy of Fallot repair. J Card Surg 2021;36:2836–49. [DOI] [PubMed] [Google Scholar]
  • 2. Gatzoulis MA, Balaji S, Webber SA, Siu SC, Hokanson JS, Poile C. et al. Risk factors for arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: a multicentre study. Lancet 2000;356:975–81. [DOI] [PubMed] [Google Scholar]
  • 3. Clarke NS, Thibault D, Alejo D, Chiswell K, Hill KD, Jacobs JP. et al. Contemporary patterns of care in tetralogy of Fallot: analysis of the Society of Thoracic Surgeons Data. Ann Thorac Surg 2023;116:768–75. [DOI] [PubMed] [Google Scholar]
  • 4. He G-W. Current strategy of repair of tetralogy of Fallot in children and adults: emphasis on a new technique to create a monocusp-patch for reconstruction of the right ventricular outflow tract. J Card Surg 2008;23:592–9. [DOI] [PubMed] [Google Scholar]
  • 5. Sung SC, Kim S, Woo JS, Lee YS.. Pulmonic valve annular enlargement with valve repair in tetralogy of Fallot. Ann Thorac Surg 2003;75:303–5. [DOI] [PubMed] [Google Scholar]
  • 6. Leobon B, Cousin G, Hadeed K, Breinig S, Alacoque X, Berthomieu L. et al. Tetralogy of Fallot: T-shaped infundibulotomy for pulmonary valve-sparing procedure. Interact CardioVasc Thorac Surg 2022;34:488–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Hiramatsu Y. Pulmonary cusp and annular extension technique for reconstruction of right ventricular outflow in tetralogy of Fallot. Ann Thorac Surg 2014;98:1850–2. [DOI] [PubMed] [Google Scholar]
  • 8. Vida VL, Zucchetta F, Stellin G.. Pulmonary valve-sparing techniques during repair of tetralogy of Fallot: the delamination plasty. J Thorac Cardiovasc Surg 2016;151:1757–8. [DOI] [PubMed] [Google Scholar]
  • 9. Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD. et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ 2021;372:n160. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD. et al. ; Cochrane Bias Methods Group. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12. Tierney JF, Stewart LA, Ghersi D, Burdett S, Sydes MR.. Practical methods for incorporating summary time-to-event data into meta-analysis. Trials 2007;8:16. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. Parmar MK, Torri V, Stewart L.. Extracting summary statistics to perform meta-analyses of the published literature for survival endpoints. Statist Med 1998;17:2815–34. [DOI] [PubMed] [Google Scholar]
  • 14. Williamson PR, Smith CT, Hutton JL, Marson AG.. Aggregate data meta-analysis with time-to-event outcomes. Stat Med 2002;21:3337–51. [DOI] [PubMed] [Google Scholar]
  • 15. Luo D, Wan X, Liu J, Tong T.. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res 2018;27:1785–805. [DOI] [PubMed] [Google Scholar]
  • 16. Wan X, Wang W, Liu J, Tong T.. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014;14:135. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Neupane B, Richer D, Bonner AJ, Kibret T, Beyene J.. Network meta-analysis using R: a review of currently available automated packages. PLoS One 2014;9:e115065. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18. Rücker G. Network meta-analysis, electrical networks and graph theory. Res Synth Methods 2012;3:312–24. [DOI] [PubMed] [Google Scholar]
  • 19. Ribassin-Majed L, Marguet S, Lee AWM, Ng WT, Ma J, Chan ATC. et al. What is the best treatment of locally advanced nasopharyngeal carcinoma? An individual patient data network meta-analysis. J Clin Oncol 2017;35:498–505. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20. Rücker G, Schwarzer G.. Ranking treatments in frequentist network meta-analysis works without resampling methods. BMC Med Res Methodol 2015;15:58. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21. Egger M, Davey Smith G, Schneider M, Minder C.. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22. Gebauer R, Chaloupecký V, Hučín B, Tláskal T, Komárek A, Janoušek J.. Survival and freedom from reinterventions in patients with repaired tetralogy of Fallot: up to 42-year follow-up of 917 patients. J Am Heart Assoc 2023;12:e024771. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23. Ishigami S, Ye XT, Buratto E, Ivanov Y, Chowdhuri KR, Fulkoski N. et al. Long-term outcomes of tetralogy of Fallot repair: a 30-year experience with 960 patients. J Thorac Cardiovasc Surg 2024;167:289–302.e11. [DOI] [PubMed] [Google Scholar]
  • 24. Schulte LJ, Miller PC, Bhat AN, Carvajal-Dominguez HG, Chomat MR, Miller JR. et al. Evolution of pulmonary valve management during repair of tetralogy of Fallot: a 14-year experience. Ann Thorac Surg 2023;115:462–9. [DOI] [PubMed] [Google Scholar]
  • 25. Guariento A, Schiena CA, Cattapan C, Avesani M, Doulamis IP, Padalino MA. et al. Pulmonary valve preservation during tetralogy of Fallot repair: midterm functional outcomes and risk factors for pulmonary regurgitation. Eur J Cardiothorac Surg 2022;62:ezac365. doi: 10.1093/ejcts/ezac365. [DOI] [PubMed] [Google Scholar]
  • 26. Guerrero AF, Pineda-Rodríguez IG, Palacio AM, Obando CE, Chalela T, Camacho J. et al. Repair with a pulmonary neovalve in tetralogy of Fallot: does this avoid ventricular dysfunction? Interact CardioVasc Thorac Surg 2022;35:ivac155. doi: 10.1093/icvts/ivac155. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27. Kobayashi Y, Kotani Y, Kuroko Y, Kawabata T, Sano S, Kasahara S.. Staged repair of tetralogy of Fallot: a strategy for optimizing clinical and functional outcomes. Ann Thorac Surg 2022;113:1575–81. [DOI] [PubMed] [Google Scholar]
  • 28. Ono Y, Hoashi T, Imai K, Okuda N, Komori M, Kurosaki K. et al. Impact of right ventriculotomy for tetralogy of Fallot repair with a pulmonary valve-sparing procedure. JTCVS Open 2022;9:191–205. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29. Huang S-W, Hsu W-F, Li H-Y, Hwang B, Wu F-Y, Weng Z-C. et al. Implantation of monocusp valve prolongs the duration of chest tube drainage in children with tetralogy of fallot after corrective surgery. J Chin Med Assoc 2022;85:364–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30. Wu M, Fan C, Liu J, Iroegbu CD, Chen W, Huang P. et al. Clinical application of individualized pulmonary bi-orifice for the reconstruction of right ventricular outflow tract in tetralogy of fallot. Front Cardiovasc Med 2021;8:772198. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31. Blais S, Marelli A, Vanasse A, Dahdah N, Dancea A, Drolet C. et al. Comparison of long-term outcomes of valve-sparing and transannular patch procedures for correction of tetralogy of fallot. JAMA Netw Open 2021;4:e2118141. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32. Amirghofran A, Edraki F, Edraki M, Ajami G, Amoozgar H, Mohammadi H. et al. Surgical repair of tetralogy of Fallot using autologous right atrial appendages: short- to mid-term results. Eur J Cardiothorac Surg 2021;59:697–704. [DOI] [PubMed] [Google Scholar]
  • 33. Jiang X, Liu J, Peng B, Zhang H, Li S, Yan J. et al. Impact of annulus-sparing on surgical adequacy of pulmonary valve in complete repair of tetralogy of fallot with right ventricular outflow tract incision. Pediatr Cardiol 2021;42:379–88. [DOI] [PubMed] [Google Scholar]
  • 34. Rawat S, Jaswal V, Thingnam SKS, Singh H, Mahajan S, Kynta RL. et al. Short-term outcome of polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of right ventricular outflow tract in tetralogy of fallot: a randomized controlled trial. Braz J Cardiovasc Surg 2021;36:39–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35. Ducas RA, Harris L, Labos C, Nair GKK, Wald RM, Hickey EJ. et al. Outcomes in young adults with tetralogy of fallot and pulmonary annular preserving or transannular patch repairs. Can J Cardiol 2021;37:206–14. [DOI] [PubMed] [Google Scholar]
  • 36. Singab H. Influence of pulmonary valve function preservation technique for tetralogy of fallot repair on right ventricular performance in children. Heart Surg Forum 2020;23:E416–21. [DOI] [PubMed] [Google Scholar]
  • 37. Samadi M, Khoshfetrat M, Keykha A, Javadi SH.. The effects of monocusp valve implantation and transannular patch angioplasty on pulmonary regurgitation and right ventricular failure after total correction of tetralogy of fallot. Biomed Res Ther 2020;7:3799–806. [Google Scholar]
  • 38. Zhao J, Cai X, Teng Y, Nie Z, Ou Y, Zhuang J. et al. Value of pulmonary annulus area index in predicting transannular patch placement in tetralogy of Fallot repair. J Card Surg 2020;35:48–53. [DOI] [PubMed] [Google Scholar]
  • 39. Mouws EMJP, de Groot NMS, van de Woestijne PC, de Jong PL, Helbing WA, van Beynum IM. et al. Tetralogy of fallot in the current era. Semin Thorac Cardiovasc Surg 2019;31:496–504. [DOI] [PubMed] [Google Scholar]
  • 40. Singh NM, Loomba RS, Gudausky TM, Mitchell ME.. Monocusp valve placement in children with tetralogy of Fallot undergoing repair with transannular patch: a functioning pulmonary valve does not improve immediate postsurgical outcomes. Congenit Heart Dis 2018;13:935–43. [DOI] [PubMed] [Google Scholar]
  • 41. Hickey E, Pham-Hung E, Halvorsen F, Gritti M, Duong A, Wilder T. et al. Annulus-sparing tetralogy of fallot repair: low risk and benefits to right ventricular geometry. Ann Thorac Surg 2018;106:822–9. [DOI] [PubMed] [Google Scholar]
  • 42. Aydın S, Suzan D, Temur B, Kırat B, İyigün M, Demir İH. et al. The impact of pulmonary valve-sparing techniques on postoperative early and midterm results in tetralogy of Fallot repair. Turk Gogus Kalp Damar Cerrahisi Derg 2018;26:370–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43. Kim H, Sung SC, Choi KH, Lee HD, Kim G, Ko H. et al. Long-term results of pulmonary valve annular enlargement with valve repair in tetralogy of Fallot. Eur J Cardiothorac Surg 2018;53:1223–9. [DOI] [PubMed] [Google Scholar]
  • 44. Hofferberth SC, Nathan M, Marx GR, Lu M, Sleeper LA, Marshall AC. et al. Valve-sparing repair with intraoperative balloon dilation in tetralogy of Fallot: midterm results and therapeutic implications. J Thorac Cardiovasc Surg 2018;155:1163–73.e4. [DOI] [PubMed] [Google Scholar]
  • 45. Simon BV, Swartz MF, Egan M, Cholette JM, Gensini F, Alfieris GM.. Use of a dacron annular sparing versus limited transannular patch with nominal pulmonary annular expansion in infants with tetralogy of fallot. Ann Thorac Surg 2017;103:186–92. [DOI] [PubMed] [Google Scholar]
  • 46. Sayyed EHN, Rana SS, Anand KM, Eram A, Harkant S.. Monocusp pulmonary valve reconstruction in childhood and adult TOF repairs: does a single cusped valve work? Indian J Thorac Cardiovasc Surg 2016;32:229–34. [Google Scholar]
  • 47. Jang WS, Cho JY, Lee JU, Lee Y.. Surgical results of monocusp implantation with transannular patch angioplasty in tetralogy of fallot repair. Korean J Thorac Cardiovasc Surg 2016;49:344–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48. Sen DG, Najjar M, Yimaz B, Levasseur SM, Kalessan B, Quaegebeur JM. et al. Aiming to preserve pulmonary valve function in tetralogy of fallot repair: comparing a new approach to traditional management. Pediatr Cardiol 2016;37:818–25. [DOI] [PubMed] [Google Scholar]
  • 49. Kim GS, Han S, Yun T-J.. Pulmonary annulus preservation lowers the risk of late postoperative pulmonary valve implantation after the repair of tetralogy of Fallot. Pediatr Cardiol 2015;36:402–8. [DOI] [PubMed] [Google Scholar]
  • 50. Sasson L, Houri S, Raucher Sternfeld A, Cohen I, Lenczner O, Bove EL. et al. Right ventricular outflow tract strategies for repair of tetralogy of Fallot: effect of monocusp valve reconstruction. Eur J Cardiothorac Surg 2013;43:743–51. [DOI] [PubMed] [Google Scholar]
  • 51. Attanawanich S, Ngodgnamthaweesuk M, Kitjanon N, Sitthisombat C.. Pulmonary cusp augmentation in repair of tetralogy of Fallot. Asian Cardiovasc Thorac Ann 2013;21:9–13. [DOI] [PubMed] [Google Scholar]
  • 52. Pande S, Agarwal SK, Majumdar G, Chandra B, Tewari P, Kumar S.. Pericardial monocusp for pulmonary valve reconstruction: a new technique. Asian Cardiovasc Thorac Ann 2010;18:279–84. [DOI] [PubMed] [Google Scholar]
  • 53. Ismail SR, Kabbani MS, Najm HK, Abusuliman RM, Elbarbary M.. Early outcome of tetralogy of Fallot repair in the current era of management. J Saudi Heart Assoc 2010;22:55–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54. Anagnostopoulos P, Azakie A, Natarajan S, Alphonso N, Brook MM, Karl TR.. Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot. J Thorac Cardiovasc Surg 2007;133:640–7. [DOI] [PubMed] [Google Scholar]
  • 55. Stewart RD, Backer CL, Young L, Mavroudis C.. Tetralogy of Fallot: results of a pulmonary valve-sparing strategy. Ann Thorac Surg 2005;80:1431–8; discussion 1438–9. [DOI] [PubMed] [Google Scholar]
  • 56. Loomba RS, Buelow MW, Woods RK.. Complete repair of tetralogy of fallot in the neonatal versus non-neonatal period: a meta-analysis. Pediatr Cardiol 2017;38:893–901. [DOI] [PubMed] [Google Scholar]
  • 57. Sinha R, Gooty V, Jang S, Dodge-Khatami A, Salazar J.. Validity of pulmonary valve z-scores in predicting valve-sparing tetralogy repairs-systematic review. Children 2019;6:67. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58. Miller JR, Stephens EH, Goldstone AB, Glatz AC, Kane L, Van Arsdell GS. et al. ; Expert Consensus Panel. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: management of infants and neonates with tetralogy of Fallot. J Thorac Cardiovasc Surg 2023;165:221–50. [DOI] [PubMed] [Google Scholar]
  • 59. Alsagheir A, Koziarz A, Makhdoum A, Contreras J, Alraddadi H, Abdalla T. et al. Duct stenting versus modified Blalock-Taussig shunt in neonates and infants with duct-dependent pulmonary blood flow: a systematic review and meta-analysis. J Thorac Cardiovasc Surg 2021;161:379–90.e8. [DOI] [PubMed] [Google Scholar]
  • 60. Wei X, Li T, Ling Y, Chai Z, Cao Z, Chen K. et al. Transannular patch repair of tetralogy of Fallot with or without monocusp valve reconstruction: a meta-analysis. BMC Surg 2022;22:18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61. Anagnostopoulos PV. Commentary: is it beneficial to add a monocusp during non-valve-sparing tetralogy of Fallot repair? Is there a way to settle this debate 3 decades later? J Thorac Cardiovasc Surg 2021;162:1322–3. [DOI] [PubMed] [Google Scholar]
  • 62. Patukale A, Daley M, Betts K, Justo R, Dhannapuneni R, Venugopal P. et al. Outcomes of pulmonary valve leaflet augmentation for transannular repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2021;162:1313–20. [DOI] [PubMed] [Google Scholar]
  • 63. Brown JW, Ruzmetov M, Vijay P, Rodefeld MD, Turrentine MW.. Right ventricular outflow tract reconstruction with a polytetrafluoroethylene monocusp valve: a twelve-year experience. J Thorac Cardiovasc Surg 2007;133:1336–43. [DOI] [PubMed] [Google Scholar]
  • 64. Turrentine MW, McCarthy RP, Vijay P, McConnell KW, Brown JW.. PTFE monocusp valve reconstruction of the right ventricular outflow tract. Ann Thorac Surg 2002;73:871–9; discussion 879–80. [DOI] [PubMed] [Google Scholar]
  • 65. Canent RV, Anthony PJ, Holder TM, Ashcraft KW.. Transannular GORE-TEX patch with pericardial unicusp for total correction of tetralogy of fallot. Tex Heart Inst J 1987;14:300–6. [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

ivae180_Supplementary_Data
ivae180_supplementary_data.zip (1.7MB, zip)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Articles from Interdisciplinary Cardiovascular and Thoracic Surgery are provided here courtesy of Oxford University Press

RESOURCES