Comparison of management strategies for neonates with symptomatic tetralogy of Fallot and weight <2.5 kg

J Thorac Cardiovasc Surg. 2022 Jan;163(1):192-207.e3. doi: 10.1016/j.jtcvs.2021.01.100. Epub 2021 Feb 3.


Objective: To compare management strategies for neonates <2.5 kg with tetralogy of Fallot and symptomatic cyanosis who either undergo staged repair (SR) (initial palliation followed by later complete repair) or primary repair (PR).

Methods: Consecutive neonates with tetralogy of Fallot and symptomatic cyanosis weighing <2.5 kg at initial intervention and between 2005 and 2017 were retrospectively reviewed from the Congenital Cardiac Research Collaborative. Primary outcome was mortality and secondary outcomes included component (eg, initial palliation, complete repair, or primary repair) and cumulative (SR: initial palliation followed by later complete repair) hospital and intensive care unit lengths of stay, durations of ventilation, inotrope use, cardiopulmonary bypass time, procedural complications, and reintervention. Outcomes were compared with propensity score adjustments with PR as the reference group.

Results: The cohort included 76 SR (initial palliation: 53 surgical and 23 transcatheter) and 44 PR patients. The observed risk of overall mortality was similar between SR and PR groups (15.8% vs 18.2%: P = .735). The adjusted hazard of mortality remained similar between groups overall (hazard ratio, 0.59; 95% confidence interval, 0.26-1.36; P = .214), as well as during short-term (<4 months: hazard ratio, 0.37; 95% confidence interval, 0.13-1.09; P = .071) and midterm (>4 months: hazard ratio, 1.32; 95% confidence interval, 0.30-5.79; P = .717) follow-up. Reintervention in the first 18 months was common in both groups (53.2% vs 48.4%; hazard ratio, 1.69; 95% confidence interval, 0.96-2.28; P = .072). Adjusted procedural complications and neonatal morbidity burden were overall lower in the SR group. Cumulative secondary outcome burdens largely favored the PR group.

Conclusions: In this study comparing SR and PR treatment strategies for neonates with tetralogy of Fallot and symptomatic cyanosis and weight <2.5 kg, mortality and reintervention burden was high and independent of treatment strategy. Other potential advantages were observed with each approach.

Keywords: congenital heart disease; neonates; tetralogy of Fallot.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Body Weight / physiology*
  • Cardiac Surgical Procedures* / adverse effects
  • Cardiac Surgical Procedures* / methods
  • Comparative Effectiveness Research
  • Cyanosis / etiology
  • Cyanosis / physiopathology
  • Female
  • Humans
  • Infant, Low Birth Weight / physiology
  • Infant, Newborn
  • Male
  • Outcome and Process Assessment, Health Care
  • Palliative Care / methods*
  • Patient Care Management / methods
  • Patient Care Management / statistics & numerical data
  • Patient Selection*
  • Postoperative Complications* / epidemiology
  • Postoperative Complications* / etiology
  • Postoperative Complications* / surgery
  • Reoperation / statistics & numerical data
  • Risk Adjustment / methods
  • Tetralogy of Fallot* / mortality
  • Tetralogy of Fallot* / physiopathology
  • Tetralogy of Fallot* / surgery