Comparative Outcomes of Left Anterior Thoracotomy Versus Resternotomyfor Pulmonic Valve Replacement After Tetralogy of Fallot Repair

Noppon Taksaudom, Amarit Phothikun, Jakaparn Horsatidkul, Thitipong Thepsuwan, Surin Woragidpoonpol.Cardiovascular surgery unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai University, Chiang Mai, Thailand.

Background: ReoperativePVR after TOF repair presents significant surgical challenges. This study compares the clinical outcomes of left anterior thoracotomy (LAT) versus resternotomyapproaches to PVR.
Methods: A retrospective analysis LAT (n=20) vs. resternotomy(n=18)
Exclusion: residual intracardiac shunts, concomitant valvular surgeries One conversion due to an abnormal valve position in TOF with absent pulmonic valve was also excluded.
Results: LAT group showed….
- Significantly higher proportion of males 75% vs. 38.89%, p=0.047
- Significantly higher proportion of beating heart operation100% vs. 38.89%, p>0.005
- Non-significantly shorter operative times 157.05 ±49.42 vs. 178.06 ±58.69 minutes, p=0.239
- Non-significantly shorter postoperative hospital stays 4.75 ±1.21 vs. 6.17 ±4.38 days, p=0.173
- Non-significantly lower drain outputs on postoperative day 1 and 2184.4 ±272.43 vs. 397.22 ±411.19, p=0.066; 105.5 ±86.78 vs. 355.56 ±581.52, p=0.065
- Significantly lower inotropic score on postoperative day 0 and 10.05 ±0.22 vs. 4.36 ±6.95, p=0.009; 0 vs. 2.17 ±4.52, p=0.039
- More intraoperative extubation15% vs. 5.56%, p=0.606
- Non-significantly shorter intubation time 6.97 ±4.18 vs. 10.26 ±9.35, p=0.195
- Similar complication rates without mortality in either cohort

Discussion:
LAT supports previous findings 1 showing better hemodynamics and myocardial preservation with beating heart techniques which may cause by beating heart operation.
Trends toward shorter CPB and operative times contrast with prior reports of longer durations in MICS2.
Trends toward faster recovery and shorter length of stay.
Similar morbidities without mortality.
One excluded case (TOF with APV) required conversion due to distorted anatomy, highlighting limitations of LAT in complex anatomy.

Conclusions:
LAT for PVR after TOF repair…
Safe alternative approach
Similar morbidities without mortality
Potential advantages in operative and recovery parameters
Shorter CPB and operative times
Significantly reduced inotropic requirements
Shorter hospital stays
Lower drain outputs
Careful preoperative imaging evaluation is crucial.

1.
Nellis JR, Vekstein AM, Meza JM, Andersen ND, Haney JC, Turek JW. Left Anterior Mini-Incision for Pulmonary Valve Replacement Following Tetralogy of Fallot Repair. Innovations (Phila). 2020;15(2):106-10 DOI: 10.1177/1556984520911025.
2.
Thornton S, Kang L, Nellis J, Andersen ND, Haney J, Turek J. Comparison of median sternotomy and left anterior mini-incision for pulmonary valve replacement following primary tetralogy of Fallot repair. Cardiol Young. 2023;33(1):21-5 DOI: 10.1017/S1047951122000105.