Total Correction of Tetralogy of Fallot in the First 60 Days of Life in Symptomatic Infants: Is It The Gold Standard?

Abstract

Background The timing of surgical repair of tetralogy of Fallot (TOF) is a key to alleviate complications and for long-term survival. Total correction was usually performed at the age of 6 months or older under the notion of decreasing the surgical risk. However, avoiding palliation with an aortopulmonary shunt and early correction of systemic hypoxia appear to be of more benefit than the inborn surgical risk in low body weight patients. Our objective was to assess early/midterm survival and operative complications and to analyze patients, surgical techniques, and morphological risk factors to determine their effects on outcomes. Patients and Methods We retrospectively reviewed 152 patients with TOF who were ≤60 days of age when they underwent total correction of TOF. All patients had either duct-dependent pulmonary blood flow or arterial blood oxygen saturation less than 65% on room air requiring urgent surgical correction. Exclusion criteria included TOF with pulmonary atresia, TOF with nonconfluent pulmonary arteries, TOF with multiple aortopulmonary collateral arteries, and associated complete atrioventricular septal defects. Results The mean age at repair was 34 ± 19 days, and the mean weight was 3.8 ± 0.9 kg. Before surgery, 96 patients received an infusion of prostaglandin, 45 were mechanically ventilated, and 32 required inotropic support. Right ventricular outflow tract obstruction was managed with a transannular patch in 112 patients, and all the others had a main pulmonary artery patch. Cardiopulmonary bypass (CPB) with moderate hypothermia was the standard, and the CPB time averaged 48 ± 21 minutes. The postoperative intensive care unit stay was 5.7 ± 6 days, with 2.8 ± 4 days of mechanical ventilation. Early mortality was 4.6% (7 of 152), and actuarial survival rates were 95% at 1 year and 92% at 5 years. Univariable and multivariable analyses of the patients' demographics, anatomical characteristics, and operative techniques revealed the presence of small pulmonary arteries and low body weight to be the only independent risk factors for death. Conclusion Early total correction of TOF during the first 60 days of life can be performed with low mortality and good intermediate-term survival and, from our point of view, “should be the gold standard for TOFs.”

Long-Term Results after Fallot Repair

“…Operative mortality has constantly decreased with rates currently close to 0% even in neonates and young infants, 19 supporting our own surgical results with no early mortality since 2004. Previous studies 19 20 including patients who underwent total repair of TOF in the earlier era of Fallot repair report that younger age at the time of operation, lower weight, and transannular patch reconstruction were risk factors for death.…”

Primary versus staged repair of Fallot with borderline pulmonary artery anatomy

“…Kanter and associates reported that primary repair or shunting of symptomatic neonates provides the same long-term outcome [5]. However, reports from other studies have shown superior results for primary total correction [4,[6][7][8][9]. The safety issue of CPB in small infants was argued.…”

“…They have shown that CPB per se is not an independent determinant of survival and concluded that effective repair and proper pre-and postoperative management are the critical determinants of survival [9]. Several recent studies supported the early total correction of TOF irrespective of age and weight [1,2,4,7].…”

“…Two-stage repair avoids the risks of heart-lung machine in low-weight children. However, the early total correction has the benefits of avoiding MBT shunt complications, such as distortion of the pulmonary arteries, early relief of systemic hypoxia, which allows a normal rate of growth, preventing progressive right ventricle (RV) hypertrophy, and early normalization of cardiac chambers flow and pressure [4].…”

Complex assessment of complications in operated patients with Fallot's tetrad at the hospital stage

“…Tetralogy of Fallot is one of the most common CHD [1,2]. Currently, considerable experience of radical and palliative correction of TF has been accumulated in many cardiac surgery clinics of the world [3,4,5,6,7,11]. However, despite the perfection of surgical technique for correction of TF, anesthetic aid and intensive care, it is impossible to prevent the development of complications in the postoperative period.…”