Neonatal Tetralogy of Fallot Complete Repair is Associated with Increased Mortality and Morbidity
Purpose: Controversy and cross-center variability exists with regards to timing of complete repair for non-ductal dependent tetralogy of Fallot (TOF) patients. We hypothesized that earlier repair of infants in the neonatal period is associated with increased mortality and morbidity.
Methods: This retrospective study involved querying the Pediatric Health Information System (PHIS), a multicenter database of pediatric hospitalizations from 43 children’s hospitals in the United States, for total surgical repair (ICD-9 procedure code 35.81) of tetralogy of Fallot (ICD-9 diagnostic code 745.2) from 2003 to 2011 in patients between the ages of 1 day to <19 years of age. Patients with pulmonary valve atresia (ICD-9 diagnostic code 745.1) and patients with TOF who received prostaglandin during the admission were excluded from the analysis. Patient demographic data and data relating to post-operative outcomes were abstracted from the database. Age at time of surgery and its association with immediate in-hospital outcomes was analyzed by univariate statistics and proportional hazard model for competing risk using Stata Version 11. A p value of < 0.05 was considered to be statistically significant.
We identified 5629 patients who met our inclusion criteria of which 6.7% (n=378) were <30 days of age (Group A), 29.0% (n=1631) were 31 to 120 days of age (Group B), and 64.3% (n=3620) were > 120 days of age (Group C). In-hospital mortality was significantly higher in Group A (7%) vs. Group B (1%) and Group C (1%); p <0.001. ICU length of stay (LOS) was significantly higher in Group A (median 10 days, inter quartile range [IQR] 6-18 days) compared to Group B (median 5 days, IQR 3-8 days) and Group C (median 4 days, IQR 2-6 days). Similarly, total hospital LOS was significantly higher in Group A (median 19 days, IQR 13–34 days) compared to Group B (median 8 days, IQR 6-15 days) and Group C (median 7 days, IQR 5–11 days). Group A compared to Group B and Group C patients were more like to require extracorporeal membrane oxygenation support (4% vs. 2% vs. 1%; p value <0.001) and gastrostomy tube insertion (7% vs. 3% vs. 1%; p value <0.001). Significant institutional variability was noted for timing of TOF complete repair (p value < 0.001).
Conclusion: Neonatal complete TOF repair is associated with increased mortality and morbidity (ICU LOS, total hospital LOS, an increased need for ECMO and gastrostomy tube placement).