Abstract 21052: Risk-Benefit Ratio May Not Justify a Further Decrease in Threshold for Pulmonary Valve Replacement Late After Tetralogy of Fallot Repair: An Experience With 2579 Patients
Bibliographic record
Abstract
Background: Recommended thresholds for pulmonary valve replacement (PVR) in asymptomatic patients after tetralogy of Fallot (TOF) repair are continually decreasing. We studied the natural history versus outcomes after PVR in various categories of indexed right ventricular end-diastolic volume (RVEDVi). Hypothesis: We hypothesized that the benefit of PVR would not be outweighed by the risk at lower RVEDVi thresholds. Methods: Acquisition of all repeated measure datapoints and cross-sectional review in 2579 patients (born 1924 - 2011), including 7553 echos, 2579 MRI scans and all interventional data. Analysis was via parametric competing risks techniques and time-related regressions adjusted for repeated measures. Results: Survival was 95%, 81% and 73% at age 20, 40 and 60 years respectively. Freedom from PVR (N=516, mean age 25 years) was 87%, 66% and 45% at 20, 40 and 60 years after repair. Overall, survival after PVR was 98%, 95% and 87% at 1, 10 and 20 years. PVR-free survival in all 345 patients with MRI RVEDVi > 150 was 95% at 15 years. Comparative survival showed no survival advantage with PVR versus natural history for RVEDVi 150-160, 160-170, 170-180 (table); these categories had excellent PVR-free survival approaching 100% at 10 years. Patients with RVEDVi > 200 had late survival decrements with PVR or without. PVR resulted in a large and significant reduction in RVEDVi (mean 40 ml/m 2 , P<.0001), after which RVEDVi remained stable (P=.10). Patients with RVEDVi 150-160, 160-170 or 170-180 had similar reductions in RVEDVi after PVR to comparable levels (table). 35% of children transitioning to adult care had RVEDVi > 150 ml/m 2 . Conclusions: Lowering the RVEDVi threshold for PVR does not appear to offer a clear survival advantage and offers small differences (if any) to RV geometry, risks potential procedure-related morbidity and would mean intervening on many teenagers with repaired TOF who could otherwise anticipate intervention in later life.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.003 | 0.007 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".