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[The prognosis of total cavo-pulmonary anastomosis in relation to age at surgery]
G Buheitel1, M Hofbeck, J von der Emde
1Kardiologische Abteilung der Klinik mit Poliklinik für Kinder und Jugendliche, Friedrich-Alexander-Universität Erlangen-Nürnberg. gernot.buheitel@rzmail.uni-erlangen.de
Insights
Performing total cavopulmonary anastomosis (TCPA) surgery earlier, ideally between ages 3-4, improves outcomes in children. Younger patients demonstrated better cardiac output and exercise capacity, with fewer arrhythmias post-surgery. Careful patient selection is crucial to mitigate higher risks in very young children.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Cardiovascular Physiology
Context:
- Total cavopulmonary anastomosis (TCPA) is a palliative surgical procedure for complex cyanotic heart disease.
- The optimal timing for TCPA in pediatric patients remains a subject of ongoing research and clinical debate.
Purpose:
- To investigate the relationship between the age at which children undergo total cavopulmonary anastomosis (TCPA) and their subsequent postoperative outcomes.
- To determine if earlier surgical intervention is associated with improved long-term results in pediatric patients after TCPA.
Summary:
- This study analyzed 53 children undergoing TCPA, comparing outcomes between those younger than 4 years and those older.
- Younger patients experienced higher perioperative mortality but demonstrated better cardiac index, maximal workload capacity, and reduced incidence of arrhythmias post-surgery.
- Late mortality was observed in older patients who underwent TCPA at ages 8.3 and 9.0 years.
Impact:
- Findings suggest that performing TCPA at 3-4 years of age is associated with superior functional outcomes in suitable pediatric patients.
- The study highlights the need to balance the increased intraoperative risks in younger children against the potential for better long-term results.
- Recommendations are made for early TCPA in carefully selected pediatric cases to optimize long-term cardiac function and quality of life.
Abstract:
The purpose of this study was to evaluate the relations between the age of surgery and the postoperative results in children after a total cavopulmonary anastomosis (TCPA). Between February 1990 and August 1995, 53 patients underwent a TCPA in our institution. At the time of the operation 26 of the patients were younger than 4 years, 27 patients were more than 4 years old. The perioperative mortality for all patients was 9.4%. Among the young children the perioperative mortality was higher than in the older patients (15.4% vs 3.7%). The only 2 patients who died late after surgery (2.8 and 2.6 years postoperatively) had been 8.3 and 9.0 years old at the time of their TCPA and represent 7.7% of the initially surviving patients of that group. The follow-up was based on routine heart catheterizations in 25 of our patients carried out 3.6 +/- 0.7 (m +/- SD) years postoperatively. Sixteen patients underwent a bicycle exercise test 4.0 +/- 1.0 years postoperatively and in 32 patients a Holter-ECG was obtained 3.2 +/- 1.2 years postoperatively (Table 1). The systemic cardiac index (CI), obtained at the catheterization laboratory, was only slightly reduced with 3.0 +/- 1.0 l/min/m2 (normal 3.5-5.5 l/min/m2). We saw a weak but significant negative correlation between the CI and the age at the TCPA (r = -0.43; p = 0.03; Figure 1). The maximal work load at the exercise test also showed a weak negative correlation to the age of surgery (r = -0.50; p = 0.05; Figure 2). Only 43.75% of our patients had no arrhythmias at the Holter-ECG. Again the group of children with no arrhythmias had been operated on at a significant lower age than the group of patients with arrhythmias (3.9 vs 7.3 years; p = 0.02; Figure 3). At follow-up the patients were all in good condition. Patients who had the TCPA in a relatively young age showed a better cardiac output, a higher work load at exercise testing and less arrhythmias than patients who were operated on when they were older. Therefore in suitable patients we recommend to carry out the TCPA at the 3rd or 4th year of life. The higher intraoperative mortality in young children should be overcome by excluding patients with additional preoperative risk factors.
