European Journal of Cardiovascular Medicine

Background: The management strategy of patients with significant intraoperative high pRV/LV ratio in Tetralogy of Fallot with PS remains a considerable debate. The traditional thinking is that an intraoperative pRV/LV in excess of 0.70 is not acceptable and revision of RVOT repair with TAP is advised -as post op RVOTO is undesirable and not well tolerated. Postoperative pulmonary insufficiency is well tolerated and that only very significant RV dilation is problematic is also a debatable concept. In the current era with evolving concepts, efforts are made to avoid ventriculotomy and or TAP in order to preserve biventricular function. Preserving pulmonary valve integrity offers a better long-term prognosis, despite a risk of residual stenosis. Objectives: We sought to analyse the need for revision of RVOT repair (Dynamic / Fixed RVOTO), early survival and perioperative complications, and morphologic risk factors to determine their effects on outcomes in patients with significant intraoperative high pRV/LV pressure ratio. Methods: ToF with pulmonary stenosis operated between October 2013 to December 2015 with high pRV/LV ratio intraoperatively >/=0.70 were chosen for the study. Results: Out of a total of 178 patients of TOF with PS, 62 patients had pRv/Lv>/= 0.70. Mean pRv/Lv was 0.82 with 4 patients having ratio >1. 6 patients underwent re RVOT resection and post revision pRv/Lv was mean 0.60. 16 patients continued to have high pRv/Lv and unstable hemodynamics. Revision surgery was performed with Trans annular patch insertion. 40 patients did not undergo revision and high ratio was accepted. Mean RvOT gradient of these patients intra op was 48.2+/-12.6. The mean RVOT gradient showed significant decrease at 12 hour and 24 hour post surgery interval. Mean RVOT gradient at 12 hours post surgery was 34 .6 +/- 8.2 and 23.5 +/-6.3 at 24 hours after surgery in patients who didn’t undergo TAP. So 40 patients did not undergo revision and high ratio was accepted. 65 % of such patients could be managed with RA / RA-PA approach without performing a Trans annular patch. Conclusions: Pulmonary valve annulus sparing procedure in ToF with PS patients with pRV / LV ratio >/= 0.70 can be accepted with less morbidity and mortality if Pulmonary annulus > -2, tricuspid Pulmonary valve, RVOT resection is adequate, RVEDP is not high, less ionotropic support and no residual lesions. It may be due to Dynamic RVOTO.