The many factors leading to resurgence of the Blalock shunt for tetralogy

Central MessageMultiple factors are coalescing to reverse the move early primary repair of tetralogy despite widespread acceptance neonatal transposition and other symptomatic anomalies.This Invited Expert Opinion provides a perspective on following paper: J Am Coll Cardiol. 2019;74(12):1570-1579. https://doi.org/10.1016/j.jacc.2019.05.057.See Commentaries pages 400 401. Multiple anomalies. This https://doi.org/10.1016/j.jacc.2019.05.057. See Feature Editor's Introduction—It is my honor introduce expert opinions Drs Jonas Fraser, 2 highly gifted respected surgeons, whom congenital editors invited share their not always congruent surgical management neonates with Fallot (ToF). Isn't this “dead horse” issue that had already been pulverized ash? In certain sense, yes, but prestigious cardiology journal recently published report based national administrative data concluded “complete for ToF associated significantly higher risk 2-year mortality compared staged approach, after accounting patient hospital characteristics.”1Savla J.J. Faerber J.A. Huang Y.V. Zaoutis T. Goldmuntz E. Kawut S.M. et al.2-year outcomes complete or procedure in neonates.J 2019; 74: 1570-1579Crossref PubMed Scopus (22) Google Scholar Given what we know about databases, would likely need invoke bit faith regarding validity specific conclusion. But was shocking best survival only 85%. Really? ToF—low single-digit mortality, right? Apparently wrong! sobering, humbling fact should cause us significant pause. there much bigger horse afoot very alive well. So I encourage you pause, clear your thoughts (and biases), proceed enjoy our experts' opinions. Ronald K. Woods, MD, PhD preprostaglandin years cardiac surgery during 1950s, 1960s, 1970s, carried an unacceptably high appropriately avoided favor palliative procedures such as shunts bands. The introduction prostaglandin E1 allowed newborns critical heart disease be stabilized accurately diagnosed. Ongoing improvements hardware cardiopulmonary bypass miniaturization circuits technologic oxygenator design, particularly membrane oxygenators, opened door low-risk major reparative first weeks life. arterial switch landmark event history because elective operation undertaken time large numbers.2Castaneda A.R. Norwood W.I. R.A. Colan S. Sanders Lang P. Transposition great arteries intact ventricular septum - anatomic correction neonate.Ann Thorac Surg. 1984; 38: 438-443Abstract Full Text PDF (203) There alternative more extremely low risk, namely, Senning Mustard operation. anatomically corrective procedure, switch, newborn period. Forty later, “elective” carries exceedingly universally accepted. Likewise, few centers surgeons who choose palliate truncus arteriosus interrupted aortic arch. Even reconstructive preferred at most over options hybrid approach hypoplastic left syndrome. interesting question ponder why (ToF) has reemerged controversy last years, reversing tide opinion becoming heavily weighted toward 10 15 ago. Early establishes normal biventricular circulation optimal development all organ systems.3Jonas Optimal timing surgery: importance repair.Comprehensive Surgical Management Congenital Heart Disease. 2nd ed. Taylor & Francis, Boca Raton, FL2014: 219-228Crossref For patients ToF, long septal defect open, pressure right ventricle will systemic progressively hypertrophied relative ventricle. important implications longer term diastolic compliance fibrosis arrhythmia. brain developing rapidly year life benefits from delivery oxygen substrate. A fetal where cerebral oxygenation blood flow can reduced impair growth maturation, so catching up done. clearly emotional psychologic new parents reassured by repair, thereby removing stress feared delayed indeterminate if child undergoes palliation. Finally, several studies have documented increased cost 2-stage including period medical interval period.4Ungerleider R.M. Kanter R.J. O'Laughlin M. Bengur Anderson P.A. Herlong J.R. al.Effect strategy infants Fallot.Ann 1997; 225: 779-783Crossref (32) Scholar,5Peer Zurakowski D. Sinha does lead postoperative resource utilization.Ann 2014; 98: 2173-2179Abstract (13) Fortunately, Aldo Castaneda John Kirklin understood limitations focusing procedural rather than longer-term diagnostic cohort transposition. They organized multi-institutional study Surgeons Society used its end point diagnosis mortality.6Castaneda Trusler G.A. Paul M.H. Blackstone E.H. J.W. results treatment simple current era.J Cardiovasc 1988; 95: 14-28Abstract Although expected, loss preoperative before atrial counterbalanced slightly procedure. words, overall improved mortality. Unfortunately, databases use around world today, Thoracic database North America, focused entirely survival. focus magnified U.S. News World Report program rankings numbers. misconception methods “risk adjustment” applied counterbalance limitation point. plain wrong. It possible fully understand inherent without also considering either interim repair. Of note, deaths these simply included ultimate And larger denominator resulting translates into lower rate whole. parallels between sports franchises United States programs. emphasis today analytics changed decision-making practices athletes managers bend rules overlook them altogether. Today, hospitals number cases performed programs often provide incentives promote own rankings. Shifting policy 100% initial palliation below arbitrary age weight substantially increase program, census intensive care unit, value units intensivists team. An additional consequence having microscope centered increasingly hostile environment teaching surgery. Teaching takes effort, operating time, cost, factored attendings' insurance reimbursement. pipeline young graduating expertise general cardiothoracic drying up, although popularity fortunately remains strong, applicant pool limited. greater dependence further training staff, which hardly conducive taking challenging one's practice. no technically demanding surgeon. Nevertheless, good result leads far easier nursing staff unit team alternatives. review recent article Savla colleagues,1Savla Journal American College Cardiology, supports noted, pushing pendulum back frequent ToF. describes analysis institution, Children's Hospital Philadelphia. authors, none surgeon, conclude powerful statement: “Complete characteristics.” persuasiveness aided “Central Image” depicting curves However, Figure Y axis (probability survival) begins just 0.8 extends 1, magnifying apparent differences visual way approaches. confidence bands error bars show variability estimates, differ 5% widest separation. addition well-known using maintained primarily billing, article.1Savla 49% (504/1032) less follow-up group 36% (478/1331) group. excluded, rates 17.4% 17.2% detailed chart 11Savla shows receiving total 8.9% (92/1032) 11.0% (147/1331) those undergoing authors1Savla inverse probability weighting propensity score achieve multivariable adjustment patient- hospital-level characteristics. unusual given k-nearest neighbor matching scores traditionally obtain comparable groups. Therefore, summary it may appropriate draw strong conclusions, stated title abstract article.