Extended Summary:
This retrospective cohort study compared the pulmonary valve-sparing and transannular patch techniques used for surgical correction of Tetralogy of Fallot (ToF) in pediatric patients. Conducted at the Royal Hospital in Muscat, Oman, it evaluated the outcomes of 102 children treated between January 2016 and December 2019. The study aimed to compare primary outcomes, such as mechanical ventilation duration, alongside secondary metrics, including intensive care unit (ICU) stays, hospitalizations, complications, and reoperation rates.
Surgical Approaches:
The pulmonary valve-sparing approach preserves the native valve, reducing the risk of pulmonary regurgitation and its associated complications. In contrast, the transannular patch technique involves placing a patch to widen the right ventricular outflow tract but often leads to severe pulmonary regurgitation, potentially resulting in long-term complications.
Key Demographics and Procedure Metrics:
Children in the valve-sparing group (Group 1) tended to be older (median age: 15 months) compared to those in the transannular patch group (Group 2, median age: 13 months). The valve-sparing approach was also associated with shorter cardiopulmonary bypass times and aortic cross-clamp durations, reflecting a less invasive procedure overall.
Primary and Secondary Outcomes:
- Mechanical Ventilation Duration:
- Group 1 had significantly shorter ventilation times (median: 16.5 hours) than Group 2 (median: 23 hours). Mechanical ventilation duration was used as a surrogate for surgical success, indicating that valve-sparing procedures may promote faster recovery.
- ICU and Hospital Stays:
- Valve-sparing patients experienced shorter ICU stays (median: 2 days vs. 3 days for Group 2) and overall hospitalizations (8 days vs. 11 days). These differences suggest that the valve-sparing technique contributes to a smoother and quicker recovery period.
- Complications and Morbidity:
- Severe pulmonary regurgitation was significantly more frequent in Group 2 (87.8%), while junctional ectopic tachycardia (JET) was also more common in this group (18.6% vs. 2.3% in Group 1).
- While mild-to-moderate pulmonary regurgitation occurred more often in the valve-sparing group, its clinical impact appeared minimal compared to severe cases.
- Right Ventricular Outflow Gradients:
- Valve-sparing repairs resulted in higher right ventricular outflow tract pressure gradients than transannular patch repairs. While this residual obstruction warrants monitoring, it does not appear to significantly impact early recovery.
Weight as a Key Predictor:
Multivariate analysis identified patient weight as an independent predictor of ventilation duration. Heavier children were less likely to require prolonged ventilation, with each additional kilogram reducing the risk of extended ventilation by approximately 40.9%.
Clinical Implications:
The study underscores the advantages of the valve-sparing approach in eligible patients, highlighting improved early postoperative outcomes. These include reduced durations of ventilation, ICU stays, and hospitalization, along with fewer complications like arrhythmias. However, the valve-sparing technique may not be suitable for all patients, as it requires adequate anatomical conditions, such as a sufficiently large pulmonary valve annulus.
Safety and Mortality:
Reassuringly, no deaths were reported in either group during the two-year follow-up period. This aligns with broader trends showing high survival rates in pediatric ToF repairs, exceeding 95% into adulthood.
Limitations:
The retrospective design introduces potential biases, such as surgeon-dependent variability in choosing the surgical approach. Additionally, unmeasured factors and evolving surgical techniques may have influenced the results. Prospective studies are needed to validate these findings and explore long-term outcomes, particularly for complications like pulmonary regurgitation and right ventricular function.
Conclusion:
Valve-sparing surgery is associated with better immediate postoperative outcomes compared to the transannular patch technique. This includes shorter recovery times and fewer complications, making it an ideal option when anatomical conditions permit. However, the higher residual outflow gradients in valve-sparing patients may necessitate close follow-up.
Future research should focus on the durability of these approaches, particularly the long-term impacts on right ventricular function and the need for reinterventions. By standardizing criteria for surgical decisions, these insights can help optimize patient outcomes and guide clinical practice.
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