Single-Stage Complete Repair versus Multistage Repair of Tetralogy of Fallot with Borderline Pulmonary Arteries
DOI:
https://doi.org/10.1532/hsf.2075Abstract
Background: Tetralogy of Fallot is the most common cyanotic congenital heart defect. Borderline pulmonary anatomy has been associated with a higher risk of mortality and morbidity. Strategies to manage this condition—namely, single- or multistage repair—have long been debated.
Objective: The overall outcomes of patients with tetralogy of Fallot with borderline pulmonary arteries (McGoon ratio 1.3 to 1.7) with regard to the need for a single-stage or multistage repair and the outcome of each surgical management were evaluated.
Patients and methods: A retrospective, nonrandomized comparative study designed to evaluate patient outcomes comprised 60 patients with tetralogy of Fallot with borderline pulmonary arteries who underwent surgery at the Cardiothoracic Surgery Academy, Ain Shams University, Cairo, Egypt, between January 2016 and December 2017. After gaining approval from the affiliated ethical and research committee, and informed consent of the guardians, the patients were assigned into one of two groups. Shunt group included 30 patients managed surgically by a modified Blalock-Taussig (MBT) shunt as a part of a multistage repair, and repair group included 30 patients managed surgically by single-stage complete repair. The medical records of the patients were reviewed, and data relating to age, sex, weight, and preoperative oxygen saturation were collected. All patients underwent preoperative echocardiography and multislice computed tomography (CT) with angiography. The follow-up was performed by echocardiography at discharge and at one month and six months after surgery. Multislice CT with angiography was performed in patients who received a shunt once the echocardiography showed acceptable pulmonary arteries.
Results: The patients’ age ranged from 5 to 50 months with a mean age of 18.63 ± 9.15 (19.84 ± 12.34 for the shunt group and 17.43 ± 8.54 for the repair group). The weight ranged from 5 kg to 18 kg with a mean of 9.6 ± 2.53 (8.82 ± 2.79 for the shunt group and 10.41 ± 2.63 for the repair group). The mean preoperative O2 saturation was 68.95% ± 7.8% for the shunt group and 87.93% ± 6.18% for the repair group. The median McGoon ratio was 1.4 for the shunt group and 1.6 for the repair group, the difference of which was highly significant (P < .0001). The mortality rate in our study was 10% (10% for the shunt group and 10% for the repair group). The morbidity incidence rate was 26.6% for the shunt and repair groups. The ICU stay ranged from 2 to 31 days, with a median of three days for the shunt group (mean 3.61 ± 1.91) and four days for the repair group (mean 6.07 ± 6.63 days). The calculated P value showed a significant difference between the two groups concerning ICU stay. The postoperative SO2 significantly increased to a mean of 85.58 ± 7.05 in the shunt group and 98.14 ± 3.36 in the repair group (P < .0001).
Conclusion: There was no statistically significant difference between multistage repair and single-stage complete repair regarding morbidity and mortality. Regarding ICU stay, patients in the single-stage had a better outcome. A McGoon ratio of 1.5 can be used as a guideline in the decision-making process.
References
Allam A, Hashem A. 2014. Fate of right ventricle outflow gradient after fallot repair. J Egyptian Soc Cardiorthorac Surg 22:53-8.
Anagnostopoulos P, Azakie A, Natarajan S, Alphonso N, Brook MM, Karl TR. 2007. Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot. J Thorac Cardiovasc Surg 133:640-7.
Anderson RH, Path MRC, Allwork SP, Ho SY, Lenox CC, Zuberbuhler JR. 1981. Surgical anatomy of tetralogy of fallot. J Thorac Cardiovasc Surg 81:887-96.
Chen B-B, Chen S-J, Wu M-H, Li YW, Lue HC. 2007. EBCT - McGoon ratio. A reliable and useful method to predict pulmonary blood flow non-invasively. 32:1-8.
Dyamenahalli U, McCrindle BW, Barker GA, Williams WG, Freedom RM, Bohn DJ. 2000. Influence of perioperative factors on outcomes in children younger than 18 months after repair of tetralogy of Fallot. Ann Thorac Surg 69:1236-42.
Ferencz C, Rubin JD, McCarter RJ, et al. 1985. Congenital heart-disease: prevalence at livebirth. The Baltimore Washington Infant Study. Am J Epidemiol 121:31-6.
Frigiola A, Redington AN, Cullen S, Vogel M. 2004. Pulmonary regurgitation is an important determinant of right ventricular contractile dysfunction in patients with surgically repaired tetralogy of Fallot. Circulation 110: II153-7.
Gladman G, McCrindle BW, Williams WG, Freedom RM, Benson LN. 1997. The modified Blalock-Taussig shunt: Clinical impact and morbidity in Fallot’s tetralogy in the current era. J Thorac Cardiovasc Surg 114:25-30.
Hirsch JC, Mosca RS, Bove EL. 2000. Complete repair of tetralogy of Fallot in the neonate. Results in the modern era. Ann Surg 232:508-14.
Horneffer PJ, Zahka KG, Rowe SA, et al. 1990. Long-term results of total repair of tetralogy of fallot in childhood. Ann Thorac Surg 50:179-85.
Ishikawa S, Takahashi T, Sato Y, et al. 2001. Growth of the pulmonary arteries after systemic-pulmonary shunt. Ann Thorac Cardiovasc Surg 7:337-40.
Jahangiri M, Lincoln C, Shinebourne EA. 1999. Does the modified Blalock-Taussig shunt cause growth of the contralateral pulmonary artery? Ann Thorac Surg 67:1397-9.
Kanter KR, Kogon BE, Kirshbom PM, Carlock PR. 2010. Symptomatic neonatal tetralogy of Fallot: repair or shunt? Ann Thorac Surg 89:858-63.
Karl TR, Sano S, Pornviliwan S, Mee RBB. 1992. Tetralogy of fallot: favorable outcome of nonneonatal transatrial, transpulmonary repair. Ann Thorac Surg 54:903-7.
Laas J, Engeser U, Meisner H, et al. 1984. Tetralogy of fallot: development of hypoplastic pulmonary-arteries after palliation. Thorac Cardiovasc Surg 32:133-8.
Lillehei CW, Cohen M, Warden HE, et al. 1955. Direct vision intracardiac surgical correction of the tetralogy of fallot, pentalogy of fallot, and pulmonary atresia defects: report of 1st 10 cases. Ann Surg 142:418-45.
Maghur HA, Ben-Musa AA, Salim ME, Abuzakhar SS. 2002.The modified Blalock-Taussig shunt: A 6-year experience from a developing country. Pediatr Cardiol 23:49-52.
Mitchell SC, Korones SB, Berendes HW. 1971. Congenital heart disease in 56,109 births: incidence and natural history. Circulation 43:323-32.
Morales DL, Zafar F, Fraser Jr CD. 2009. Tetralogy of Fallot repair: the right ventricle infundibulum sparing (RVIS) strategy. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 54-8.
Neill CA, Clark EB. 1994. Tetralogy of fallot: the 1st 300 years. Texas Hear Inst J 21:272-9.
Stewart RD, Mavroudis C, Backer CL. 2013. Pediatric Cardiac Surgery, Fourth Edition. Eds: Mavroudis C and Backer CL. Blackwell Publishing Ltd. p. 415.
Ross ET, Costello JM, Backer CL, Brown LM, Robinson JD. 2015. Right ventricular outflow tract growth in infants with palliated tetralogy of fallot. Ann Thorac Surg 99:1367-72.
Sabri MR, Sholler G, Hawker R, Nunn G. 1999. Branch pulmonary artery growth after Blalock-Taussig shunts in tetralogy of Fallot and pulmonary atresia with ventricular septal defect: A retrospective, echocardiographic study. Pediatr Cardiol 20:358-63.
Sasikumar D, Sasidharan B, Tharakan JA, Dharan BS, Mathew T, Karunakaran J. 2014. Early and 1-year outcome and predictors of adverse outcome following monocusp pulmonary valve reconstruction for patients with tetralogy of Fallot: A prospective observational study. Ann Pediatr Cardiol 7:5-12.
Saygi M, Ergul Y, Tola HT, et al. 2015. Factors affecting perioperative mortality in tetralogy of Fallot. Pediatr Int 57:832-9.
Singh SP, Chauhan S, Choudhury M, et al. 2014. Modified Blalock Taussig shunt: Comparison between neonates, infants, and older children. Ann Card Anaesth 17:191-7.
Stewart RD, Backer CL, Young L, Mavroudis C. 2005. Tetralogy of Fallot: Results of a pulmonary valve-sparing strategy. Ann Thorac Surg 80:1431-9.
Taussig HB. 1979. Tetralogy of fallot: early history and late results. Am J Roentgenol 133:423-31.
Wilder TJ, Van Arsdell GS, Pham-Hung E, et al. 2016. Aggressive patch augmentation may reduce growth potential of hypoplastic branch pulmonary arteries after tetralogy of Fallot repair. Ann Thorac Surg 101:996-1004.
