Transannular Patch Repair Research Articles

Right ventricular outlet tract reconstruction for tetralogy of fallot: systematic review and network meta-analysis.

Concerns persist regarding pulmonary regurgitation after transannular patch repair (TAP) for Tetralogy of Fallot. Despite various architectural preservation techniques being introduced, the optimal strategy remains controversial. We aimed to compare different right ventricular outlet tract reconstruction techniques. PubMed, EMBASE and Cochrane Central were searched through March 2024 to identify comparative studies on right ventricular outlet tract reconstruction techniques (PROSPERO ID: CRD42024519404). The primary outcome was mid-term pulmonary regurgitation, with secondary outcomes including postoperative mortality, postoperative pulmonary regurgitation, length of intensive care unit stays, postoperative right ventricular outlet tract pressure gradient, and mid-term mortality. We performed a network meta-analysis to compare outcomes among TAP, valve-repairing (VR), TAP with neo-valve creation (TAPN), and valve-sparing (VS). Two randomized controlled studies and 32 observational studies were identified with 8,890 patients. TAP carried a higher risk of mid-term pulmonary regurgitation compared to TAPN (HR, 0.53; 95％CI [0.33; 0.85]) and VS (HR, 0.27; 95% CI [0.19; 0.39]), with no significant difference compared to VR. VS was also associated with reduced postoperative mortality compared to TAP (RR, 0.31; 95% CI [0.18; 0.56]), in addition to reduced ventilation time. TAP also carried an increased risk of postoperative pulmonary regurgitation compared to the other groups. The groups were comparable in terms of length of intensive care unit stay, right ventricular outlet tract pressure gradient, and mid-term mortality. VR was associated with a reduced risk of postoperative pulmonary regurgitation, while TAPN was associated with reduced risks of both postoperative and mid-term pulmonary regurgitation.

Different microRNA expression in the right ventricular outflow tract myocardium of tetralogy of Fallot

Abstract Background When repairing tetralogy of Fallot (TOF), there are two surgical options according to the size of the pulmonary valve: transannular patch repair and valve-preserving repair. Since the development of the pulmonary valve depends on the degree of obstruction of the right ventricular outflow tract (RVOT), molecular profiles of the RVOT muscles may be associated with the surgical decision. As a recent study shows altered microRNA expression of the right ventricular myocardium even in TOF patients, microRNA expression of the RVOT infundibular muscle may be different between the two procedures. Purpose To evaluate differences in microRNA expression levels of RVOT infundibular muscles between the transannular patch repair and valve-preserving repair groups. Methods Surgically resected infundibular muscles from TOF patients are frozen in liquid nitrogen and stored in our hospital biobank. Nine samples collected between August 2020 and July 2022 were used in this study. Five patients underwent a valve-preserving repair and the others underwent a transannular patch repair. Six patients were female and mean age at operation was 453 ± 240 days. These samples were homogenized and total RNA including microRNAs were extracted. MicroRNA expression levels were measured using a microRNA array capable of detecting over 2000 microRNAs simultaneously. Results 1171 microRNAs were detected in all nine samples. The expression levels of 22 microRNAs were significantly different between the transannular patch repair group and the valve-preserving repair group (P<0.05). The expression levels of 19 microRNAs were significantly higher in the transannular patch repair group and the others were significantly higher in the valve-preserving repair group. More than 2-fold changes were observed in 2 microRNAs between the transannular patch repair and valve-preserving repair groups. Conclusion MicroRNA expression of RVOT infundibular muscle differs between the transannular patch repair and valve-preserving repair groups. Therefore, microRNA analysis will be useful to evaluate the pathophysiology of TOF. In addition, microRNAs may become a useful biomarker for surgical decision making in TOF.

Comparing clinical and echocardiographic outcomes following valve-sparing versus transannular patch repair of tetralogy of Fallot: a systematic review and meta-analysis.

Transannular patch (TAP) repair of tetralogy of Fallot (ToF)relieves right ventricular tract obstruction but may lead to pulmonary regurgitation. Valve-sparing (VS) procedures can avoid this situation, but there is a potential for residual pulmonary stenosis. Our goal was to evaluate clinical and echocardiographic outcomes of TAP and VS repair for ToF. A systematic search of the PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials and Web of Science databases was carried out to identify articles comparing conventional TAP repair and VS repair for ToF. Random-effects models were used to perform meta-analyses of the clinical and echocardiographic outcomes. Forty studies were included in this meta-analysis with data on 11723 participants (TAP: 6171; VS: 5045). Participants who underwent a VS procedure experienced a significantly lower cardiopulmonary bypass time [mean difference (MD): -14.97; 95% confidence interval (CI): -22.54, -7.41], shorter ventilation duration (MD: -15.33; 95% CI: -30.20, -0.46) and shorter lengths of both intensive care unit (ICU) (MD: -0.67; 95% CI: -1.29, -0.06) and hospital stays (MD: -2.30; 95% CI: [-4.08, -0.52). There was also a lower risk of mortality [risk ratio: 0.40; 95% CI: (0.27, 0.60) and pulmonary regurgitation [risk ratio: 0.35; 95% CI: (0.26, 0.46)] associated with the VS group. Most other clinical and echocardiographic outcomes were comparable in the 2 groups. This meta-analysis confirms the well-established increased risk of pulmonary insufficiency following TAP repair while also demonstrating that VS repairs are associated with several improved clinical outcomes. Continued research can identify the criteria for adopting a VS approach as opposed to a traditional TAP repair.

Tetralogy of Fallot transannular patch repair with or without monocusp valve reconstruction

Tetralogy of Fallot transannular patch repair with or without monocusp valve reconstruction

Machine Learning Quantification of Pulmonary Regurgitation Fraction from Echocardiography.

Assessment of pulmonary regurgitation (PR) guides treatment for patients with congenital heart disease. Quantitative assessment of PR fraction (PRF) by echocardiography is limited. Cardiac MRI (cMRI) is the reference-standard for PRF quantification. We created an algorithm to predict cMRI-quantified PRF from echocardiography using machine learning (ML). We retrospectively performed echocardiographic measurements paired to cMRI within 3months in patients with ≥ mild PR from 2009 to 2022. Model inputs were vena contracta ratio, PR index, PR pressure half-time, main and branch pulmonary artery diastolic flow reversal (BPAFR), and transannular patch repair. A gradient boosted trees ML algorithm was trained using k-fold cross-validation to predict cMRI PRF by phase contrast imaging as a continuous number and at > mild (PRF ≥ 20%) and severe (PRF ≥ 40%) thresholds. Regression performance was evaluated with mean absolute error (MAE), and at clinical thresholds with area-under-the-receiver-operating-characteristic curve (AUROC). Prediction accuracy was compared to historical clinician accuracy. We externally validated prior reported studies for comparison. We included 243 subjects (median age 21years, 58% repaired tetralogy of Fallot). The regression MAE = 7.0%. For prediction of > mild PR, AUROC = 0.96, but BPAFR alone outperformed the ML model (sensitivity 94%, specificity 97%). The ML model detection of severe PR had AUROC = 0.86, but in the subgroup with BPAFR, performance dropped (AUROC = 0.73). Accuracy between clinicians and the ML model was similar (70% vs. 69%). There was decrement in performance of prior reported algorithms on external validation in our dataset. A novel ML model for echocardiographic quantification of PRF outperforms prior studies and has comparable overall accuracy to clinicians. BPAFR is an excellent marker for > mild PRF, and has moderate capacity to detect severe PR, but more work is required to distinguish moderate from severe PR. Poor external validation of prior works highlights reproducibility challenges.

Assessment of the pulmonary arterial growth and results of two-stage repair in infants with severe form of tetralogy of Fallot

Aim: assess of the pulmonary artery growth and the outcomes of complete repair after palliative treatment in infants with critical form of Tetralogy of Fallot.Methods. This was prospective randomized two-center study (2019 to 2022). Its included infants with Tetralogy of Fallot who underwent palliation with either stenting of the right ventricular outflow tract (stent group, n=21) or modified Blalock-Taussig shunt (shunt group, n=21).Results. In the stent group Nakata index increase from median 104.2 to 208.6 mm2/m2, while in the shunt group, it increased from 107.3 to 169.4 mm2/m2 (p<0,01). Mixed model analysis showed that in stent group the right pulmonary artery growth rate was 2.05*10-2 z scores/day, which was 3.01 times higher than in the shunt group. In stent group the left pulmonary artery growth rate was 2.3*10-2 z scores/day, which was 1.47 times higher than in the shunt group. In the stent group, there was one noncardiac-related mortality during the intermediate period. Transannular patch repair of the right ventricular outflow tract was performed in 12 patients (60%) in the stent group and in 15 patients (71.4%) in the shunt group (p=0.52) during complete repair. At 8 cases (40%) in the stent group and 6 cases (28.6%) in the shunt group, pulmonary artery replacement was performed. Time to surgical repair was shorter in the stent group (p=0.046), while the aortic cross clamp time (p<0,01) and cardiopulmonary bypass time (p<0,01) were significantly shorter in the shunt group.Conclusions. Right ventricular outflow tract stenting provides hemodynamic stabilization and uniform growth of the pulmonary artery compared to modified Blalock-Taussig shunt.

Pulmonary Artery Stenosis in Tetralogy of Fallot.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital cardiac defect. The survival rate after primary complete repair is high (98-100%); however, pulmonary artery stenosis (PAS) is not uncommon after TOF repair, and severe PAS aggravates pulmonary regurgitation, resulting in right ventricle dilation, ventricular arrhythmia, and possibly death. PAS in TOF can be congenital due to hypoplasia or coarctation or can be acquired secondary to a surgical procedure. The latter may be caused by an exogenous conduit implant, compression from the adjacent enlarged ascending aorta, or outflow tract dilation after transannular patch repair. PAS can also be caused by the pulmonary artery plasty strategy itself. Here, the intrinsic mechanisms underlying PAS and pulmonary artery plasty techniques and strategies are reviewed to provide guidance for surgeons.

Abstract 13830: Pheochromocytoma in a Patient With Tetralogy of Fallot and Chromosome 17p12 Duplication

Description of Case: A 22-year-old male with Tetralogy of Fallot (TOF) status post transannular patch repair, hypothyroidism, and known partial duplication of chromosome 17p12 concerning for Charcot-Marie-Tooth disease (CMT), presented to his cardiologist with exertional angina and dyspnea, difficulty gaining weight, and diaphoresis. Cardiac MRI demonstrated moderate to severe pulmonic regurgitation with regurgitation fraction of 35% and RV end-diastolic volume index of 150 cc/m 2 . He was referred for pulmonic valve replacement surgery. While awaiting surgical evaluation, he presented to an ER with new hypertension with blood pressure to 240/140 and tachycardia to 107. A CT scan demonstrated a 4.3 x 5.0 x 4.4 cm mass in the right adrenal gland. On admission he was started on phenoxybenzamine and carvedilol. Workup revealed elevated catecholamines and metanephrines ( Table ). He underwent surgical adrenalectomy without complications. Immunohistochemical staining was consistent with pheochromocytoma. Post-procedurally, he was normotensive off medications. He was seen in clinic three weeks after surgery with significant improvement in symptoms. Discussion: We report on a novel genetic association of chromosome 17p12 duplication and pheochromocytoma. The region transcribes peripheral myelin protein-22, which has associations with CMT. Overlap has been demonstrated in other CMT-associated mutations and pheochromocytoma syndromes (e.g. kinesin family member 1B). In congenital heart disease, risk for pheochromocytoma is felt to be driven by hypoxia causing catecholamine secretion, adrenal hyperplasia, and eventual neoplasia. Further study is needed to characterize genetic associations between pheochromocytoma, neuropathy, and congenital heart disease. This patient’s presentation is a lesson in maintaining a high index of suspicion for pheochromocytoma in congenital heart disease, especially with associated genetic syndromes.

Blood biomarkers to detect functional impairment in adult patients with repaired tetralogy of Fallot

BackgroundThe relationship between plasma brain natriuretic peptide (NT-proBNP) and soluble suppression of tumorigenicity-2 (sST2) with structural adaptions and exercise capacity remains incompletely described in patients with repaired Tetralogy of Fallot (rTOF). MethodsPeripheral venous blood samples were drawn for 99 patients with repaired TOF, 59 patients with severe pulmonary regurgitation (PR) and 40 patients with no or mild PR. NT-proBNP was measured using enzyme-linked immunosorbent assays (Roche Diagnostics, Indianapolis, IN). Soluble ST2 levels were assessed on Aspect-plus ST2 quantitative rapid test. ResultsThe mean value of NT-proBNP was 160 ± 137 pg/ml, and sST2 was 29 ± 13, ng/ml in the entire population. 58 % had an elevated NT-proBNP, while sST2 was abnormal in 40 %. Mean NT-proBNP was significantly higher in patients with severe PR (169 ± 150 vs145 ± 118, pg/ml, p < 0.001), while similar sST2 levels were observed in both groups (29 ± 14 vs30 ± 12, ng/ml, p > 0.05). NT-proBNP and sST2 levels were higher in patients with transannular patch when compared to other RVOT intervention (174 ± 145 vs 107 ± 100, pg/ml, p < 0.001); (31 ± 13 vs 29 ± 15, ng/ml, p < 0.05). Both biomarkers were significantly associated with exercise capacity, but NT-proBNP (r = −0.60, p < 0.001) was stronger. The optimal cut-off of 90 pg/ml for NT-proBNP had a sensitivity of 74 % and specificity of 63 % for detection of impaired exercise capacity. ConclusionsSerum levels of sST2 and NT-proBNP are elevated in patients with repaired TOF, with higher values observed in those with severe PR, but also in patients undergoing transannular patch repair. Incorporating both markers in these patients increased the ability to detect impairment in exercise capacity.

Treatment of Severe Pulmonary Regurgitation in Enlarged Native Right Ventricular Outflow Tracts: Transcatheter Pulmonary Valve Replacement with Three-Dimensional Printing Guidance.

Severe pulmonary regurgitation (PR) often occurs following a transannular patch repair of tetralogy of Fallot, resulting in an enlarged native right ventricular outflow tract (nRVOT) with varying shapes. We conducted a single-center study with eight patients having severe PR and enlarged nRVOT (diameters ≥ 29 mm). Transcatheter pulmonary valve replacement (TPVR) was performed using the self-expanding PT-Valve. Preoperative evaluation included echocardiography, computed tomography, and magnetic resonance imaging. A 3D-printed model of the nRVOT was used for preoperative assessment. Follow-up data were collected in 1-year follow-up. PT-Valve was successfully implanted in all patients, resulting in immediate improvement of severe PR. Pulmonary artery diastolic pressure increased significantly (p < 0.001). No deaths or coronary compression occurred during the procedure. Over a 1-year follow-up, no stent displacement or fracture occurred. Only two patients had trace paravalvular leaks. Magnetic resonance imaging revealed a reversal of right ventricular remodeling, with a significant reduction in right ventricular end-diastolic volume index (p < 0.001) and improved right ventricular ejection fraction (p < 0.001). All patients achieved primary endpoints. 3D printing-guided PT-Valve implantation in enlarged nRVOT for severe PR is safe and effective, expanding TPVR indications and offering potential treatment for a broader patient population.

Adverse events after repair of tetralogy of Fallot: prediction models by machine learning of a retrospective cohort study in western China.

The incidence of clinical adverse events after tetralogy of Fallot (TOF) repair remains high. This study was performed to explore risk factors for adverse events and develop a prediction model through machine learning (ML) to forecast the incidence of clinical adverse events after TOF repair. A total of 281 participants who were treated with cardiopulmonary bypass (CPB) at our hospital from January 2002 to January 2022 were included in the study. Risk factors for adverse events were explored by composite and comprehensive analyses. Five artificial intelligence (AI) models were used for ML to build prediction models and screen out the model with the best performance in predicting adverse events. CPB time, differential pressure of the right ventricular outflow tract (RVOTDP or DP), and transannular patch repair were identified as the main risk factors for adverse events. The reference point for CPB time was 116.5 minutes and that for right ventricular (RV) outflow tract differential pressure was 70 mmHg. SPO2 was a protective factor, with a reference point of 88%. By integrating the results for the training and validation cohorts, we confirmed that, among all models, the logistic regression (LR) model and Gaussian Naive Bayes (GNB) model were stable, showing good discrimination, calibration and clinical practicability. The dynamic nomogram can be used as a predictive tool for clinical application. Differential pressure of the RV outflow tract, CPB time, and transannular patch repair are risk factors, and SPO2 is a protective factor for adverse events after complete TOF repair. In this study, models developed by ML were established to predict the incidence of adverse events.

Comparison of postoperative outcomes of milrinone versus dobutamine in tetralogy of Fallot with transannular patch

Background: Since the original description of TOF, its management modalities are continuously evolving. Present modality includes complete correction of the pathology by intra-cardiac repair with or without using transannular patch. Various finer aspects of intraoperative and postoperative management of the TOF repair are still evolving. Aims and Objectives: In this single centre study we are aiming to compare short term outcomes in patients of tof operated with transannular patch repair treated postoperatively with dobutamine vs milrinone. Materials and Methods: Total 100 patients undergoing TOF repair with transannular patch were grouped with respect to the inotropes used. One group who received milrinone and other who received dobutamine. Postoperative outcomes depending upon the need of other inotropic support, duration of ventilatory support, icu stay, inotropic support, hospital stay, morbidity and mortality are compared between the groups. Observations: No significant difference was seen in both groups for mean ventilation time, duration of icu and hospital stay. Only parameter which was significant was increase in usage of adjuvant inotropic support in milrinone group which were depicted in terms of increased VIS (Vasoactive inotrope score). Almost equal incidence of adverse events were noted in both the groups. Conclusion: Milrinone and dobutamine are fairly comparable to each other in cases of TOF repair with transannular patch. Dobutamine being a cheaper alternative have a better scope in developing countries like India.

Incidence of branch pulmonary artery stenosis requiring intervention based on surgical repair type for tetralogy of Fallot

BackgroundTetralogy of Fallot is a common form of cyanotic congenital heart disease. The right ventricular outflow tract obstruction and pulmonary stenosis are typically repaired using either a transannular patch or valve sparing repair. Following repair, one recognized complication is branch pulmonary artery stenosis. ObjectiveThis study sought to evaluate if there was a higher incidence of branch pulmonary artery stenosis requiring intervention in patients with tetralogy of Fallot who underwent transannular patch repair as compared to valve sparing repair. MethodsIn this retrospective study, 62 pediatric patients with tetralogy of Fallot underwent surgical repair at our institution between January 1, 2006 and August 2, 2016. Data, including echocardiographic measurements, surgical repair details, and post-operative follow up was recorded. Statistical analysis was performed, including chi-square test, Student t-test, multiple logistic regression, and Kaplan-Meier analysis. ResultsMedian length of follow up was 7.3 years (IQR 4.7–9.1). Of the 62 patients, 8 (13 %) developed branch pulmonary artery stenosis requiring intervention. A significantly higher incidence was seen in the transannular patch group (n = 7, 37 %) compared to the valve sparing repair patients (n = 1, 2 %) (p = 0.0002). Most patients required intervention within one year following repair. The effect of repair type persisted after controlling for multiple potential confounding variables, including Blalock-Taussig shunt placement and patch augmentation of the branch pulmonary arteries. ConclusionThere is a significantly higher incidence of branch pulmonary artery stenosis requiring intervention in patients with classic tetralogy of Fallot who underwent transannular patch repair as compared to valve sparing repair.

Early results of Pulsta® transcatheter heart valve in patients with enlarged right ventricular outflow tract and severe pulmonary regurgitation due to transannular patch.

The purpose of this study is to assess the feasibility, effectivity, and safety of a novel self-expandable valve system, Pulsta® transcatheter heart valve in patients with tetralogy of fallot and severe pulmonary regurgitation after transannular patch repair. Severe pulmonary regurgitation after tetralogy of fallot repair is a life-threatening problem and should be treated by pulmonary valve implantation. Although percutaneous pulmonary valve implantation has been ever increasingly used for this purpose, available balloon-expandable valves have limitations and cannot be used by most patients. Pulsta® transcatheter heart valve is a new self-expandable valve system and offers a new solution to be used in patients with different types of native right ventricular outflow tract geometry. Ten patients with severe regurgitation after tetralogy of fallot repair with a transannular patch have been enrolled in the study according to echocardiographic examination. MRI was used in asymptomatic patients to delineate the indication and the right ventricular outflow tract geometry. Pulsta® transcatheter heart valve implantation was performed in ten patients, and preprocedural, procedure, and 6 months follow-up findings of the patients were evaluated. Pulsta® pulmonary valve implantation was performed in ten patients successfully without any severe complications. Valve functions were perfect in six of ten patients, while the others had insignificant regurgitation by echocardiographic examination at the end of 6 months follow-up. This study showed that Pulsta® transcatheter heart valve is a feasible, effective, and safe method in the treatment of severe pulmonary regurgitation due to transannular patch repair in patients with tetralogy of fallot.

Role of great artery annulus ratio to predict transannular patch enlargement in repair of tetralogy of Fallot

BackgroundTraditionally, the pulmonary valve annulus (PVA) z-score is used to predict the requirement of transannular patch enlargement (TAPE) of right ventricular outflow tract (RVOT) and main pulmonary artery (MPA) in repair of tetralogy of Fallot (TOF). PVA z-score is highly variable and many other parameters are being reported to be accurate in predicting need of TAPE. In this study, we analyze the role of great artery annulus ratio (pulmonary valve annulus to aortic valve annulus ratio, PVA/AVA) to be used as a predictor for TAPE.MethodsWe analyzed 90 patients of TOF retrospectively who underwent repair between January 2021 and December 2021. The patients were divided as TAPE group who required TAPE of RVOT and MPA and non-TAPE group who did not have TAPE. Their baseline parameters, PVA Z-score, and cut-off great artery annulus ratio were compared.ResultsTotal 44 (48.9%) patients had transannular patch (TAPE) repair and 46 (51.1%) patients had non-transannular patch repair. The great artery annulus ratio and PVA z-score was lower in case of TAPE group with statistical significance. Receiver operating characteristic curve analysis showed great artery annulus ratio as more accurate predictor of TAPE.ConclusionGreat artery annulus ratio can be used as a simple and accurate predictor for transannular patch enlargement along with PVA z-score during repair of TOF.

Technique for Neo-Pulmonary Valve Creation With Living Tissue for Repair of Atrioventricular Septal Defect and Tetralogy of Fallot.

Long-standing effects of pulmonary regurgitation after transannular patch repair in Tetralogy of Fallot (ToF) can be especially deleterious in the setting of combined ToF and complete atrioventricular septal defect (CAVSD). We present a technique for a complete repair of combined ToF/CAVSD using right atrial appendage tissue to create a competent neo-pulmonary valve. This technique provides advantages of right heart protection via pulmonary valve competence and the use of living tissue capable of growth with the patient, potentially obviating the need for repeat interventions.

Early post-operative benefits of a pulmonary valve-sparing strategy during Fallot repair

BackgroundPatients undergoing complete repair of tetralogy of Fallot generally have an excellent prognosis. Unfortunately, pulmonary valve reconstruction with a transannular patch is generally required. Resulting pulmonary regurgitation is associated with late right ventricular dysfunction and morbidity. Early pulmonary regurgitation may also be poorly tolerated. This study compares immediate outcomes of non-valved transannular patch repair (NV-TAP) to a valve-sparing (V-Sp) approach. Methods67 patients, with tetralogy of Fallot and severe pulmonary annular hypoplasia underwent complete repair between 2010 and 2018.23 patients had a NV-TAP repair while a V-Sp technique was used in 44 patients. Mortality, length of stay in the intensive care unit and hospital, use of inotropes, duration of mechanical ventilation, use and duration of dialysis, chest drainage duration, reinterventions, and postoperative complications were compared. Immediate outcomes were assessed by biological data and postoperative echocardiography. ResultsICU stay was shorter in the V-Sp group (5 days vs 8 days, p = 0.009). At postoperative day 1, Vasoactive Inotropic Score and mean dosage of adrenaline were significantly lower in the V-Sp group. Duration of inotrope use was significantly shorter. Hospital stay, mechanical ventilation, and chest drainage duration, the incidence and duration of dialysis all showed a trend towards being lower in the V-Sp group. Surgical complications were similar despite longer cardiopulmonary bypass and aortic cross-clamp durations. ConclusionRepair of the native pulmonary valve by a V-Sp technique reduces length of stay in the ICU and the use of inotropic agents in the immediate post-operative period.

Transannular patch repair of tetralogy of Fallot with or without monocusp valve reconstruction: a meta-analysis

BackgroundTetralogy of Fallot (TOF) is one of the most common cyanotic congenital heart diseases. Pulmonary regurgitation is the most common and severe comorbidity after transannular patch (TAP) repair of TOF patients. It has not been confirmed whether a TAP repair with monocusp valve reconstruction would benefit TOF patients in perioperative period compared to those without monocusp valve reconstruction. The purpose of the study is to review and analyze all clinical studies that have compared perioperative outcomes of TOF patients undergoing TAP repair with or without monocusp valve reconstruction and conduct a preferable surgery.MethodsEligible studies were identified by searching the electronic databases. The year of publication of studies was restricted from 2000 till present. The primary outcome was perioperative mortality, and secondary outcomes included cardiopulmonary bypass time, aortic cross-clamp time, ventilation duration, ICU length of stay, hospital length of stay, perioperative right ventricular outflow tract (RVOT) pressure gradient, and moderate or severe pulmonary regurgitation (PR). The meta-analysis and forest plots were drawn using Review Manager 5.3. Statistically significant was considered when p-value ≤ 0.05.ResultsEight studies were included which consisted of 8 retrospective cohort study and 2 randomized controlled trial. The 10 studies formed a pool of 526 TOF patients in total, in which are 300 undergoing TAP repair with monocusp valve reconstruction (monocusp group) compared to 226 undergoing TAP repair without monocusp valve reconstruction (non-monocusp group). It demonstrated no significant differences between two groups in perioperative mortality (OR = 0.69, 95% CI 0.20–2.41, p = 0.58). It demonstrated significant differences in perioperative cardiopulmonary bypass time (minute, 95% CI 17.93–28.42, p < 0.00001), mean length of ICU stay (day, 95% CI − 2.11–0.76, p < 0.0001), and the degree of perioperative PR (OR = 0.03, 95% CI 0.010.12, p < 0.00001). Significant differences were not found in other secondary outcomes.ConclusionTransannular patch repair with monocusp valve reconstruction have significant advantages on decreasing length of ICU stay and reducing degree of PR for TOF patients. Large, multicenter, randomized, prospective studies which focuse on perioperative outcomes and postoperative differences based on long-term follow-up between TAP repair with and without monocusp valve reconstruction are needed.

Applicability and Durability of Valve-Sparing Tetralogy of Fallot Repair.

Although valve-sparing repair remains ideal for patients with tetralogy of Fallot, the durability of valve-sparing repair and which patients may have been better served with a transannular patch remain unclear. Retrospective review was performed of tetralogy of Fallot operations at our institution from January 2008 to December 2018. Standard demographic data were collected, including echocardiographic parameters, operative details, and clinical outcomes. Statistical analysis was performed comparing the transannular patch and valve-sparing repair groups. Sixty-seven patients underwent tetralogy of Fallot repair with a median age of 4.5 (3.2-6.0) months and weight of 5.8 (5.2, 6.7) kg. Seventeen (25%) patients underwent transannular patch repair and 50 (75%) patients underwent valve-sparing repair. There was no difference in age or weight between patients who underwent a transannular patch repair and those who underwent a valve-sparing repair. At last follow-up (median 42 months), there was a trend of a higher peak pulmonary valve/right ventricular outflow tract gradient (P = .06) in the valve-sparing group, but no difference in the pulmonary valve annulus z-scores. Additionally, the pulmonary valve z-scores in the valve-sparing group decreased from -2.3 ± 1.0 on predischarge echocardiogram of to -1.2 ± 1.6 on last follow-up, with the peak gradient on predischarge 23 (0-37) mm Hg remaining stable on last follow-up at 18 (0-29) mm Hg. There was one reoperation: pulmonary valve replacement six years after a transannular patch. Obtaining a postrepair pulmonary valve z-score of -2 yields satisfactory, stable valve-sparing repair with pulmonary valve growth, acceptable gradients, minimal regurgitation, and high freedom from reintervention during follow-up.

Staged Repair of Tetralogy of Fallot: A Strategy for Optimizing Clinical and Functional Outcomes

BackgroundThis 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. MethodsThis retrospective study involved 330 patients with tetralogy of Fallot who underwent intracardiac repair between 1991 and 2019 and included 57 patients (17%) who underwent BTS. The mean follow-up period was 15.0 ± 7.3 years. We compared the data of patients who underwent BTS and patients who did not undergo BTS before intracardiac repair. ResultsThe median age before BTS was 71 days (range, 28 to 199) and the median body weight was 4.3 kg (range, 3.3 to 6.8 kg). There were no inhospital or interstage deaths after BTS. The pulmonary valve annulus Z scores of patients with BTS revealed significant growth after BTS (from −4.2 ± 1.8 to −3.0 ± 1.7, P < .001). Valve-sparing repair was eventually performed in 207 patients (63%), including 26 (46%) who underwent staged repair. The overall freedom from pulmonary regurgitation-related reintervention was 99.7%, 99.1%, and 95.8% at 1, 5, and 20 years, respectively. ConclusionsA staged surgical strategy incorporating BTS as the first palliation for symptomatic patients resulted in no mortality. Blalock-Taussig shunt may have contributed to the avoidance of primary transannular patch repair and facilitated pulmonary valve annulus growth; therefore, approximately half of the symptomatic neonates and infants were recruited for valve-sparing repair. Staged repair may have led to functionally reliable delayed transannular patch repair, thereby resulting in fewer surgical reinterventions.