Primary Repair vs. Pulmonary Artery Banding in Complete Atrioventricular Canal Defects in the Modern Surgical Era

Impact of early age on outcomes for repair of complete atrioventricular canal defects (CAVC) remains poorly defined. We evaluated young infants with CAVC, comparing those who underwent primary repair vs. primary pulmonary artery banding (PAB) and results related to left atrioventricular valve (AVV) re-intervention and survival. CAVC patients (age <60 days) were evaluated (01/2005-04/2022) at a single institution. Patients were categorized as having primary CAVC repair or PAB. Patients with complex unbalanced CAVC and severely hypoplastic ventricles and those not undergoing CAVC repair following PAB were excluded. Outcome measures included: total number of operations, re-operation on the left AVV, hospital length of stay (LOS) and mortality. CAVC was identified in 135 patients, mean age 33±19 days and weight 3.4±0.7kg at primary operation. Additional diagnosis included: TGA (n=4), TOF (n=9), DORV (n=13) and TAPVR (n=7). 33 patients required pre-operative respiratory support. Primary CAVC repair was performed in 101 patients at 38±16.6 days and 3.5±0.7kg and primary PAB was performed in 34 patients at 16±15days and 3.2±0.7 kg of which 62% (n=21) underwent subsequent CAVC repair at 6.9±4.7 months and 6.6±2.3 kg. Comparing primary CAVC vs. PAB patients; 55% vs. 48% had preoperative mild and 39% vs. 29% ≥ mild-moderate AVV regurgitation (AVVR). In CAVC repair patients, a 2-patch repair was utilized in 66% of cases and posterior left AVV annuloplasty in 34%. Pre-discharge re-operation for left AVVR was required in 13% (n=14/101) patients while in PAB patients was required in 14% (n=3/21). Hospital length of stay was less for primary CAVC (25 vs. 41 days). Overall, median follow-up was 4.5 years. Patients undergoing primary CAVC had less total number of operations (1.3 vs.2.5, p<0.001) and less re-operations on the left AVV (18% vs. 24%, p=0.56). Overall, freedom from reoperation in primary CAVC for left AVVR at 1 and 5 years was 85% and 82% compared to PAB patients (89% and 69%). At follow-up, 88% of patients undergoing primary CAVC repair had ≤ mild left AVVR while 82% undergoing initial PAB had ≤ mild left AVVR. There were 10 deaths; overall mortality was 6% in primary CAVC and 19% in PAB patients. Similarly, follow-up rates of significant AVVR and mortality did not differ significantly between groups (p>0.05). Definitive CAVC repair at ≤60 days can be performed with acceptable mid-term survival. Primary CAVC repair vs. primary PAB for young CAVC patients have a trend toward fewer total operations, less reoperations for AVVR, decreased hospital LOS and less mortality. However, reoperation rates for AVVR and mortality were not statistically different, and pacemaker implantation occurred in 10% of primary repair patients. These results underscore the need for cautious interpretation given the limitations of statistical power. Reoperation for left AVV regurgitation remains a challenge and occurs early after repair. Evolving surgical techniques to avoid postoperative left AVV dysfunction should further reduce early postoperative morbidity and hospital resource utilization.