Tetralogy of Fallot: Choice of surgical procedure

Abstract

Deferment of total correction for tetralogy of Fallot until the age of 4 or 5 years, with the preference for a palliative shunt prior to that age, recently has been challenged by several authors. The reason is a reported operative mortality rate of 4 to 8 percent for total correction in infants compared to an accumulative operative mortality rate of 10 to 25 percent for the staged method. To determine the most effective management, we compiled data from 33 patients undergoing a palliative shunt and 218 consecutive patients undergoing total correction at Stanford University Hospital from June, 1960, through August, 1975. These data were computer processed for analysis of the effect of multiple factors upon the initial clinical result: moderate-to-severe hypoplasia of the pulmonary annulus, the type of pulmonary outflow tract patch, the need for pressor drugs postoperatively, and the presence of a previous palliative shunt. We have reached the following conclusions: (1) The operative mortality rate for total correction of tetralogy of Fallot after the age of 4 years (2.35 percent) is less than that in infancy (5 percent). (2) If surgical therapy is required in the first 24 months of life, total correction is preferred over palliative shunting with later total correction (operative mortality rate 5 percent versus 5.66 percent). (3) The Blalock-Taussig procedure, rather than the Waterston or Potts shunt, is preferred as the palliative shunt at any age because of the lower initial operative mortality rate (zero versus 28.57 percent) and the much lower accumulative operative mortality rate (5.66 percent versus 41.90 percent). (4) Severe hypoplasia of the right and left pulmonary arteries seems to be the main indication for initial palliative shunting in the first 24 months. (5) The accumulative operative mortality rate of 5.66 percent (3/53) for the Blalock-Taussig anastomosis with later total correction is significantly lower than the commonly reported rate of 10 to 25 percent.