Transannular patch repair remains popular: the reasons for choosing the transannular patch should be discussed.

Abstract

We would like to refer to the recently published article by Luijten et al. describing the unfavourable outcome associated with transannular patch (TP) repair [1]. At the same time, they also reported favourable 25 year survival after tetralogy of Fallot (TOF) repair with a transatrial approach, which was great work. However, we would like to add some comments on the topic. Luijten et al. divided operative procedures into two groups, which were with or without TP. As they mentioned, the chief reason for choosing TP was personal selection by the attending surgeon. The surgeon’s decision might depend on the anatomical manifestations, which could not be measured in this study. Furthermore, among patients who underwent the same transatrial repair procedure, the long-term outcome and procedural details were different for each patient [2]. This might be due to heterogeneities of congenital heart disease, such as anatomical and physiological problems, including developmental problems. The recent trend in TOF operations has also been reported from the Society of Thoracic Surgeons Database [3]; in >60% of TOF patients TP repair was performed, which is compatible with the results of Luijten et al. [1]. These data prompted us to consider the reason for selecting TP repair, which might be important. We should not ignore the surgeon’s experiencedand art-based approach. In Japan, surgery with or without minimal right ventriculotomy was developed in the early 1980s [4]. Selection of a small incision was also determined personally by experienced surgeons. Our recently reported data [5] were also associated with favourable outcomes (10.5% arrhythmia and only 2.6% mortality in 30 years) even in a large number of patients with patch repair (17.0% TP 62.0% right ventricular outflow patch), which is comparable with the study by Luijten et al. [1]. The most common indication for reoperation was not pulmonary regurgitation but right ventricular outflow obstruction (32%), followed by right ventricular stenosis (29%), even when we were applying a TP in large number of patients [6]. There have been many discussions about TP repair and long-term outcome, and it has been concluded that the TP is associated with a poor outcome. As mentioned above, however, we are convinced that we should instead focus on the reason for selection of TP repair and the details of the surgical procedures. We completely agree with the necessity for life-long appropriate follow-up in the editorial comments on the study by Luijten et al. [1]. We are now confronting the worldwide problems associated with the methods and long-term management of tetralogy of Fallot. We are grateful for the chance to join the wide discussion on this theme.