Impact of clinical follow-up and diagnostic testing on intervention for tetralogy of Fallot

Abstract

ObjectiveOur purpose was to evaluate yield of tools commonly advocated for surveillance of tetralogy of Fallot (TOF).MethodsAll patients (pts) with TOF, seen at any time from 1/2008 to 9/2013 in an academic cardiology practice were studied. At the first and each subsequent outpatient visit, the use of tools including history and physical (H&P), ECG, Holter (HOL), echocardiogram (Echo), MR or CT (MR-CT) and stress testing (STR) were noted. Recommendations for intervention (INT) and for time to next follow-up were recorded; rationale for each INT with attribution to one or more tools was identified.ResultsThere were 213 pts (mean 11.5 years, 130 male) who had 916 visits, 123 of which (13.4%) were associated with 138 INTs (47 surgical, 54 catheter-mediated, 37 other medical). Recommended follow-up interval was 9.44±6.5 months, actual mean follow-up interval was 11.7 months. All 916 (100%) patient visits had a H&P which contributed to 47.2% of INT decisions. Echo was performed in 652 (71.2%) of visits, and contributed to 53.7% of INTs. MR-CT was obtained in 129 (14.1%) of visits, and contributed to 30.1% of INTs. ECG was applied in 137 (15%) visits, and contributed to 1.6% of INTs. HOL was obtained in 188 (20.5%) visits, and contributed to 11.3% of INTs. STR was performed at 101 (11%) of visits, and contributed to 8.9% of INTs.ConclusionsINTs are common in repaired TOF, but when visits average every 11–12 months, most visits do not result in INT. H&P, Echo and HOL were the most frequently applied screens, and all frequently yielded relevant information to guide INT decisions. STR and MR/CT were applied as targeted testing and in this limited, non-screening role had high relevance for INT. There was low utilisation of ECG and major impact on INT was not demonstrated. Risk stratification in TOF may be possible, and could result in more efficient surveillance and targeted testing.

Can Abbreviated Cardiac Magnetic Resonance Imaging Adequately Support Clinical Decision Making After Repair of Tetralogy of Fallot?

“…Within the US, similar trends of increasing CMR utilization for CHD are well documented [26,27,28]. Our own institutional series revealed 0.14 CMR or CT examinations per patient year of observation in repaired TOF patients [22].…”

“…In late adolescents and adults however, CMR is recommended as a routine surveillance test, since the hemodynamic burden of residual lesions is likely to have become more significant and echocardiographic windows are often more restricted. Despite these practice guidelines and consensus-based appropriate use criteria, there is wide variation in practice patterns [22]. This is especially noteworthy in the context of burgeoning utilization of CMR globally for congenital heart disease.…”

“…Published guidelines from the European Society of Cardiology, the Canadian Society of Cardiology, and the American Heart Association address recommended frequency of surveillance and imaging tests [15,16,17,18,19,20,21]. Despite guidelines, there is considerable variation in practice between providers and centers [22]. Best patient value is achieved by efforts to improve processes without compromising quality, which may be promoting the gradual shift within the cardiac imaging community from a broad diagnostic screening process to one of targeted testing.…”