Early primary repair of congenital heart disease: Advantages and the importance of database configuration

The introduction of the neonatal arterial switch operation in the 1980s demonstrated that early repair of congenital heart anomalies could be performed with improved patient survival relative to initial palliation and delayed repair in later infancy or beyond. Over the next decade or two, there was a continuing move away from a staged approach at most congenital heart programs. Studies from that era documented that the staged approach increased overall cost and reduced ultimate patient survival. However, over the last decade or two, there has been resurgent popularity of a staged approach, particularly for the management of very small and premature newborns. This paper reviews the factors that have led to increasing enthusiasm for the staged approach to management of congenital heart disease. The danger of using procedural databases like the Society for Thoracic Surgery (STS) and European Association for Cardiothoracic Surgery (EACTS) surgical databases to measure the quality of overall patient management strategy is emphasized. Until diagnosis-based, patient survival databases are used for Quality Assurance, it will not be possible to define whether a tipping point exists, below which very small and complex neonates should be managed with a staged approach. However, current data strongly suggest that neonates of at least average size as well as young infants have improved survival and reduced reintervention as well as markedly reduced time in hospital and overall costs when a strategy of early primary repair is pursued.