Repair of tetralogy of Fallot in neonates: a single-center case series
Original Article

Repair of tetralogy of Fallot in neonates: a single-center case series

Can Jin1#, Yongtao Wu1#, Yalun Qu1, Zhiyi Wang1, Bin Li1, Jun Yan1, Francesco Nappi2, Stiljan Hoxha3, Qiang Wang1

1Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; 2Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, France; 3Division of Cardiac Surgery, Department of Surgery, Dentistry, Pediatrics and Gynecology, Verona, Italy

Contributions: (I) Conception and design: Q Wang; (II) Administrative support: J Yan; (III) Provision of study materials or patients: Y Wu; (IV) Collection and assembly of data: Z Wang, Y Qu; (V) Data analysis and interpretation: B Li; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

#These authors contributed equally to this work.

Correspondence to: Qiang Wang, PhD. Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing 100029, China. Email: wqcory@126.com.

Background: The optimal timing for surgical intervention in the management of tetralogy remains a subject of ongoing debate. This investigation involved a retrospective analysis of neonatal patients who had received continuous treatment for tetralogy of Fallot (TOF) at our centre. The objective of this study was to examine the feasibility and necessity of treating TOF in the neonatal period.

Methods: A retrospective analytical investigation was undertaken of 33 cases of neonates who underwent consecutive one-stage surgical repair for TOF at the Beijing Anzhen Hospital from June 2022 to December 2023. The subjects had an average gestational age of 38.1 weeks (range, 31.3–40.0 weeks) and a median age at surgery of 14.0 days [interquartile range (IQR): 9.75–20.0 days]. Their mean weight at the time of surgery was 3.25±0.53 kg, and their mean pulse blood oxygen saturation (SpO2) level was 93.0% (range, 80–98%).

Results: The mean duration for which aortic cross-clamping was performed during the surgical procedure was 74.24 minutes, with a standard deviation of ±16.33 minutes. The average duration of cardiopulmonary bypass (CPB) was 118.85±17.94 minutes. The average duration of postoperative mechanical ventilation was 110.6 hours (±89.2 hours). The patients’ average postoperative intensive care unit (ICU) stay was 10 days (range, 6.75–13.25 days), and their median postoperative stay was 14 days (IQR, 11.75–15.5 days). Postoperative complications were observed in two patients (6%), who required peritoneal dialysis catheter insertion at the bedside to manage fluid imbalances. No further interventions nor mortalities occurred during the follow-up period. The median follow-up period after surgery was 201 days (range, 51–417 days).

Conclusions: The curative effect of TOF repair in the neonatal period is well-documented, with its ability to prevent the effects of pulmonary artery development and collateral circulation formation. Consequently, we suggest considering TOF repair during the neonatal period.

Keywords: Tetralogy of Fallot (TOF); neonatal period; one-stage surgical repair

Submitted Feb 25, 2025. Accepted for publication Jun 06, 2025. Published online Jun 25, 2025.

doi: 10.21037/tp-2025-133

Highlight box

Key findings

• Complete surgical repair of tetralogy of Fallot (TOF) in the neonatal period is well documented. This definitive intervention has been shown to effectively mitigate adverse effects on pulmonary artery development and prevent collateral circulation formation. Therefore, primary complete repair should be prioritized during the neonatal period for anatomically eligible patients.

What is known, and what is new?

• Historically, the limitations of early surgical techniques resulted in high mortality rates for primary complete repair of TOF in neonates. However, advancements in surgical methods have significantly reduced mortality. Nevertheless, controversy persists regarding the optimal age for primary complete repair. The fundamental prerequisite for definitive repair is adequate pulmonary artery development to sustain near-total cardiac output, as indicated by a McGoon ratio >1.2 and a Nakata index >150 mm2/m2.

• Beijing Anzhen Hospital’s study of 33 neonates undergoing single-stage TOF repair (median surgical age of 14 days) showed a 6% complication rate and no mortality during follow-up, confirming neonatal TOF repair is safe and effective; the surgery promotes pulmonary artery development and reduces collateral circulation formation.

What is the implication, and what should change now?

• Future research should prioritize longitudinal studies comparing prenatal/postnatal pulmonary artery development in TOF-affected vs. healthy fetuses, guiding timely interventions and refining neonatal surgical protocols.

Introduction

Tetralogy of Fallot (TOF) constitutes the most common cyanotic congenital heart disease, with a prevalence of approximately 35 per 100,000 live births. This renders it a significant concern within the domain of conotruncal defects and paediatric cardiology (1). The evolution of surgical interventions for TOF marks a pivotal milestone in congenital heart surgery. Initial palliative approaches in the 1940s aimed at augmenting pulmonary blood flow were superseded by definitive intracardiac repairs by 1954 (2). Primary repair is pursued when anatomically feasible, requiring (I) adequate pulmonary artery dimensions, (II) absence of major aortopulmonary collateral arteries, and (III) clinical stability to tolerate cardiopulmonary bypass (CPB). Early infant repairs initially carried high mortality rates, reflecting technical limitations of the era. However, advancements in surgical techniques, preoperative imaging, and perioperative care have significantly improved outcomes (3-5). Despite these advances, long-term complications—including ventricular dysfunction, arrhythmias, and mortality—remain prevalent by the third postoperative decade (6). Delayed repair risks irreversible right ventricular compliance loss and secondary left ventricular dysfunction, underscoring the importance of timely intervention (7,8).

The concept of early repair for TOF has garnered increased interest, yet it is imperative to acknowledge the inherent risks for neonates, including those associated with CPB, right ventriculotomy, and pulmonary insufficiency. Advances in neonatal TOF repair since the 1990s—including transatrial-pulmonary artery approaches to minimize ventriculotomy, hybrid palliation for high-risk infants, and refined CPB strategies—have significantly improved outcomes (9). Consequently, the benefits of early repair over palliation have become more evident. The advantages of early repair over palliation include the fostering of normal organ growth and development, the eradication of hypoxemia, the minimisation or elimination of right ventricular muscle removal, and the reduction of late-stage dysrhythmias (10). Furthermore, the advent of prenatal diagnosis and fetal echocardiography has led to significant improvements in the feasibility of early detection and planning for neonatal intervention.

The present case-series study retrospectively analysed 33 neonatal patients who underwent primary surgical repair for TOF at Beijing Anzhen Hospital. The aim of the study was to elucidate the benefits and insights gained from early, one-stage corrective surgery in neonates with such congenital conditions. The investigation focused on clinical outcomes, with the objective of generating valuable data on the efficacy of neonatal repair in promoting enhanced cardiac function, facilitating normal growth and development, and potentially reducing the necessity for future cardiac interventions. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-133/rc).

Methods

A retrospective review of the data of 33 consecutive neonatal patients who underwent primary surgical repair for TOF at Beijing Anzhen Hospital from June 2022 to December 2023 was conducted. Patients diagnosed with TOF who were over one month of age at the time of hospital admission, those with the pulmonary atresia type of TOF, and those with additional congenital anomalies or chromosomal disorders were excluded from the study. The postnatal age of the preterm infants was calculated as the corrected age. The final study population comprised 33 neonates. The patients’ data, including in-hospital records, echocardiograms, and postoperative follow-up examination data, were retrieved from the database of the Beijing Anzhen Hospital. Follow-up telephone interviews were conducted to collect data on the patients’ growth status, general postoperative recovery, and motor development.

Statistical analysis

A comprehensive set of baseline data was collected, encompassing various demographic and physiological characteristics, as well as preoperative medication details. The data set included variables such as age, gender, birth weight, gestational age, preoperative weight, age at the time of the procedure, inotrope use prior to surgery (categorised as binary, ‘yes’ or ‘no’), and preoperative oxygen therapy (categorised similarly). The following data were also collected: pulse blood oxygen saturation (SpO2) before surgery, surgical approach, postoperative complications, preoperative diagnostic examination, aortic cross-clamp time, CPB time, length of intensive care unit (ICU) stay, length of hospital stay, mortality, and complications.

Z-scores were calculated for the left pulmonary artery (LPA) and right pulmonary artery (RPA) diameters, as well as the pulmonary valve diameter. This was achieved by measuring these Z-scores by means of fetal echocardiography, and then recording and analysing them using the echocardiography data from preoperative, postoperative and post-discharge follow-ups. Furthermore, additional numerical values such as the pulmonary valve peak gradient, as ascertained by cardiac ultrasound prior to surgery, following surgery and during post-discharge follow-up, were meticulously recorded. A follow-up survey was administered in order to gather data on patients’ age, height, weight, surgery date, occurrence of re-hospitalisation, gross motor development, and latest cardiac ultrasound examination results.

Data analysis

The Shapiro-Wilk test was utilised for the purpose of assessing the normality of the data. For the statistical analysis, indices which conformed to a normal distribution were evaluated by analysis of variance. Non-normally distributed indices, however, were instead evaluated by the Friedman test, a non-parametric alternative.

Ethical statement

The present study was reviewed and approved by the Ethics Committee of Beijing Anzhen Hospital (No. 2025007x). The informed consent form was dispatched to the parents of each patient via the postal service, and subsequently returned signed by the parents of each patient. Consent was subsequently re-verified by the patients and their relatives during the ensuing telephonic consultations. The data collected were dedicated solely to the objectives of this research initiative. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Results

The study comprised a total of 33 newborns who underwent primary repair of TOF. The patients had a mean gestational age of 38.1 weeks (range, 31.3–40.0 weeks), a median age at the time of surgery of 14.0 days [interquartile range (IQR), 9.75–20.0 days], an average weight at surgery of 3.25±0.53 kg, an average height at the time of surgery of 50.0 cm (IQR, 49.0–50.25 cm) and an average SpO2 level of 93.0% (range, 80–98%). Eight patients (24.2%) received non-invasive oxygen therapy, while prostaglandin infusion was administered to two patients (6%). Prior to undergoing surgery, patients were able to breathe without the need for assistance. The median duration of the post-surgical follow-up was 201 days, ranging from 51 to 417 days. The baseline characteristics of the patients are outlined in Table 1.

Table 1

Patients’ baseline characteristics

Variable Values
Gestational age (weeks), mean (range) 38.1 (31.3–40.0)
Age at surgery (days), median (IQR) 14.0 (9.75–20.0)
Weight at surgery (kg), mean ± SD 3.25±0.53
Height at surgery (cm), mean (IQR) 50.0 (49.0–50.25)
SpO2 before surgery (%), mean (range) 93.0 (80–98)
Non-invasive oxygen therapy, n (%) 8 (24.2)
Interventional procedure before repair, n (%) 0 (0)
Ventilation before surgery, n (%) 0 (0)
Prostaglandin infusion, n (%) 2 (6)
Follow-up interval (d), median (range) 201 (51–417)

IQR, interquartile range; SD, standard deviation; SpO2, oxygen saturation.

The 33 patients underwent surgical treatment involving pulmonary valve plasty, with no cases of transannular patch repair. Right ventricular outflow tract obstruction was treated by right ventricular outflow tract obstruction repair via right ventriculotomy. The mean aortic cross-clamp time for the operation was 74.24±16.33 minutes. The CPB time averaged 118.85±17.94 minutes. None of the patients required deep hypothermic circulatory arrest.

Postoperative data showed that patients required mechanical ventilation for an average duration of 110.6 hours, with a standard deviation of ±89.2 hours. Patients spent, on average, 10 days (range, 6.75–13.25 days) in the ICU following surgery, with a median postoperative hospital stay of 14 days (IQR, 11.75–15.5 days). Postoperatively, complications occurred in two patients (6%), requiring peritoneal dialysis catheter insertion to manage fluid imbalances. No instances of reintervention nor mortality were observed during the follow-up period. The surgical and recovery details for the patients are summarised in Table 2.

Table 2

Operative and postoperative characteristics

Variables Values
Intraoperative and postoperative data
   Aortic cross-clamp time (min), mean ± SD 74.24±16.33
   Cardiopulmonary bypass time (min), mean ± SD 118.85±17.94
   Use of deep hypothermic circulatory arrest, n (%) 0 (0)
   Pulmonary valve preservation, n (%) 33 (100)
   Transventricular repair, n (%) 33 (100)
   Postoperative ventilation time (h), mean ± SD 110.6±89.2
   Postoperative ICU stay (days), mean (range) 10.0 (6.75–13.25)
   Postoperative hospital stay (days), median (IQR) 14.0 (11.75–15.5)
   Postoperative complication, n (%) 2 (6)
Follow-up
   Reintervention, n (%) 0 (0)
   Mortality, n (%) 0 (0)

ICU, intensive care unit; IQR, interquartile range; SD, standard deviation.

Transthoracic echocardiography revealed that the pulmonary valve peak gradient was low at birth, increased significantly in the days following, and decreased post-surgery (Figure 1). Subsequent follow-ups demonstrated a gradual increase, though the gradient remained below the levels recorded pre-surgery. Key temporal points for echocardiography of the pulmonary valve annulus LPA and RPA diameters included the fetal stage, birth, a few days after birth, before surgery, the first day post-surgery, pre-discharge, early follow-up, and the most recent follow-up.

Figure 1 Pulmonary valve peak gradient at different time points measured by transthoracic echocardiograph. (A) Pulmonary valve peak gradient at birth. (B) Pulmonary valve peak gradient on the 6th day post-birth. (C) Pulmonary valve peak gradient at the most recent follow-up, 3 months post-surgery.

The results demonstrated progressive narrowing of diameters during fetal development, followed by a rebound at birth. Preoperatively, the pulmonary valve annulus remained stable with minimal changes in the LPA and RPA diameters. A significant postoperative increase in the pulmonary valve annulus diameter was observed on postoperative day 1, whereas LPA and RPA diameters remained stable. From discharge through early and late follow-up, the pulmonary valve annulus exhibited sustained growth, paralleled by significant increases in both LPA and RPA diameters, particularly during follow-up phases (Figure 2).

Figure 2 Trends in pulmonary measurements from fetal to postoperative periods. (A) Pulmonary valve peak gradient. (B) Pulmonary valve annulus diameter. (C) Left pulmonary artery diameter. (D) Right pulmonary artery diameter.

In order to make meaningful comparisons, a range of statistical tests, including both paired and unpaired t-tests, were utilised to analyse the Z-scores for the pulmonary valve annulus (PVAz), Z-scores for right pulmonary artery (RPAz), and Z-scores for left pulmonary artery (LPAz). The timing of these analyses was meticulously scheduled to coincide with key phases of the patient’s journey, as outlined in Table 3: at the fetal stage, birth, pre-surgery (a few days after birth), postoperative day 1, and the latest follow-up. The results obtained from these analyses revealed a statistically significant increase in Z-scores for pulmonary artery (PVz) (P=0.02) from the fetal stage to birth. Furthermore, both RPAz and LPAz demonstrated highly significant increases (P<0.001). Following a thorough examination, no substantial variations were identified in the PVz, RPAz, and LPAz parameters when comparing birth data with pre-surgical records (all P>0.01). No statistically significant variations were identified when comparing postoperative day 1 with the most recent follow-up across all three parameters (all P>0.01). However, a comparison of the pre-surgery results with the latest post-surgical follow-up revealed significant increases in PVz (P<0.001), RPAz (P=0.02), and LPAz (P=0.01).

Table 3

Changes of the pulmonary valve and pulmonary artery Z-scores at different time points

Time points Fetal [1] Birth [2] Pre-op [3] Post-op
day 1 [4]		 Latest
follow-up [5]		 P
1 vs. 2 1 vs. 3 2 vs. 3 4 vs. 5 3 vs. 5
PV Z-score –2.46±1.31 –1.94±1.56 –2.11±1.48 –0.6±1.15 –0.38±0.82 0.02 0.09 0.17 0.19 <0.001
RPA Z-score –5.7 (–7.54 to –0.5) –0.24±0.95 –0.55±1.19 0.71±1.02 0.41±1.39 <0.001 <0.001 0.04 0.84 0.02
LPA Z-score –6.09 (–7.61 to –0.5) –0.16±0.82 –0.16±0.82 0.74±1.04 0.58±1.15 <0.001 <0.001 0.55 0.54 0.01

Data are presented as mean (range) or mean ± standard deviation. LPA, left pulmonary artery; PV, pulmonary artery; RPA, right pulmonary artery.

Discussion

The utilisation of corrective surgery for TOF in newborns is a subject that has given rise to considerable controversy (11-13). There is a divergence of opinion and a lack of consensus within the medical community regarding the timing of corrective surgery, with some advocating for its performance during the neonatal period (14,15), and others opposed to its use in this context (9,16). A substantial body of literature has reported that corrective surgery in this context is associated with an elevated risk of postoperative complications, including, but not limited to, delayed chest closure, arrhythmia, atrioventricular block requiring pacemaker implantation, extracorporeal membrane oxygenation support, and reintervention (17). Some medical practitioners may elect to undertake Blalock-Taussig (B-T) shunt surgery during the neonatal period, subsequently performing corrective surgery at a later time (18). However, challenges may be posed by blood volume control during B-T shunt surgery, and the timing and success rate of subsequent corrective surgery are influenced by various factors, including pulmonary artery hypoplasia and enhanced collateral circulation (19,20). The present study examined the outcomes of neonatal corrective treatment in 33 consecutive patients diagnosed with TOF. It is noteworthy that none of the patients underwent the B-T shunt operation. The study observed successful outcomes among all patients, with no occurrence of mortality nor the need for subsequent interventions.

TOF has been observed to exhibit a high incidence of postoperative complications in the context of neonatal surgery (17), a phenomenon that may be associated with the timing of the surgical intervention. The surgical intervention is predominantly undertaken in patients presenting with symptomatic manifestations (21-24). Among these patients, some may eventually require emergency surgery. Compared to planned procedures, emergency surgeries present significantly higher risks due to poorer preoperative patient conditions. Elective operations allow better control over preoperative preparation and reduce overall surgical risks. Therefore, our center now prioritizes performing scheduled surgeries in asymptomatic patients whenever possible. This proactive approach helps avoid the compromised preoperative status typically seen in emergency surgical cases.

The development of pulmonary arteries is a significant factor in determining the necessity of corrective surgery (25). Consequently, some medical practitioners opt for corrective surgery over B-T shunt surgery, guided by the developmental stage of the pulmonary artery. However, it is important to note that the assessment of pulmonary artery development in newborns is not an exact science. Echocardiography, a non-invasive diagnostic imaging modality, serves as a crucial method for evaluating pulmonary artery development (26,27). Although cardiac computed tomography (28) and cardiac magnetic resonance imaging (28) have also been used to evaluate pulmonary artery development in adults, research on their use in newborns is still insufficient. Furthermore, it should be noted that such tools merely evaluate the pulmonary artery condition at a single moment in time and are unable to provide a comprehensive assessment of the pulmonary vascular bed. Postnatal adaptive changes in pulmonary blood vessels have been observed to result in persistent pulmonary arterial hypertension (29). However, the question remains unanswered as to whether these adaptive changes are comparable in both normal newborns and those with TOF. The hypothesis that the pulmonary artery conditions of children with TOF are analogous to those of normal children was formulated, and consequently, B-T shunt surgery was rejected in favour of neonatal corrective TOF surgery.

The development of collateral circulation in patients with TOF represents a physiological adaptation to the disease, although it can also result in complications (30). In newborns, the formation of collateral circulation has not yet occurred; consequently, corrective treatment during the neonatal period can reduce the complexity and risk of surgery. In addition, neonatal corrective surgery can reduce the possible complications and risk of death caused by waiting for surgery. Furthermore, it has been demonstrated that early surgical intervention can prevent developmental problems caused by hypoxia. Specifically, surgical intervention during the neonatal period has been demonstrated to expeditiously rectify hypoxemia and mitigate the deleterious effects of protracted hypoxia on the development of the brain and other organs. Furthermore, it has been demonstrated that surgical intervention can prevent the delayed development of pulmonary arteries. It is important to note that early surgical intervention can promote normal development of pulmonary arteries and prevent underdeveloped pulmonary vascular beds caused by long-term pulmonary artery stenosis. It has also been demonstrated that early surgical intervention can prevent the formation of collateral vessels. In patients with TOF, collateral vessels may develop to bypass pulmonary artery stenosis, thereby providing an additional blood supply. These collateral vessels can lead to additional health complications, and early surgical intervention can mitigate their formation.

The treatment of the pulmonary valve is contingent on the specific condition of the valve. In certain cases (14,31), the necessity of a transannular patch is contingent on the degree of stenosis of the pulmonary valve annulus (32). A study (33) has indicated a high demand for transannular patches in newborns. However, in this particular study, no such transannular patches were employed, and the PVAz was found to be above −2, indicating a satisfactory postoperative pulmonary artery transvalvular pressure gradient.

While the indications for performing TOF corrective surgery during the neonatal period are suitable, the difficulty and complexity of the procedure remain considerable. The heart and blood vessels of newborns are particularly diminutive, which serve to compound the complexity of the surgical operation. Furthermore, the physiological state of newborns is characterised by fragility, and their tolerance to surgery and anaesthesia is reduced. Postoperative management of these patients is complex and necessitates close monitoring and adjustment to ensure optimal recovery. Consequently, the decision regarding the performance of TOF corrective surgery in the neonatal period must be made by experienced cardiac surgeons and teams, taking into account the unique circumstances of each child. This decision-making process necessitates a comprehensive evaluation of the structure and function of the child’s heart, in addition to a meticulous appraisal of the risks associated with surgery and the potential benefits thereof.

On the other hand, it is important to exercise caution when the TOF is not treated in its initial phase, as this may result in later-life presentations of the untreated pathology. For instance, the duration for which a neonate must undergo ventilation support following treatment for TOF depends chiefly on the age of the neonate at the time of treatment. Patients older than 12 months have been observed to demonstrate interesting findings in relation to the duration of post-operative invasive mechanical ventilation and the exploration of associations with pre-operative clinical markers of the severity of right ventricular outflow tract obstruction. A multivariate analysis revealed that baseline oxygen saturation and repair type exhibited a significant association with the duration of mechanical ventilation. In a separate analysis, patients of a notably older demographic undergoing TOF repair exhibited a higher probability of prolonged mechanical ventilation when exhibiting lower baseline saturation and undergoing a non-valve preserving repair. Conversely, other clinical markers indicative of the magnitude of right ventricular outflow tract obstruction failed to demonstrate independent correlation with the duration of mechanical ventilation (34).

Conclusions

The curative effect of TOF repair in the neonatal period is well-documented, with its ability to prevent the effects of pulmonary artery development and collateral circulation formation. Consequently, it is recommended to treat TOF in the neonatal period.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-133/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-133/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-133/prf

Funding: This study was funded by the Science and Technology Innovation Fund-Major Science and Technology Innovation Research and Development Special Project (KCZD202202); Capital’s Funds for Health Improvement and Research (CRF-2024-1-2062); and Noncommunicable Chronic Diseases-National Science and Technology Major Project (2023ZD0514400).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-133/coif). F.N. serves as an unpaid editorial board member of Journal of Thoracic Disease from April 2023 to March 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The present study was reviewed and approved by the Ethics Committee of Beijing Anzhen Hospital (No. 2025007x). Informed consent was taken from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: L. Huleatt)

Cite this article as: Jin C, Wu Y, Qu Y, Wang Z, Li B, Yan J, Nappi F, Hoxha S, Wang Q. Repair of tetralogy of Fallot in neonates: a single-center case series. Transl Pediatr 2025;14(6):1278-1286. doi: 10.21037/tp-2025-133

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