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Surgery for tetralogy of Fallot at less than six months of age
M Sousa Uva1, F Lacour-Gayet, T Komiya
1Marie Lannelongue Hospital, Le Plessis Robinson, France.
Insights
Early primary repair for symptomatic tetralogy of Fallot in infants is safe and effective, showing low mortality. Initial palliation is reserved for specific complex cases, guiding surgical decisions.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease
Background:
- Consensus on optimal surgical timing for symptomatic tetralogy of Fallot in infants is lacking.
- Surgical approaches include primary repair and initial palliation.
Purpose of the Study:
- To evaluate the outcomes of early primary repair versus initial palliation for tetralogy of Fallot in infants.
- To identify factors influencing surgical strategy and outcomes.
Main Methods:
- Retrospective review of 56 infants (<6 months) with tetralogy of Fallot from 1987-1992.
- Comparison of outcomes between 41 patients undergoing primary repair and 15 undergoing initial palliation.
- Analysis of mortality, reoperation rates, and need for transannular patch.
Main Results:
- Overall mortality was 3.6% (2 deaths), with no significant difference between groups (p=0.47).
- Initial palliation patients were younger, had smaller pulmonary arteries, or anomalous coronary arteries.
- Transannular patch was needed in 50% of repairs, significantly less in the initial palliation group (13% vs 56%, p=0.03).
- Eight patients from the initial palliation group underwent subsequent repair with increased pulmonary annulus size.
Conclusions:
- Early primary repair of symptomatic tetralogy of Fallot in infants is associated with low mortality and is the preferred approach.
- Initial palliation is indicated for infants with associated anomalies, very low weight, or severely hypoplastic pulmonary arteries.
Abstract:
Absence of consensus persists regarding the optimal procedure and timing for the surgical treatment of young infants with symptomatic tetralogy of Fallot. From 1987 through 1992, 56 patients with tetralogy of Fallot were operated on at less than 6 months of age. Forty-one patients (median age 2.9 months) underwent primary repair and 15 (median age 2.4 months) underwent initial palliation. Mean follow-up was 24.2 +/- 16.4 months. No strict protocol was used but patients who received initial palliation were younger, had a smaller pulmonary arterial tree, or had anomalous coronary artery. Two patients died (overall mortality 3.6%; 95% confidence limits 0% to 11%), one after initial palliation (6.7%), and one after primary repair (2.4%) (P = 0.47). Eight of the 15 patients who received initial palliation underwent repair and had an increase in pulmonary anulus size at the time of definitive repair (mean difference Z-value = 2.2 +/- 1.6 standard deviation; p = 0.006). Transannular patch was required in 50% of patients who underwent repair (56% among patients having primary repair versus 13% for patients having initial palliation; P = 0.03). Five patients underwent reoperation. Early primary repair of symptomatic tetralogy of Fallot was achieved with a low mortality rate and is the preferred protocol. Initial palliation remains indicated in case of associated cardiac anomaly, very low weight, or severely hypoplastic pulmonary artery tree.