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Shahanavaz S, Qureshi AM, Petit CJ, Goldstein BH, Glatz AC, Bauser-Heaton H, McCracken CE, Kelleman MS, Nicholson GT, Zampi JD, Pettus J, Meadows J, Hock KM, Law MA. Outcomes Following Balloon Pulmonary Valvuloplasty in Symptomatic Neonates With Tetralogy of Fallot-A CCRC Study. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101062. [PMID: 39129888 PMCID: PMC11307412 DOI: 10.1016/j.jscai.2023.101062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/23/2023] [Accepted: 06/13/2023] [Indexed: 08/13/2024]
Abstract
Background Complete repair (CR) can be delayed in neonates with symptomatic tetralogy of Fallot (sTOF) using surgical or transcatheter palliation to relieve cyanosis. Balloon pulmonary valvuloplasty (BPV) is an established treatment for pulmonary valve stenosis; however, its effectiveness in palliating neonates with sTOF has not been well investigated. Methods A retrospective chart review between 2005 and 2017 on neonates with sTOF who underwent initial BPV from 9 participating centers of the Congenital Cardiac Research Collaborative was performed. Primary outcome was CR at >30 days after BPV without interval reintervention (RI). Results In total, 47 neonates with sTOF underwent BPV, of whom 27 (57%) underwent CR at >30 days after BPV without RI. The median time to CR was 151 days (106-210). RI before CR occurred in 17 patients (36%): surgical shunt (n = 7), outflow tract stenting (n = 6), patent ductus arteriosus stenting (n = 2), and surgical outflow patch (n = 2). Valve-sparing repair at CR was performed in 6 patients (13%) after initial BPV. RI or CR ≤30 days from BPV was associated with smaller infundibular diastolic diameter (P = .004). An infundibular diastolic diameter of <3.4 mm demonstrated 75% sensitivity and 67% specificity to predict early CR or RI. Conclusions BPV can be an effective palliative therapy in select neonates with sTOF to delay CR. A smaller diastolic infundibulum diameter is a predictor of RI or early CR, and valve-sparing repair is uncommon, making patient selection and alternative palliative methods key when considering BPV palliation in neonates with sTOF.
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Affiliation(s)
- Shabana Shahanavaz
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Athar M. Qureshi
- Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Christopher J. Petit
- Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
- Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York, New York
| | - Bryan H. Goldstein
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew C. Glatz
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri
- The Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Holly Bauser-Heaton
- Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Courtney E. McCracken
- Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Michael S. Kelleman
- Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - George T. Nicholson
- Division of Pediatric Cardiology, Ann and Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Jeffrey D. Zampi
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Joelle Pettus
- Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Jeffery Meadows
- Division of Pediatric Cardiology, University of California, San Francisco, California
| | - Kristal M. Hock
- Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark A. Law
- Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
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Whaidee K, Lekchuensakul S, Lertsapcharoen P, Namchaisiri J, Benjacholamas V. Effect of Balloon Pulmonary Valvuloplasty on Growth of Pulmonary Annulus in Infants with Tetralogy of Fallot. Pediatr Cardiol 2023; 44:1471-1478. [PMID: 37439830 DOI: 10.1007/s00246-023-03205-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/02/2023] [Indexed: 07/14/2023]
Abstract
Percutaneous balloon pulmonary valvuloplasty (PBPV) is an alternative intervention in infants with Tetralogy of Fallot (TOF). It can not only improve hypoxia but also promote pulmonary annulus (PA) growth. In this study, we evaluated the effect of PBPV on PA growth in infants with TOF. To eliminate the effect of the systemic to pulmonary shunt (SPS) that may promote PA growth, we divided TOF infants into 2 groups: group A, patients who underwent PBPV with or without other SPS, and group B, patients who attempted SPS but without PBPV. Sixty patients were included, 28 patients in group A and 32 patients in group B. Age at the time of intervention in group A (range, 0.4-5.4; median 1.4 months) was lower than that in group B (range, 2.3-7.7; median 4.8 months), p-value 0.02. The body weight in group A (range, 3-5.5; median 3.7 kg) was also lower than that in group B (range 4.1-6.4; median 5.9 kg), p-value 0.02. Echocardiographic data at the mean follow-up period of 37.2 months (3-88 months) in group A and 39.6 months (6-95 months) in group B demonstrated an increase in mean PA diameter from 5.0 ± 1.3 mm to 10.2 ± 2.9 mm, p-value < 0.001 in group A; and from 6.2 ± 2 mm to 9.5 ± 2.9 mm, p-value < 0.001 in group B. The median PA z-score increased from - 3.4SD (- 3.9 to - 2.6SD) to - 1.8SD (- 2.5 to - 0.8SD), with the p-value of 0.002 in group A; and increased from - 2.9SD (- 4.5 to - 1.3SD) to - 2.7SD (- 3.6 to - 1.4SD), with the p-value of 0.73 in group B. By using the PA z-score as the absolute value, there was a statistically significant increase in the PA z-score during follow-up in group A, but not in group B. Balloon pulmonary valvuloplasty in infants with TOF can facilitate the growth of the pulmonic annulus even after eliminating the effect of the systemic to pulmonary shunt.
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Affiliation(s)
- Khwaunrat Whaidee
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and Cardiac Center, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, 1873 Rama IV Rd. Pathumwan, Bangkok, 10330, Thailand
| | - Sarin Lekchuensakul
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and Cardiac Center, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, 1873 Rama IV Rd. Pathumwan, Bangkok, 10330, Thailand.
| | - Pornthep Lertsapcharoen
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and Cardiac Center, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, 1873 Rama IV Rd. Pathumwan, Bangkok, 10330, Thailand
| | - Jule Namchaisiri
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and Cardiac Center, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Vichai Benjacholamas
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and Cardiac Center, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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Petit CJ, Glatz AC, Goldstone AB, Law MA, Romano JC, Maskatia SA, Chai PJ, Zampi JD, Meadows JJ, Nicholson GT, Shahanavaz S, Qureshi AM, McCracken CE, Mascio CE, Batlivala SP, Asztalos IB, Healan SJ, Smith JD, Pettus JA, Beshish A, Raulston JEB, Hock KM, Pajk AL, Goldstein BH. Pulmonary Artery Hypoplasia in Neonates With Tetralogy of Fallot. J Am Coll Cardiol 2023; 82:615-627. [PMID: 37558375 DOI: 10.1016/j.jacc.2023.05.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/27/2023] [Accepted: 05/22/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Neonates with symptomatic tetralogy of Fallot (sTOF) with hypoplastic pulmonary arteries (hPA) are considered high risk. Data are needed to inform the impact of hPA on outcomes, and the ideal management strategy. OBJECTIVES The objectives of this study were to quantify the impact of hPA on outcomes in neonates with sTOF and measure the impact of strategy on pulmonary artery (PA) growth in this population. METHODS Neonates with sTOF from 2005 to 2017 were reviewed from the Congenital Cardiac Research Collaborative. Criteria for hPA included a unilateral PA z score <-2.0 and contralateral PA z score <0. Primary outcome was mortality. Secondary outcomes included reintervention and PA growth. RESULTS We included 542 neonates with sTOF, including 188 (35%) with hPA and 354 (65%) with normal PA, with median follow-up of 4.1 years. Median right and left hPA z scores were -2.19 (25th-75th percentile: -2.55 to -1.94) and -2.23 (25th-75th percentile: -2.64 to -1.91), respectively. Staged repair (vs primary TOF repair) was less common in the hPA cohort (36 vs 44%; P = 0.07). Survival was similar between groups (unadjusted P = 0.16; adjusted P = 0.25). Reintervention was more common in the hPA group (HR: 1.28; 95% CI: 1.01-1.63; P = 0.044); there was no difference after definitive repair (HR: 1.21; 95% CI: 0.93-1.58; P = 0.16). PA growth at 1 year was greater in the hPA cohort, particularly for the right PA (P < 0.001). CONCLUSIONS Despite perception, the presence of hPA in neonates with sTOF conferred no increase in overall hazard of mortality or reintervention after definitive repair. PA growth was superior in the hPA cohort. These findings suggest that the presence of hPA does not adversely impact outcomes in sTOF.
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Affiliation(s)
- Christopher J Petit
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA; Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
| | - Andrew C Glatz
- Division of Pediatric Cardiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Division of Pediatric Cardiology, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri, USA
| | - Andrew B Goldstone
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Mark A Law
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Jennifer C Romano
- University of Michigan School of Medicine, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Shiraz A Maskatia
- University of California San Francisco School of Medicine, Benioff Children's Hospital, San Francisco, California, USA
| | - Paul J Chai
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jeffrey D Zampi
- University of Michigan School of Medicine, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Jeffery J Meadows
- University of California San Francisco School of Medicine, Benioff Children's Hospital, San Francisco, California, USA
| | - George T Nicholson
- Division of Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shabana Shahanavaz
- Division of Pediatric Cardiology, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri, USA; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Athar M Qureshi
- Baylor College of Medicine, Texas Children's Hospital, Waco, Texas, USA
| | - Courtney E McCracken
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Christopher E Mascio
- Division of Pediatric Cardiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of West Virginia School of Medicine, Morgantown, West Virginia, USA
| | | | - Ivor B Asztalos
- Division of Pediatric Cardiology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Steven J Healan
- Division of Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin D Smith
- University of Michigan School of Medicine, Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Joelle A Pettus
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Asaad Beshish
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - James E B Raulston
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Krissie M Hock
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Amy L Pajk
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bryan H Goldstein
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Conal Septal Hypoplasia in Tetralogy of Fallot-Impact on Clinical Course, Treatment Strategies, and Outcomes After Surgical Intervention. Pediatr Cardiol 2023; 44:587-598. [PMID: 35852568 DOI: 10.1007/s00246-022-02962-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
We sought to characterize the clinical course and outcomes of intervention for Tetralogy of Fallot (TOF) with associated conal septal hypoplasia (CSH) compared to those with identifiable conal septum on initial newborn echocardiogram. We performed a retrospective, 1:2 case-control study of children with TOF anatomy, 33 with CSH and 66 with typical TOF, who underwent surgical repair from 1991-2019 at Children's Wisconsin. Data on echocardiographic anatomic features, systemic oxygen saturations, medical therapies, admissions, palliative interventions, operative strategies, and long-term follow-up were compared. The CSH group had fewer hypercyanotic spells (6% vs 42%, p < 0.001), beta-blockers prescribed (12% vs 41%, p = 0.005), and hospital admissions for cyanosis (12% vs 44%; p = 0.001) prior to any intervention. Of 14 who required palliative intervention, 8 had balloon pulmonary valvuloplasty (BPV) (7 from the CSH group and 1 from the control group), and 6 had systemic-to-pulmonary artery shunts (all from the control group). Definitive repair was performed at a significantly older age in the CSH group (10.2 ± 10 vs 5.6 ± 5.9 months, p = 0.011), with less subpulmonary muscle resection (57.6% in vs 92.4%, p < 0.001) and higher use of a transannular patch (84.8% vs 65.2%, p = 0.040). The average time to surgical reintervention was similar in both groups (9.7 ± 5.9 vs 8.6 ± 6.4 years in controls). We conclude that infants with TOF and CSH have a milder preoperative clinical course with fewer hypercyanotic spells or need for medical therapy. They also respond well to palliative BPV and can safely undergo later definitive repair compared to typical TOF with a well-developed conal septum.
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Qureshi AM, Caldarone CA, Wilder TJ. Transcatheter Approaches to Palliation for Tetralogy of Fallot. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2022; 25:48-57. [PMID: 35835516 DOI: 10.1053/j.pcsu.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/11/2022]
Abstract
To this day, controversy still exists regarding the optimal method to treat symptomatic neonates and infants with Tetralogy of Fallot (TOF). Symptomatic (severely cyanotic or ductal dependent) infants with TOF can undergo either a staged repair approach (consisting of initial palliation followed by complete repair) or primary repair. Traditionally, initial palliative procedures have been surgical, for example placement of a Blalock-Taussig-Thomas (BTT) shunt. Recent advances in technology have facilitated the introduction of catheter-based procedures as palliative techniques, for example, patent ductus arteriosus (PDA) stenting and right ventricular outflow tract (RVOT) stenting as more durable solutions than balloon pulmonary valvuloplasty (BPV). In this article, we discuss the rationale for these procedures, technical aspects of these procedures and outcomes data compared to traditional surgical procedures. Recent data have suggested that RVOT and PDA stenting procedures offer many advantages over traditional surgical palliative procedures as palliative methods in this patient population. This comes at a cost of increased reintervention burden, which may be considered part of the overall treatment strategy in smaller neonates and can be minimized with a focus on technical aspects and overall treatment strategies. Advanced surgical techniques are required at the eventual complete repair to negotiate removal of stent material and pulmonary artery reconstruction in some instances. Further adoption of catheter based palliative procedures for infants with symptomatic TOF has the potential to tip the outcomes towards favoring a staged approach, particularly in high-risk infants.
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Affiliation(s)
- Athar M Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital and Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
| | - Christopher A Caldarone
- Congenital Heart Surgery, Texas Children's Hospital and Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Travis J Wilder
- Division of Congenital Heart Surgery, University Hospitals, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
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Yi K, Wang D, Xu J, Zhang X, Wang W, Gao J, Wang W, You T, Tian J. Surgical Strategies for Preservation of Pulmonary Valve Function in a Radical Operation for Tetralogy of Fallot: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:888258. [PMID: 35911536 PMCID: PMC9326161 DOI: 10.3389/fcvm.2022.888258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the efficacy and safety of different surgical strategies to preserve pulmonary valve function. Surgical procedures evaluated include intraoperative balloon pulmonary valvuloplasty (IBPV), pulmonary valve reconstruction, and commissurotomy and pulmonary cusp augmentation (PCA) in patients who underwent a radical operation for Tetralogy of Fallot (ToF). Materials and Methods The five databases searched in the current study included the Cochrane Library, PubMed, China National Knowledge Infrastructure, VIP, and WanFang data. A systematic search for control trials was performed in each database from the start date of each database until December 2021. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of included studies. Results A total of 15 retrospective studies with a total number of 1,396 participants were included in this study. In subgroup 1 (IBPV vs. TAP), patients undergoing IBPV had a less degree of regurgitation at 1-2 years after the surgery. The reintervention rate increased in the IBPV group at 5 years. In subgroup 2 (pulmonary valve reconstruction vs. TAP), the degree of regurgitation decreased in the pulmonary valve reconstruction group at 1 month after the surgery. In subgroup 3 (valve-sparing operation vs. TAP), the comparison demonstrated decreased rates for surgical mortality and reintervention at 5-10 years after the surgery. Conclusion We proposed that pulmonary valve function in a radical operation for ToF was preserved. IBPV, pulmonary valve reconstruction, and commissurotomy and PCA can be performed during the surgical procedure based on the developmental status and anatomical characteristics of the right ventricular outflow tract (RVOT), pulmonary valve, and pulmonary artery. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022300987].
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Affiliation(s)
- Kang Yi
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Department of Cardiovascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
| | - Dan Wang
- Department of Geriatric Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jianguo Xu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xin Zhang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenxin Wang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, China
| | - Jie Gao
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Wei Wang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Tao You
- Department of Cardiovascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China
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Tetralogy of Fallot: stent palliation or neonatal repair? Cardiol Young 2021; 31:1658-1666. [PMID: 33682651 DOI: 10.1017/s1047951121000846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Surgical repair of Tetralogy of Fallot has excellent outcomes, with over 90% of patients alive at 30 years. The ideal time for surgical repair is between 3 and 11 months of age. However, the symptomatic neonate with Tetralogy of Fallot may require earlier intervention: either a palliative intervention (right ventricular outflow tract stent, ductal stent, balloon pulmonary valvuloplasty, or Blalock-Taussig shunt) followed by a surgical repair later on, or a complete surgical repair in the neonatal period. Indications for palliation include prematurity, complex anatomy, small pulmonary artery size, and comorbidities. Given that outcomes after right ventricular outflow tract stent palliation are particularly promising - there is low mortality and morbidity, and consistently increased oxygen saturations and increased pulmonary artery z-scores - it is now considered the first-line palliative option. Disadvantages of right ventricular outflow tract stenting include increased cardiopulmonary bypass time at later repair and the stent preventing pulmonary valve preservation. However, neonatal surgical repair is associated with increased short-term complications and hospital length of stay compared to staged repair. Both staged repair and primary repair appear to have similar long-term mortality and morbidity, but more evidence is needed assessing long-term outcomes for right ventricular outflow tract stent palliation patients.
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Abstract
The current treatment practice for Tetralogy of Fallot (TOF) is to undertake complete surgical repair between 6–9 months of age with excellent immediate and long-term results. In patients with increased cyanosis or frequent cyanotic spells, younger age of complete repair as early as 3 months is usually acceptable. Although neonatal TOF repair is reported with good immediate survival from a few centres, post-operative morbidity is significant, and the hospital stay is prolonged. Hence, in neonates and small term and preterm infants with severe cyanosis, palliative procedures such as modified Blalock-Taussig (BT) shunt, ductal stenting, right ventricular outflow tract (RVOT) stenting and balloon pulmonary valvotomy (BPV) have been reported. With the development of low-profile stents, an increasing clinician experience and more predictable outcome with both duct and RVOT stenting, these procedures have gained popularity as the preferred palliations for TOF at most centres. We reviewed the literature to analyse whether BPV for TOF palliation, a technique first reported three decades ago, still has a role in the present era of paediatric cardiac care. In this review, we have concluded that BPV has very specific indications in patients with TOF, with predominantly valvar pulmonary stenosis, and may be a preferred option over other palliative strategies in hypoxemic preterm or low-birth weight infants.
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Early palliative balloon pulmonary valvuloplasty in neonates and young infants with tetralogy of Fallot. Heart Vessels 2019; 35:252-258. [DOI: 10.1007/s00380-019-01468-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
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Gu Y, Jin M, Wang XF, Guo BJ, Ding WH, Wang ZY, Zhang YH. Balloon Angioplasty as a Modality to Treat Children with Pulmonary Stenosis Secondary to Complex Congenital Heart Diseases. Chin Med J (Engl) 2017; 130:2793-2801. [PMID: 28952468 PMCID: PMC5717857 DOI: 10.4103/0366-6999.215715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Pulmonary stenosis is common in children with complex congenital heart diseases. Proper management of this problem, especially postoperatively, is still controversial. This study was designed to assess the rate and determinants of success or failure of balloon angioplasty for such lesions. METHODS Clinical and hemodynamic data from 40 pediatric patients (24 boys and 16 girls) with complex congenital heart diseases who underwent balloon angioplasty were reviewed retrospectively from January 2012 to December 2016. Patients were divided into four groups according to the site of stenosis, which included pulmonary valve stenosis (PVS), valved conduit stenosis, pulmonary artery stenosis (PAS), and supravalvular pulmonary stenosis (SVPS). Success rates were calculated according to defined criteria for initial success and favorable clinical impacts, and comparison between the successful subgroup and the unsuccessful subgroups was analyzed. RESULTS Grouped by the site of stenosis, initial success rates varied from 40.0% to 52.4% with the greatest success being seen in the PVS group, followed by the PAS group and SVPS group. In the PVS group and the PAS group, there was no statistical difference among age at dilation, postoperative interval, balloon/stenosis ratio, or pressure gradient predilation between the successful and the unsuccessful subgroups. Favorable clinical impacts included success rates of balloon angioplasty in the SVPS group, which was best (100%), followed by the PVS group (90.9%) and the PAS group (85.7%). There were a total of two transient complications (5.0%). CONCLUSIONS Balloon angioplasty was proven to be a safe and useful modality in children with complex congenital heart diseases and postoperative pulmonary stenosis, which should be the initial therapeutic modality in selected patients.
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Affiliation(s)
- Yan Gu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Mei Jin
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Xiao-Fang Wang
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Bao-Jing Guo
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Wen-Hong Ding
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Zhi-Yuan Wang
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Ya-Hui Zhang
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
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Abstract
Tetralogy of Fallot can be corrected with very low mortality at any age, even in neonates, but this does not necessarily mean that it should be corrected in the neonatal period. Although there are many advantages to early correction, a high proportion of these neonates have residual stenosis or pulmonary regurgitation that impairs ventricular function and may require further surgery or implantation of a pulmonary valve. Before we had the ability to correct this anomaly with low mortality in small children, a variety of palliative procedures had to be performed. Today, with better understanding of the anatomy of tetralogy of Fallot, we should consider what forms of palliation will increase growth of the right ventricular outflow tract in order to reduce the complications of very early surgery.
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