Preoperative Morphological Prediction of Early Reoperation Risk After Primary Repair in Tetralogy of Fallot: A Contemporary Analysis of 83 Cases

ObjectivesTreatment of infants with tetralogy of Fallot (ToF) has evolved in the last two decades with increasing use of primary surgical repair (PrR) and transcatheter right ventricular outflow tract palliation (RVOTd), and fewer systemic-to-pulmonary shunts (SPS). We aim to report contemporary results using these treatment options in a comparative study.MethodsThis a retrospective study using data from the UK National Congenital Heart Disease Audit. All infants (n=1662, median age 181 days) with ToF and no other complex defects undergoing repair or palliation between 2000 and 2013 were considered. Matching algorithms were used to minimise confounding due to lower age and weight in those palliated.ResultsPatients underwent PrR (n=1244), SPS (n=311) or RVOTd (n=107). Mortality at 12 years was higher when repair or palliation was performed before the age of 60 days rather than after, most significantly for primary repair (18.7% vs 2.2%, P<0.001), less so for RVOTd (10.8% vs 0%, P=0.06) or SPS (12.4% vs 8.3%, P=0.2). In the matched groups of patients, RVOTd was associated with more right ventricular outflow tract (RVOT) reinterventions (HR=2.3, P=0.05 vs PrR, HR=7.2, P=0.001 vs SPS) and fewer pulmonary valve replacements (PVR) (HR=0.3 vs PrR, P=0.05) at 12 years, with lower mortality after complete repair (HR=0.2 versus PrR, P=0.09).ConclusionsWe found that RVOTd was associated with more RVOT reinterventions, fewer PVR and fewer deaths when compared with PrR in comparable, young infants, especially so in those under 60 days at the time of the first procedure.

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Routine Primary Repair of Tetralogy of Fallot in Neonates and Infants Less Than Three Months of Age

The Annals of Thoracic Surgery ◽

10.1016/s0003-4975(21)01206-6 ◽

1995 ◽

Vol 60 (6) ◽

pp. S592-S596

Author(s):

V. Mohan Reddy ◽

John R. Liddicoat ◽

Doff B. McElhinney ◽

Michael M. Brook ◽

Paul Stanger ◽

...

Keyword(s):

Tetralogy Of Fallot ◽

Primary Repair ◽

Neonates And Infants

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Abstract 15338: Comparison of Treatment Strategies for Neonates With Tetralogy of Fallot and Pulmonary Atresia: A Report From the Congenital Catheterization Research Collaborative

Circulation ◽

10.1161/circ.142.suppl_3.15338 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Holly Bauser Heaton ◽

Bryan H Goldstein ◽

Christopher Petit ◽

Athar M Qureshi ◽

Courtney McCracken ◽

...

Keyword(s):

Mechanical Ventilation ◽

Tetralogy Of Fallot ◽

Primary Repair ◽

Ductus Arteriosus ◽

Survival Rates ◽

Pulmonary Atresia ◽

Treatment Strategies ◽

Hospital Length Of Stay ◽

Complete Repair ◽

Mechanical Ventilation Duration

Introduction: Neonates with tetralogy of Fallot and pulmonary atresia (TOF/PA) with pulmonary blood flow supplied by the ductus arteriosus require early intervention. This may be accomplished by: initial palliation (IP) followed by complete repair (CR) or initial primary repair (PR). The optimal approach for patients with TOF/PA has not been established. Methods: Neonates with TOF/PA who underwent IP or PR from 2005-17 were retrospectively reviewed from the Congenital Catheterization Research Collaborative. The primary outcome was mortality. Outcomes were compared as IP vs PR and IP+CR vs PR. Secondary outcomes included hospital and procedural complications and are listed in table 1. Propensity scoring was used to adjust for baseline differences between strategies. Results: Of 282 neonates with TOF/PA, 106 underwent PR and 176 underwent IP (144 surgical, 32 transcatheter). Prior to initial intervention, IP patients had higher rates of mechanical ventilation (83.9% vs 72.2%, p=0.023) and DiGeorge syndrome (14.77% vs 4.72%, p=0.009). Mortality was greater in the IP cohort (HR 2.7, 95% CI 1.02 - 7.1, p = 0.046), with no mortality in the PR cohort after 6 months post-repair. After adjustment, differences in survival were no longer significant (HR 1.4, 95% CI 0.7 - 3.1, p=0.39). Both cohorts had similar mechanical ventilation duration and inotrope use as well as procedural and hospital complications. Intensive care and hospital length of stay, cardiac bypass (CPB) and anesthesia time favored PR when compared to IP+CR (p=<0.001). Early reintervention was more common in patients undergoing IP (rate ratio 1.42, p 0.003), but post-complete repair rates were similar (p=0.837). Conclusions: In neonates with TOF/PA, the IP approach is more often utilized in higher-risk patients. Accounting for this difference, IP and PR strategies have similar adjusted survival rates. Perioperative morbidities and lower risk for reintervention generally favor PR.

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Combined primary repair of tetralogy of Fallot and aortic root replacement

The Annals of Thoracic Surgery ◽

10.1016/s0003-4975(01)02695-9 ◽

2001 ◽

Vol 72 (6) ◽

pp. 2124-2125 ◽

Cited By ~ 6

Author(s):

H.Tarik Kiziltan ◽

Semra Topcu ◽

Nazan Ozbarlas ◽

Fazilet Kayaselcuk

Keyword(s):

Tetralogy Of Fallot ◽

Aortic Root ◽

Primary Repair ◽

Aortic Root Replacement

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Surgical ligation of Major Aorto Pulmonary Collateral Arteries (MAPCAs) in Tetralogy of Fallot at the time of primary repair

Indian Journal of Thoracic and Cardiovascular Surgery ◽

10.1007/s12055-013-0212-6 ◽

2013 ◽

Vol 29 (2) ◽

pp. 157-158 ◽

Cited By ~ 1

Author(s):

Ajeya Joshi ◽

Saket Agarwal ◽

Deepak Kumar Satsangi

Keyword(s):

Tetralogy Of Fallot ◽

Primary Repair ◽

Surgical Ligation ◽

Collateral Arteries

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Primary Repair of Tetralogy of Fallot May Be Cheaper but for How Long? Is There a Universal Truth?

World Journal for Pediatric and Congenital Heart Surgery ◽

10.1177/2150135118793085 ◽

2018 ◽

Vol 9 (5) ◽

pp. 548-549

Author(s):

Yves d’Udekem

Keyword(s):

Tetralogy Of Fallot ◽

Primary Repair ◽

Universal Truth

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Symptomatic Tetralogy of Fallot in Young Infants: Primary Repair or Shunt—Pediatric Health Information System Database Analysis

World Journal for Pediatric and Congenital Heart Surgery ◽

10.1177/2150135118780615 ◽

2018 ◽

Vol 9 (5) ◽

pp. 539-545 ◽

Cited By ~ 7

Author(s):

Karthik V. Ramakrishnan ◽

David Zurakowski ◽

William Pastor ◽

Richard A. Jonas ◽

Pranava Sinha

Keyword(s):

Information System ◽

Pulmonary Artery ◽

Health Information ◽

Tetralogy Of Fallot ◽

Primary Repair ◽

Health Information System ◽

Hospital Charges ◽

Pediatric Health ◽

Group 2 ◽

Early Primary

Background: Compare the early outcomes and hospital charges of early primary repair and systemic-to-pulmonary artery shunt for neonates and young infants (≤90 days of age) with tetralogy of Fallot using data from the Pediatric Health Information System database. Methods: The Pediatric Health Information System database was queried for patients <90 days of age with primary diagnosis of tetralogy of Fallot who underwent nonelective surgical repair or palliation between January 2008 and December 2014. The initial cohort of 821 patients (group 1 early primary repair, N = 554; group 2 systemic-to-pulmonary artery shunt, N = 267) was propensity score matched (248 patients in each group) to account for baseline imbalances in age and prostaglandin use. Results: Comparison of unmatched groups revealed younger age and higher incidence of extracardiac anomalies ( P = .02) and prematurity ( P = .04) in group 2. Mortality was comparable between the groups (group 1: 20 [4%] of 554 vs group 2: 11 [4%] of 267, P = .74). Irrespective of the type of procedure, prematurity (odds ratio [OR] = 3.3, 95% confidence interval [CI]: 1.5-7.4) and extracardiac anomalies (OR = 2.5, 95% CI: 1.2-5.3) were independent risk factors for mortality. Propensity score–matched analysis revealed no significant differences in patient mortality ( P = 1), duration of ventilation ( P = .64), hospital length of stay ( P = .69), or hospital charges ( P = .08) between the two groups. Conclusion: Outcomes and hospital charges associated with nonelective early primary repair are comparable to systemic-to-pulmonary artery shunt in symptomatic patients <90 days old with tetralogy of Fallot.

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Abstract 16503: Comparison of Management Strategies for the Neonate With Symptomatic Tetralogy of Fallot and Hypoplastic Branch Pulmonary Arteries: Results From the Congenital Catheterization Research Collaborative

Circulation ◽

10.1161/circ.142.suppl_3.16503 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Christopher J Petit ◽

Mark Law ◽

Andrew C Glatz ◽

Paul Chai ◽

Jennifer Romano ◽

...

Keyword(s):

Tetralogy Of Fallot ◽

Reference Group ◽

Primary Repair ◽

Management Strategies ◽

Pulmonary Arteries ◽

Pulmonary Atresia ◽

Treatment Strategies ◽

Z Score ◽

Risk Management Strategies ◽

Secondary Outcomes

Introduction: Symptomatic neonates with tetralogy of Fallot (sTOF) and hypoplastic branch pulmonary arteries (hPA) are at high risk. Management strategies include staged repair (SR) - initial palliation (IP) followed by later complete repair (CR) - or primary repair (PR). A balanced comparison of these approaches is needed in the sTOF neonate with hPA. Methods: Consecutive neonates with sTOF and hPA - defined as one hPA z-score <-2.0 with contralateral z-score <0 - who underwent SR or PR from 2005-17 were retrospectively reviewed by the Congenital Catheterization Research Collaborative. Primary outcome was mortality and secondary outcomes included component (IP, CR, PR) and cumulative (SR): hospital, ICU and surgical morbidities, and reintervention. Outcomes were compared between treatment strategies using propensity score adjustment (PSA) to account for baseline differences between groups (PR=reference group). Results: The cohort comprised 188 neonates including 121 SR (IP: 29 transcatheter; 54 surgery) and 67 PR patients. Presence of pulmonary atresia, lower gestational age and birthweight were more common in the SR cohort. Median right and left hPA z-scores were -2.19 (IQR -2.65, -1.92) and -2.33 (-2.84, -1.99), respectively. There were significant differences in treatment strategy across centers (p<0.01). Overall survival was similar between groups, before (p=0.33) and after PSA (HR 1.91, 0.48-7.7, p=0.36). Reintervention was more common in the SR group overall (HR 1.7, 1.03-2.7, p=0.04), but there was no difference after definitive repair (HR 1.21, 0.71-2.0, p=0.49). Secondary outcomes are shown in Table 1. Conclusions: In this multicenter comparison of SR or PR for management of neonates with sTOF and hPA, after PSA, no difference in mortality was found. Neonatal morbidities largely favored the SR group, but cumulative morbidities and reintervention favored the PR group. Further study is needed to determine late impact of these early advantages to SR.

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