Managing cyanotic neonates with tetralogy of Fallot: A national perspective on surgical approaches

Abstract Background Management of cyanotic neonates with Tetralogy of Fallot (ToF) remains an important clinical challenge without Level 1 evidence. The Healthcare Cost and Utilization Project Kids Inpatient Dataset (HCUP-KID) is underutilized for evaluating and comparing a national sample of neonates undergoing primary repair, ductal stents, and systemic to pulmonary shunts over time. Methods Using HCUP-KID, a four-stage algorithm was designed to capture records for neonates with ToF who underwent primary repair, ductal stents, and systemic-to-pulmonary shunts in HCUP-KID years 2016, 2019, and 2022. Hospitalization estimates (n) and percent reported (SE, standard error) reflect weighted results based on survey design. Resource utilization was represented by median hospital length of stay (days) and inflation-adjusted cost in 2023 United States Dollars (USD). Results An estimated 159.5 discharges nationally were identified for primary repair, 145.3 for ductal stents, and 407.4 discharges undergoing surgical systemic to pulmonary shunt. An estimated 256.3 discharges nationally were identified for infants undergoing definitive repairs following ductal stents. National discharge estimates indicate that ductal stents increased in utilization (linear trend p=0.0011) while surgical shunts decreased (trend p=0.0012). There was an observed decrease in primary repair (trend p = 0.12). Primary repair had the greatest resource utilization (median LOS 46.9 days and adjusted cost $342,504 2023-USD), followed by surgical shunts (35.1 days, $208,358 2023-USD), ductal stents (21.1 days, $132,259 2023-USD), and definitive repair following ductal stents (7.4 days, $82,788 2023-USD). Between 2016 and 2022, there was a significant increase in the median cost for stent (difference, $77,252 2023-USD, p=0.035) and shunt (difference, $81,111 2023-USD, p=0.043) palliations and an observed decrease in primary repair cost (difference, $76,337, p=0.44). Conclusions This investigation demonstrates an increased utilization of ductal stents for neonatal ToF across centers nationally. Despite this increase, observed changes in cost reflect a complex paradigm shift that may reflect patient/center-specific decision-making.