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Routine primary repair vs two-stage repair of tetralogy of Fallot
Insights
Primary repair of tetralogy of Fallot is risky for young children. A two-stage approach may be safer for infants, especially when transannular patching is used during primary repair.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease Management
Background:
- Routine primary repair of tetralogy of Fallot (TOF) in young children carries significant in-hospital mortality.
- Low cardiac output and patient size are major contributors to operative mortality.
Purpose of the Study:
- To compare the risks of in-hospital mortality between primary repair and a two-stage surgical approach for tetralogy of Fallot.
- To identify risk factors influencing outcomes in tetralogy of Fallot repair.
Main Methods:
- Retrospective analysis of in-hospital deaths for patients undergoing primary repair of TOF since 1972.
- Analysis of in-hospital deaths for patients undergoing secondary intracardiac repair after palliative shunting (1967-1978).
- Risk factor analysis including age, size, hematocrit, and surgical techniques like transannular patching.
Main Results:
- In-hospital mortality for primary repair was 7.7% (15/194), with young age and small size being significant risk factors.
- No deaths occurred in patients older than 4 years undergoing primary repair.
- Transannular patching independently increased surgical risk.
- In-hospital mortality for the two-stage approach was 3.2% (5/158).
Conclusions:
- Primary repair of tetralogy of Fallot is associated with higher mortality in very young and small patients.
- A two-stage approach appears safer for infants and small children, particularly when transannular patching is considered in primary repair.
- Surgical strategy for tetralogy of Fallot should be individualized based on patient factors and surgical techniques.
Abstract:
Fifteen of 194 patients (7.7%) with tetralogy of Fallot operated upon since January 1, 1972 under a protocol of routine primary repair despite young age died in-hospital. Most deaths were from low cardiac output. Young age and smallness of size increased the risk of operation. No deaths occurred among patients older than 4 years. High hematocrit was also a risk factor. Transannular patching has an independent effect in increasing risk. The post-repair ratio of peak pressure in the right ventricle to that in the left did not exert an independent effect. To project current risks of a two-stage approach, we determined that five of 158 patients (3.2%) died in-hospital after secondary intracardiac repair after a previous Blalock-Taussig or Waterston anastomosis between 1967--1978. Using these data and those we have published on the risk of shunting, we project that except in very small babies, the risks of hospital death of a two-stage approach are not less than those of primary repair done without a transannular patch, except when body surface area is less than about 0.35 m2. When a transannular patch is used in the primary repair, the two-stage approach is projected to be safer when the child has a body surface area of about 0.48 m2 or smaller.