Propranolol palliation after right ventricular outflow tract stenting reduces the reintervention rate until complete repair of Fallot tetralogy and variants

Abstract

Introduction: Stenting of the right ventricular outflow tract (RVOT) is a reasonable palliation in symptomatic infants with tetralogy of Fallot (ToF) and variants. However, this procedure needs reintervention until corrective surgery.

Aim: To compare RVOT stenting followed with or without propranolol medication until complete repair of ToF and variants.

Material and methods: Twenty-five cyanotic infants under 6 months of age with ToF and variants underwent RVOT stenting between March 2017 and May 2024 including the first 11 followed without propranolol medication and the next 14 followed with propranolol medication.

Results: Median age at initial RVOT stent implantation was 92 days and similar in both groups. At the time of this writing, total correction of ToF has been performed in 23 patients including 11 followed without propranolol medication and 12 followed with propranolol medication. Median age at the time of surgery was 258 days and similar in both groups. The rate of reintervention before complete repair was 8/25 (32%) during follow-up for recurrence of cyanosis, including 6/11 (54%) patients followed without propranolol medication and 2/14 (14%) in patients with propranolol medication (p = 0.041). The remaining 2 patients followed with propranolol medication required reintervention 150 and 170 days after initial intervention.

Conclusions: Long-term treatment with propranolol given after RVOT stenting in ToF and variants, particularly under 3 months of age, may reduce the need for further interventions prior to complete repair.

Keywords: palliative care; stent; tetralogy of Fallot; ventricular outflow.

Figure 1

Kaplan-Meier analysis showed significant difference in reintervention rate between groups followed with or without propranolol medication after right ventricular outflow tract stenting (p = 0.041, log rank test). Furthermore, reintervention events of group followed without propranolol medication were more likely to be concentrated in the early period of initial RVOT stenting and follow-up

Figure 2

Right ventricular outflow tract (RVOT) stenting procedure in a 3.6 kg neonate with tetralogy of Fallot and recurrent stenosis occurred at the proximal stent end within 3 months of initial stenting. A – Initial right ventricular outflow tract angiogram in 30° right anterior oblique and cranial angulation. B – 4 mm 16 mm long coronary stent in position. Saturations improved from 72% to 89%. C – Progressive muscular narrowing below the stent (white arrow). D – The muscular stenosis was treated by restenting the outflow tract, with the 4.5 mm 12 mm stent covering the muscular band proximally and extending telescopically well into the prior stent. Saturations improved from 68% to 92%