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PCCD:

Early

Repair Safe

in Tetralogy

of Fallot

By Kristina Fiore,Staff Writer,MedPage TodayPublished: February04, 2011Reviewed byDori F.Zaleznik, MD;

Associate ClinicalProfessor ofMedicine, HarvardMedical School,Boston and DorothyCaputo, MA, RN, BC-

ADM, CDE, NursePlanner

http://www.medpagetoday.com/reviewer.cfm?reviewerid=512http://www.medpagetoday.com/reviewer.cfm?reviewerid=512http://www.medpagetoday.com/reviewer.cfm?reviewerid=512http://www.medpagetoday.com/reviewer.cfm?reviewerid=512http://www.medpagetoday.com/reviewer.cfm?reviewerid=512

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SCOTTSDALE, Ariz. -- Elective surgery for tetralogy of Fallot can be done early, long before infants

develop symptoms, researchers said here.

There were no inhospital deaths and the complication rate was low -- about 12% over about 15

years -- among asymptomatic patients under 6 months who were treated at a single center,

according to Roxanne Kirsch, MD, of the Children's Hospital of Philadelphia, and colleagues.

They reported their findings during a poster session at the Pediatric and Congenital Cardiovascular

Disease meeting here.

"Patients should be electively referred prior to the development of symptoms," Kirsch told MedPage

Today. "Waiting for them to develop symptoms is not favorable. It doesn't alter the ... key problem --

the underlying anatomy that needs surgical repair."

Primary, complete repair of tetralogy of Fallot is an established practice, the researchers said, and

surgical intervention during infancy has become routine in many centers -- although the optimal

timing of elective surgical intervention is still unclear, especially in asymptomatic patients.

"We wanted to know if it's a safe and appropriate strategy," Kirsch told MedPage Today.

So from over 500 patients, Kirsch and colleagues whittled it down to 277 patients with the condition

who'd had elective repair between 1995 and 2009 at their institution before the age of 6 months.

Kirsch said patients were excluded from their retrospective chart review if they were older than 6

months when they'd had the surgery, as well as if they'd had any complications that could indicate

being symptomatic or if they'd had prior surgery or interventional palliation.

The median age at repair was 3.5 months, and the median weight was 5.5 kg.

A transannular patch was used in 68% of patients, while 83% had atrial communication and just 25%

had ventriculotomy.

The researchers found no inhospital mortality, although there were a total of 48 adverse events in 32

patients, largely involving re-operation for bleeding and pleural/pericardial drain placement or

reintubation.

Still, the complication rate was low, Kirsch said, at 11.6%.

The researchers also noted that between 1995 and 2009, there was a decrease in preoperative

cardiac catheterization and in median hospital length of stay.

Surgical volume increased over the study period, though the use of ventriculotomy fell.

The total support time declined as well, and the use of deep hypothermic circulatory arrest fell off

significantly, which Kirsch attributed to a "philosophical change."

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When stratified by complications, the researchers saw that those with more complications had a

longer length of stay, as might be expected. They also had more deep hypothermic circulatory arrest,

"for unclear reasons," Kirsch said.

She noted that there was no correlation between the number of complications and patient age.

Though the study was limited by its retrospective nature, the findings suggest that elective repair for

asymptomatic infants with tetralogy of Fallot is safe and effective, and that these patients should be

referred for surgery early in infancy, prior to the development of symptoms.

Kirsch said patients should be referred between ages 2 and 6 months, but literature doesn't yet exist

that "delineates exactly which month is the perfect month. There may not be a perfect month."

Tetralogy of Fallot is one of three conditions -- along with transposition of the great arteries and

single-ventricle lesions -- that is being discussed in-depth here at the meeting as researchers work

to create relevant treatment guidelines.