Surgical management of competing pulmonary blood flow affects survival before Fontan/Kreutzer completion in patients with tricuspid atresia type I.
OBJECTIVES
To determine the association between surgical management of pulmonary blood flow (PBF) at initial and staged procedures with survival to Fontan/Kreutzer operation (Fontan) in patients with tricuspid atresia.


METHODS
Infants aged <3 months with tricuspid atresia type I (n = 303) were enrolled from 34 institutions (1999-2013). Among those who underwent surgical intervention (n = 302), initial procedures were: systemic to pulmonary artery shunt (SPS; n = 189; 62%); pulmonary artery banding (PAB; n = 50; 17%); and superior cavopulmonary connection (SCPC; n = 63; 21%). Multiphase parametric-hazard models were used to analyze competing outcomes.


RESULTS
Risk-adjusted 6-year survival was lower after SPS (85%; P = .04) versus PAB (93%) or SCPC (93%). Survival after SPS when the main pulmonary artery (MPA) was closed (n = 21) or banded (n = 4) was 60%, versus 93% without MPA intervention (P = .02). After SPS, survival before SCPC was lower with an open ductus arteriosus (n = 7; 76% vs 97%; P = .02). Similarly, after SPS, risk-adjusted survival was similar to that for patients who had an initial PAB or SCPC when MPA intervention was avoided and the ductus arteriosus either closed spontaneously before SPS, or was closed during SPS. For all patients reaching SCPC (n = 277), survival to Fontan was not significantly influenced by whether PBF persisted through the MPA.


CONCLUSIONS
Tricuspid atresia patients with SPS represent a high-risk subgroup. Avoiding an open ductus arteriosus and concomitant MPA intervention during SPS may help mitigate the risk associated with SPS. The presence of antegrade PBF through the MPA, at initial and staged operations, did not significantly influence survival to Fontan operation.
['Wilder|Travis J|TJ|', 'Ziemer|Gerhard|G|', 'Hickey|Edward J|EJ|', 'Gruber|Peter J|PJ|', 'Karamlou|Tara|T|', 'Kirshbom|Paul M|PM|', 'Blackstone|Eugene H|EH|', 'DeCampli|William M|WM|', 'Williams|William G|WG|', 'McCrindle|Brian W|BW|']
D002170:Canada D018729:Fontan Procedure D006801:Humans D007223:Infant D053208:Kaplan-Meier Estimate D011183:Postoperative Complications D011446:Prospective Studies D011651:Pulmonary Artery D011652:Pulmonary Circulation D012307:Risk Factors D013997:Time Factors D016896:Treatment Outcome D018785:Tricuspid Atresia D014261:Tricuspid Valve D014481:United States
tricuspid atresia systemic to pulmonary artery shunt accessory pulmonary blood flow congenital heart disease