Comparison of Management Strategies for Neonates With Symptomatic Tetralogy of Fallot

Goldstein, Bryan H; Petit, Christopher J.; Qureshi, Athar M.; McCracken, Courtney; Kelleman, Michael; Nicholson, George T.; Law, Mark A.; Meadows, Jeffery; Zampi, Jeffrey D.; Shahanavaz, Shabana; Mascio, Christopher E.; Chai, Paul J.; Romano, Jennifer C.; Batlivala, Sarosh P.; Maskatia, Shiraz A.; Asztalos, Ivor; Kamsheh, Alicia M.; Healan, Steven; Smith, Justin D.; Ligon, R. Allen; Pettus, Joelle; Juma, Sarina; Raulston, James E B; Hock, Krissie; Pajk, Amy; Eilers, Lindsay F.; Khan, Hala Q; Merritt, Taylor C.; Canter, Matthew W.; Juergensen, Stephan; Rinderknecht, Fatuma-Ayaan; Bauser‐Heaton, Holly; Glatz, Andrew C.

doi:10.1016/j.jacc.2020.12.048

Cited by 50 publications

(28 citation statements)

References 60 publications

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“…4 This excess mortality risk for small patients is similar in magnitude to that recently reported across a spectrum of congenital cardiac anomalies. 5 Perhaps the more important finding of this study is the fact that neither approach is inarguably superior, and so we will continue to argue. "Stagers" will emphasize the ever-improving results with transcatheter palliation and suggest that the present work is of only historical relevance.…”

mentioning

confidence: 78%

Commentary: Comparison of management strategies for the neonate with symptomatic tetralogy of Fallot and weight <2.5 kg—jogging towards equipoise?

Baltagi

Jaquiss

2022

The Journal of Thoracic and Cardiovascular Surgery

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confidence: 78%

Commentary: Comparison of management strategies for the neonate with symptomatic tetralogy of Fallot and weight <2.5 kg—jogging towards equipoise?

Baltagi

Jaquiss

2022

The Journal of Thoracic and Cardiovascular Surgery

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“…Recent multicentre studies have shown that staged repair of ToF has superior outcome and less morbidity compared to single stage neonatal complete repair 1–3 . Although some studies did not show superiority of one approach over the other, and although some centers can achieve excellent results with early primary repair, 4,5 the decision to opt for a primary approach remains subjective and experience‐based and may not be generalizable. Over the past decade, RVOT stenting in Fallot has been established as a good and frequently superior alternative to BT shunt for staged repair 7–11 …”

Section: Discussionmentioning

confidence: 99%

“…mortality and neonatal morbidity. 4,5 The Blalock Taussig (BT) shunt was the principal choice for initial palliation but continues to have very high mortality rates. 6 Over the past decade right ventricular outflow tract (RVOT) stenting as initial palliation has emerged as an alternative to BT shunts, with improved survival and better pulmonary artery (PA) growth.…”

mentioning

confidence: 99%

Anomalous coronary artery in Tetralogy of Fallot—Feasibility of right ventricular outflow tract stenting as initial palliation

Afifi

Mehta

Bhole

et al. 2022

Cathet Cardio Intervent

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This study addresses the outcome of right ventricle outflow tract (RVOT) stenting in Tetralogy of Fallot (ToF) with anomalous coronaries crossing the RVOT. RVOT stenting in ToF patients has emerged as an alternative to Blalock Taussig shunting. This is a single center study of patients who underwent RVOT stenting for symptomatic ToF at Birmingham Children's Hospital between 2005 and 2020. A total of 122 patients underwent RVOT stenting as initial palliation over a 15‐year period, 10 patients had anomalous coronaries crossing the RVOT (study group) and 112 not (comparative group). Median age of the study group was 72.5 days (interquartile range [IQR]: 28–103) with a weight of 4.7 kg (IQR: 3.5–4.9). No significant differences were found between the two groups regarding the patients’ weights and ages, procedure and screening times, or hospital stay. Four had valve sparing stenting. Oxygen saturations increased from a median of 75.5% (IQR: 70–82) to 94.5% (IQR: 90–95), p < 0.002. Postprocedure median hospital stay was 3 days (IQR: 2–6). Six patients underwent interstage catheterization reintervention and one needed early surgical palliation due to stent suboptimal position. Complete repair could be delayed for a median of 11.1 months (IQR: 5.6–19.2). At surgical repair, the patients had a median age of 12.3 months (IQR: 7.5–25.6) and weight of 7.7 kg (IQR: 6.8–10.8). There were no deaths. RVOT stenting in ToF with anomalous coronaries is safe and effective. Dilatable stents should be used when two‐stage delayed conduit repair is the default approach.

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“…These initial observations should be used in future analyses to derive clinical prediction rules for post-operative complications that can be incorporated into TOF pre-surgical planning. Strategies targeting modifiable factors could include, for example, modifying the age at complete repair by palliating the neonate with a stent in the ductus arteriosus, altering the intraoperative management with optimization of temperature, pH, and hematocrit, and more aggressive use of perioperative drugs to support RV systolic function (24,42,43).…”

Section: Discussionmentioning

confidence: 99%

Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach

Faerber

Huang

Zhang

et al. 2021

Front. Cardiovasc. Med.

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Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair.Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication.Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models.Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.

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Comparison of Management Strategies for Neonates With Symptomatic Tetralogy of Fallot

Cited by 50 publications

References 60 publications

Commentary: Comparison of management strategies for the neonate with symptomatic tetralogy of Fallot and weight <2.5 kg—jogging towards equipoise?

Commentary: Comparison of management strategies for the neonate with symptomatic tetralogy of Fallot and weight <2.5 kg—jogging towards equipoise?

Anomalous coronary artery in Tetralogy of Fallot—Feasibility of right ventricular outflow tract stenting as initial palliation

Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach

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