Making a Case for Late Repair of Tetralogy of Fallot

Abstract

The history of management of tetralogy of Fallot illustrates the arc of progress in congenital heart surgery. From Blalock and Thomas to Lillehei and Kirklin, operations transitioned from palliation alone to palliation followed by staged repair in childhood. In the 1970s Barratt-Boyes and Castaneda pioneered primary repair in infancy. Subsequently there was a gradual evolution from staged repair toward single-stage repair at a progressively younger age, a phenomenon that mirrored the course of the specialty. 1 Barron D.J. Tetralogy of Fallot: controversies in early management. World J Pediatr Congenit Heart Surg. 2013; 4: 186-191 Crossref PubMed Scopus (28) Google Scholar As experience grew, middle infancy was recommended as the optimal timing for elective repair. 1 Barron D.J. Tetralogy of Fallot: controversies in early management. World J Pediatr Congenit Heart Surg. 2013; 4: 186-191 Crossref PubMed Scopus (28) Google Scholar ,2 Van Arsdell G.S. Maharaj G.S. Tom J. et al. What is the optimal age for repair of tetralogy of Fallot?. Circulation. 2000; 102: III123-III129 PubMed Google Scholar Over a decade ago The Society of Thoracic Surgeons Database revealed that primary repair in infants under 1 year of age had become the dominant strategy in North America. 3 Al Habib H.F. Jacobs J.P. Mavroudis C. et al. Contemporary patterns of management of tetralogy of Fallot: data from The Society of Thoracic Surgeons Database. Ann Thorac Surg. 2010; 90: 813-820 Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar Most patients underwent repair in the first year of life, with the majority during the first half of infancy. Although not significant, the lowest mortality for primary repair (0.6%) was observed in the most prevalent age category (3-6 months). Palliative shunting had decreased to around 10% and was mostly confined to neonates. More recently a large meta-analysis corroborated this shift toward repair in younger patients with a corollary decline in palliative staging; notably it also showed that increased mortality was associated with older patient age and prior palliation. 4 Romeo J.L.R. Etnel J.R.G. Takkenberg J.J.M. et al. Outcome after surgical repair of tetralogy of Fallot: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2020; 159: 220-236 Abstract Full Text Full Text PDF Scopus (13) Google Scholar Staged Repair of Tetralogy of Fallot: A Strategy for Optimizing Clinical and Functional OutcomesThe Annals of Thoracic SurgeryVol. 113Issue 5PreviewThis study evaluated the impact of a staged surgical strategy incorporating a modified Blalock-Taussig shunt (BTS) for tetralogy of Fallot on pulmonary valve annulus growth, the rate of valve-sparing repair at the time of intracardiac repair, and long-term functional outcomes. Full-Text PDF