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Early primary repair of tetralogy of Fallot
R A Gustafson1, G F Murray, H E Warden
1Department of Surgery, West Virginia University Medical Center, Morgantown 26505.
Insights
Primary intracardiac repair of tetralogy of Fallot is safe and effective for symptomatic children, regardless of age or weight. This study found no deaths and good long-term outcomes, even with transannular patch use.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Tetralogy of Fallot Repair
Background:
- Young age, low weight, and transannular patch reconstruction for the right ventricular outflow tract (RVOT) are traditionally considered risk factors for tetralogy of Fallot (TOF) repair.
- Complete repair of TOF in infants and children has evolved, with ongoing debate regarding optimal surgical timing and techniques.
Purpose of the Study:
- To evaluate the safety and efficacy of primary intracardiac repair of tetralogy of Fallot in symptomatic children, irrespective of age or weight.
- To assess early and late postoperative outcomes, including mortality, RVOT gradients, and residual defects.
Main Methods:
- A retrospective review of 40 patients undergoing complete repair of TOF between January 1984 and January 1987.
- Surgical approach involved Dacron patch closure of the ventricular septal defect, minimized infundibular resection, and leaving atrial communications open.
- Transannular RVOT patch reconstruction was utilized in the majority of patients.
Main Results:
- No mortality was observed in the 40 patients undergoing intracardiac repair.
- Postoperative RVOT pullback gradients ranged from 0 to 35 mm Hg (mean 18.5 mm Hg).
- Follow-up revealed no residual ventricular septal defects and only one moderate RVOT gradient on serial echocardiograms and cardiac catheterization.
Conclusions:
- Primary intracardiac repair of tetralogy of Fallot is a viable and safe option for symptomatic children, even those who are younger or have lower weights.
- The use of a transannular RVOT patch does not appear to adversely affect early or late outcomes in this patient cohort.
- These findings support the continued practice of primary repair for symptomatic tetralogy of Fallot, challenging previous concerns about age and weight limitations.
Abstract:
Young age, low weight, and the requirement for transannular patch reconstruction of the right ventricular outflow tract (RVOT) are thought to adversely affect intracardiac repair of tetralogy of Fallot. Forty patients underwent complete repair between January, 1984, and January, 1987. Only infants with pulmonary atresia, complete atrioventricular canal, or coronary artery anomalies were shunted initially. The malalignment ventricular septal defect was closed with a Dacron patch. Infundibular resection was minimized. All atrial communications were left open. Thirty-four patients (85%) had a transannular RVOT patch, and 2 patients (5%) had a nontransannular patch. All 10 infants weighing 3.4 to 9.6 kg had a transannular RVOT patch at 7 weeks to 12 months of age. An RVOT patch was used in 26 of 30 children operated on between 1 and 6 years of age (median age, 24 months). No patient undergoing intracardiac repair died. Postoperative RVOT pullback gradients were between 0 and 35 mm Hg (mean, 18.5 mm Hg). Postoperative pulmonary artery saturation (mean, 73%) did not reveal any residual ventricular septal defect. The right ventricular/arterial pressure ratio was always less than 0.6 (mean, 0.4). All children are doing well at follow-up from two to 37 months. Serial echocardiograms reveal no residual ventricular septal defect and only 1 moderate RVOT gradient. Follow-up cardiac catheterization in 15 patients revealed no residual ventricular septal defect and RVOT gradients between 5 and 35 mm Hg. The right ventricular/left ventricular pressure ratio was always less than 0.6 (mean, 0.48). The early and late results justify continued primary repair of tetralogy of Fallot in symptomatic children, regardless of age or weight.(ABSTRACT TRUNCATED AT 250 WORDS)