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We appreciate the thoughtful response from Drs Peer and Jonas1Peer S.M. Jonas R.A. Controlling the cost management of congenital heart disease (letter).Ann Thorac Surg. 2020; 109: 988-989Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar on our article.2McHugh K.E. Mahle W.T. Hall M.A. et al.Hospital costs related to early extubation after infant cardiac surgery.Ann Thorac Surg. 2019; 107: 1421-1426Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The number of patients who previously underwent staged management of tetralogy of Fallot was not evaluated in our study,2McHugh K.E. Mahle W.T. Hall M.A. et al.Hospital costs related to early extubation after infant cardiac surgery.Ann Thorac Surg. 2019; 107: 1421-1426Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar because this is unlikely to influence the change in hospital costs after implementation of an early extubation clinical practice guideline. Drs Peer and Jonas make a valid point that the costs of 2 hospitalizations for a staged repair would likely result in higher costs than a single surgery for primary repair. However a more important question is whether there is truly better value, which would require a comprehensive assessment of the costs for both inpatient and outpatient care for tetralogy of Fallot as well as longitudinal clinical outcomes for patients who undergo primary repair versus staged repair for tetralogy of Fallot and adjustment for patient-level risk factors. In addition it must be taken into consideration that the impact of 1 versus 2 stages of repair may vary among institutions.3Kanter K.R. Kogon B.E. Kirshbom P.M. Carlock P.R. Symptomatic neonatal tetralogy of Fallot: repair or shunt?.Ann Thorac Surg. 2010; 89: 858-863Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Unfortunately this evaluation is outside the scope of our study whose primary aim was to investigate the effect of implementation of an early extubation clinical practice guideline on hospital costs for several common infant cardiac surgeries. However we do agree this would be an interesting investigation to undertake in the future to address the question posed by Drs Peer and Jonas. Controlling the Cost of Management of Congenital Heart DiseaseThe Annals of Thoracic SurgeryVol. 109Issue 3PreviewWe read with interest three reports by McHugh and colleagues.1-3 Early extubation after two index operations, complete repair tetralogy of Fallot (TOF), and coarctation repair has been evaluated as a strategy to improve patient outcomes and decrease hospital costs. Importantly, the article does not specify how many patients underwent primary repair versus staged management of TOF. Full-Text PDF