Optimal Timing for Elective Early Primary Repair of Tetralogy of Fallot: Analysis of Intermediate Term Outcomes.
BACKGROUND
We have previously demonstrated that early primary repair of tetralogy of Fallot with pulmonary stenosis (TOF) can be safely performed without increase in hospital resource utilization or compromise to surgical technical performance scores (TPS). We sought to identify the optimal timing for elective early primary repair of TOF with respect to intermediate-term reintervention.


METHODS
Retrospective review of all patients with TOF undergoing elective primary repair between September 2004 and December 2013 was performed. Patients were stratified into reintervention group or no reintervention group. Multivariable Cox regression analysis identified independent predictors of reintervention. Youden's J-index in receiver operating characteristic analysis identified optimal age cutoff predictive of reintervention. Kaplan-Meier analysis with the log-rank test compared reintervention rates stratified by age and TPS.


RESULTS
A total of 129 patients with median (interquartile range) age and weight of 78 days (56 to 111) and 5 kg (4.1 to 5.7), respectively, underwent primary repair. After a median (interquartile range) follow-up of 2.3 years (0.1 to 4.6), 18 patients (14%) required a total of 22 reinterventions. Youden's J-index revealed significantly lower risk of intermediate-term reintervention when repaired after 55 days of age (8% for >55 days old versus 31% for ≤55 days of age). Multivariable Cox regression identified age 55 days and younger (hazard ratio [HR] 4.5, 95% confidence interval [CI] 1.6 to 12.8, p = 0.004), valve sparing repair (HR 15.3, 95% CI 1.8 to 128.5, p < 0.001), residual right ventricular outflow tract (RVOT) gradient (HR 1.11, 95% CI 1.1 to 1.2, p < 0.001), and inadequate TPS (HR 21.5, 95% CI 7.4 to 63, p < 0.001) as independent predictors of overall intermediate-term reintervention.


CONCLUSIONS
Elective repair in patients greater than 55 days of age, irrespective of size of the patient, can be safely performed without any increase in reintervention rates. Both residual peak RVOT gradient and TPS are effective in identifying patients at increased risk of reintervention.
Department of Cardiology, Children's National Health System, Washington, District of Columbia.
Michael E A
ME
Cunningham
Department of Cardiology, Children's National Health System, Washington, District of Columbia.
Mary T
MT
Donofrio
Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia.
Syed Murfad
SM
Peer
Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
David
D
Zurakowski
Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia.
Richard A
RA
Jonas
Department of Cardiovascular Surgery, Children's National Health System, Washington, District of Columbia. Electronic address: psinha@childrensnational.org.
Pranava
P
Sinha
D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D016016:Proportional Hazards Models; D012372:ROC Curve; D013771:Tetralogy of Fallot / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome