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Tetralogy of Fallot: selective surgical management can minimize operative mortality
Insights
For infants with tetralogy of Fallot, preliminary shunting before corrective surgery may improve outcomes. Early repair before age one and transannular patch use increase operative mortality.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
Background:
- Tetralogy of Fallot (TOF) is a complex congenital heart defect.
- Complete correction is possible at any age, but optimal timing for interventions like shunting is debated.
Purpose of the Study:
- To determine the optimal age for palliative shunting in infants with tetralogy of Fallot.
- To analyze factors influencing operative mortality in TOF repair.
Main Methods:
- Retrospective review of 105 patients with tetralogy of Fallot treated between 1975 and 1984.
- Analysis of operative mortality based on age at repair, need for transannular patch, and left ventricular size.
Main Results:
- Operative mortality was higher for intracardiac repair before age one (14.3%) compared to after age one (5.6%).
- Transannular patch reconstruction for right ventricular outflow tract hypoplasia was associated with significantly higher mortality (13% vs. 2.2%).
- Palliative shunting in very young children was safe, with no increased mortality in subsequent corrective surgery.
Conclusions:
- Palliative shunting can be safely performed in very young children with tetralogy of Fallot.
- Age less than one year and the need for transannular patch reconstruction are significant risk factors for operative mortality in TOF repair, with additive effects.
Abstract:
Although tetralogy of Fallot can be completely corrected at any age, it appears that preliminary shunting may be of benefit in infancy. To better define the optimum age for shunting, the following patient data were reviewed. One hundred five patients with tetralogy of Fallot were treated between December, 1975, and July, 1984. Eight of 100 patients undergoing intracardiac repair died. Operative mortality was 14.3% (4 of 28 patients) when intracardiac repair was done before the patient was a year old, but only 5.6% (4 of 72 patients) after that age. Seven (13%) of 54 patients requiring transannular patch reconstruction of the right ventricular outflow tract died, whereas only 1 (2.2%) of 46 having repair without this type of reconstruction died (p less than 0.05). Twenty-one patients were initially palliated with systemic-pulmonary artery shunts, with 1 noncardiac death related to associated congenital neurological anomalies (4.8%). There was no statistically significant difference in mortality for primary versus secondary intracardiac repair. Left ventricular end-diastolic volume determination in 26 patients less than 2 years old demonstrated that 14 patients had small left ventricles and that 3 of them less than 1 year of age died at corrective operation. The remaining 12 had a left ventricle of normal size, and 1 of them died at operation. Palliative shunts can be performed safely in the very young child with no increased mortality at subsequent intracardiac repair. Diffuse hypoplasia of the right ventricular outflow tract and pulmonary arteries requiring transannular patch reconstruction, and age less than 1 year both alter operative mortality, their combined impact being additive.