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Transcatheter Approaches to Palliation for Tetralogy of Fallot

  • Athar M. Qureshi
    Correspondence
    Address reprint requests to Athar M. Qureshi, MD, Medical Director, CE Mullins Cardiac Catheterization Laboratories, The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Professor of Pediatrics, Baylor College of Medicine, Attending Physician, Internal Medicine/Cardiology, Baylor St. Luke's Medical Center, 6651 Main Street, E 1920, Houston, TX, 77030.
    Affiliations
    The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital and Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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  • Christopher A. Caldarone
    Affiliations
    Congenital Heart Surgery, Texas Children's Hospital and Department of Surgery, Baylor College of Medicine, Houston, Texas
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  • Travis J. Wilder
    Affiliations
    Division of Congenital Heart Surgery, University Hospitals, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
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      To this day, controversy still exists regarding the optimal method to treat symptomatic neonates and infants with Tetralogy of Fallot (TOF). Symptomatic (severely cyanotic or ductal dependent) infants with TOF can undergo either a staged repair approach (consisting of initial palliation followed by complete repair) or primary repair. Traditionally, initial palliative procedures have been surgical, for example placement of a Blalock-Taussig-Thomas (BTT) shunt. Recent advances in technology have facilitated the introduction of catheter-based procedures as palliative techniques, for example, patent ductus arteriosus (PDA) stenting and right ventricular outflow tract (RVOT) stenting as more durable solutions than balloon pulmonary valvuloplasty (BPV). In this article, we discuss the rationale for these procedures, technical aspects of these procedures and outcomes data compared to traditional surgical procedures. Recent data have suggested that RVOT and PDA stenting procedures offer many advantages over traditional surgical palliative procedures as palliative methods in this patient population. This comes at a cost of increased reintervention burden, which may be considered part of the overall treatment strategy in smaller neonates and can be minimized with a focus on technical aspects and overall treatment strategies. Advanced surgical techniques are required at the eventual complete repair to negotiate removal of stent material and pulmonary artery reconstruction in some instances. Further adoption of catheter based palliative procedures for infants with symptomatic TOF has the potential to tip the outcomes towards favoring a staged approach, particularly in high-risk infants.

      Graphical abstract

      Keywords

      Abbreviations:

      BPV (balloon pulmonary valvuloplasty), mBTTS (modified Blalock-Taussig-Thomas Shunt), CCRC (Congenital Cardiac Research Collaborative), CT (Computerized Tomography), MAPCAs (Major aortopulmonary collateral arteries), PDA (patent ductus arteriosus), PA (pulmonary artery), PA (pulmonary atresia), PHIS (Pediatric Health Information System), RVOT (right ventricular outflow tract), TOF (Tetralogy of Fallot)
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