Impact of Right Ventricular Pressure Load After Repair of Tetralogy of Fallot
Authors: Latus Heiner , Stammermann Jana , Voges Inga , Waschulzik Birgit , Gutberlet Matthias , Diller Gerhard‐Paul , Schranz Dietmar , Ewert Peter , Beerbaum Philipp , Kühne Titus , Sarikouch Samir , Kerst Gunter , Kanaan Majed , Lebherz Corinna , Rüffer André , Gkalpakiotis Dimitrios , Schedifka Andrea , Buheitel Gernot , Streble Joachim , Willing Rainer , Schubert Stephan , Laser Kai Thorsten , Sandica Eugen , Trusen Burkhard , Berger Felix , Miera Oliver , Ovroutski Stanislav , Schmitt Katharina , Photiadis Joachim , Berger Felix , Opgen‐Rhein Bernd , Weiss Katja , Klaassen Sabine , Berns Christoph , Boeckel Thomas , Haverkämper Guido , Kästner Andreas , Koch Heike , Peters Björn , Schmidt Florian , Timme Jens , Engel Konstanze , Franzbach Birgit , Senft Gabriela , Beyer Frank , Winter Klaus , Breuer Johannes , Schneider Martin , Bahlmann Jens , Griese Eberhard , Lê Trong Phi , Hebe Joachim , Nürnberg Jan‐Hendrik , Magsaam Annette , Müller Ronald , Potthoff Ludger , Voigt Renate , Krüger Tim , Gerleve Hubert , Kleideiter Ulrich , Schneider‐Kulla Dirk , Krülls‐Münch Jürgen , Menke Thomas , Lehn Martin , Heilmann Antje , Tomczak Helge , Tarusinov Gleb , Scheid Michael , Mayatepek Ertan , Pillekamp Frank , Lichtenberg Artur , Terpeluk Christiane , Kolterer Bruno , Dittrich Sven , Gundlach Ulrike , Cesnjevar Robert , Müntjes Carsten , Morf Geert , Esmaeili Anoosh , Backhoff Stephan , Stiller Brigitte , Beyersdorf Friedhelm , Kroll Johannes , Häffner Nicole , Siaplaouras Jannos , Masri‐Zada Antje , Jux Christian , Böning Andreas , Akintürk Hakan , Paul Thomas , Sigler Matthias , Tirilomis Theodor , Schürer Gabriele , Hartmann Johannes , Grabitz Ralph , Liebaug Uta , Rotzsch Claudius , Kozlik‐Feldmann Rainer , Rickers Carsten , Mir Thomas , Hübler Michael , Sachweh Jörg , Renz Stefan , Schemm Andreas , Friedrich Bernd , Schlobohm Otmar , Böthig Dietmar , Wermter Burkhard , Kelter‐Klöpping Andrea , Horke Alexander , Bauersachs Johann , Westhoff‐Bleck Mechthild , Gorenflo Matthias , Karck Matthias , Loukanov Tsvetomir , Schrüfer Hermann , Wilken Martin , Abdul‐Khaliq Hashim , Rädle‐Hurst Tanja , Rentzsch Axel , Schäfers Hans‐Joachim , Reichert Hagen , Vilser Daniel , Kriebel Thomas , Boysen Arnulf , Uebing Anselm , Voges Inga , Attmann Tim , Cremer Joachim Thomas , Scheewe Jens , Buchholz‐Berdau Regina , Möller Peter , Horter Thorsten , Brockmeier Konrad , Bennink Gerardus B. W. E , Baldus Stephan , Gillor Alex , Niehues Tim , Lawrenz Wolfgang , Leidig Steffen , Dähnert Ingo , Riede Frank‐Thomas , Kostelka Martin , Kändler Liane , Bethge Martin , Köster Stefan , Schröder Christoph , Karstedt Jens , Seitz Uwe , Kampmann Christoph , Dohle Daniel‐Sebastian , Stahl Frank , Abedini Mojtaba , Müller‐Scholden Joachim , Ewert Peter , Hager Alfred , Huntgeburth Michael , Kaemmerer Harald , Nagdyman Nicole , Schoetzau Jörg , Tutarel Oktay , Lange Rüdiger , Hörer Jürgen , Haas Nikolaus A , Hörer Jürgen , Hauser Michael , Roithmaier Alexander , Kehl Hans‐Gerd , Lammers Astrid , Malec Edward , Baumgartner Helmut , Diller Gerhard , Bahle Roswitha , Hofner Gerald , Zink Stefan , Reif Roland , Singer Helmut , Parlasca Christoph , Freund Matthias W , Schumacher Michael , Dewald Oliver , Darrelmann Christine , Willmann Olaf , Schmiedl Norbert , Quick Peter , Hillebrand Dirk , Michele Eiselt Stephan , Nekarda Torsten , Eberhard Michael , Baier Georg , Uhlemann Frank , Tzanavaros Ioannis , Beyer Alexander , Binz Gudrun , Hess Steffen , Teufel Thomas , Handke Ronald‐Peter , Hofbeck Michael , Kaulitz Renate , Sieverding Ludger , Schlensak Christian , Apitz Christian , Kaestner Michael , Holtvogt Jürgen , Wippermann Carl‐Friedrich , Hinz Sönke , Heusch Andreas , Wirbelauer Johannes , Brosi Wolfgang 
Published: March 2022

Background
Right ventricular outflow tract (RVOT) stenosis after repair of tetralogy of Fallot has been linked with favorable right ventricular remodeling but adverse outcomes. The aim of our study was to assess the hemodynamic impact and prognostic relevance of right ventricular pressure load in this population.

Methods and Results

A total of 296 patients with repaired tetralogy of Fallot (mean age, 17.8±7.9 years) were included in a prospective cardiovascular magnetic resonance multicenter study. Myocardial strain was quantified by feature tracking technique at study entry. Follow‐up, including the need for pulmonary valve replacement, was assessed. The combined end point consisted of ventricular tachycardia and cardiac death. A higher echocardiographic RVOT peak gradient was significantly associated with smaller right ventricular volumes and less pulmonary regurgitation, but lower biventricular longitudinal strain. During a follow‐up of 10.1 (0.1–12.9) years, the primary end point was reached in 19 of 296 patients (cardiac death, n=6; sustained ventricular tachycardia, n=2; and nonsustained ventricular tachycardia, n=11). A higher RVOT gradient was associated with the combined outcome (hazard ratio [HR], 1.03; 95% CI, 1.00–1.06;
P
=0.026), and a cutoff gradient of ≥25 mm Hg was predictive for cardiovascular events (HR, 3.69; 95% CI, 1.47–9.27;
P
=0.005). In patients with pulmonary regurgitation ≥25%, a mild residual RVOT gradient (15–30 mm Hg) was not associated with a lower risk for pulmonary valve replacement.

Conclusions
Higher RVOT gradients were associated with less pulmonary regurgitation and smaller right ventricular dimensions but were related to reduced biventricular strain and emerged as univariate predictors of adverse events. Mild residual pressure gradients did not protect from pulmonary valve replacement. These results may have implications for the indication for RVOT reintervention in this population.