Influence of Technical Performance Score on Outcomes After Tetralogy of Fallot Repair in a Low-Middle-Income Country

Objectives Tetralogy of Fallot (TOF) repair is associated with low mortality in high-performance centers, but outcomes are worse in low- and middle-income countries (LMICs). Prior studies have not demonstrated a strong link between Technical Performance Score (TPS) and mortality. The aim of this was to evaluate risk factors for mortality and complications after TOF repair in a high-volume LMIC heart center with a focus on surgical performance. Methods We retrospectively reviewed children undergoing TOF repair between 2015 and 2022. Patients over two years of age or with complex defects beyond atrial septal defect and persistent ductus arteriosus were excluded. Preoperative factors included age, weight, genetic syndromes, urgency, and pulmonary artery z-scores. Intraoperative variables included transannular patch use, cardiopulmonary bypass and cross-clamp times, surgeon, and TPS classification. Postoperative variables included delayed sternal closure (DSC), extracorporeal membrane oxygenation (ECMO), and Vasoactive Inotropic Score (VIS) during the first 24 h. Outcomes included mortality, complications, and length of stay (LOS). Analyses included logistic regression and Kaplan-Meier estimates. Results Among 255 patients, in-hospital mortality was 7.5% (n = 19). Technical Performance Score class 3 was an independent predictor of mortality ( P = .027), along with VIS 24 h and ECMO. Cardiopulmonary bypass time, ECMO, and DSC were associated with major complications. Technical Performance Score class 3 correlated with longer LOS, but multivariable analysis identified low weight and ECMO as independent LOS predictors. Five-year survival was worse in TPS class 3 ( P = .007). Conclusions Inadequate TPS is an independent predictor of mortality after TOF repair in an LMIC context. Class 3 TPS also relates to longer hospitalization and worse medium-term survival. Surgical quality remains essential for better outcomes.