The first open heart corrections of tetralogy of Fallot. A 26-31 year follow-up of 106 patients

The Right Heart in Congenital Heart Disease, Mechanisms and Recent Advances

In patients with congenital heart disease, the right heart may support the pulmonary or the systemic circulation. Several congenital heart diseases primarily affect the right heart including Tetralogy of Fallot, transposition of great arteries, septal defects leading to pulmonary vascular disease, Ebstein anomaly and arrhythmogenic right ventricular cardiomyopathy. In these patients, right ventricular dysfunction leads to considerable morbidity and mortality. In this paper, our objective is to review the mechanisms and management of right heart failure associated with congenital heart disease. We will outline pearls and pitfalls in the management of congenital heart disease affecting the right heart and highlight recent advances in the field.

Tetralogy of Fallot: Current surgical perspective

Tetralogy of Fallot (TOF) is an important lesion for all pediatric and congenital heart surgeons. In designing the most appropriate operation for children with TOF, the postoperative physiology should be taken into account, both in the short and long term. The balance between pulmonary stenosis (PS) and pulmonary insufficiency (PI) may be critical for preservation of ventricular function. A unified repair strategy that limits both residual PS and PI is presented, along with supporting experimental evidence, a strategy for dealing with coronary anomalies, and comments regarding best timing of operation.

Tetralogy of fallot repair in patients 40 years or older

OBJECTIVE

To report the outcomes of patients with tetralogy of Fallot (TOF) undergoing surgical repair at age 40 years or older.

PATIENTS AND METHODS

We reviewed records of patients (age, ≥40 years) who underwent TOF repair from January 1, 1970, through December 31, 2007. Symptoms, palliative procedures, surgical reports, and long-term outcomes were analyzed.

RESULTS

Fifty-two patients (30 men [58%]) had surgery at a mean ± SD age of 50±8 years; 27 (52%) had prior palliative surgery at a mean ± SD age of 17±11 years. Procedures for TOF repair included pulmonary valve replacement (n=10), transannular patch (n=10), and native pulmonary valve preservation (n=32). The 30-day mortality rate was 6% (stroke, n=2; ventricular fibrillation, n=1). A mean ± SD follow-up of 14.9±9.3 years was feasible in 48 of 49 survivors; improvement in functional class was observed in 42 patients. Reoperation was performed in 7 patients (4 for pulmonary regurgitation). Twenty-nine patients died (mean ± SD age, 65±12 years); causes of death were cardiac (n=7), noncardiac (n=4), and unknown (n=18). Mean ± SD age at death was younger in patients with previous palliation (59±11 years vs 70±12 years; P=.03). The 10-year survival rate was lower than expected compared with an age- and sex-matched population (73% vs 91%; P<.001).

CONCLUSION

Complete repair of TOF in patients 40 years or older is feasible but carries increased operative risk. Surgical survivors have improvement in functional class; however, survival remains lower than expected. Reduced survival and need for reoperation emphasize the importance of pulmonary valve replacement at the time of initial repair and long-term follow-up.

Indications for reoperation late after correction of tetralogy of Fallot

OBJECTIVE

Correction of tetralogy of Fallot has excellent long-term results. The present retrospective study investigates the indications for reoperation late after corrective surgery.

METHODS

Data from 914 consecutive cases who underwent correction of tetralogy of Fallot in our department between 1960 and 2002 were retrospectively reviewed and analysed. In 91 patients, a total of 102 reoperations were performed late after repair.

RESULTS

The mean time interval between corrective surgery and the first reoperation was 12.8 years. The main indication for reoperation was residual ventricular septal defect in nearly half of the cases, mostly isolated, but also in combination with a right ventricular outflow tract aneurysm or pulmonary stenosis. One-fourth of reoperated patients underwent a procedure on their pulmonary artery or pulmonary valve: replacement of pulmonary valve, replacement of primary implanted pulmonary artery conduits with or without concomitant surgery, and surgery for isolated peripheral pulmonary stenosis. The remaining indications were right ventricular outflow tract aneurysms and others. Aneurysms of the right ventricular outflow tract were seen mostly after the use of autologous - untreated - pericardial patch in 18 of 21 cases.

CONCLUSION

The number of reoperations for residual ventricular septal defect decreased during the study period. The primary use of conduits led to an increased number of reoperations for conduit exchange due to degeneration or failure. Use of an untreated autologous pericardial patch for enlargement of the right ventricular outflow tract should be avoided due to increased risk for aneurysm formation.

Congenital heart disease and multi-modality imaging

The increasing prevalence of adult congenital heart disease (CHD) can be attributed to major improvements in diagnosis and treatment of children with CHD. Although, echocardiography is the most commonly used imaging modality for diagnosis and follow up of subjects with CHD, the evolution of both cardiovascular magnetic resonance (MR) imaging and computed tomography (CT) does offer new ways to visualise the heart and great vessels. Cardiovascular MR techniques such as spin-echo and gradient-echo imaging, velocity-encoded phase-contrast MR and gadolinium-enhanced MR angiography allow comprehensive assessment of cardiac anatomy and function. This provides information about the long-term sequelae of the underlying anatomy, haemodynamic assessment of residual post-operative lesions and complications of surgery. Similarly, the development of spiral and subsequently multi-detector CT enables the acquisition of data during a single breath-hold and during the first pass of a contrast bolus, so that images can be reconstructed in any two-dimensional plane or in three-dimensions. As much of the functional data in CHD patients was traditionally acquired with invasive X-ray angiography, non-invasive alternatives such as cardiovascular MR and CT are desirable. This review evaluates the role of imaging modalities in the management of subjects with CHD, particularly detailing recent developments in imaging techniques as they relate to the various CHD diagnoses commonly encountered in practice.

Mortality associated with adult congenital heart disease: Trends in the US population from 1979 to 2005

BACKGROUND

Significant advances over the last 5 decades have allowed most patients with congenital heart disease to survive well past childhood and into adulthood. Population-based data from the United States are limited regarding mortality in adult survivors.

METHODS

We used the Center for Disease Control Multiple Cause-of-Death registry to determine trends in mortality from 1979 to 2005 among individuals with congenital heart disease in the United States.

RESULTS

There were significant reductions in death rates for adults with a number of congenital defects including ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, and Ebstein anomaly. Notably, when all ages were analyzed, there was a 71% decline in deaths associated with transposition of the great arteries (P = .001) and a 40% reduction in deaths associated with tetralogy of Fallot (P < .001). Mortality related to other lesions declined as well. Among adults with cyanotic lesions, the primary contributing cause of death was arrhythmia followed by heart failure. For adults with noncyanotic lesions, the major contributing cause before 1990 was arrhythmia; after 1990, myocardial infarction became the leading contributing cause of death. There was an overall decrease in the incidence of arrhythmia as the cause of death in all ages, particularly among children.

CONCLUSIONS

Patients with congenital heart disease are living longer. Arrhythmia remains the primary contributing cause of death for those with cyanotic lesions. Myocardial infarction is now the leading contributing cause for adults with noncyanotic congenital heart disease consistent with late survival and an increasing impact of acquired heart disease.

Aortic aneurysm formation five decades after tetralogy of Fallot repair

Surgical repair of tetralogy of Fallot is recognized as one of the most successful palliative cardiac surgical procedures. We report a patient in whom cystic medial necrosis developed 50 years after tetralogy of Fallot repair that caused a pathologic ascending aortic aneurysm requiring operative repair. Thus, long-term clinical follow-up along with echocardiography, when indicated, is mandatory in patients undergoing tetralogy of Fallot repair.

Noncontact mapping and radiofrequency catheter ablation of fast and hemodynamically unstable ventricular tachycardia after surgical repair of tetralogy of Fallot

OBJECTIVES

The goal of this work was to assess efficacy of radiofrequency (RF) ablation of fast ventricular tachycardia (VT) in patients after surgical repair of tetralogy of Fallot (TOF) guided by noncontact mapping.

BACKGROUND

Ventricular tachycardias after repair of TOF are associated with significant morbidity and mortality.

METHODS

Ten patients after surgical repair of TOF underwent electrophysiological study for hemodynamically unstable VT using the noncontact mapping system. Dynamic substrate mapping was performed and activation was recorded during basic rhythm and induced VT (mean cycle length 269 ms) using color-coded isopotential maps and reconstructed unipolar electrograms.

RESULTS

A total of 13 VTs were induced in the 10 patients. In 11 of 13 VTs, a macro-re-entrant mechanism was identified; 2 had a focal origin. For macro-re-entrant VT, RF current lesion lines were created between areas of residual conduction; in 2 patients, no RF current was delivered due to high risk of atrioventricular block. Focal applications were performed for the focal VTs. Ventricular tachycardia was not inducible after RF application in the 8 patients in whom ablation was attempted (100%, 80% of all patients). An internal cardioverter-defibrillator had already been implanted in 2 patients and was recommended to the rest of the group. During follow-up (mean 35.4 months), 6 of 8 patients with a successful procedure were still free of VT, and 2 patients had recurrence of VT with a different cycle length.

CONCLUSIONS

In patients with fast and unstable VT after surgical repair of TOF, noncontact mapping helped to identify the tachycardia substrate and allowed for effective and safe treatment by RF ablation.

Long-Term Functional Assessment After Correction of Tetralogy of Fallot in Adulthood

BACKGROUND

Tetralogy of Fallot presenting in adulthood is a surgical challenge. We present the long-term outcomes of surgical correction in this subset of patients, including results of postoperative effort tolerance as assessed by treadmill testing.

METHODS

Fifty-eight patients older than 18 years operated on between January 1995 and June 2004 are included in the study. Mean age at surgery was 22.5 +/- 5 years. Forty-seven patients were in New York Heart Association functional class II and 11 were in class III. Two patients had previous shunts. Forty-four patients received a transannular patch, and 14 had a right ventricular outflow tract patch. The prospective arm objectively assessed postoperative ventricular function by treadmill testing and echocardiography.

RESULTS

Hospital mortality was 6.9%. Follow-up was 89% complete, with mean follow-up of 69.9 +/- 43 months. Late mortality occurred in 2 patients, both with infective endocarditis. Significant improvement in functional class was demonstrated (p < 0.001). Eight patients had significant pulmonary regurgitation on follow-up. The probability of survival after repair was 89% at 15 years. Thirty-five of 36 patients who underwent treadmill testing had good effort tolerance, with an average of 10.47 +/- 1.4 metabolic equivalents achieved. None had a positive result. One patient with transannular patch, in functional class III, had fair exercise tolerance with severe pulmonary regurgitation on echocardiography.

CONCLUSIONS

Repair of adult tetralogy of Fallot has acceptable morbidity and mortality rates with good long-term surgical outcome in terms of effort tolerance as demonstrated by treadmill testing. Transannular patching does not appear to be a significant risk factor for right ventricular failure at long-term follow-up.

Aortic root disease in tetralogy of Fallot

PURPOSE OF REVIEW

Progressive aortic root dilatation is a recognized feature of tetralogy of Fallot even in patients following initial reparative surgery. The underlying pathophysiology was initially attributed to altered hemodynamics resulting from longstanding volume overloading and stretching of the aortic root from increased right to left shunting. This review explores the pathophysiology and possible mechanisms for the aortic dilatation, and whether these changes are a reflection of the initial hemodynamic stress or a cellular expression of an unrecognized gene associated with conotruncal defects.

RECENT FINDINGS

The recent publication of two case reports of aortic aneurysm and dissection in tetralogy of Fallot patients re-emphasized the fact that aortic root dilatation can no longer be regarded as a benign problem in tetralogy of Fallot patients. Findings of intrinsic histological abnormalities in the aortic root and ascending aorta of tetralogy of Fallot patients suggest that intrinsic abnormalities may also play an important causative role.

SUMMARY

A better understanding of the pathophysiology will help to formulate future treatment and management strategies in the subgroup of tetralogy of Fallot patients with progressive aortic dilatation.

Surgery Insight: late complications following repair of tetralogy of Fallot and related surgical strategies for management

Biventricular correction of tetralogy of Fallot was devised more than 50 years ago. Current short-term outcomes are excellent. The potential for late complications is, however, an important concern for the growing number of postrepair survivors. Progressive pulmonary valve regurgitation leading to right heart failure and arrhythmia are centrally important problems faced by these patients. New techniques are, however, likely to change the future outcomes for postrepair survivors. These techniques include percutaneous valve replacement, arrhythmia ablation surgery, and strategies that emphasize preservation of the pulmonary valve even at the cost of leaving some residual valvular stenosis. The objectives of this Review are to outline the major complications that arise late after repair of tetralogy of Fallot, to describe the surgical approaches that have been developed to avoid and manage arising complications, and to briefly explore how novel treatment paradigms could change the future long-term outlook for patients following tetralogy repair.

Rupture of a Synthetic VSD Patch 28 Years After Total Correction of Fallot’s Anomaly

Patients operated on for complex congenital heart malformations need continuous follow-up. We present a male patient born in 1948 with Fallot's anomaly. A total correction was performed when he was 21 years old. Twenty-eight years after the operation, at routine follow-up, he presented with a significant left-to-right shunt because of a new ventricular septal defect. During the operation we found the original patch to be fractured with a central perforation. The patient received a new patch and has been without any clinical symptoms since.

Cardiac MR Imaging Assessment Following Tetralogy of Fallot Repair

Survivors of tetralogy of Fallot (TOF) repair constitute a large and growing population of patients. Although postsurgical outcome is generally favorable, as these patients move into adulthood, late morbidity is becoming more prevalent and the notion that TOF has been "definitively repaired" is increasingly being challenged. Recent evidence suggests that adverse long-term postsurgical outcome is related to chronic pulmonary regurgitation, right ventricular dilatation, and deteriorating ventricular function. Cardiac magnetic resonance (MR) imaging has been established as an accurate technique for quantifying ventricular size, ejection fraction, and valvular regurgitation. Cardiac MR imaging does not expose the patient to ionizing radiation and is therefore ideal for serial postsurgical follow-up. Familiarity with the anatomic basis of TOF, the surgical approaches to repair, and postrepair sequelae is essential for performing and interpreting cardiac MR imaging examinations. For example, awareness of the complications and sequelae that can occur will assist in determining when to intervene to preserve ventricular function and will improve long-term outcome. Technical facility is necessary to tailor the examination to the individual patient (eg, familiarity with non-breath-hold modifications that allow evaluation of young and less compliant patients). The radiologist can play an essential role in the treatment of patients with repaired TOF by providing noninvasive anatomic and physiologic cardiac MR imaging data. Further technologic advances in cardiac MR imaging are likely to bring about new applications, better normative data, and more examinations that are operator independent.

Three-vessel coronary artery disease complicated with congestive heart failure in a highly aged patient with tetralogy of Fallot having undergone palliative surgeries

An increasing number of patients with tetralogy of Fallot (TOF) are reaching older age. We encountered a 75-year-old woman with uncorrected TOF and concomitant severe coronary artery disease (CAD) with congestive heart failure. Her CAD risk factor was hyperlipidemia, which had been untreated. Successful percutaneous coronary interventions have improved her clinical condition and provided long-term survival. Although CAD is considered to be a rare complication in adults with TOF, both strict modification of CAD risk factors and early detection of CAD would be also required in this population, given the residual TOF lesions relating to acute exacerbation of clinical presentation.

Intrinsic histological abnormalities of aortic root and ascending aorta in tetralogy of Fallot: evidence of causative mechanism for aortic dilatation and aortopathy

BACKGROUND

Dilatation of the aortic root is a known feature in tetralogy of Fallot (TOF) patients with pulmonary stenosis (PS) or pulmonary atresia (PA). We hypothesized that intrinsic histological abnormalities of the aortic wall present since infancy are an important causative factor leading to aortic root dilatation.

METHODS AND RESULTS

We examined the aortic histology of 17 cases with TOF and PS/PA from our cardiac morphology archive and compared them with a control group of normal aortas. Measured circumference of the aortic root at the sinotubular junction and at the ascending aorta was indexed to the left ventricle. Aortic walls were studied by light microscopy with the use of various stains. Seventeen TOF cases (7 with PS, 10 with PA) including 7 infants, 2 children, and 8 adults were compared with 11 hearts with normal aorta. Aortic root circumference to left ventricular index and ascending aortic circumference to left ventricular index were 1.24+/-0.25 and 1.37+/-0.24, respectively, in the TOF group versus 0.89+/-0.10 and 0.88+/-0.11, respectively, in the control group (P<0.001). Histological changes of grade 2 or 3 were present in 29% (medionecrosis), 82% (fibrosis), 35% (cystic medial necrosis), and 59% (elastic fragmentation) in the ascending aorta of the TOF group. Histology grading scores were significantly higher in the TOF group (median score, 7; range, 1 to 12) compared with normal controls (median score, 2; range, 0 to 6) and correlated with the ascending aortic circumference to left ventricular index (r=0.525, P=0.03).

CONCLUSIONS

There are marked histological abnormalities in the aortic root and ascending aortic wall of patients with TOF present from infancy, suggesting a causative mechanism for subsequent aortic root dilatation.

The Adult With Congenital Heart Disease

The population of patients with adult congenital heart disease is approximately 800,000 in the U.S. Those with prior cardiac surgery often consider themselves "cured," although the majority faces a lifetime of problems including arrhythmias, ventricular dysfunction, and one or more re-operations. Even patients with repaired "simple" lesions such as an atrial septal defect may not have normal survival if they are repaired in adulthood. Patients with repaired coarctation may have premature cardiovascular complications including sudden cardiac death, myocardial infarction, and stroke. They also have aortic complications such as aneurysm and dissection, which result from a diffuse arteriopathy and continued hypertension that may be caused by underlying endothelial dysfunction. In addition, bicuspid aortic valve occurs in more than one-half of the patients with coarctation, so continued surveillance for significant aortic valvular heart disease is necessary. More complex lesions also pose problems after "total correction." Patients with repaired tetralogy of Fallot often have pulmonary regurgitation, which is frequently overlooked on clinical exam and echocardiography. Pulmonary valve replacement should be performed before the development of irreversible right ventricular dysfunction and an increased risk of ventricular tachycardia or sudden cardiac death. Because they are vulnerable to deterioration of systemic ventricular function, those with congenitally corrected transposition require special vigilance, usually with concomitant atrio-ventricular valve regurgitation. Late referral is common with a deleterious effect on long-term survival. These patients need lifelong follow-up and the residua and sequelae of their complex anomalies must be understood in order to provide optimum care.

Late pulmonary valve implantation after repair of tetralogy of Fallot

Ten cases of elective late pulmonary valve implantation after repair of tetralogy of Fallot were reviewed. The interval after initial repair ranged from 1.5 to 43 years (mean, 20.0 +/- 12.3 years). There was no hospital mortality or late death during a mean follow-up of 12.5 months. Preoperatively, 9 patients were in New York Heart Association functional class III-IV; after pulmonary valve implantation, all 10 patients were in class I-II (average improvement, 1.7 classes). Left ventricular ejection fraction improved significantly (from 62.1% +/- 4.7% to 70.2% +/- 4.9%), as did fractional shortening (from 34.0% +/- 5.0% to 40.0% +/- 4.2%). Right ventricular diameter decreased significantly (from 32.3 +/- 7.5 to 24.4 +/- 5.4 mm). QRS duration decreased significantly (155.2 +/- 27.1 vs. 140.0 +/- 21.2 msec), but there was no significant difference in QT interval (460.9 +/- 29.6 vs. 451.9 +/- 50.6 msec). Hospital stay was 4-7 days. One patient had preoperative ventricular fibrillation requiring resuscitation and an implantable cardiac defibrillator; another needed a defibrillator at the time of pulmonary valve implantation, because of ventricular arrhythmias. It was concluded that late pulmonary valve implantation after tetralogy of Fallot repair had significant benefits and carried low operative risk.

Late results and quality of life after pediatric cardiac surgery in Finland: a population-based study of 6,461 patients with follow-up extending up to 45 years

This population-based study characterizes the history and progress of pediatric cardiac surgery in Finland. For the first time in the literature, all defects and procedures are included in an outcome study, reflecting the true effectiveness of operative treatment. All the patients operated on since the beginning of pediatric cardiac surgery in Finland in 1953 and through the end of 1989 were included in this population-based, long-term outcome study. The survival was defined from the Finnish Population Registry Center. The survival rates were compared with those of an age- and sex-matched general population. During the study period, 6,461 patients underwent surgery; 96% of them were traced. A questionnaire was used to study the quality of life. The 45-year survival of patients was 15% less than that of the general population. The survival and the number of necessary operations varied widely with the defect. The patients coped well with their defects when compared with the general population. The education level was similar, and the employment level was higher than expected. Patients were living in a steady relationship as often as the general population, but parenthood was less frequent than expected. The incidence of congenital heart disease among the children of the patients was 2.4%. The overall survival of children operated on for heart defects is fairly good. The patients, especially those with simpler defects, do not have increased risk of death years after successful operation. The majority of patients are feeling well, and their life situation is similar to the general population.

Right Ventricular Function after Pulmonary Valve Replacement in Patients with Tetralogy of Fallot

PURPOSE

To assess the time course of right ventricular (RV) function improvement after pulmonary valve replacement (PVR) in patients 25.2 years +/- 7.0 after repair of tetralogy of Fallot.

MATERIALS AND METHODS

The medical ethics committee approved this study, and informed consent was obtained. Cardiac magnetic resonance (MR) imaging was performed before, 7 months after, and 19 months after PVR in 25 consecutive patients with tetralogy of Fallot with a 1.5-T MR imager. RV function was assessed with gradient-echo sequences in the short-axis plane. Pulmonary flow was assessed with a velocity-encoded phase-contrast sequence. Paired t test was used to evaluate follow-up data. Independent samples t test was used to assess differences based on the presence of recurrent pulmonary regurgitation (PR).

RESULTS

Mean indexed RV end-diastolic volume decreased from 166.9 mL/m(2) +/- 41.3 before PVR to 113.5 mL/m(2)+/- 35.7 (P < .001) at 7-month follow-up and 111.7 mL/m(2)+/- 41.1 (P = .46) at 19-month follow-up. The RV ejection fraction was corrected for PR and improved from 25.0% +/- 7.7 before surgery to 44.1% +/- 11.9 (P < .001) and 45.2% +/- 11.1 (P = .39), at 7- and 19-month follow-up, respectively. Recurrent PR after PVR was found in 11 patients; 14 patients did not have recurrent PR. Total reduction of indexed RV end-diastolic volume at 19 months follow-up was more prominent in patients who did not have recurrent PR than in patients who did have recurrent PR (P < .05). Furthermore, improvement of RV ejection fraction corrected for regurgitation was more marked in patients who did not have recurrent PR than in patients who did have recurrent PR (P < .05).

CONCLUSION

In patients with tetralogy of Fallot, RV function improves rapidly after PVR and is sustained at 19-month follow-up in most patients; however, recurrence of PR after PVR appears to reduce recovery of RV systolic function.

Outcomes of pregnancy in women with tetralogy of fallot

OBJECTIVES

We sought to determine pregnancy outcomes in patients with tetralogy of Fallot (TOF).

BACKGROUND

Pregnancy outcomes in patients with TOF are incompletely defined.

METHODS

Clinical, hemodynamic, and obstetric data were reviewed for women with TOF and prior pregnancy.

RESULTS

Of 72 respondents, 43 (mean age, 26 years) had 112 pregnancies (range, 1 to 5); 82 pregnancies were successful. Eight women had unrepaired TOF at the time of their 20 successful pregnancies. At first assessment (age > or =18 years), six patients had pulmonary hypertension, three had moderate or severe right ventricular (RV) systolic dysfunction, and 13 had severe RV dilation due to pulmonic regurgitation. Sixteen patients had 30 miscarriages (27%) and one term stillbirth. Mean overall birth weight was 3.2 kg (range, 2.1 to 4.2 kg). Unrepaired TOF (p = 0.05) and morphologic pulmonary artery abnormality (p = 0.03) were independently predictive of infant birth weight. Six patients had cardiovascular complications during pregnancy: supraventricular tachycardia in two, heart failure in two, pulmonary embolism in a patient with pulmonary hypertension, and progressive RV dilation in a patient with severe pulmonic regurgitation. Five infants (6%) had congenital anomalies.

CONCLUSIONS

Patients with TOF have an increased risk of fetal loss, and their offspring are more likely to have congenital anomalies than offspring in the general population. Adverse maternal events, although rare, may be associated with left ventricular dysfunction, severe pulmonary hypertension, and severe pulmonic regurgitation with RV dysfunction.

Late myocardial revascularization in patients with tetralogy of Fallot

Since surgical correction of congenital heart diseases began in the early 1950s, a growing number of patients are reaching older age and becoming a risk for developing coronary artery disease. This study presents the clinical experience of myocardial revascularization in 4 symptomatic coronary artery disease patients with unrepaired or corrected tetralogy of Fallot. Three patients had surgery and 1 patient had percutaneous angioplasty. One corrected tetralogy of Fallot patient developed symptomatic coronary artery disease and responded favorably to medical therapy.

Arrhythmias Late After Repair of Tetralogy of Fallot-A Japanese Multicenter Study-

BACKGROUND

Arrhythmia is a major late complication in adults with repaired tetralogy of Fallot, although a large-scale study has not been carried out in Japan.

METHODS AND RESULTS

A nationwide multicenter study with 512 operative survivors was performed. Actuarial survival rate at 30 years (maximum follow-up) was 98.4%. Fifty-four patients (10.5%) had clinically important arrhythmias, including 23 patients with bradycardia caused by sick sinus syndrome or atrioventricular block (AVB). A patient with complete AVB (CAVB) without pacemaker implantation (PMI) died later. Two patients had sustained ventricular tachycardia (VT) and syncope was reported in 18 patients with ventricular arrhythmias (VA). Atrial tachyarrhythmias were observed in 13 patients. Older age at operation was a risk factor for atrial fibrillation/flutter, longer postoperative survival duration for VA, and QRS duration >120 ms for VT. Perimembranous ventricular septal defect was related to CAVB. Right ventricular outflow patch was not a risk factor. Importantly, 60% of the subjects had QRS duration <120 ms.

CONCLUSION

The prevalence of serious arrhythmias is low in Japanese TOF patients as compared with the results from Western countries. CAVB without PMI and VT are the major risk factors for late morbidity and mortality. The excellent result could be related to the narrow QRS after surgery.

Risk factors for sudden death after repair of tetralogy of Fallot

BACKGROUND

Sudden cardiac death remains the most common cause of death after repair of tetralogy of Fallot. It has been suggested that sudden cardiac death is related to right ventricular hypertrophy or dilation. However, it is uncertain whether the preoperative patient status or operative techniques predispose for sudden cardiac death.

METHODS

From 1958 to 1977, 658 patients underwent repair of tetralogy of Fallot at our institution at a median age of 12.2 +/- 8.6 years. One third had at least one previous palliative operation 4.6 +/- 2.5 years earlier. A total of 490 patients survived the first postoperative year and were analyzed for sudden cardiac death. During a follow-up period of 25.3 +/- 5.8 years (range, 1.0 to 35.5 years), 42 patients died, and 15 (36%) of those deaths were as a result of sudden cardiac death.

RESULTS

Actuarial 10-year, 20-year, and 30-year survival rates were 97%, 94%, and 89%. Freedom from sudden cardiac death was 99%, 98%, and 95% after 10, 20, and 30 years. The risk of sudden cardiac death increased after 10 years from 0.06%/y to 0.20%/y. Univariate predictors (p < 0.1) of sudden cardiac death were use of an outflow tract patch (p = 0.068), male sex (p = 0.048), no previous palliation (p = 0.013), and higher preoperative New York Heart Association status (p = 0.014). Multivariate analysis confirmed these risk factors except use of an outflow tract patch.

CONCLUSIONS

The most important risk factors for sudden cardiac death were higher preoperative New York Heart Association class and no previous palliation. Thus, early surgical intervention is recommended. The risk of sudden cardiac death increases with time, suggesting that long-term follow-up by specialized cardiologists or pediatricians should be intensified. However, all patients who died suddenly had at least two risk factors at the time of surgery.

Long-term results of pediatric cardiac surgery in Finland: education, employment, marital status, and parenthood

OBJECTIVE

This population-based study was designed to examine the psychosocial outcome of Finnish patients who had been operated on for congenital heart disease during childhood.

METHODS

A questionnaire was mailed to 3789 adult patients who had been operated on for congenital heart defects in Finland. Of these, 2896 (76%) answered the questionnaire. The mean age of patients was 33 years (range: 18-59 years), and they had had their first operation 9 to 46 years earlier.

RESULTS

The patients had coped well with their defects when compared with the general Finnish population. The educational level of patients was comparable to and employment level was higher than expected (70% vs 66%, respectively). They were living in a steady relationship as often as the general population, but the number of parents among the patients was lower than that expected (47% vs 49%, respectively). The incidence of congenital heart disease among the 2697 children of the patients was 2.4%.

CONCLUSION

Our results confirm that in addition to high survival rate, the long-term psychosocial outcome of patients with surgically treated congenital heart defects is good if they do not have any additional syndromes that cause mental retardation.

Left ventricular dysfunction is a risk factor for sudden cardiac death in adults late after repair of tetralogy of Fallot

OBJECTIVES

The purpose of this study was to determine if left ventricular (LV) systolic dysfunction was also a predictor of sudden cardiac death (SCD) in adults late after repair of tetralogy of Fallot (TOF).

BACKGROUND

Previous studies looking at risk factors for SCD in adults with repair of TOF have focused on the right ventricle (RV).

METHODS

A retrospective chart review of patients assessed at the Toronto Congenital Cardiac Centre for Adults was performed. Twelve adult patients with repaired TOF and SCD were identified (SCD group). A total of 125 living adult patients with repaired TOF were randomly selected for comparison (control group).

RESULTS

Patients with SCD were more likely to exhibit moderate or severe pulmonary regurgitation (92% vs. 51%, p = 0.02), have a history of sustained ventricular tachycardia (42% vs. 6%, p < 0.01), and have a QRS > or =180 ms (56% vs. 13%, p = 0.02). Moderate or severe LV systolic dysfunction was also significantly more common in patients with SCD than in the control group (42% vs. 9%, p < 0.01) with a positive predictive value of 29%. The combination of moderate or severe LV systolic dysfunction and QRS > or =180 ms had a positive and negative predictive value for SCD of 66% and 93%, respectively.

CONCLUSIONS

Moderate or severe LV systolic dysfunction is significantly more common in adult patients with repaired TOF and SCD. The combination of QRS > or =180 ms and significant LV systolic dysfunction has high positive and negative predictive value for SCD. The implication of the role of prophylactic antiarrhythmic implantable cardiac defibrillator insertion in these patients needs further elucidating.

Magnetic Resonance Imaging to Assess the Hemodynamic Effects of Pulmonary Valve Replacement in Adults Late After Repair of Tetralogy of Fallot

Background— Pulmonary regurgitation (PR) late after total correction for tetralogy of Fallot may lead to progressive right ventricular (RV) dilatation and an increased incidence of severe arrhythmias and sudden death. Timing of pulmonary valve replacement (PVR) is subject to discussion, because the effect of PVR on RV function in adults is unclear. In this study, MRI was used to assess the effect of PVR on RV function and PR. Clinical improvement was established by means of the NYHA classification.

Methods and Results— Twenty-six adult patients were included. Cardiac MRI was performed at a median of 5.1±3.4 months before and 7.4± 2.4 months after PVR. Mean preoperative PR was 46±10% (range, 25% to 64%). After PVR, 20 of 26 patients (77%) showed no residual PR, 5 patients showed mild residual PR, and 1 patient showed moderate PR. RV end-diastolic volume (RV-EDV) decreased from 305±87 to 210±62 mL ( P <0.001), and RV end-systolic volume (RV-ESV) decreased from 181±67 to 121±58 mL ( P <0.001). No significant change was found in RV-EF (42% versus 42%). However, RVEF corrected for regurgitations and shunting increased from 25.2±8.0% to 43.3±13.7% ( P <0.001). Mean validity class improved from 2.0 to 1.3 ( P <0.001).

Conclusions— In adult patients with PR and RV dilatation, late after total correction of tetralogy of Fallot, MRI measurements show remarkable hemodynamic improvement of RV function after PVR and improvement of validity. We therefore advocate a less restrictive management concerning PVR in these patients.

Influence of early repair of tetralogy of fallot without an outflow patch on late arrhythmias and sudden death: a 27-year follow-up study following a uniform surgical approach

Pulmonary regurgitation and older age at the time of repair may have a large impact late after repair on subsequent mortality of patients with tetralogy of Fallot. We aimed to identify whether age at repair, and preservation of the pulmonary valve, had a favorable influence on morbidity and mortality. We also analyzed risk factors for late death subsequent to surgical repair. We identified 167 patients who, between 1965 and 1975, and at a mean age of 6 years, underwent total repair of tetralogy of Fallot by a single surgical team without use of an outflow patch. All patients were known to have survived for at least 30 days after repair, and late mortality was identified though the use of hospital records, interviews, and death certificates. The 29-year actuarial survival rate was 86%, with 24 late deaths. Of these deaths, seven occurred suddenly (4.2%). Morbidity was analyzed in 99 of the patients by means of a written questionnaire and telephone interview. It proved possible to analyze ventricular and valvar function in 50 of the patients. Survivors experienced no re-intervention, and 89% of them were in class I of the grading system of the New York Heart Association. We found evidence of 3 episodes of sustained ventricular tachycardia (3.0%), and two episodes of atrial tachycardia (2.0%). Of the 50 patients in whom serial examinations were available, 18 had pulmonary regurgitation of moderate degree or greater, and none had more than moderate tricuspid regurgitation, with a mean QRS duration of 148 ms and an ejection fraction for the left ventricle of 50%. Older age at repair (p = 0.03), and longer periods of cardiac arrest during repair (p = 0.02), were associated with late mortality. Although the mortality was similar to that observed in previous reports, our operative method might have a better effect in terms of late morbidity.

Long-term results after early primary repair of tetralogy of Fallot

OBJECTIVE

Early primary repair of tetralogy of Fallot has been routinely performed at Children's Hospital, Boston, since 1972. We evaluated the long-term outcome of this treatment strategy including the influence of a transannular patch.

METHODS

Fifty-seven patients less than 24 months of age (median 8 months) underwent primary repair of tetralogy of Fallot between January 1972 and December 1977. Thirty-one patients had a transannular patch. Survival and freedom from reintervention were determined by the Kaplan-Meier method with 95% confidence intervals.

RESULTS

There were 8 early deaths, and 1 patient died 24 years after initial repair. Recent follow-up was obtained for 45 of the 49 long-term survivors (92%). Median follow-up was 23.5 years. Ten patients underwent reintervention, 8 of whom underwent relief of right ventricular outflow tract obstruction. Right ventricular outflow tract obstruction occurred in 6 patients without a transannular patch and 2 with a transannular patch (33% vs 6%, P =.04). One pulmonary valve replacement was performed at another institution 20 years after the repair. Forty-one long-term survivors were in New York Heart Association class I and 4 were in class II. Actuarial survival was 86% at 20 years (95% confidence intervals = 80%-92%). Freedom from reintervention was 93% at 5 years (95% confidence intervals = 87%-99%) and 79% at 20 years (95% confidence intervals = 70%-86%). No significant differences were found between patients with and without a transannular patch (survival, P =.34; freedom from reintervention, P =.09, log-rank tests).

CONCLUSIONS

Long-term survival is excellent and the freedom from reintervention is satisfactory after early primary repair of tetralogy of Fallot in the 1970s. Use of a transannular patch does not reduce late survival and is associated with a lower incidence of right ventricular outflow tract obstruction.

Significance of early transient complete heart block as a predictor of sudden death late after operative correction of tetralogy of fallot

We evaluated the long-term outcome and incidence of sudden death in the 288 patients discharged after corrective operation for tetralogy of Fallot at the University of Minnesota between 1954 and 1974. The perioperative characteristics of these patients were evaluated with respect to their long-term outcome. A health status survey was sent to each survivor and their functional status was evaluated with respect to the perioperative variables. Current follow-up was available in 279 of 288 of the postoperative survivors (97%); the mean duration of follow-up was 28 years. The 40-year survival rate was 76% and 154 of 163 of survey responders (95%) were in New York Heart Association class I or II. Twenty-six of the 288 died suddenly (9%). Those with transient complete heart block that persisted beyond the third postoperative day had a lower long-term survival rate (p <0.001) and a higher incidence of late sudden death (p <0.001). Patients aged >12 years at operation had a lower long-term survival rate (p <0.001) and less favorable long-term functional status. The use of a transannular patch was associated with increased late morbidity but not mortality. Thus, the very long-term outcome after operative correction of tetralogy of Fallot is excellent. Late sudden death remains a concern for operative survivors, occurring in 9% of these patients. Late sudden death is strongly associated with transient complete heart block that persisted beyond the third postoperative day.

Tetralogy of Fallot: surgical management individualized to the patient

BACKGROUND

Over the past four decades, the surgical trend has been toward early, complete repair of tetralogy of Fallot (TOF). Many centers currently promote all neonates for total correction irrespective of anatomy and symptoms, with some surgeons advocating hypothermic circulatory arrest for repair in small infants. We believe this approach increases morbidity.

METHODS

Based on approximately 40 years' experience in 2,175 patients, we developed a management protocol focused on patient size, systemic arterial saturations, and anatomy. Symptomatic patients (hypercyanotic spells, ductal dependent pulmonary circulation) weighing less than 4 kg undergo palliative modified Blalock-Taussig shunt (BTS) followed by complete repair at 6 to 12 months. Asymptomatic patients, weighing less than 4 kg who have threatened pulmonary artery isolation, undergo BTS and repair at 6 to 12 months. All other patients undergo complete repair after 6 months.

RESULTS

From July 1, 1995, to December 1, 1999, 144 patients underwent operation for TOF (129 patients) or TOF with atrioventricular septal defect (TOF/AVSD, 15 patients). Ninety-four patients underwent one stage complete repair (88 TOF, 6 TOF/AVSD). Thirty-nine patients underwent repair after initial BTS (32 TOF, 7 TOF/AVSD). Ten patients are awaiting repair after BTS. The mean age and weight at complete repair were 18 months and 9 kg. There were no operative deaths. There have been 3 late deaths with complete follow-up (mortality 3 of 144 [2.1%]). Four of 133 patients (3%) have required reoperation after total correction.

CONCLUSIONS

This management strategy optimizes outcomes by individualizing the operation to the patient. Advantages include avoidance of circulatory arrest, low morbidity and mortality, and low incidence of reoperation after complete repair.

Sustained atrial arrhythmias in adults late after repair of tetralogy of fallot

We determined the prevalence of sustained atrial tachyarrhythmia (AT) in adults late after repair of tetralogy of Fallot (ToF) and examined its impact on subsequent heart failure, reoperation, and mortality. Ventricular arrhythmias are associated with increased morbidity and mortality in patients with repair of ToF. The clinical impact of AT in this population has not been established. A retrospective cohort study of 242 patients with repaired ToF identified 29 patients (prevalence of 12%) with sustained episodes of AT. Patients with repaired ToF but without sustained arrhythmia (n = 213) constituted a comparison group. Baseline characteristics and clinical outcomes in the 2 groups were compared. An echocardiographic analysis compared 15 patients with AT and 15 matched for age at operation and timing of echocardiography. The development of AT was associated with substantial morbidity including congestive heart failure, reoperation, subsequent ventricular tachycardia, stroke, and death (combined events, 20 of 29 patients [69%]). The rate of combined events (congestive heart failure, stroke, and deaths) in the 213 "arrhythmia-free" patients was 30% (64 of 213 patients). Event-free survival after repair was 18 +/- 2 years for the AT group and 28 +/- 1 years for the arrhythmia-free group (p < 0.001). Patients with AT were older at surgical repair (25 +/- 16 vs 10 +/- 9 years, p = 0.001), and at most recent assessment were aged 48 +/- 12 vs 32 +/- 10 years (p = 0.001). The AT group had a higher mean right atrial volume and proportion of significant pulmonary regurgitation than matched controls. The development of AT in the adult late after ToF repair identifies patients at risk and is associated with older age at repair, a higher frequency of hemodynamic abnormalities, and increased morbidity.

Late pulmonary valve replacement after repair of tetralogy of Fallot

BACKGROUND

Pulmonary regurgitation appears to be well tolerated early after repair of tetralogy of Fallot; however, it may result in progressive right ventricular dilatation and dysfunction necessitating eventual valve replacement. Our objective was to review our experience with late pulmonary valve replacement after complete repair of tetralogy of Fallot.

METHODS AND RESULTS

A total of 42 patients (16 female and 26 male) were operated on between July 1, 1974, and January 1, 1998. Mean age was 22 years (range 2-65 years). The mean interval between tetralogy repair and pulmonary valve replacement was 10.8 years (range 1.6 months-33 years). Mean follow-up was 7.8 +/- 6.0 years (maximum 23 years). Indications for pulmonary valve replacement included decreased exercise tolerance in 58%, right heart failure in 21%, arrhythmia in 14%, syncope in 10%, and progressive isolated right ventricular dilatation in 7%. Heterograft prostheses were used in 33 patients and homografts in 9. Five patients underwent isolated pulmonary valve replacement; concomitant procedures performed in 37 patients included tricuspid valve repair/replacement (n = 18), residual ventricular septal defect repair (n = 12), atrial septal defect closure (n = 4), pulmonary artery patch angioplasty (n = 17), and right ventricular outflow tract enlargement (n = 13). One patient died early (2%) of multiorgan failure. There were 6 late deaths, 3 of which were cardiac related. Survival was 95.1% +/- 3.4% and 76.4% +/- 8.9% at 5 and 10 years, respectively. Functional class of patients was improved significantly; preoperatively, 76% of patients were in New York Heart Association class III-IV, and after pulmonary valve replacement, 97% of surviving patients were in class I-II (P =.0001). Moderate to severe reduction in right ventricular function was noted on preoperative echocardiography in 59% and on late echocardiography in 18% (P =.03). Of the 5 patients who had supraventricular arrhythmias before pulmonary valve replacement, 1 had postoperative recurrence and the arrhythmia is controlled with antiarrhythmic therapy; the other 4 are in normal sinus rhythm at late follow-up. Eight patients subsequently underwent pulmonary valve re-replacement without early mortality at a mean interval of 9.0 +/- 4.2 years (range 3.8-16.8 years). Freedom from pulmonary valve re-replacement was 93.1% +/- 4.7% and 69.8% +/- 10.7% at 5 and 10 years, respectively. The only significant risk factor for re-replacement was young age at the time of the initial pulmonary valve replacement (P =.023).

CONCLUSION

Late pulmonary valve replacement after tetralogy repair significantly improves right ventricular function, functional class, and atrial arrhythmias, and it can be performed with low mortality. Subsequent re-replacement may be necessary to maintain functional improvement.

Mode of death in adults with congenital heart disease

An increasing number of patients with congenital heart disease (CHD) are entering adulthood. Although prior studies have focused on the causes of death in the pediatric population, the modes of death for adults with CHD have not been well defined. In a cross-sectional study performed on a population of 2,609 consecutive adults assessed at a CHD specialty clinic, there were adequate information available in 197 of 199 deceased patients. Mean age at death was 37 +/- 15 years. Mortality was highest in patients with congenitally corrected transposition of the great arteries (26%), tricuspid atresia (25%), and univentricular connection (23%). Youngest mean age at death was observed in patients with tricuspid atresia (27 +/- 5 years), complete transposition of the great arteries (27 +/- 7 years), pulmonary atresia (27 +/- 6 years), and aortic coarctation (29 +/- 6 years). Sudden death (26%) was the most common cause of death followed by progressive heart failure (21%) and perioperative death (18%). Postmortem examinations were performed in 77 of 197 deceased patients (39%) and provided incremental data on the mechanism of death in 22% of autopsies. Thus, the 3 major causes of death in the growing population of adults with CHD are sudden, perioperative, and progressive heart failure.

Risk factors for arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: a multicentre study

BACKGROUND

Ventricular arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot are devastating complications in adult survivors of early surgery, but their prediction remains difficult.

METHODS

We examined surgical, electrocardiographic, and late haemodynamic data, and their relation to clinical arrhythmia and sudden death occurring over 10 years, in a multicentre cohort of patients with repaired tetralogy, who were alive in 1985.

RESULTS

Of 793 patients (mean age at repair 8.2 years [SD 8], mean time from repair 21.1 years [8.7]) who entered the study, 33 patients developed sustained monomorphic ventricular tachycardia, 16 died suddenly, and 29 had new-onset sustained atrial flutter or fibrillation. Electrocardiographic markers (QRS duration, QRS rate of change between 1985 and 1995) were significantly greater in the ventricular tachycardia and sudden-death groups. Older age at repair was associated with a higher risk of sudden death and atrial tachyarrhythmia. Pulmonary regurgitation was the main underlying haemodynamic lesion for patients with ventricular tachycardia and sudden death, whereas tricuspid regurgitation was for those with atrial flutter/fibrillation. Despite adverse haemodynamics, no patient who died suddenly had undergone late reoperation.

CONCLUSION

Arrhythmia and sudden death are important late sequelae for patients after repair of tetralogy of Fallot. The electrophysiological and haemodynamic substrate of sudden death resembled that of sustained ventricular tachycardia, with pulmonary regurgitation being the predominant haemodynamic lesion. Preservation or restoration of pulmonary valve function may thus reduce the risk of sudden death. Furthermore, electrocardiographic markers can help to identify patients at risk.

Right ventricular outflow tract after non-conduit repair of tetralogy of Fallot with coronary anomaly

BACKGROUND

A total of 25 patients with tetralogy of Fallot and an important coronary artery crossing the right ventricular outflow tract underwent complete repair without use of an extracardiac conduit between January 1990 and December 1994. Repair was exclusively done by the transatrial or transatrial-transpulmonary approach. Age of these patients ranged from 1 to 12 years (mean 3.6 years). Three of the patients had already received a systemic to pulmonary artery shunt.

METHODS

All patients reporting for follow-up (n = 18) were subjected to transthoracic echocardiography and, if required, cardiac catheterization and angiography. Right ventricle to pulmonary artery gradients were noted preoperatively, at discharge following repair and at follow-up study.

RESULTS

Mean follow-up was 40.6 months (24 to 62 months). Mean early postoperative gradient was 23.5+/-13.4 mm Hg and 4 patients had significant (> 30 mm Hg) gradients. Mean late postoperative gradient was 20.6+/-12.4 mmHg and 2 patients had gradients greater than 30 mmHg. All the patients were in New York Heart Association functional class I at the time of last follow-up.

CONCLUSIONS

Acceptable gradients across the right ventricular outflow tract are achievable following repair of tetralogy of Fallot in the presence of anomalous coronary artery across the right ventricular outflow tract using the transatrial or transatrial-transpulmonary approach. Most gradients were found not to vary significantly on subsequent follow-up.

Psychosocial profile of adults with complex congenital heart disease

OBJECTIVE

Despite the increasing number of adults with congenital heart disease (CHD), little is known of the emotional life of these long-term survivors; hence, we undertook a study to establish a psychological profile of these individuals so as to optimize their care.

PATIENTS AND METHODS

We performed psychiatric evaluation by both interview and questionnaire on 29 ambulatory patients with CHD (mean age, 38 years; range, 26-56 years).

RESULTS

Although many met symptomatic criteria for psychiatric diagnosis, most were functional in day-to-day life and used denial in adapting to their CHD. In childhood, extended absences from school, cyanosis, scars, and sports restrictions hindered friendships and conflicted with a sense of "normalcy"; teasing and low self-esteem were more notable in boys; girls more readily hid behind makeup, nail polish, and clothing. In adulthood most were concerned about shortened life expectancy, disability, and childbearing and child rearing. Virtually all were highly committed to both school and work performance. All but those with complete, uncomplicated early repair expressed unresolved frustration, anger, and fears of a future that might include further medical complications.

CONCLUSION

Listening to this selected group of patients offers insight that may be helpful to the clinical care of patients with CHD and other patients with lifelong disease.

Electrocardiographic predictors of right ventricular volume measured by magnetic resonance imaging late after total repair of tetralogy of Fallot

BACKGROUND

Right ventricular dysfunction occurs in many patients with significant pulmonary valve regurgitation late after initial total repair of tetralogy of Fallot. Methods to predict which of these patients are at increased risk of late morbidity and mortality are not yet known.

HYPOTHESIS

This study evaluated electrocardiographic (ECG) predictors of severe right ventricular dilatation determined by magnetic resonance imaging (MRI) volumes in patients with tetralogy of Fallot late after initial corrective repair.

METHODS

We retrospectively reviewed the ECGs and MRI right ventricular volume measurements of 20 patients (age 4.4 to 19.3 years, mean 10.0 years) with significant pulmonary valve regurgitation late after repair of tetralogy of Fallot. All patients had enlarged, hypokinetic right ventricles by echocardiography. The patients were grouped based on an indexed right ventricular end-diastolic volume (RVEDV/BSA) of < 102 ml/m2 (Group 1) or > or = 102 ml/m2 (Group 2). We determined the sensitivity, specificity, positive and negative predictive values of QRS duration, and mean frontal plane QRS axis for predicting right ventricular volumes.

RESULTS

A maximal QRS duration of > or = 150 ms or a northwest quadrant frontal plane QRS axis had 85% sensitivity, 86% specificity, 92% positive predictive value, and 75% negative predictive value for predicting an RVEDV/BSA of > or = 102 ml/m2. The mean QRS duration was significantly longer in Group 2 than in Group 1 patients (156 ms vs. 125 ms, p = 0.005).

CONCLUSIONS

In patients late after repair of tetralogy of Fallot with significant pulmonary valve regurgitation a maximal manually measured QRS duration of > or = 150 ms and/or a frontal plane QRS northwest quadrant axis can predict patients with marked right ventricular enlargement. The presence of either of these findings on the ECG signifies patients who require further evaluation and consideration for pulmonary valve replacement.

Twenty-to-thirty-seven-year follow-up after repair for Tetralogy of Fallot

OBJECTIVE

To describe the long-term prognosis after repair of Tetralogy of Fallot with pulmonary stenosis beyond 20 years.

METHODS

One hundred and eighty five patients underwent corrective repair of Tetralogy of Fallot at Rigshospitalet in Copenhagen between January 1960 and July 1977. Ninety seven patients had undergone a palliative operation prior to Tetralogy of Fallot repair. All the 125 patients who were discharged from the hospital were traced through the population register and the patients alive July 1997 were contacted by mail and/or telephone and questioned about use of medicine, professional status, family status and ability to perform sport activities.

RESULTS

Sixty patients died in hospital and 125 patients, 78 males and 47 females, were discharged alive. Among operative survivors, median age at operation was 12.8 years (range 0.4-41 years). Thirteen patients required a reoperation, the main indication was failed VSD closure. There were 16 late cardiac deaths, out of which seven were sudden and unexpected and three were in immediate relation to reoperations. One hundred and nine patients were alive at follow-up. The mean follow-up time was 25.5 years (range 20-38 years). Sixteen percent used cardiac drugs, 89% were, or had been, working normally (all professions from academics to hard manual labors were represented), 53% (64% of women) had given birth after the repair and 51% performed sport activities regularly. No patients were lost to follow-up.

CONCLUSIONS

The vast majority of the patients seemed to live normal lives 20-37 years after Tetralogy of Fallot repair. Late deaths were cardiac in origin, including sudden death from arrhythmias. The number of late reoperation has been low. Considering the natural history of the disease, Fallot repair has proven to be a beneficial procedure even including the very early experience short after introduction of open heart surgery.

Reoperation in adults with repair of tetralogy of fallot: indications and outcomes

OBJECTIVE

The purpose of this study is to review indications, surgical procedures, and outcomes in adults with repaired tetralogy of Fallot referred for reoperation.

METHOD

Sixty consecutive adults (age >/= 18 years) who underwent reoperation between 1975 and 1997 after previous repair of tetralogy of Fallot were reviewed. Mean age at corrective repair was 13.3 +/- 9.6 years and at reoperation 33.3 +/- 9.6 years. Mean follow-up after reoperation is 5.0 +/- 4.9 years.

RESULTS

Long-term complications of the right ventricular outflow tract (n = 45, 75%) were the most common indications for reoperation: severe pulmonary regurgitation (n = 23, 38%) and conduit failure (n = 13, 22%) were most frequent. Less common indications were ventricular septal patch leak (n = 6) and severe tricuspid regurgitation (n = 3). A history of sustained ventricular tachycardia was present in 20 patients (33%) and supraventricular tachycardia occurred in 9 patients (15%). A bioprosthetic valve to reconstruct the right ventricular outflow tract was used in 42 patients. Additional procedures (n = 115) to correct other residual lesions were required in 46 patients (77%). There was no perioperative mortality. Actuarial 10-year survival is 92% +/- 6%. At most recent follow-up, 93% of the patients are in New York Heart Association classification I or II. Sustained ventricular tachycardia occurred in 4 patients (7%) during follow-up.

CONCLUSIONS

Long-term complications of the right ventricular outflow tract were the main reason for reoperation. Mid-term survival and functional improvement after reoperation are excellent.

A 26-year experience with surgical management of tetralogy of Fallot: risk analysis for mortality or late reintervention

BACKGROUND

Over the past decade repair of tetralogy of Fallot (TOF) in infancy has gained favor. It is still uncertain what effect early complete repair will have on survival or late reoperation on the right ventricular outflow tract.

METHODS

To assess these outcomes, we reviewed our experience (1971-1997) with 294 patients undergoing operation at one institution. Median follow-up was 10.6 years (range, 0.1 to 26 years), and was complete for 90.2% patients.

RESULTS

Primary complete repair was done in 199 patients (68%), and a staged repair in 62 patients (21%). Thirty-three patients had only a palliative procedure. Sixty-eight patients (23.1%) had complex pathologic processes, including pulmonary atresia in 53. Hospital mortality for primary repair was 11.1% (22/199), for staged repair was 17.7% (11/62), and for palliative procedures was 15.5% (16/103 procedures). Since 1990 mortality has been 2.1%, 11.8%, and 0% respectively (p < 0.001), despite younger age at repair (0.6+/-0.1 versus 2.1+/-0.2 years; p < 0.001). Multivariate analysis identified longer period of hypothermic circulatory arrest, pulmonary artery patch angioplasty, earlier year of operation, and closure of the foramen ovale as risk factors for hospital death. For hospital survivors 20-year survival was 98%+/-3% for TOF with pulmonary stenosis and 88%+/-9% for TOF with pulmonary atresia (p=0.09). Reintervention on the right ventricular outflow tract was needed in 14.1% (37/261) patients. Freedom from reintervention on the right ventricular outflow tract at 20 years was 86%+/-4% for TOF with pulmonary stenosis and 43%+/-16% for TOF with pulmonary atresia (p=0.001). For the subgroup TOF with pulmonary stenosis, this was 85%+/-5% after primary repair and 91%+/-8% after staged repair (not significant). At 15-year follow-up, this was 78%+/-10% for patients not older than 1 year at operation compared with 88%+/-4% for older patients (not significant).

CONCLUSIONS

Early mortality after primary repair of TOF has significantly improved and late survival is excellent. Primary repair in infancy does not increase risk for reintervention on the right ventricular outflow tract.