Feasibility and Surgical Effect of Annulus Sparing in Consecutive Patients with Tetralogy of Fallot:A Retrospective Cohort Study

Objective:Annulus-sparing(AS)repair for tetralogy of Fallot(TOF)with a dysplastic pulmonary valve annulus(PVA)is a challenging procedure and is controversial.This study aimed to assess the feasibility and surgical effect of AS repair versus transannular patch enlargement(TAPE)repair,especially in individuals with dysplastic pulmonary valves.Methods:This retrospective cohort study included 375 pediatric patients with a primary diagnosis of TOF in the Center for Pediatric Cardiac Surgery of Fuwai hospital from January 2014 to June 2017.Among them,60 consecutive and nonselective patients underwent 1-stage repair of TOF with aggressive PVA-preserving strategies performed by a single surgeon were enrolled in AS cohort.In AS cohort,patients were divided into AS,PVA z-score≥−2 group(33 patients)and AS,PVA z-score<−2 group(27 patients).During the same period,315 patients underwent TAPE repair by other surgeons were enrolled as TAPE cohort,of these,87 patients with PVA z-score≥−2 were excluded.From the 228 patients in the TAPE group,27 cases were selected as TAPE,PVA z-score<−2 group according to the propensity score and 1:1 ratio with AS,PVA z-score<−2 group.The primary outcome was a composite of reintervention,significant pulmonary regurgitation,and significant annular peak gradient(APG).Kaplan-Meier curve was plotted to show the survival rate of severe pulmonary regurgitation.Results:One death occurred after the TAPE operation in TAPE group,and 1 patient in the AS z≥−2 group needed reintervention with a balloon.After a median follow-up of(30.3±11.6)months,compared with AS z≥−2 group,there was no difference in the technical performance score for severe pulmonary stenosis(APGs>20 mmHg)in the AS z<−2 group.Compared with TAPE,AS repair was often accompanied by a postoperative APGs over 20 mmHg(P=0.001).More patients underwent TAPE suffered from moderate or severe pulmonary regurgitation than those who received AS repair(20(74.1%)vs.7(26.0%),P<0.001).AS repair was associated with a shorter duration of mechanical ventilation(20 vs.29 hours,P=0.039),faster discharge from the intensive care unit(2.0 vs.4.0 days,P=0.022)and shorter postoperative hospitalization(8.0 vs.11.0 days,P=0.008)compared with TAPE.Conclusions:APG demonstrated an upward trend in the TAPE group and a downtrend in the AS group after discharge from hospital.AS repair had an acceptable surgical effect in TOF patients,even in those with a dysplastic PVA.A higher APG remained upon hospital discharge in dysplastic patients with AS,but a downward trend was observed over time.