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Congenital heart disease
Original research article
Primary repair versus surgical and transcatheter palliation in infants with tetralogy of Fallot
  1. Dan M Dorobantu1,2,3,
  2. Alireza S Mahani4,
  3. Mansour T A Sharabiani5,
  4. Ragini Pandey1,
  5. Gianni D Angelini3,
  6. Andrew J Parry1,
  7. Robert M R Tulloh1,3,
  8. Robin P Martin1,
  9. Serban C Stoica1,3
  1. 1 Cardiac Surgery, Bristol Royal Hospital for Children, University Hospital Bristol NHS Trust, Bristol, UK
  2. 2 Cardiology Department, “Prof. CC Iliescu” Emergency Institute for Cardiovascular Diseases, Bucuresti, Romania
  3. 3 School of Clinical Sciences, University of Bristol, Bristol, UK
  4. 4 Davidson Kempner Capital Management, New York City, New York, USA
  5. 5 Statistics Department, Royal Marsden Hospital, Royal Brompton NHS Trust, London, UK
  1. Correspondence to Dr Dan M Dorobantu, Department of Cardiology, “Prof. C.C. Iliescu” Emergency Institute for Cardiovascular Diseases, Bucuresti 022322, Romania; dn.dorobantu{at}gmail.com

Abstract

Objectives Treatment of infants with tetralogy of Fallot (ToF) has evolved in the last two decades with increasing use of primary surgical repair (PrR) and transcatheter right ventricular outflow tract palliation (RVOTd), and fewer systemic-to-pulmonary shunts (SPS). We aim to report contemporary results using these treatment options in a comparative study.

Methods This a retrospective study using data from the UK National Congenital Heart Disease Audit. All infants (n=1662, median age 181 days) with ToF and no other complex defects undergoing repair or palliation between 2000 and 2013 were considered. Matching algorithms were used to minimise confounding due to lower age and weight in those palliated.

Results Patients underwent PrR (n=1244), SPS (n=311) or RVOTd (n=107). Mortality at 12 years was higher when repair or palliation was performed before the age of 60 days rather than after, most significantly for primary repair (18.7% vs 2.2%, P<0.001), less so for RVOTd (10.8% vs 0%, P=0.06) or SPS (12.4% vs 8.3%, P=0.2). In the matched groups of patients, RVOTd was associated with more right ventricular outflow tract (RVOT) reinterventions (HR=2.3, P=0.05 vs PrR, HR=7.2, P=0.001 vs SPS) and fewer pulmonary valve replacements (PVR) (HR=0.3 vs PrR, P=0.05) at 12 years, with lower mortality after complete repair (HR=0.2 versus PrR, P=0.09).

Conclusions We found that RVOTd was associated with more RVOT reinterventions, fewer PVR and fewer deaths when compared with PrR in comparable, young infants, especially so in those under 60 days at the time of the first procedure.

  • congenital heart disease surgery
  • transcatheter valve interventions
  • tetralogy of fallot
  • pulmonic valve disease

https://doi.org/10.1136/heartjnl-2018-312958

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    Footnotes

    • Contributors D Dorobantu - data analysis, study design, statistical analysis, manuscript writing. A Mahani, M Sharabiani - statistical analysis, manuscript writing. R Pandey - study design, manuscript writing, data interpretation. G Angelini - study design, manuscript writing, data interpretation. A Parry - study design, manuscript writing. R Tulloh - manuscript writing, data interpretation. R Martin - manuscript writing, data interpretation. S Stoica - study design, manuscript writing, data interpretation, overseeing of the project.

    • Funding This research was supported by National Institute for Health Research (NIHR) Bristol Cardiovascular Biomedical Research Unit, the British Heart Foundation (Grant number CH/1992027/7163) and used data provided by the National Institute for Cardiovascular Outcomes Research, as part of the National Congenital Heart Disease Audit (NCHDA). The NCHDA is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) and within the National Health Service, United Kingdom.

    • Disclaimer The views expressed are those of the authors and not necessarily those of the National Health Service, NIHR, or Department of Health.

    • Competing interests None declared.

    • Patient consent Not required.

    • Ethics approval National Institute for Cardiovascular Outcomes Research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement There is no unpublished data relevant to this study.