Young infants with symptomatic tetralogy of Fallot: shunt or primary repair?

Objectives The optimal strategy for symptomatic young infants with tetralogy of Fallot (TOF) is unclear. We sought to compare the outcomes of staged repair (SR) (shunt palliation followed by second-stage complete repair) versus primary repair (PR) at two institutions that have exclusively adopted each strategy. Methods We performed propensity score-matched comparison of 143 infants under 4 months of age who underwent shunt palliation at one institution between 1993 and 2021 with 122 infants who underwent PR between 2004 and 2018 at another institution. The primary outcome was mortality. Secondary outcomes were postoperative complications, durations of perioperative support and hospital stays, and reinterventions. Median follow-up was 8.3 (interquartile range: 8.1 – 13.4) years. Results After the initial procedure, hospital mortality (shunt: 2.8% vs. PR: 2.5%; p = 0.86) and 10-year survival (shunt: 95% [95% CI: 90-98%] vs. PR: 90% [95% CI: 81-95%]; p = 0.65) were similar. The SR group had a higher risk of early reinterventions but similar rates of late reinterventions. Propensity score-matching yielded 57 well-balanced pairs. In the matched cohort, the SR group had similar freedom from reintervention (55% [95% CI: 39-68%] vs. 59% [95% CI: 43-71%]; p = 0.85) and higher survival (98% [95% CI: 88-99.8%] vs. 85% [95% CI: 69-93%]; p = 0.02) at 10-years, due to more non-cardiac-related mortalities in the PR group. Conclusions In symptomatic young infants with TOF operated at two institutions with exclusive treatment protocols, the SR strategy was associated with similar cardiac-related mortality and reinterventions as the PR strategy at medium-term follow-up.