Pulmonary valve replacement in adults with repaired tetralogy of Fallot

There is a growing population of young adults with tetralogy of Fallot. Although surgical approaches have evolved, many adults with repaired tetralogy of Fallot have been left with residual pulmonary regurgitation. Pulmonary regurgitation is an important contributor to a number of late complications including exercise limitations, right heart failure, arrhythmia, and sudden death. Because bioprosthetic valves are used in this population, clinicians must weigh the beneficial effects of pulmonary valve replacement against the associated risks, including subsequent re-operation. In this review, we will appraise the evidence supporting pulmonary valve replacement in the adult with repaired tetralogy of Fallot, as well as the optimal timing and mode of intervention.

Balloon pulmonary valvuloplasty in tetralogy of Fallot: effects on growth of pulmonary annulus and transannular patch

BACKGROUND

Balloon pulmonary valvuloplasty and its benefit on the growth of pulmonary annulus and pulmonary artery in tetralogy of Fallot (TOF) patients remains controversial. The purpose ofthe present study was to determine the growth of pulmonary valve annulus and pulmonary artery and to evaluate the need of transannular patch during total surgical correction in patients with tetralogy of Fallot (TOF) after balloon pulmonary valvuloplasty.

MATERIAL AND METHOD

Fifty-one severely hypoxic TOF patients, who underwent balloon dilatation ofpulmonary valve, were included in the present study. The clinical outcomes, oxygen saturation, and echocardiographic parameters before and after balloon dilatation were analyzed.

RESULTS

There were 33 males and 18females. The mean age was 3 years 5 months old (range, I month-15 years 8 months old). The mean oxygen saturation increasedfrom 73.9 +/- 9.1 to 84.8 +/- 6.7% immediately after the procedure (p-value < 0.05). There was no serious procedural-related complication. At the mean follow-up period of 2 years and 4 months, the mean Z-score of pulmonary annulus size increased from -2.56 SD to -1.87 SD (p-value < 0.05) and the right pulmonary artery size from -0.29 SD to + 0.46 SD (p-value < 0.05). Thirty-seven patients (66.1%) underwent corrective surgery. Pulmonary transannular patch was performed in 11 of37 patients (29.7%).

CONCLUSION

Pulmonary valve dilatation in patients with TOF is safe. It promotes the growth ofthe pulmonary valve annulus and pulmonary artery and may decrease the need of transannular patch at the time of surgical correction.

Unusual cardiac associations with Tetralogy of Fallot-a descriptive study

We present a large single-center series (>2200 cases) operated for Tetralogy of Fallot (TOF). We analyzed the incidence of associated unusual and uncommonly described cardiac lesions and their diagnostic and therapeutic implications in TOF patients. This retrospective study was conducted by reviewing records of patients operated for TOF at a large tertiary care pediatric cardiac centre. From 2002 to 2008, a total of 2235 cases of TOF were evaluated with echocardiography, cardiac catheterization, and/or cardiac computed tomography followed by cardiac surgery. Known and well-described associations were excluded from the study. Unusual associations were tabulated. Several unusual associations having an incidence >0.1% were detected. These included subaortic membrane (1%), pulmonary venous abnormalities (0.5%), small left ventricle (0.5%), interrupted inferior vena cava (0.5%), mitral valve abnormalities (0.4%), hemitruncus (0.4%), tricuspid valve abnormalities (0.4%), biventricular dysfunction (0.3%), retroaortic innominate vein (0.3%), bicuspid aortic valve (0.2%), and pericardial effusion (0.2%). This series describes unusual, not previously routinely reported cardiac lesions associated with TOF that may affect management and should be sought on preoperative evaluation. We demonstrate that more unusual associations do exist in not infrequent numbers, i.e., a TET is not just a TET.

Left hemitruncus associated with tetralogy of fallot: fetal diagnosis and postnatal echocardiographic and cardiac computed tomographic confirmation

Anomalous origin of one pulmonary artery from the aorta, or hemitruncus, is a rare cardiac malformation. We report a case of left hemitruncus (aortic origin of the left pulmonary artery) associated with tetralogy of Fallot diagnosed in utero. To the authors' knowledge, this is the first such case diagnosed by fetal echocardiography to be described in the literature. The condition was documented by postnatal echocardiogram and cardiac computed tomography. Prompt recognition of this lesion is essential for early repair to improve outcome.

Improved accuracy in flow mapping of congenital heart disease using stationary phantom technique

BACKGROUND

Flow mapping by cardiovascular magnetic resonance has become the gold standard for non-invasively defining cardiac output (CO), shunt flow and regurgitation. Previous reports have highlighted the presence of inherent errors in flow mapping that are improved with the use of a stationary phantom control. To our knowledge, these studies have only been performed in healthy volunteers.

RESULTS

We analyzed the variation in flow measurements made with and without stationary phantom correction in 31 patients with congenital heart disease. Variation in stroke volume (SV) measurements was seen in all vessels across all patient groups. The variation was largest when analyzing the right ventricular outflow tract (RVOT), with a range of absolute differences in SV from 0.2 to 70 ml and in CO from 0.02 to 4.8 L/min. In patients with repaired Tetrology of Fallot (ToF), the average ratio of pulmonary to systemic blood flow (Qp:Qs) was 1.18 without and 1.02 with phantom correction. Without performing phantom correction, 23% of the repaired ToF patients were classified as having a residual shunt as compared to 0% when flow mapping was performed with phantom correction. Similarly, in patients with known atrial level shunting (ASD/PAPVR) 20% of patients had no shunt when flow mapping was performed without phantom correction as compared to 0% with phantom correction. In patients with bicuspid aortic valves (BAV), the differences in the regurgitant fraction between measuring flow with and without phantom correction ranged from 0 to 30%, while the regurgitant fraction in the RVOT of ToF patients varied by as much as 31%.

CONCLUSION

The impact of inherent errors in CMR flow mapping should not be underestimated. While the variation across a population may not display a significant trend, for any individual patient it can be quite large. Failure to correct for such variation can lead to clinically significant misinterpretation of flow data. The use of the stationary phantom correction technique appears to improve accuracy both in normal patients as well as those with congenital heart disease.

Tetralogy of Fallot

Tetralogy of Fallot is the most common form of cyanotic congenital heart disease, and one of the first to be successfully repaired by congenital heart surgeons. Since the first procedures in the 1950s, advances in the diagnosis, perioperative and surgical treatment, and postoperative care have been such that almost all those born with tetralogy of Fallot can now expect to survive to adulthood. The startling improvement in outcomes for babies born with congenital heart disease in general-and for those with tetralogy of Fallot in particular-is one of the success stories of modern medicine. Indeed, in many countries adults with tetralogy of Fallot outnumber children. Consequently, new issues have emerged, ranging from hitherto unpredicted medical complications to issues with training for caregivers and resource allocation for this population of survivors. Therefore, evolution of treatment, recognition of late complications, research on disease mechanisms and therapies-with feedback to changes in care of affected children born nowadays-are templates on which the timely discussion of organisation of care of those affected by congenital heart diseases from the fetus to the elderly can be based. Here, we focus on new developments in the understanding of the causes, diagnosis, early treatment, and late outcomes of tetralogy of Fallot, emphasising the continuum of multidisciplinary care that is necessary for best possible lifelong treatment of the 1% of the population born with congenital heart diseases.

Left Ventricular Diverticulum Associated with Cantrell's Syndrome and Tetralogy of Fallot in an Adult

In this report we describe the surgical treatment of a 27-year-old patient with complete Cantrell's syndrome, i.e. multiple ventricular septal defect, left ventricular diverticulum, dextrorotation of the heart, an anterior diaphragmatic defect, and a midline supraumbilical abdominal wall defect with tetralogy of Fallot. Resection of the diverticulum was combined with correction of the tetralogy of Fallot and thoracoabdominal defects. The postoperative period was uncomplicated. We have have found only one previous report describing resection of the diverticulum combined with correction of Fallot's tetralogy and thoracoabdominal defects in an adult. One-stage repair of these complex anomalies is technically feasible and should be the treatment of choice.

[Tetralogy of Fallot--new appearance of an old technique]

Tetralogy of Fallot represents one of the most frequent congenital heart disease in medical practice and a "corner stone" of any paediatric surgical team due to great anatomic and functional variability and clinical aspects. This paper presents a retrospective study of surgical experience in patients with tetralogy of Fallot admitted in Paediatric Cardiovascular Centre of Târgu Mureş, Romania, between 2005, October to 2009, January.

METHOD

There where retrospectively studied medical records of patients who undergo a surgical procedure: age, morphologic diagnosis, symptoms and type of surgical procedure, intraoperative data, postoperative follow-up and complications.

RESULTS

In this period 110 cases of tetralogy of Fallot were operated, 81 total surgical repair (54 primary and 27 secondary procedures); also there were performed 29 "palliative" procedures: systemic/pulmonary shunts (eg. Blalock-Taussig). No intraoperative deaths were recorded; the percentage of in-hospital mortality was 1.8%.

CONCLUSIONS

It's ideal to perform total primary repair of tetralogy of Fallot, especially in the first year of life; extreme cases (severe hypoplasic pulmonary arteries, emergency cases) benefit from "palliative" procedures. Surgical repair of Fallot tetralogy can be performed, with good results in specialised paediatric cardiac surgery centres. This paper represents the first Romanian clinical study on a large number of patients with tetralogy of Fallot surgically treated.

Pregnancy in a woman with uncorrected tetralogy of fallot

Tetralogy of Fallot (ToF) is the most common form of cyanotic congenital heart disease after 1 year of age, with overall incidence approaching 10% of all congenital heart disease. Natural survival (i.e. without corrective procedure) into the fourth decade is extremely rare (only about 3%), but there is a tendency of increasing number of women with cyanotic congenital heart disease living 3 to 4 decades and are becoming pregnant. Because of significant physiology adaptation and changes, pregnancy and delivery process are troublesome for mostly unhealthy women, including those with uncorrected ToF. For ToF patients, it remains an important cause of maternal morbidity (62,5%), and even mortality (10%) and has significant effects on fetal outcome. Discussed below a case of pregnancy in a 28 year old woman with uncorrected ToF, was diagnosed to have pneumonia, ToF-class III-IV of New York Heart Association, secondary polycythemia caused by hypoxia, and uncompensated metabolic acidosis on 25th week pregnancy. Through delicate medical care, patient's condition improvement can be seen. Patient decided to continue the pregnancy. Without optimal either obstetrical or medical management, prognosis of pregnancy in patient with uncorrected ToF is poor.

Isolated left pulmonary artery in absent pulmonary valve syndrome

A very rare combination including tetralogy of Fallot (TOF), absent pulmonary valve, and isolated left pulmonary artery is described. A 4-month-old girl presented with mild cyanosis and severe dyspnea. Echocardiography established the diagnosis of TOF and absent pulmonary valve with severe pulmonary regurgitation and moderate stenosis at the pulmonary valve site. A right ventricle angiogram showed the severe aneurismal dilation of the proximal right pulmonary artery and the remarkable pulmonary annular stenosis but failed to show the left pulmonary artery (LPA). An angiography after pulmonary vein wedge injection demonstrated the isolated and hypoplastic LPA.

Surgical correction of tetralogy of Fallot in a seventy-five year old patient

Tetralogy of Fallot is a congenital heart disease which is mostly diagnosed and treated in infancy. In the literature there are some cases where the diagnosis was made in adults. This report describes the case of a seventy-five year old man who presents with a dilated and severely hypertrophic right ventricle, a ventricular septum defect, an overriding aorta and a severe infundibular stenosis in the right ventricular outflow tract. The diagnosis of an unrepaired Tetralogy of Fallot was made. A full surgical correction of the Tetralogy was performed and the patient received an implantable defibrillator, making him the oldest patient repaired for Tetralogy of Fallot.

Axenfeld–Rieger syndrome and pseudotruncus arteriosus

Axenfeld-Rieger syndrome (ARS) is an autosomal dominant disorder. It is described as the association of malformation of the anterior chamber of the eye with extraocular anomalies. Cardiovascular defects are considered an occasional findings with this syndrome. We present a patient having the features of Axenfeld-Rieger syndrome with pseudotruncus arteriosus as a different cardiac association.

Unoperated tetralogy of Fallot in a 68-year-old patient

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, generally treated with total correction within the first two years of life. Occasionally, some unoperated cases can reach older ages. A 68-year-old woman with diabetes mellitus presented with swelling in legs and abdomen, weakness, exertional dyspnea, and orthopnea. On physical examination, she had mild cyanosis with clubbing. Her blood pressure was 110/60 mmHg and pulse rate was 79 beat/min. She had a systolic ejection murmur and bilateral rales on basal lung areas. Massive edema was noted in both lower limbs. Electrocardiography showed atrial fibrillation with normal ventricular response. Chest radiography showed an increased cardiothoracic ratio and bilateral minimal pleural effusion. Echocardiography showed biatrial dilatation (right atrium 62 mm, left atrium 49 mm) and thickening of left ventricular walls. There was right ventricular hypertrophy with decreased systolic function. A very large ventricular septal defect and severe pulmonary stenosis were noted. The patient did not accept any interventional procedure. To our knowledge, this is the oldest unoperated TOF case reported from our country.

Randomized trial of hematocrit 25% versus 35% during hypothermic cardiopulmonary bypass in infant heart surgery

OBJECTIVES

We previously reported that postoperative hemodynamics and developmental outcomes were better among infants randomized to a higher hematocrit value during hypothermic cardiopulmonary bypass. However, worse outcomes were concentrated in patients with hematocrit values of 20% or below, and the benefits of hematocrit values higher than 25% were uncertain.

METHODS

We compared perioperative hemodynamics and, at 1 year, developmental outcome and brain magnetic resonance imaging in a single-center, randomized trial of hemodilution to a hematocrit value of 25% versus 35% during hypothermic radiopulmonary bypass for reparative heart surgery in infants undergoing 2-ventricle repairs without aortic arch obstruction.

RESULTS

Among 124 subjects, 56 were assigned to the lower-hematocrit strategy (24.8% +/- 3.1%, mean +/- SD) and 68 to the higher-hematocrit strategy (32.6% +/- 3.5%). Infants randomized to the 25% strategy, compared with the 35% strategy, had a more positive intraoperative fluid balance (P = .007) and lower regional cerebral oxygen saturation at 10 minutes after cooling (P = .04) and onset of low flow (P = .03). Infants with dextro-transposition of the great arteries in the 25% group had significantly longer hospital stay. Other postoperative outcomes, blood product usage, and adverse events were similar in the treatment groups. At age 1 year (n = 106), the treatment groups had similar scores on the Psychomotor and Mental Development Indexes of the Bayley Scales; both groups scored significantly worse than population norms.

CONCLUSIONS

Hemodilution to hematocrit levels of 35% compared with those of 25% had no major benefits or risks overall among infants undergoing 2-ventricle repair. Developmental outcomes at age 1 year in both randomized groups were below those in the normative population.

Pre-operative evaluation with magnetic resonance imaging in tetralogy of fallot and pulmonary atresia with ventricular septal defect

BACKGROUND

Preoperative evaluation of patients with pulmonary atresia and ventricular septal defect (PA/ VSD) are generally done by echocardiogram and cardiac catheterization. The authors' objective of the present study was to compare the findings of Gadolinium (Gd) enhanced cardiac magnetic resonance angiography (MRA) with cardiac catheterization.

MATERIAL AND METHOD

Patients who had PA/VSD were prospectively evaluated using cardiac catheterization and cardiac MRA. A branch of the pulmonary arteries was divided into: main pulmonary artery (MPA), left and right branch pulmonary artery (LPA & RPA), major aortopulmonary collateral arteries (MAPCA) and minor collaterals. Each study was interpreted blindly. The agreement of findings was compared using Kappa statistics.

RESULTS

There were 43 patients who received both cardiac catheterization and cardiac MRI within a 2 month period The average age was 13.8 +/- 8.4 (2-30) years-old. There was an agreement among measurement of both MPA and LPA & RPA with Kappa statistics of more than 0.8. Gd-enhanced MRA was able to identify more branches of MAPCA when compared to cardiac catheterization.

CONCLUSIONS

The results of the present study indicate that Gd-enhanced MRA is a feasible, fast and accurate technique for identification of all sources of pulmonary blood supply in patients with complex pulmonary atresia. The present study was a noninvasive alternative to cardiac catheterization. Gd-enhanced MRA can better delineate small (minor) branches of collateral.

[Surgical relevance of some aspects of heart's embriology]

We consider some aspects of cardiac embriology which explain the formation of pericardial cysts, anomalies of venae cavae, types of atrial septal defect (ostium primum, secundum, foramen ovale), anomalies in septal ventricular development by absence of structures to perform the septum (atrio-ventricularis communis, truncus arteriosus), lack of alineation (Taussig-Bing's complex, transposition of the great vessels, Eisenmenger's complex, Fallot's tetralogy) or interruption in their development (isolated ventricular septal defect). Finally the evolution of aortic arcs, ductus, aorta's istmus and anomalies in coronary arteries, are also considered.

Right ventricle outflow tract stenting as a method of palliative treatment of severe tetralogy of Fallot

We present the case of a 3-month-old infant with tetralogy of Fallot (ToF) with pulmonary artery hypoplasia, critical right ventricle outflow tract (RVOT) obstruction and the presence of major aortopulmonary collateral arteries (MAPCA) and CATCH 22 syndrome. Due to anatomical conditions (severe pulmonary artery hypoplasia), the patient was not qualified for palliative operative treatment Blalock-Taussig shunt. We conducted catheterization with an attempt of balloon plasty and stent implantation into the right ventricle outflow tract and main pulmonary artery. Successful stent implantation into the right ventricle outflow tract was performed. The stent created a 4.1 mm diameter channel and allowed for unrestricted blood flow from the right ventricle to the pulmonary arteries. After the procedure we observed an increase in blood saturation of up to 89%. Control echocardiography revealed blood flow through the stent to the pulmonary arteries with a pressure gradient of 45 mm Hg. There were neither rhythm nor conduction disturbances in the control ECG after the procedure. After 6 days of observation the patient was discharged from our department. We conclude that successful stent implantation into the RVOT in patients with ToF and hypoplastic pulmonary arteries improves their clinical condition, increases pulmonary blood flow by physiological means and leads to an improvement of pulmonary artery development before surgical treatment.

[Congenitally absent pulmonary valve--analysis of ten prenatally diagnosed cases and review of the literature]

OBJECTIVES

To assess in a population of 10 fetuses diagnosed with absent pulmonary valve the incidence of associated cardiac extracardiac and chromosomal anomalies and the outcome of pregnancies.

METHOD

Retrospective analysis of data of prenatally diagnosed absent pulmonary valve cases between 1 January 1993 and 31 December 2005 in Fetal Echocardiography Laboratory of Ist Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary. The diagnosis was controlled with autopsy or postnatal examinations. The time of the prenatal diagnosis, indications, connected cardiac, extracardiac and chromosomal anomalies were studied.

RESULTS

Absent pulmonary valve was diagnosed prenatally in 10 pregnancies. The mean gestational age at the time of the diagnosis was 23.1 weeks (18-33 weeks). In 6 cases the malformation was diagnosed before the 24th gestational week, in 4 cases after the 24th gestational week. In 6 cases pregnancies were terminated. Fetal hydrops were found in 2 cases. Among 4 continued pregnancies one intrauterine fetal demise and two neonatal death occurred, one baby was successfully operated and survived. The Botallo duct was normally developed in five cases, in this group the absent pulmonary valve was isolated at 3 fetuses, at 1 fetus absent aortic valve and at 1 fetus tricuspid valve dysplasia were diagnosed. The Botallo duct was absent in five cases, in this group at 3 fetuses tetralogy of Fallot, at 1 fetus atrioventricular septal defect and at 1 fetus subaortic ventricular septal defect were diagnosed. Extracardiac malformations associated with cardiac abnormality at 3 fetuses. The indication for fetal echocardiography was positive family history in 3 cases, abnormal four chamber view in 2 cases, suspicion of thoracal cyst in 3 cases, fetal hydrops in 1 case, extracardiac malformation in 1 case.

CONCLUSION

The absent pulmonary valve is a severe malformation, the prognosis is poor and highly dependent on associated malformations. The correct early prenatal diagnosis is possible. The recurrence risk is higher than in multifactorial inheritance.

Uncorrected tetralogy of Fallot: adult presentation in the 61st year of life

Tetralogy of Fallot (TOF) is the commonest form of cyanotic congenital heart defect after infancy [Brickner ME, Hillis LD, Lange RA. Congenital Heart Disease in Adults-Second of Two Parts. NEJM 2000; 342(5):334-342.]. There are few studies assessing the risk of surgical correction in adult patients and long-term survival into the fourth decade of life is rare. The case history is described of a 61-year old female presenting with probable viral myocarditis. Subsequent investigations revealed an underlying diagnosis of tetralogy of Fallot. The patient remains asymptomatic despite persistent hypoxia. Potential factors contributing to longevity in this case are relatively good pulmonary blood flow via large branch pulmonary arteries, and the possible gradual development of right ventricular outflow tract obstruction over a long time period.