Mid-term outcomes of right atrial appendage–derived pulmonary valve reconstruction during transannular repair of tetralogy of Fallot

Objectives Transannular patch (TAP) repair remains necessary when pulmonary annular preservation is not feasible during tetralogy of Fallot (TOF) repair, but the resulting pulmonary regurgitation (PR) may contribute to progressive right ventricular volume loading and late reintervention. We evaluated early and mid-term outcomes of right atrial appendage (RAA)-derived bicuspid pulmonary valve reconstruction compared with monocusp and valve-free TAP reconstruction. Methods We conducted a two-center retrospective comparative cohort study of 49 patients undergoing TOF repair requiring transannular RVOT reconstruction by a single surgeon. Twenty-two patients underwent RAA-derived bicuspid pulmonary valve reconstruction, 14 underwent monocusp TAP reconstruction, and 13 underwent valve-free TAP reconstruction. The three reconstruction strategies were analyzed separately, with an additional RAA-versus-monocusp sensitivity comparison. Because age at repair differed among groups, an additional sensitivity analysis for the principal echocardiographic outcome was restricted to the overlapping age range of the RAA and monocusp groups. Results Median follow-up was 31.5 months (IQR, 28.0–36.0) after RAA reconstruction, 25.5 months (23.0–34.5) after monocusp TAP, and 30.0 months (26.0–36.0) after valve-free TAP ( p = 0.224). At the last available follow-up echocardiographic examination, moderate/severe PR was present in 1 of 22 patients (4.5%) after RAA reconstruction, 13 of 14 (92.9%) after monocusp TAP, and 13 of 13 (100%) after valve-free TAP ( p < 0.001). The association persisted in the direct RAA-versus-monocusp comparison (4.5% vs. 92.9%; risk ratio, 0.05; 95% CI, 0.01–0.33; Fisher's exact p < 0.001) and in the age-restricted sensitivity analysis [1/16 [6.3%] vs. 9/10 [90.0%]; Fisher's exact p < 0.001]. No patient in the RAA or monocusp group underwent pulmonary valve replacement (PVR), whereas three patients in the valve-free TAP group underwent PVR during subsequent clinical follow-up. Conclusions RAA-derived bicuspid pulmonary valve reconstruction was feasible and was associated with a lower prevalence of moderate/severe PR during mid-term follow-up compared with both monocusp and valve-free TAP reconstruction in this retrospective cohort. The association persisted after exclusion of the valve-free TAP group and in an age-restricted sensitivity analysis. These findings warrant confirmation in larger prospective studies with standardized longitudinal imaging and longer follow-up before conclusions regarding long-term durability, right ventricular remodeling, or PVR risk can be established.