Key result
Valve-sparing RVOT reconstruction is linked to ~1.0 higher preoperative pulmonary valve annulus z-scores versus TAP repair.
Why the study?
While transannular patch repair resolves pulmonary stenosis in Tetralogy of Fallot, it often results in long-term pulmonary regurgitation, prompting investigation into pulmonary valve annulus z-scores to guide valve-sparing surgery.
Does the preoperative pulmonary valve annulus z-score predict the feasibility of valve-sparing surgery compared to transannular patch repair in patients with Tetralogy of Fallot?
Meta-Analysis (n=5,931)
Yes
Does the preoperative pulmonary valve annulus z-score predict the feasibility of valve-sparing surgery compared to transannular patch repair in patients with Tetralogy of Fallot?
Mean Difference: 0.99 (95% CI 0.73–1.25)
Absolute Event Rate: -1.48% vs -2.93%
p-value: p=<0.00001
A preoperative pulmonary valve annulus z-score threshold of ≥ -2.59 can effectively guide the selection of valve-sparing surgery over transannular patch repair in patients with Tetralogy of Fallot.
Supports z-score-guided selection for valve-sparing repair in Tetralogy of Fallot; extends meta-analytic evidence but requires prospective validation before changing practice.
Background/Objectives Tetralogy of Fallot (ToF) is the most prevalent cyanotic congenital heart defect, requiring timely surgical intervention to improve survival. Two primary techniques for right ventricular outflow tract (RVOT) reconstruction are transannular patch (TAP) repair and valve-sparing (VS) surgery as a less invasive alternative. While TAP resolves pulmonary stenosis, it often results in long-term pulmonary regurgitation (PR). This meta-analysis investigates the pulmonary valve annulus (PVA) z-score as a predictor for choosing VS techniques to minimize complications, mean difference and cut-off analysis. Methods A systematic review and meta-analysis were conducted across 29 studies (N=5,806) assessing preoperative PVA z-scores in patients undergoing TAP or VS RVOT reconstruction. Data extraction followed PRISMA guidelines, with statistical analyses using a random-effects model by Review Manager 5.4.1 and receiver operating characteristic (ROC) curve evaluation. Results The meta-analysis showed significantly higher preoperative PVA z-scores in the VS group (MD: 1.01, 95% CI: 0.75–1.28, p < 0.001). The pooled grand mean PVA z-scores were −1.39 for VS and −2.97 for TAP. ROC analysis identified a z-score threshold of ≥ −2.59 (sensitivity: 88%, specificity: 80%) as optimal for maximizing VS surgery. Conclusions This study establishes the PVA z-score as a potential predictor for VS approaches in ToF repair, with a proposed threshold of ≥ −2.59 for optimal outcomes. Adoption of VS techniques guided by standardized z-score criteria may reduce PR-associated complications and enhance long-term survival and quality of life.
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Fakhri et al. (2025) conducted a meta-analysis in Tetralogy of Fallot (n=5,931). Valve-sparing right ventricular outflow tract reconstruction vs. Transannular patch right ventricular outflow tract reconstruction was evaluated on Preoperative pulmonary valve annulus z-score (MD 0.99, 95% CI 0.73-1.25, p=<0.00001). Valve-sparing right ventricular outflow tract reconstruction was associated with significantly higher preoperative pulmonary valve annulus z-scores compared to transannular patch repair (MD 0.99).
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