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Assessment of a right-ventricular infundibulum-sparing approach in transatrial-transpulmonary repair of tetralogy of Fallot

Thierry Bové (UGent) , Katrien Francois (UGent) , Kristof Vandekerckhove (UGent) , Joseph Panzer (UGent) , Katya De Groote (UGent) , Daniël De Wolf (UGent) and Guido Van Nooten (UGent)
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Abstract
OBJECTIVE: The study aimed to evaluate the outcome of transatrial-transpulmonary repair of tetralogy of Fallot in relation to a right-ventricular outflow tract (RVOT)-sparing surgery. METHODS: Based on the surgical management of right-ventricular outflow tract obstruction (RVOTO) at repair of tetralogy of Fallot, 140 children were retrospectively divided into three groups: (1) pulmonary valve (PV)-sparing, (2) infundibulum-sparing and (3) extended trans-annular patch (TAP). Clinical and echocardiographic outcome was assessed with regards to three equally divided study time eras between January 1994 and June 2010. RESULTS: Over a 15-year study period, median age decreased from 11 (2-101) to 5 (1-11) months (p < 0.001), whereas type of RVOT repair changed significantly between the first and the last era (group 1: 18-40%, group 2: 25-40% vs group 3: 57-20% (p = 0.002)). Mortality was 0%. Complications were mainly related to clinical restrictive RV physiology (27%) and arrhythmia (10%). This cardiac morbidity remained constant over the eras and was associated with younger age (p = 0.04), increased postoperative right ventricle/left ventricle (RV/LV) pressure ratio (p = 0.01) and type of RVOT repair at the cost of TAP (p = 0.03). Median follow-up of 8 years (1-16 years) showed an overall freedom from RVOT re-operation of 84% and 73%, respectively at 5 and 10 years. Most re-operations were for residual/recurrent RVOTO (12%) occurring more frequently in the latter era: 16% versus 7% in era 1 (p = 0.08). Late echocardiographic evaluation revealed a strong correlation between severity of pulmonary regurgitation and increased RV/LV size ratio, which was mainly determined by increased TAP length (p < 0.001) and duration of follow-up (p = 0.06). CONCLUSION: In a 15-year's experience with transatrial-transpulmonary correction of tetralogy of Fallot, a valve-and infundibulum-sparing approach has been advanced by lowering the age for elective repair. This change has been performed without compromising immediate clinical outcome, despite an increased early re-operation rate for residual obstruction. However, longer follow-up will disclose whether this approach is protective against progressive and late RV dysfunction.
Keywords
Transatrial repair, PULMONARY VALVE, Right-ventricular outflow tract, Tetralogy of Fallot, PHYSIOLOGY, INFANCY, AGE

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Chicago
Bové, Thierry, Katrien Francois, Kristof Vandekerckhove, Joseph Panzer, Katya De Groote, Daniël De Wolf, and Guido Van Nooten. 2012. “Assessment of a Right-ventricular Infundibulum-sparing Approach in Transatrial-transpulmonary Repair of Tetralogy of Fallot.” European Journal of Cardio-thoracic Surgery 41 (1): 126–133.
APA
Bové, T., Francois, K., Vandekerckhove, K., Panzer, J., De Groote, K., De Wolf, D., & Van Nooten, G. (2012). Assessment of a right-ventricular infundibulum-sparing approach in transatrial-transpulmonary repair of tetralogy of Fallot. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY, 41(1), 126–133.
Vancouver
1.
Bové T, Francois K, Vandekerckhove K, Panzer J, De Groote K, De Wolf D, et al. Assessment of a right-ventricular infundibulum-sparing approach in transatrial-transpulmonary repair of tetralogy of Fallot. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY. 2012;41(1):126–33.
MLA
Bové, Thierry, Katrien Francois, Kristof Vandekerckhove, et al. “Assessment of a Right-ventricular Infundibulum-sparing Approach in Transatrial-transpulmonary Repair of Tetralogy of Fallot.” EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY 41.1 (2012): 126–133. Print.
@article{2016414,
  abstract     = {OBJECTIVE: The study aimed to evaluate the outcome of transatrial-transpulmonary repair of tetralogy of Fallot in relation to a right-ventricular outflow tract (RVOT)-sparing surgery. 
METHODS: Based on the surgical management of right-ventricular outflow tract obstruction (RVOTO) at repair of tetralogy of Fallot, 140 children were retrospectively divided into three groups: (1) pulmonary valve (PV)-sparing, (2) infundibulum-sparing and (3) extended trans-annular patch (TAP). Clinical and echocardiographic outcome was assessed with regards to three equally divided study time eras between January 1994 and June 2010. 
RESULTS: Over a 15-year study period, median age decreased from 11 (2-101) to 5 (1-11) months (p {\textlangle} 0.001), whereas type of RVOT repair changed significantly between the first and the last era (group 1: 18-40\%, group 2: 25-40\% vs group 3: 57-20\% (p = 0.002)). Mortality was 0\%. Complications were mainly related to clinical restrictive RV physiology (27\%) and arrhythmia (10\%). This cardiac morbidity remained constant over the eras and was associated with younger age (p = 0.04), increased postoperative right ventricle/left ventricle (RV/LV) pressure ratio (p = 0.01) and type of RVOT repair at the cost of TAP (p = 0.03). Median follow-up of 8 years (1-16 years) showed an overall freedom from RVOT re-operation of 84\% and 73\%, respectively at 5 and 10 years. Most re-operations were for residual/recurrent RVOTO (12\%) occurring more frequently in the latter era: 16\% versus 7\% in era 1 (p = 0.08). Late echocardiographic evaluation revealed a strong correlation between severity of pulmonary regurgitation and increased RV/LV size ratio, which was mainly determined by increased TAP length (p {\textlangle} 0.001) and duration of follow-up (p = 0.06). 
CONCLUSION: In a 15-year's experience with transatrial-transpulmonary correction of tetralogy of Fallot, a valve-and infundibulum-sparing approach has been advanced by lowering the age for elective repair. This change has been performed without compromising immediate clinical outcome, despite an increased early re-operation rate for residual obstruction. However, longer follow-up will disclose whether this approach is protective against progressive and late RV dysfunction.},
  author       = {Bov{\'e}, Thierry and Francois, Katrien and Vandekerckhove, Kristof and Panzer, Joseph and De Groote, Katya and De Wolf, Dani{\"e}l and Van Nooten, Guido},
  issn         = {1010-7940},
  journal      = {EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY},
  language     = {eng},
  number       = {1},
  pages        = {126--133},
  title        = {Assessment of a right-ventricular infundibulum-sparing approach in transatrial-transpulmonary repair of tetralogy of Fallot},
  url          = {http://dx.doi.org/10.1016/j.ejcts.2011.03.050},
  volume       = {41},
  year         = {2012},
}

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