Catheter-based palliation for infants with tetralogy of Fallot

Abstract

Background: The optimal management of symptomatic tetralogy of Fallot in neonates and younger infants with unfavourable anatomy is unclear and is further constrained by resource limitations in low and middle income countries. Methods: Retrospective medical record review of infants with tetralogy of Fallot undergoing corrective or palliative procedures between January 2016 and June 2019. Results: The study included 120 infants; of whom 83 underwent primary complete repair, four underwent surgical palliation, and 33 underwent catheter-based palliation, including balloon pulmonary valvuloplasty (n = 18), right ventricular outflow tract stenting (n = 14), and stenting of the patent arterial duct (n = 1). Infants undergoing catheter-based procedures were younger in age (median 32 days; inter-quartile range (IQR) 7–144 versus 210 days; IQR 158–250), with lower baseline saturation (65 ± 12% versus 87 ± 7%) and had smaller pulmonary artery z-scores compared to the complete repair cohort. Follow-up was available for 31/33 (94%) infants (median 7 months [IQR 4–11]) who underwent trans-catheter palliation; 12 underwent complete repair, 10 are well, awaiting repair, eight required further palliation (catheter: 6; surgical: 2), and one died post-discharge from non-cardiac causes. Conclusion: Catheter-based palliation is a safe and effective alternative in infants with tetralogy of Fallot who are at high risk for primary surgical repair.

Rescue right ventricular outflow tract stenting for refractory hypoxic spells

“…From 2015 to 2022, 38 patients underwent RVOTS as initial palliation for TOF, for indications described previously 1 . Of these, 11 patients with median age of 27 days, IQR (8.5–442.5) weight of 3.27 kg IQR (2.7–8.96); and body surface area of 0.21 kg/cm 2 IQR (0.2–0.436) had refractory cyanotic spells and form the study group.…”

“…From 2015 to 2022, 38 patients underwent RVOTS as initial palliation for TOF, for indications described previously. 1 1.…”

“…Our study shows that RVOT stenting is an acceptable alternative to palliative surgery in patients with hypoxic spells. In the past two decades, catheter‐based palliation has evolved as an important adjunct in the management of cyanotic congenital heart disease 1–9 . Majority of patients undergo catheter‐based palliation for other indications such as hypoplastic annulus and pulmonary arteries, severe hypoxia in young infants, comorbidities like genetic syndromes or noncardiac conditions 1 .…”

“…Surgical options include a palliative procedure such as the Blalock ‐Taussig ‐Thomas Shunt (BTTS) or corrective surgery. A significant number of children with TOF in low resource settings continue to present with severe desaturation and/or refractory spells and mobilizing resources for emergent surgical management can be challenging 1 …”

“…Right ventricular outflow tract stenting (RVOTS) is considered an acceptable alternative to BTTS for symptomatic patients with TOF who are otherwise not suitable for an intracardiac repair (ICR). [1][2][3][4][5] While there are potential concerns about the safety of crossing a severely narrow RVOT, the utility of RVOTS in emergent management of the sickest subset of TOF patients with refractory hypoxic spells is unclear. This study reports our institutional experience with RVOTS as rescue therapy for intractable hypoxic spells.…”