Primary repair versus pulmonary artery banding in complete atrioventricular canal defects in the modern surgical era.

Abstract

Objective: The impact of early age on outcomes for repair of complete atrioventricular canal defects (CAVCs) remains poorly defined. We evaluated young infants with CAVC, comparing those who underwent primary repair versus primary pulmonary artery banding (PAB) and results related to left atrioventricular valve (AVV) reintervention and survival.

Methods: Patients (age <60 days) with CAVC were evaluated (January 2005 to April 2022) at a single institution. Patients were categorized as having primary CAVC repair or PAB. Patients with complex unbalanced CAVC and severely hypoplastic ventricles and those not undergoing CAVC repair after PAB were excluded. Outcome measures included total number of operations, reoperation on the left AVV, hospital length of stay, and mortality.

Results: CAVC was identified in 135 patients, mean age 33 ± 19 days and weight 3.4 ± 0.7 kg at primary operation. Additional diagnosis included transposition of the great arteries (n = 4), tetralogy of Fallot (n = 9), transposition of the great arteries (n = 13), and total and partial anomalous pulmonary venous return (n = 7). Thirty-three patients required preoperative respiratory support. Primary CAVC repair was performed in 101 patients at 38 ± 16.6 days and 3.5 ± 0.7 kg, and primary PAB was performed in 34 patients at 16 ± 15 days and 3.2 ± 0.7 kg, of whom 62% (n = 21) underwent subsequent CAVC repair at 6.9 ± 4.7 months and 6.6 ± 2.3 kg. When we compared patients undergoing primary CAVC versus PAB; 55% versus 48% had preoperative mild and 39% versus 29% mild-moderate or greater atrioventricular valve regurgitation (AVVR). In patients who underwent CAVC repair, a 2-patch repair was used in 66% of cases and posterior left AVV annuloplasty in 34%. Predischarge reoperation for left AVVR was required in 13% (n = 14/101) patients whereas in patients who underwent PAB, it was required in 14% (n = 3/21). Hospital length of stay was shorter for primary CAVC (25 vs 41 days). Overall, median follow-up was 4.5 years. Patients undergoing primary CAVC had fewer total number of operations (1.3 vs 2.5, P < .001) and fewer reoperations on the left AVV (18% vs 24%, P = .56). Overall, freedom from reoperation in primary CAVC for left AVVR at 1 and 5 years was 85% and 82% compared with patients who underwent PAB (89% and 69%). At follow-up, 88% of patients undergoing primary CAVC repair had mild or less left AVVR, whereas 82% undergoing initial PAB had mild or less left AVVR. There were 10 deaths; overall mortality was 6% in patients who underwent primary CAVC and 19% in patients who underwent PAB. Similarly, follow-up rates of significant AVVR and mortality did not differ significantly between groups (P > .05).

Conclusions: Definitive CAVC repair at ≤60 days can be performed with acceptable midterm survival. Primary CAVC repair versus primary PAB for young patients undergoing CAVC has a trend toward fewer total operations, fewer reoperations for AVVR, decreased hospital LOS, and less mortality. However, reoperation rates for AVVR and mortality were not statistically different, and pacemaker implantation occurred in 10% of patients who underwent primary repair. These results underscore the need for cautious interpretation, given the limitations of statistical power. Reoperation for left AVVR remains a challenge and occurs early after repair. Evolving surgical techniques to avoid postoperative left AVV dysfunction should further reduce early postoperative morbidity and hospital resource use.