Adherence to clinical practice guidelines for pulmonary valve intervention after tetralogy of Fallot repair: A nationwide cohort studyCentral MessagePerspective
Danielle Massarella, MD, MSc,
Brian W. McCrindle, MD, MPH,
Kyle Runeckles, MSc,
Steve Fan, PhD,
Nagib Dahdah, MD,
Frédéric Dallaire, MD,
Christian Drolet, MD,
Jasmine Grewal, MD,
Camille L. Hancock-Friesen, MD,
Edward Hickey, MD,
Gauri Rani Karur, MD,
Paul Khairy, MD, PhD,
Benedetta Leonardi, MD,
Michelle Keir, MD,
Syed Najaf Nadeem, MD,
Ming-Yen Ng, MD,
Ashish Shah, MD,
Edythe B. Tham, MBBS,
Judith Therrien, MD,
Andrew E. Warren, MD,
Isabelle F. Vonder Muhll, MD,
Alexander Van de Bruane, MD,
Kenichiro Yamamura, MD, MSc, PhD,
Michael Farkouh, MD,
Rachel M. Wald, MD
Affiliations
Danielle Massarella, MD, MSc
University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
Brian W. McCrindle, MD, MPH
Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
Kyle Runeckles, MSc
University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
Steve Fan, PhD
University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
Nagib Dahdah, MD
Division of Pediatric Cardiology, Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
Frédéric Dallaire, MD
Division of Pediatrics, University of Sherbrooke, Sherbrooke, Quebec, Canada
Christian Drolet, MD
Division of Pediatric and Congenital Cardiology, Department of Pediatrics, Laval University Hospital, Quebec, Quebec, Canada
Jasmine Grewal, MD
Yasmin and Amir Virani Provincial Adult Congenital Heart Program, Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
Camille L. Hancock-Friesen, MD
Division of Cardiovascular Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada
Edward Hickey, MD
Division of Cardiovascular Surgery, Texas Children's Hospital, Houston, Tex
Gauri Rani Karur, MD
Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
Paul Khairy, MD, PhD
Adult Congenital Center, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
Benedetta Leonardi, MD
Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Hospital and Research Institute, Scientific Institute for Research, Hospitalization, and Health Care, Rome, Italy
Michelle Keir, MD
Southern Alberta Adult Congenital Heart Disease Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
Syed Najaf Nadeem, MD
Division of Cardiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
Ming-Yen Ng, MD
Department of Diagnostic Radiology, School of Clinical Medicine, The University of Hong Kong, Hong Kong; Department of Medical Imaging, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
Ashish Shah, MD
Division of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada
MAUDE Unit (McGill University Health Network/Beth Raby Adult Congenital Heart Disease Clinic, Jewish General Hospital), Montreal, Quebec, Canada
Andrew E. Warren, MD
Division of Pediatric Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
Isabelle F. Vonder Muhll, MD
Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
Alexander Van de Bruane, MD
Division of Cardiology, University Hospitals Leuven, Leuven, Belgium
Kenichiro Yamamura, MD, MSc, PhD
Department of Pediatrics, Kyushu University Hospital, Fukuoka, Japan
Michael Farkouh, MD
University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
Rachel M. Wald, MD
University Health Network, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada; Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada; Address for reprints: Rachel M. Wald, MD, 585 University Ave, Room 5N 517, Toronto, Ontario, Canada, M5G 2N2.
Objectives: To determine guideline adherence pertaining to pulmonary valve replacement (PVR) referral after tetralogy of Fallot (TOF) repair. Methods: Children and adults with cardiovascular magnetic resonance imaging scans and at least moderate pulmonary regurgitation were prospectively enrolled in the Comprehensive Outcomes Registry Late After TOF Repair (CORRELATE). Individuals with previous PVR were excluded. Patients were classified according to presence (+) versus absence (−) of PVR and presence (+) versus absence (−) of contemporaneous guideline satisfaction. A validated score (specific activity scale [SAS]) classified adult symptom status. Results: In total, 498 participants (57% male, mean age 32 ± 14 years) were enrolled from 14 Canadian centers (2013-2020). Mean follow-up was 3.8 ± 1.8 years. Guideline criteria for PVR were satisfied for the majority (n = 422/498, 85%), although referral for PVR occurred only in a minority (n = 167/498, 34%). At PVR referral, most were asymptomatic (75% in SAS class 1). One participant (0.6%) received PVR without meeting criteria (PVR+/indication–). The remainder (n = 75/498, 15%) did not meet criteria for and did not receive PVR (PVR–/indication–). Abnormal cardiovascular imaging was the most commonly cited indication for PVR (n = 61/123, 50%). The SAS class and ratio of right to left end-diastolic volumes were independent predictors of PVR in a multivariable analysis (hazard ratio, 3.33; 95% confidence interval, 1.92-5.8, P < .0001; hazard ratio, 2.78; 95% confidence interval, 2.18-3.55, P < .0001). Conclusions: Although a majority of patients met guideline criteria for PVR, only a minority were referred for intervention. Abnormal cardiovascular imaging was the most common indication for referral. Further research will be necessary to establish the longer-term clinical impact of varying PVR referral strategies.
