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Long-Term Results of Right Ventricular Outflow Tract Reconstruction in Neonatal Cardiac Surgery; Options and Outcomes.
A. K. Kaza, H. Lim, C. Allan, P. Laussen, V. Bautista-Hernandez, D. J. Dibardino, E. Bacha, P. Del Nido, J. Mayer, F. Fynn-Thompson, F. Pigula. Boston Children's, Boston, MA,
BACKGROUND: Neonatal surgery for tetralogy of Fallot (TOF) and truncus arteriosus (TA) requires reconstruction of the right ventricular outflow tract (RVOT) . While the method of reconstruction is often dictated by the individual anatomy, choices exist. This review examines the durability and outcomes of RVOT reconstruction in the neonate.
METHODS: This is a retrospective review of all 278 neonates with the diagnosis of TOF and TA undergoing RVOT reconstruction at a single center between 1990-2007. Diagnostic variants included TOF/PS (n=83), TOF/PA (n=81), and TOF with absent pulmonary valve (n=17). TA was present in 97 patients. Patients were analyzed on the basis of diagnosis and the method of RVOT reconstruction; aortic homograft, pulmonary homograft, transannular patch, transannular patch with monocusp pulmonary valve, and non-transannular patch. Freedom from reoperation/reintervention was determined by the log-rank test, with significance assumed at p<0.05.
RESULTS:The mean age at RVOT reconstruction was 11.8+/- 8 days, and overall mortality was 11.5%. Actuarial survival at 16 years was similar between TOF (85.7±3.9%) and TA (82.5±4.2%), p>0.05. Survival improved significantly after 1994 for TOF ( 1990-1994, 76.2±5.1% vs 1995-2007, 89.8±2.8%, p= 0.003) and for TA (1990-1994, 70.9±7.8% vs 1995-2007, 88.7±5%). Overall freedom from reoperation/reintervention at 10 years was 76.2±14.8% in the non-transannular patch group and 59.5±6.8%, in the transannular patch group; both significantly greater than either aortic ( 0%) or pulmonary (6.7±4.2%) homografts, p<0.05, and there was no difference between aortic and pulmonary homografts. Among patients with TOF/PS there was no difference in 10 year freedom from reoperation/reintervention between transannular (70.8±7.4%) and nontransannular patch methods (76.2±14.8%), p= 0.53. At 10 years, the diagnosis of TOF/PS was associated with a greater freedom from reoperation/reintervention (68±6.8%) when compared to TOF/PA (5.3±4.3%, p=0.0001)) TOF/absent valve (0%, p= .00315), or TA (4.2±2.8%, p=.0001). Eight patients ( 4 TOF/PS, 3 TOF/PA, 1 TOF/absent valve) underwent transannular patch with monocusp valve placement. Among this group, freedom from reoperation/reintervention is 41.7±20.5% at 2.5 years. Monocusp function by echo obtained at 11.4±11.7 months(.3-31 months) showed an average monocusp gradient of 23.5+/- 26.1 mmHg and 3 patients (37.5%) had more than moderate pulmonary regurgitation.  
CONCLUSIONS:The durability of neonatal RVOT reconstruction is diagnosis and method dependent. Anatomy allowing RVOT patching (either transannular or nontransannular) provides a durability advantage, as compared to a homograft. There was no difference in performance between aortic and pulmonary homografts, and the monocusp valve has limited durability and effectiveness in neonatal RVOT surgery. The longterm outcomes of transannular and nontransannular patching techniques for neonatal repair of TOF/PS are similar.
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