Shunt vs. Repair of Tetralogy of Fallot in Small Children
Is there a difference in outcome between initial shunt palliation versus complete repair for tetralogy of Fallot (ToF) in children ≤4 kg?
This single-center retrospective study evaluated all patients ≤4 kg with ToF, excluding those with major aortopulmonary collaterals, who underwent cardiac surgery from 2005-2013.
Twenty-five patients were in the shunt group and 51 underwent initial full repair. Patients in the shunt group had a lower body weight (but not body surface area [BSA]), a lower oxygen saturation, and more surgical procedures. Two required revisions of an occluded shunt, with two deaths. Complete repair was subsequently performed at >7 months of age without need for further surgery. Of the full repair group, all survived: seven, four, and three underwent “pulmonary valve sparing,” pulmonary conduit placement, and transannular patch, with delayed sternal closure in three patients. A second surgery was required in 25%, and two required a third surgery—the addition of a Blalock-Taussig shunt and right ventricular outflow tract patch with pulmonary artery plasty. No significant differences were seen between the two groups in terms of age, BSA, need for preoperative PGE, length of stay, mortality, length of follow-up, presence of syndromes or other major anomalies, and need for therapeutic catheterization procedures.
In children ≤4 kg, results from initial complete repair of ToF are favorable, with less surgical procedures. The type of initial surgery does not correlate with the need for future catheterization-based therapeutic interventions.
Whether to shunt or perform initial complete repair in the small child with symptomatic ToF is controversial, with proponents touting the benefits of both. With improving surgical techniques, many groups are advocating complete initial repair. Transcatheter interventions have become an adjunct to surgical procedures and a means to optimize less than perfect results from early single stage surgery. Initial shunt procedures or transcatheter ductal stenting may be preferable in very small sick patients requiring urgent palliation. The therapy of ToF in small, moderately symptomatic children is currently evolving.
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