Van Arsdell G S, Maharaj G S, Tom J, Rao V K, Coles J G, Freedom R M, Williams W G, McCrindle B W
Division of Cardiac Surgery and Cardiology, The Hospital for Sick Children, Toronto, University of Toronto, Toronto, Canada.
Circulation. 2000 Nov 7;102(19 Suppl 3):III123-9. doi: 10.1161/01.cir.102.suppl_3.iii-123.
Controversy regarding the timing for the repair of tetralogy of Fallot centers around initial palliation versus primary repair for the symptomatic neonate/young infant and the optimal age for repair of the asymptomatic child. We changed our approach from one of initial palliation in the infant to one of primary repair around the age of 6 months, or earlier if clinically indicated. We examined the effects of this change in protocol and age on outcomes.
The records of 227 consecutive children who had repair of isolated tetralogy of Fallot from January 1993 to June 1998 were reviewed. The median age of repair by year fell from 17 to 8 months (P:<0.01). The presence of a palliative shunt at the time of repair decreased from 38% to 0% (P:<0.01). Mortality (6 deaths, 2. 6%) improved with time (P:=0.02), with no mortality since the change in protocol (late 1995/early 1996). Multivariate analysis for physiological outcomes of time to lactate clearance, ventilation hours, and length of stay, but not death, demonstrated that an age <3 months was independently associated with prolongation of times (P:<0.03). Each of the deaths occurred with primary repair at an age >12 months. The best survival and physiological outcomes were achieved with primary repair in children aged 3 to 11 months.
On the basis of mortality and physiological outcomes, the optimal age for elective repair of tetralogy of Fallot is 3 to 11 months of age.
法洛四联症修复时机的争议主要围绕有症状的新生儿/幼儿是进行初始姑息治疗还是一期修复，以及无症状儿童的最佳修复年龄。我们将治疗方法从婴儿期的初始姑息治疗改为6个月左右的一期修复，如有临床指征则更早进行。我们研究了方案和年龄的这种变化对治疗结果的影响。
回顾了1993年1月至1998年6月期间连续227例接受单纯法洛四联症修复手术的儿童的记录。每年修复的中位年龄从17个月降至8个月（P<0.01）。修复时存在姑息性分流术从38%降至0%（P<0.01）。死亡率（6例死亡，2.6%）随时间改善（P=0.02），自方案改变后（1995年末/1996年初）无死亡病例。对乳酸清除时间、通气小时数和住院时间等生理结果进行多因素分析，但不包括死亡情况，结果表明年龄<3个月与时间延长独立相关（P<0.03）。每例死亡均发生在年龄>12个月的一期修复手术中。3至11个月大的儿童进行一期修复可获得最佳的生存和生理结果。
基于死亡率和生理结果，法洛四联症择期修复的最佳年龄为3至11个月。
