Cunningham Michael E A, Donofrio Mary T, Peer Syed Murfad, Zurakowski David, Jonas Richard A, Sinha Pranava
Department of Cardiology, Children's National Health System, Washington, District of Columbia.
Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia.
Ann Thorac Surg. 2017 Mar;103(3):845-852. doi: 10.1016/j.athoracsur.2016.07.020. Epub 2016 Sep 28.
We have previously demonstrated that early primary repair of tetralogy of Fallot with pulmonary stenosis (TOF) can be safely performed without increase in hospital resource utilization or compromise to surgical technical performance scores (TPS). We sought to identify the optimal timing for elective early primary repair of TOF with respect to intermediate-term reintervention.
Retrospective review of all patients with TOF undergoing elective primary repair between September 2004 and December 2013 was performed. Patients were stratified into reintervention group or no reintervention group. Multivariable Cox regression analysis identified independent predictors of reintervention. Youden's J-index in receiver operating characteristic analysis identified optimal age cutoff predictive of reintervention. Kaplan-Meier analysis with the log-rank test compared reintervention rates stratified by age and TPS.
A total of 129 patients with median (interquartile range) age and weight of 78 days (56 to 111) and 5 kg (4.1 to 5.7), respectively, underwent primary repair. After a median (interquartile range) follow-up of 2.3 years (0.1 to 4.6), 18 patients (14%) required a total of 22 reinterventions. Youden's J-index revealed significantly lower risk of intermediate-term reintervention when repaired after 55 days of age (8% for >55 days old versus 31% for ≤55 days of age). Multivariable Cox regression identified age 55 days and younger (hazard ratio [HR] 4.5, 95% confidence interval [CI] 1.6 to 12.8, p = 0.004), valve sparing repair (HR 15.3, 95% CI 1.8 to 128.5, p < 0.001), residual right ventricular outflow tract (RVOT) gradient (HR 1.11, 95% CI 1.1 to 1.2, p < 0.001), and inadequate TPS (HR 21.5, 95% CI 7.4 to 63, p < 0.001) as independent predictors of overall intermediate-term reintervention.
Elective repair in patients greater than 55 days of age, irrespective of size of the patient, can be safely performed without any increase in reintervention rates. Both residual peak RVOT gradient and TPS are effective in identifying patients at increased risk of reintervention.
我们之前已经证明，法洛四联症合并肺动脉狭窄（TOF）的早期一期修复可以安全进行，且不会增加医院资源利用，也不会影响手术技术性能评分（TPS）。我们试图确定TOF择期早期一期修复在中期再次干预方面的最佳时机。
对2004年9月至2013年12月期间所有接受择期一期修复的TOF患者进行回顾性研究。患者被分为再次干预组或无再次干预组。多变量Cox回归分析确定再次干预的独立预测因素。受试者工作特征分析中的约登指数确定了预测再次干预的最佳年龄临界值。采用Kaplan-Meier分析和对数秩检验比较按年龄和TPS分层的再次干预率。
共有129例患者接受了一期修复，年龄中位数（四分位间距）为78天（56至111天），体重中位数（四分位间距）为5 kg（4.1至5.7 kg）。在中位（四分位间距）随访2.3年（0.1至4.6年）后，18例患者（14%）共需要22次再次干预。约登指数显示，55日龄后进行修复的中期再次干预风险显著降低（＞55日龄为8%，≤55日龄为31%）。多变量Cox回归确定55日龄及以下（风险比[HR] 4.5，95%置信区间[CI] 1.6至12.8，p = 0.004）、保留瓣膜修复（HR 15.3，95% CI 1.8至128.5，p ＜ 0.001）、右心室流出道（RVOT）残余压差（HR 1.11，95% CI 1.1至1.2，p ＜ 0.001）和TPS不足（HR 21.5，95% CI 7.4至63，p ＜ 0.001）是总体中期再次干预的独立预测因素。
55日龄以上患者的择期修复，无论患者大小，均可安全进行，且再次干预率不会增加。RVOT残余峰值压差和TPS均能有效识别再次干预风险增加的患者。
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