Thorac Cardiovasc Surg 2016; 64 - OP109
DOI: 10.1055/s-0036-1571561

Tetralogy of Fallot Repair — Long Term Follow-up: Preservation Strategy Improves Late Outcomes

P. Pondorfer 1, 2, T.-J. Yun 2, M. Cheung 2, D. Ashburn 2, B. McCrindle 3, L. Mertens 3, L. Grosse-Wortmann 3, C. Manlhiot 3, O. Al'Radi 2, R. Vanderlaan 2, D. Chetan 2, A. Redington 4, G. Van Arsdell 2
  • 1Medizinische Universität Graz, Herzchirurgie, Graz, Austria
  • 2Sickkids Hospital Toronto, Cardiovascular Surgery, Toronto, Canada
  • 3Sickkids Hospital Toronto, Heart Centre, Toronto, Canada
  • 4Children's Hospital, Cincinnati, United States

Introduction: Late outcome of repaired TOF is driven by the impact of residual lesions. We shifted strategy from liberal transannular patch (TAP) use to aggressive valve and annulus preservation (AP) hypothesizing that for equivalent anatomy, AP would leave a mixed stenosis regurgitation lesion that would lead to a healthier right ventricle (RV).

Methods: Between 1996 and 2002, 185 children underwent TOF repair (median age 7.7 m). A regression equation for predicting annulus preservation, in the AP group, was derived from preoperative anatomic parameters and applied to all. Patients were identified (n = 107) that could have had either AP or TAP on the basis of anatomical equivalency (subgroup validation with propensity matching was performed) with 52 having a TAP and 55 having AP. These patients with equivalent anatomy are the primary study group.

Results: Cardiac MRI at mean age 13.1 ± 2.3 years (TAP n = 28, AP n = 23) showed AP was associated with significantly lower indexed RV end diastolic vol (AP: 120 ± 29; TAP: 181 ± 35 mL), RV end systolic vol (AP: 57 ± 23; TAP: 95 ± 25 mL), RV stroke volume (AP: 64 ± 15; TAP: 86 ± 15 mL), MPA regurgitant fraction (AP: 28 ± 11; TAP: 45 ± 9%), all p< 0.0001, and LV mass (AP: 46 ± 6; TAP: 54 ± 8 g/m2); p = 0.001). Echo RVOT gradient was not different (AP 31 vs TAP 25 mm Hg (p = ns). MRI LVEF (AP: 57 ± 4; TAP: 55 ± 4%; p = 0.031) and RVEF (AP: 54 ± 7; TAP: 48 ± 6%; p = 0.004) was higher after AP.

Freedom from surgical reintervention at 15 years was 89.3% (AP) and 71.7%, with early reoperation for RVOTO predominating in AP and late pulmonary valve replacement most frequent in TAP. VO2 max for all AP vs TAP was higher in AP (p< 0.05).

Conclusion: This is the first long-term follow-up study demonstrating that, for equivalent anatomy, an aggressive AP strategy leads to a lower reoperative incidence, less pulmonary insufficiency, smaller indexed RV volumes and better LV function as compared with a standard TAP. Surgical strategy directly impacts ventricular health and should be reflected in practice.