# Impact of right ventricular incision extent on early outcomes after tetralogy of Fallot repair: a two-center retrospective cohort study

## TL;DR

This study examines how the extent of right ventricular incisions during tetralogy of Fallot repair affects early surgical outcomes, finding that incision extent influences risk profiles but not major adverse events.

## Contribution

The study provides two-center retrospective evidence on the impact of varying right ventricular incision extent in tetralogy of Fallot repair.

## Key findings

- Patients without right ventricular incision had more favorable outcomes, likely due to better baseline anatomy.
- Rates of major adverse events did not differ significantly after adjusting for baseline imbalances.
- Hemodynamic parameters and residual right ventricular outflow tract gradients were comparable across groups.

## Abstract

The role of right ventricular (RV) incision during tetralogy of Fallot (TOF) repair remains controversial. Although RV incisions facilitate the closure of ventricular septal defects (VSDs) and relieve right ventricular outflow tract (RVOT) obstruction, concerns remain regarding late ventricular dysfunction. Alternative approaches that limit or avoid RV incision have been advocated; however, most evidence derives from single-center retrospective reports, leaving the clinical impact uncertain.

We retrospectively analyzed 237 patients who underwent repair of TOF at two tertiary centers between 2015 and 2019. Patients were stratified into three groups: Group 1 (no RV incision), Group 2 (incision confined to the infundibulum), and Group 3 (incision extending beyond the infundibulum). The primary endpoint was major adverse events (MAEs, defined as in-hospital mortality, need for extracorporeal membrane oxygenation, malignant arrhythmias, delayed sternal closure, reoperation requiring cardiopulmonary bypass, and reintubation). Secondary endpoints included length of intensive care unit (ICU) stay, total hospital stay, ventilation duration, 24-h drainage output, and other postoperative complications. Both crude and propensity score-matched (PSM) analyses were performed.

In crude analyses, delayed sternal closure was more frequent in Group 2 but did not reach statistical significance (P = 0.052), while rates of infection and transfusion were higher in Group 3 compared with Group 1. After PSM, differences between Groups 2 and 3 persisted, whereas Group 1 continued to demonstrate more favorable outcomes, likely reflecting more favorable baseline anatomy. Hemodynamic parameters and residual RVOT gradients were comparable across groups after matching.

The extent of RV incision during repair of TOF was associated with distinct perioperative risk profiles; however, rates of major adverse events did not differ significantly after adjustment for baseline imbalances. The more favorable outcomes observed in patients without an RV incision primarily reflected anatomical advantages rather than an intrinsic superiority of the surgical approach. These findings suggest that RV incision should be minimized when technically feasible while ensuring adequate relief of RVOT to ensure procedural safety. Prospective multicenter studies with long-term, imaging-based follow-up are required to determine the impact of incision strategy on RV function, pulmonary regurgitation, and late outcomes.