Outcomes of Surgical Repair for Truncus Arteriosus: A 30-Year Single-Center Experience

Abstract

Background:We investigated the long-term outcomes of truncus arteriosus repair at a single institution with a 30-year study period. Methods: Patients who underwent repair of truncus arteriosus between 1993 and 2022 were reviewed retrospectively. Factors associated with early mortality, overall attrition, and reintervention were identified using appropriate statistical methods. Results: In total, 42 patients were enrolled in this study. The median age and weight at repair were 26 days and 3.5 kg, respectively. Thirty patients (71.4%) underwent 1-stage repair. There were 8 early deaths (19%). In the univariable analysis, undergoing surgery before 2011 was associated with early mortality (p=0.031). The overall survival rate at 10 years was 73.8%. In the multivariable analysis, significant truncal valve (TrV) dysfunction (p=0.010), longer cardiopulmonary bypass time (p=0.018), and the earlier era of surgery (p=0.004) were identified as risk factors for overall mortality. During follow-up, 47 reinterventions were required in 27 patients (64.3%). The freedom from all-cause reintervention rate at 10 years was 23.6%. In the multivariable analysis, associated arch obstruction (p<0.001) and significant TrV dysfunction (p=0.011) were identified as risk factors for all-cause reintervention. Arch obstruction (p=0.027) and a number of TrV cusps other than 3 (p=0.014) were identified as risk factors for right ventricle to pulmonary artery (RV-PA) reintervention, and significant TrV dysfunction was identified as a risk factor for TrV reintervention (p=0.002). Conclusion: Despite recent improvements in survival outcomes after repair of truncus arteriosus, RV-PA or TrV reinterventions were required in a significant number of patients during follow-up.

Commentary: Treatment for Truncus Arteriosus Needs to Be Tailored

“…Truncal valve regurgitation causes detrimental side effects of volume loading and diastolic runoff in diastolic ventricular dysfunction. In the present study [3], truncal valve dysfunction was a risk factor for overall mortality and truncal valve reintervention. As adequate truncal valve intervention improves survival, timely and advanced tailored techniques are required for truncal valve repair before left ventricular dysfunction occurs [4].…”

“…In the present study [3], freedom from RV-PA reintervention at 3 years for initial RV-PA connection was found in 75.0% of patients treated with homografts, 66.7% of those who underwent direct connection (réparation à l'étage ventriculaire [REV] procedure), 46.7% of those who received a valveless polytetrafluoroethylene (PTFE) conduit, 40.0% of those who received a valved PTFE conduit, and 20.0% of those treated with a Contegra conduit. Although freedom from RV-PA reintervention was not significantly different according to the type of conduit, homograft, REV, and valveless conduits tended to be more durable, whereas valved nonhomograft conduits tended to be less durable.…”

“…RV function and cardiopulmonary exercise tests during long-term follow-up need to be compared to achieve better results according to the type and size of conduit. Complex anatomy, such as arch obstruction and a number of truncal valve cusps other than 3, was a risk factor for RV-PA reintervention [3]. An unfavorable course from the RV to PA and a tight space at the distal end of the RV-PA conduit, which are more likely to be present in complex anatomy, might be related to earlier reintervention, and a tailored approach with an optimal conduit type and size is critical, particularly in patients with complex anatomy.…”

“…The Kaplan-Meier method only assesses the first reintervention after complete repair, and cannot comprehensively assess all reinterventions of a patient experiencing several similar events sequentially [3]. However, modulated renewal is an optimized analysis for multiple reinterventions that assesses the risk of subsequent reoperation from the most recent reoperation, rather than from complete repair [2].…”

“…A longer CPB time means intraoperative complications, revisions, or residual lesions because of anatomical complexities and difficulty in repair, and is a risk factor for overall mortality [3,5]. However, the duration of CPB is also related to performing more precise repair, additional revisions for minimal residual lesions, and complete myocardial resuscitation.…”