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Miller JR, Stephens EH, Goldstone AB, Glatz AC, Kane L, Van Arsdell GS, Stellin G, Barron DJ, d'Udekem Y, Benson L, Quintessenza J, Ohye RG, Talwar S, Fremes SE, Emani SM, Eghtesady P. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot. J Thorac Cardiovasc Surg 2023; 165:221-250. [PMID: 36522807 DOI: 10.1016/j.jtcvs.2022.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice. METHODS The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement. RESULTS In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation. CONCLUSIONS Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.
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Affiliation(s)
- Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Andrew B Goldstone
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Andrew C Glatz
- Division of Pediatrics, Department of Pediatric Cardiology, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Glen S Van Arsdell
- Division of Cardiothoracic Surgery, Department of Surgery, UCLA Mattel Children's Hospital, Los Angeles, Calif
| | - Giovanni Stellin
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Lee Benson
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Quintessenza
- Department of Cardiovascular Surgery, Johns Hopkins All Children's Heart Institute, St Petersburg, Fla
| | - Richard G Ohye
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Sachin Talwar
- Department of Cariothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass.
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
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Ye XT, Buratto E, Ishigami S, Weintraub RG, Brizard CP, Konstantinov IE. Long-term Outcomes of Transatrial-Transpulmonary Repair of Tetralogy of Fallot With Anomalous Coronary Arteries. Semin Thorac Cardiovasc Surg 2022; 35:549-561. [PMID: 35594979 DOI: 10.1053/j.semtcvs.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/11/2022]
Abstract
Repair of tetralogy of Fallot (TOF) can be complicated by the presence of an anomalous coronary artery (ACA) crossing the right ventricular outflow tract (RVOT). This study sought to evaluate the late outcomes of a policy of transatrial-transpulmonary repair for this condition. The transatrial-transpulmonary approach was used in 864 consecutive TOF repairs between 1993 and 2018 at a single institution, of which 55 (6%) patients had an ACA. Nineteen (35%,19/55) patients underwent prior palliation. Late survival and freedom from reoperations were compared with the general cohort of 809 patients who underwent complete repair during the same period. Early mortality was 2% (1/55). Median follow-up was 15.6 years. Late mortality was 6% (3/54). Absence of a preoperative diagnosis of ACA was not a risk factor for worse outcomes in terms of late re-interventions, acute coronary syndrome, residual RVOT gradient, and late mortality. Survival was 91% (95% confidence interval [CI]: 77-96%) at 20 years and was comparable to the general TOF cohort (95%, 95% CI: 90-98%, P = 0.12). Actuarial freedom from any re-intervention was 46% (95% CI: 27-62%) at 20 years, which was also comparable to the general cohort (31%, 95% CI: 20-42%, P = 0.19). The presence of an ACA does not appear to affect late survival or re-intervention rates in patients undergoing transatrial-transpulmonary repair of TOF.
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Affiliation(s)
- Xin Tao Ye
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Edward Buratto
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Shuta Ishigami
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Robert G Weintraub
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.; Department of Cardiology, Royal Children's Hospital, Melbourne, Victoria, Australia.; The Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.; The Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.; The Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Murdoch Children's Research Institute, Melbourne, Victoria, Australia..
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Afifi ARSA, Mehta C, Bhole V, Chaudhari M, Khan NE, Jones TJ, Stumper O. Anomalous coronary artery in Tetralogy of Fallot-Feasibility of right ventricular outflow tract stenting as initial palliation. Catheter Cardiovasc Interv 2022; 100:105-112. [PMID: 35544946 DOI: 10.1002/ccd.30223] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 04/17/2022] [Indexed: 11/06/2022]
Abstract
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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Affiliation(s)
- Ahmed R S A Afifi
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Department of Pediatrics, Faculty of Medicine, Benha University, Banha, Egypt
| | - Chetan Mehta
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Vinay Bhole
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Milind Chaudhari
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Natasha E Khan
- Department of Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Timothy J Jones
- Department of Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Oliver Stumper
- Department of Cardiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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Hanser A, Michel J, Hornung A, Sieverding L, Hofbeck M. Coronary Artery Anomalies and Their Impact on the Feasibility of Percutaneous Pulmonary Valve Implantation. Pediatr Cardiol 2022; 43:8-16. [PMID: 34363499 PMCID: PMC8766387 DOI: 10.1007/s00246-021-02684-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
One of the major obstacles preventing successful percutaneous pulmonary valve implantation (PPVI) is related to the close proximity of coronary artery branches to the expected landing zone. The aim of this study was to assess the frequency of coronary artery anomalies (CAAs) especially those associated with major coronary branches crossing the right ventricular outflow tract (RVOT) and to describe their relevance for the feasibility of percutaneous pulmonary valve implantation (PPVI). In our retrospective single-center study 90 patients were evaluated who underwent invasive testing for PPVI in our institution from 1/2010 to 1/2020. CAAs were identified in seven patients (8%) associated with major branches crossing the RVOT due to origin of the left anterior descending (LAD) or a single coronary artery from the right aortic sinus. In 5/7 patients with CAAs balloon testing of the RVOT and selective coronary angiographies revealed a sufficiently large landing zone distal to the coronary artery branch. While unfavorable RVOT dimensions prevented PPVI in one, PPVI was performed successfully in the remaining four patients. The relatively short landing zone required application of the "folded" melody technique in two patients. All patients are doing well (mean follow-up 3 years). CAAs associated with major coronary branches crossing the RVOT can be expected in about 8% of patients who are potential candidates for PPVI. Since the LAD crossed the RVOT below the plane of the pulmonary valve successful distal implantation of the valve was possible in 4/7 patients. Therefore these coronary anomalies should not be considered as primary contraindications for PPVI.
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Affiliation(s)
- Anja Hanser
- Department of Pediatric Cardiology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Andreas Hornung
- Department of Pediatric Cardiology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Ludger Sieverding
- Department of Pediatric Cardiology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, University Children's Hospital Tuebingen, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany.
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High take-off right coronary artery in a patient with tetralogy of Fallot. Cardiol Young 2021; 31:1876-1878. [PMID: 34016215 DOI: 10.1017/s1047951121001761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High take-off coronary artery anomaly is a quite rare anomaly which is usually seen in isolated form and diagnosed incidentally. Association with tetralogy of Fallot is also rare and it is not one of the well-known coronary anomalies seen in this disease. Here, we describe high take-off right coronary artery in a 10-month-old female patient with tetralogy of Fallot which was diagnosed during catheter angiography. It is very important to show this anomaly sometimes with additional imaging techniques as it alters all the surgical approach including aortic cannulation.
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Talwar S, Sengupta S, Marathe S, Vaideeswar P, Airan B, Choudhary SK. Tetralogy of Fallot with coronary crossing the right ventricular outflow tract: A tale of a bridge and the artery. Ann Pediatr Cardiol 2021; 14:53-62. [PMID: 33679061 PMCID: PMC7918034 DOI: 10.4103/apc.apc_165_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/04/2019] [Accepted: 08/03/2020] [Indexed: 12/03/2022] Open
Abstract
A coronary artery crossing the right ventricular outflow tract is a subset of a larger pathomorphological cohort known as an anomalous coronary artery (ACA) in the tetralogy of Fallot (TOF). The best possible outcome in a patient with TOF and ACA is decided by judicious selection of optimum preoperative investigative information, the timing of surgery, astute assessment of preoperative surgical findings, and appropriate surgical technique from a wide array of choices. In most instances, the choice of surgical technique is determined by the size of the pulmonary annulus and the anatomical relation of ACA to the pulmonary annulus. In the present era, complete, accurate preoperative diagnosis and primary repair is a routine procedure with strategies to avoid a right ventricle-to-pulmonary artery conduit.
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Affiliation(s)
- Sachin Talwar
- Heart Center, Boston Children's Hospital, Boston, MA, United States
| | - Sanjoy Sengupta
- Heart Center, Boston Children's Hospital, Boston, MA, United States
| | - Supreet Marathe
- Heart Center, Boston Children's Hospital, Boston, MA, United States
| | | | - Balram Airan
- Heart Center, Boston Children's Hospital, Boston, MA, United States
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Koppel CJ, Jongbloed MR, Kiès P, Hazekamp MG, Mertens BJ, Schalij MJ, Vliegen HW. Coronary anomalies in tetralogy of Fallot – A meta-analysis. Int J Cardiol 2020; 306:78-85. [DOI: 10.1016/j.ijcard.2020.02.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 10/25/2022]
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