Modified Transannular Patching Palliation versus Modified Blalock-Taussig-Thomas Shunt in Infants with Severe Tetralogy of Fallot with Diminutive Pulmonary Arteries
DOI:
https://doi.org/10.59958/hsf.5807Keywords:
congenital heart disease, tetralogy of Fallot, pulmonary arterial, Blalock-Taussig-Thomas shunt, infant, surgical procedureAbstract
Objective: The purpose of this study was to compare pulmonary arterial (PA) growth and morbidity, mortality, reintervention and complete repair rates after modified transannular patching palliation (mTAP) versus modified Blalock-Taussig-Thomas shunt (mBTS) for palliation in infants with severe tetralogy of Fallot (TOF) with diminutive pulmonary arteries. Methods: This was a retrospective case review study of 107 patients (64 males) with severe TOF who underwent staged repair with either mTAP (n = 55) or mBTS (n = 52) over an 8-year period. Procedure-related PA growth and morbidity, mortality, reintervention and complete repair rates were compared. Results: Two deaths occurred in the mBTS group due to sudden cardiac arrest, and five patients needed reintervention after the mBTS procedure because of shunt thrombosis or stenosis. Postoperative complications of mBTS included sudden cardiac arrest, shunt thrombosis/stenosis, vocal cord palsy and diaphragmatic palsy. Unlike in the mBTS group, no death, severe complications or reintervention occurred in the mTAP group. Oxygen saturations post mTAP and mBTS were significantly higher, which improved from 67.73 ± 4.36% to 94.33 ± 2.19% in the mTAP group and from 68.24 ± 3.87% to 86.87 ± 3.38% in the mBTS group. The increase in oxygen saturation and pulmonary artery growth (from pre- to post palliation) was significantly better with mTAP than with mBTS palliation (p < 0.01). All 55 patients showed complete repair after mTAP, and the time from palliation to complete repair was significantly shorter in the mTAP group. Conclusions: In a severe form of TOF with the hypoplastic PA tree, mTAP seems to be a better strategy that is safe and better facilitates satisfactory pulmonary arterial growth until complete repair than the mBTS procedure.
References
Hoashi T, Kagisaki K, Meng Y, Sakaguchi H, Kurosaki K, Shiraishi I, et al. Long-term outcomes after definitive repair for tetralogy of Fallot with preservation of the pulmonary valve annulus. The Journal of Thoracic and Cardiovascular Surgery. 2014; 148: 802–809.
Nollert G, Fischlein T, Bouterwek S, Böhmer C, Klinner W, Reichart B. Long-term survival in patients with repair of tetralogy of Fallot: 36-year follow-up of 490 survivors of the first year after surgical repair. Journal of the American College of Cardiology. 1997; 30: 1374–1383.
Smith CA, McCracken C, Thomas AS, Spector LG, St Louis JD, Oster ME, et al. Long-term Outcomes of Tetralogy of Fallot: A Study From the Pediatric Cardiac Care Consortium. JAMA Cardiology. 2019; 4: 34–41.
Owen AR, Gatzoulis MA. Tetralogy of Fallot: Late outcome after repair and surgical implications. Seminars in Thoracic and Cardiovascular Surgery. Pediatric Cardiac Surgery Annual. 2000; 3: 216–226.
Chowdhury UK, Jha A, Ray R, Kalaivani M, Hasija S, Kumari L, et al. Histopathology of the right ventricular outflow tract and the relation to hemodynamics in patients with repaired tetralogy of Fallot. The Journal of Thoracic and Cardiovascular Surgery. 2019; 158: 1173–1183.e5.
Tan C, Soquet J, Brizard CP, d'Udekem Y. Evolution of residual and recurrent right ventricular outflow tract obstruction after tetralogy of Fallot repair. The Journal of Thoracic and Cardiovascular Surgery. 2020; 159: e275–e277.
Korbmacher B, Heusch A, Sunderdiek U, Gams E, Rammos S, Langenbach MR, et al. Evidence for palliative enlargement of the right ventricular outflow tract in severe tetralogy of Fallot. European Journal of Cardio-thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2005; 27: 945–948.
Chiu SN, Wang JK, Chen HC, Lin MT, Wu ET, Chen CA, et al. Long-term survival and unnatural deaths of patients with repaired tetralogy of Fallot in an Asian cohort. Circulation. Cardiovascular Quality and Outcomes. 2012; 5: 120–125.
Gill CC, Moodie DS, McGoon DC. Staged surgical management of pulmonary atresia with diminutive pulmonary arteries. The Journal of Thoracic and Cardiovascular Surgery. 1977; 73: 436–442.
Wilder TJ, Van Arsdell GS, Benson L, Pham-Hung E, Gritti M, Page A, et al. Young infants with severe tetralogy of Fallot: Early primary surgery versus transcatheter palliation. The Journal of Thoracic and Cardiovascular Surgery. 2017; 154: 1692–1700.e2.
Li D, Wang Y, Lin K, An Q. Modified Blalock-Taussig Shunt: A Single-Center Experience and Follow-Up. The Heart Surgery Forum. 2020; 23: E053–E057.
Younis Memon MK, Akhtar S, Mohsin M, Ahmad W, Arshad A, Ahmed MA. Short And Midterm Outcome Of Fallot's Tetralogy Repair In Infancy: A Single Center Experience In A Developing Country. Journal of Ayub Medical College, Abbottabad: JAMC. 2019; 31: 383–387.
Quandt D, Ramchandani B, Penford G, Stickley J, Bhole V, Mehta C, et al. Right ventricular outflow tract stent versus BT shunt palliation in Tetralogy of Fallot. Heart (British Cardiac Society). 2017; 103: 1985–1991.
Donahoo JS, Gardner TJ, Zahka K, Kidd BS. Systemic-Pulmonary shunts inneonates and infants using microporous expanded polytetrafluoroethylene: immediate and late results. The Annals of Thoracic Surgery. 1980; 30: 146–150.
Bigdelian H, Ghaderian M, Sedighi M. Surgical repair of Tetralogy of Fallot following primary palliation: Right ventricular outflow track stenting versus modified Blalock-Taussig shunt. Indian Heart Journal. 2018; 70 Suppl 3: S394–S398.
Barron DJ. Tetralogy of Fallot: controversies in early management. World Journal for Pediatric & Congenital Heart Surgery. 2013; 4: 186–191.
Latus H, Stammermann J, Voges I, Waschulzik B, Gutberlet M, Diller GP, et al. Impact of Right Ventricular Pressure Load After Repair of Tetralogy of Fallot. Journal of the American Heart Association. 2022; 11: e022694.
Yoo BW, Kim JO, Kim YJ, Choi JY, Park HK, Park YH, et al. Impact of pressure load caused by right ventricular outflow tract obstruction on right ventricular volume overload in patients with repaired tetralogy of Fallot. The Journal of Thoracic and Cardiovascular Surgery. 2012; 143: 1299–1304.
Spiewak M, Biernacka EK, Małek ŁA, Petryka J, Kowalski M, Miłosz B, et al. Right ventricular outflow tract obstruction as a confounding factor in the assessment of the impact of pulmonary regurgitation on the right ventricular size and function in patients after repair of tetralogy of Fallot. Journal of Magnetic Resonance Imaging: JMRI. 2011; 33: 1040–1046.