Clinical Status and Reintervention in Neonates With Symptomatic Tetralogy of Fallot: A Landmark Analysis

Background: In symptomatic neonates with tetralogy of Fallot (sTOF), the initial treatment strategy significantly affects early outcomes, but its long-term impact remains less well defined. Objectives: The aim of the study was to compare primary (PR) vs staged repair (SR) in sTOF with respect to reintervention (RI) rates and types, clinical and echocardiographic outcomes, and medication use. Methods: Neonates with sTOF undergoing PR or SR and with >1 year of follow-up after complete repair were included. The primary outcome was cumulative RI incidence; secondary outcomes included mortality and late echocardiographic and clinical findings. Propensity scoring adjusted for baseline differences. Landmark analysis assessed RI risk at yearly intervals following complete repair. Results: Of 441 neonates, 182 (41%) underwent PR, and 259 (59%) underwent SR. Groups differed in gestational age, intubation, and 22q11 status. Median follow-up postrepair was 5.26 (2.91, 8.21) years. RI burden was high in both groups, with a small, consistent but nonsignificant advantage to PR. The type of RI varied over time. PR was associated with greater pulmonary insufficiency and larger pulmonary arteries. RV pressure was ≤half systemic in 80%; 10% had ≥moderate tricuspid regurgitation, without between-group difference. Elevated RV pressure was associated with ≥moderate tricuspid regurgitation. Conclusions: Among sTOF survivors beyond the early perioperative period, late RI burden and residual hemodynamic lesions are common and largely unrelated to initial strategy. PR is associated with increased pulmonary insufficiency and pulmonary artery size.