Symptomatic Neonates With Tetralogy of Fallot: Shunt or Primary Repair?

BACKGROUND

The optimal management strategy for symptomatic neonates with tetralogy of Fallot is unclear. We compared the outcomes of staged repair (SR) (shunt palliation followed by complete repair) and primary repair (PR) in two institutions that have each exclusively adopted one of these strategies.

METHOD

We retrospectively compared 65 symptomatic neonates who underwent shunt palliation between 1993 and 2021 at the Royal Children's Hospital, Melbourne, Australia with 38 symptomatic neonates who underwent PR between 2005 and 2018 at the Children's National Hospital, Washington, USA. Median follow-up duration was 8.0 (interquartile range 2.9-13.5) years.

RESULTS

After the initial procedure, hospital mortality (shunt 4.6% vs PR 7.9%; p=0.50) and 5-year survival (shunt 94%; 95% confidence interval [CI] 84%-98% vs PR 89%; 95% CI 72%-96%; p=0.21) were not significantly different. The SR group had shorter durations of cardiopulmonary bypass and intensive care admission during the neonatal period, but a higher burden of unplanned re-interventions before discharge. Five-year freedom from re-interventions was not significantly different (shunt 63%; 95% CI 49%-74% vs PR 49%; 95% CI 29%-66%; p=0.13). Postoperative morbidity, mortality, and re-interventions were not significantly different among 13 propensity score-matched pairs balanced for operative weight. For neonates weighing <3 kg, PR was associated with significantly more early re-interventions.

CONCLUSIONS

In symptomatic neonates with tetralogy of Fallot operated at two institutions with distinct treatment protocols, no statistically significant difference in medium-term survival and re-intervention was observed between the two strategies. SR was associated with lower neonatal morbidity but more unplanned re-interventions before discharge. PR in neonates weighing <3 kg may result in more early re-interventions.