Late repair of tetralogy of Fallot during childhood in patients from developing countries
Open accessAbstract
OBJECTIVES: Although the current surgical approach of tetralogy of Fallot (TOF) is primary complete repair in infancy, late diagnosis and lack of surgical facilities in developing countries may delay surgical treatment. Some of these patients exposed to prolonged chronic hypoxaemia are transferred to more privileged countries to undergo surgical repair with the support of non-governmental organizations. The objective of this single-centre retrospective study was to compare the postoperative outcomes of these foreign patients undergoing delayed repair with those of patients born in France undergoing timely repair during the same time period. METHODS: The computer database of our institution was searched for all cases of TOF in foreign patients younger than 15 years, supported by two non-profit organizations, who underwent complete repair between January 2007 and December 2013. The control population consisted of the patients with TOF born in France, who underwent timely complete repair during the same period. RESULTS: The 47 foreign children were older (57.6 ± 38.4 vs 8.3 ± 9.1 months, P < 0.0001), more hypoxaemic (SaO2 79 ± 11 vs 91 ± 8%, P < 0.0001), more growth-retarded (body mass index Z-score -1.35 ± 1.5 vs -0.46 ± 1.3, P = 0.0034), and had higher haematocrit level (52.5 ± 11.7 vs 37.5 ± 6.1%, <0.0001) and worse left ventricular ejection fraction (LVEF 62 ± 8 vs 69 ± 3.8%, P < 0.0001) than the 90 French patients. Postoperative mortality and morbidity (sepsis, arrhythmia, bleeding and need for surgical revision) were similar in the two groups, except for a higher rate of pericardial and/or pleural effusion in foreign children (36 vs 17%, P = 0.02). Length of stay was shorter in foreign than in French patients (11 ± 6 vs 15 ± 15 days, P = 0.0012). CONCLUSIONS: In our experience, despite the presence of several risk factors (growth retardation, chronic hypoxaemia, polycythaemia and left ventricular dysfunction), late repair of TOF was undertaken during childhood in patients from developing countries with no difference in postoperative morbidity and mortality compared with that of timely repair during infancy. These older patients can be discharged sooner. However, patients undergoing late surgery may be at higher risk of complications of right ventricular failure, such as pleural and/or pericardial effusion.
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In LMICs, delayed diagnosis due to scarcity of congenital cardiology experts, lack of infrastructures, and lack of financial resources are among the hurdles found in most countries.
“Delayed diagnosis due to the scarcity of congenital cardiology experts, lack of infrastructures, and lack of financial resources are among the hurdles found in most of these countries.12,13”
From Tetralogy of Fallot in Low- and Middle-Income Countries (2024) · cites this paper as [13]
The Introduction (page unavailable) says diagnosis is often delayed in developing countries and surgical centres are limited. It does not attribute delayed diagnosis to a scarcity of congenital cardiology experts, inadequate infrastructure, or financial constraints, nor establish that these hurdles occur in most countries. (LLM, conf=0.88)
Experimental — accuracy not yet measuredBased on humanitarian experience, the mean age of repair between 4.7 and 21 years is more representative of the reality in LMICs.
“Based on our humanitarian experience (with Ste-Justine au Coeur du Monde for almost 20 years with missions in Morocco, Senegal, Ethiopia, South Africa, and Egypt), these metrics are more representative of the reality in LMICs.13,17, 21, 22”
From Tetralogy of Fallot in Low- and Middle-Income Countries (2024) · cites this paper as [13]
Table 1 reports a mean repair age of 57.6 months (4.8 years) for 47 children from developing countries, supporting the lower end of the stated range. The Introduction describes delayed repair in those countries, but this study does not report a mean age of 21 years or establish that its selected patients are representative of LMICs generally. The humanitarian experience in the citing sentence is the citing authors’ own. (LLM, conf=0.86)
Experimental — accuracy not yet measuredLimited data from LMICs suggest that the mean age of repair for tetralogy of Fallot is between 4.7 and 21 years.
“Indeed, the limited data from LMICs suggest that the mean age of repair is instead between 4.7 and 21 years.”
From Tetralogy of Fallot in Low- and Middle-Income Countries (2024) · cites this paper as [13]
Table 1 (page unavailable) reports a mean age at repair of 57.6 months, or 4.8 years, for children from developing countries—close to the claimed lower endpoint of 4.7 years. The paper does not report a 21-year mean or establish the claimed range. (LLM, conf=0.87)
Experimental — accuracy not yet measuredPatients from LMICs exhibit a higher number of symptoms due to prolonged hypoxic exposure.
“Patients from LMICs exhibited a higher number of symptoms due to prolonged hypoxic exposure.”
From Tetralogy of Fallot in Low- and Middle-Income Countries (2024) · cites this paper as [13]
The Preoperative characteristics section says the foreign children were more symptomatic and had lower oxygen saturation; Table 1 reports symptoms in 57% of foreign children versus 35% of French children. The paper describes prolonged chronic hypoxaemia in children from developing countries, but it does not establish that hypoxic exposure caused the higher symptom rate or that individual patients had a greater number of symptoms. (LLM, conf=0.84)
Experimental — accuracy not yet measuredMore than half of patients with tetralogy of Fallot in LMICs experience dyspnea, syncope, chest pain, and seizures.
“Indeed, more than half of the patients experienced dyspnea, syncope, chest pain, and seizures.12,13,17, 21, 22, 23”
From Tetralogy of Fallot in Low- and Middle-Income Countries (2024) · cites this paper as [13]
Table 1 (Clinical and echographic preoperative characteristics; page unavailable) reports that 27 of 47 foreign children (57%) had symptoms, including dyspnoea, cyanosis or cyanotic spells, and squatting. It does not report that more than half experienced dyspnoea specifically, or identify syncope, chest pain, or seizures among those symptoms. The finding is also from this group of children, not LMIC patients generally. (LLM, conf=0.88)
Experimental — accuracy not yet measured
Patients from LMICs had a lower oxygenation rate and a higher haematocrit than French patients due to sustained hypoxia.
“Furthermore, patients from LMICs had a lower oxygenation rate and a higher haematocrit than French patients due to sustained hypoxia.”
From Tetralogy of Fallot in Low- and Middle-Income Countries (2024) · cites this paper as [13]
In a study in France, patients from LMICs operated for tetralogy of Fallot were operated significantly later and had a significantly lower body mass index Z-score at intervention than French patients.
“The patients from LMICs were operated on significantly later and had a significantly lower body mass index Z-score at the time of the intervention than the French patients.13”
From Tetralogy of Fallot in Low- and Middle-Income Countries (2024) · cites this paper as [13]
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References 15 · Cited by 23
- Authors
- Benbrik, N., Romefort, B., Le Gloan, L., Warin, K., Hauet, Q., Guerin, P., Baron, O., & Gournay, V.
- Affiliations
- Centre Hospitalier Universitaire de Nantes (FR)
- Corresponding author
- Gournay, Véronique
- Venue
- European Journal of Cardio-Thoracic Surgery
- Publisher
- Oxford University Press (OUP)
- Published
- 2014-12-03
- Volume
- 47
- Issue
- 3
- Pages
- e113-e117
- ISSN
- 1010-7940 (ISSN-L)
- 1873-734X
- OpenAlex
- W2134004465
- Cited by
- 23
- References
- 15
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 2 · 2023: 3 · 2022: 3 · 2021: 2 · 2019: 3 · 2018: 4 · 2017: 1 · 2016: 2
- FWCI
- 0.76
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- European Journal of Cardio-Thoracic Surgery (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Congenital Heart Disease Studies
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiovascular Conditions and Treatments
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Congenital heart defects research
- Keywords
- tetralogy of Fallot, delayed surgical repair, delayed diagnosis, chronic hypoxaemia, polycythemia, growth retardation, left ventricular dysfunction, pericardial effusion, pleural effusion, postoperative outcomes, foreign patients, developing countries, non-governmental organizations, international patient transfer, length of hospital stay, surgical revision, sepsis, cardiac arrhythmias
- MeSH terms
- Developing Countries, Female, France, Humans, Male, Postoperative Complications, Retrospective Studies, Tetralogy of Fallot
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