Original article
Pediatric cardiac
Contemporary Patterns of Management of Tetralogy of Fallot: Data From The Society of Thoracic Surgeons Database

Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010.
https://doi.org/10.1016/j.athoracsur.2010.03.110Get rights and content

Background

The Society of Thoracic Surgeons Database was queried to ascertain current trends in management of tetralogy of Fallot (TOF) and to determine the prevalence of various surgical techniques.

Methods

The study population (n = 3059 operations) was all index operations in 2002–2007, age 0–18 years with Primary Diagnosis of TOF, and Primary Procedure TOF repair or palliation. Patients with Pulmonary Atresia, Absent Pulmonary Valve, and Atrioventricular Canal were excluded.

Results

294 patients had initial palliation, including 178 neonates. 2534 patients had repair of TOF as the initial operation (primary repair), including 154 neonates. 217 patients had repair of TOF after prior palliation. Of patients who had primary repair (n = 2534), 975 had repair at 3 to 6 months, 614 at 6 months to 1 year, 492 at 1 to 3 months, and 154 at 0 to 30 days. Of patients who had repair following prior palliation (n = 217), 65 had repair in the first 6 months of life, 111 at 6 months to 1 year, and only 41 (18.9%) at more than 1 year of age. Type of repair: Of 2534 primary repairs, 581 (23%) had no ventriculotomy, 571 (23%) had nontransanular patch, 1329 (52%) had transanular patch, and 53 (2%) had right ventricle to pulmonary artery conduits. Of repairs after prior palliation (n = 217), 20 (9%) had no ventriculotomy, 30 (14%) had nontransanular patch, 144 (66%) had transanular patch, and 24 (11%) had conduits. Discharge mortality (95% confidence interval; CI) was 22 of 294 (7.5%; CI: 4.7%–11.1%) for initial palliation, 33 of 2534 (1.3%; CI: 0.9%–1.8%) for primary repair, and 2 of 217 (0.9%; CI: 0.1%–3.3%) for secondary repair. For neonates, discharge mortality was 11 of 178 (6.2%; CI: 3.1%–10.8%) for palliation and 12 of 154 (7.8%; CI: 4.1%–13.2%) for primary repair.

Conclusions

Primary repair in the first year of life is the most prevalent strategy. Despite contemporary awareness of the late consequences of pulmonary insufficiency, ventriculotomy with transanular patch remains the most prevalent technique, both for primary repair and for repair following palliation.

Section snippets

Material and Methods

This study was approved by the Access and Publications Committee of the Society of Thoracic Surgeons (STS) Workforce for National Databases and the Institutional Review Board of the Montreal Children's Hospital of the McGill University Health Centre.

Operation Types and Age at Operation

There were 2534 instances of repair of TOF without a previous cardiac operation, and 217 instances of repair of TOF with a previous cardiac operation. There were 294 instances of palliation without a previous cardiac operation, and 14 instances of palliation with a previous cardiac operation.

Table 3 depicts the relationship between type of procedure and age at operation. For the neonatal age group (age 0 to 30 days), primary procedures (those without previous cardiac operations) were about

Comment

The systemic-to-pulmonary artery shunt was pioneered by Blalock in 1944, and the first intracardiac repair of TOF was accomplished by Lillehei in 1954. Shortly thereafter, Lillehei and colleagues [1, 22] introduced patch enlargement of the right ventricular infundibulum, and in 1959 Kirklin [1, 23] reported the use of transanular patching. For at least 2 decades, initial palliation followed by reparative operation later in childhood was the most prevalent strategy.

By the early 1980s, primary

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