Tetralogy of Fallot: Results of a Pulmonary Valve-Sparing Strategy

Assessment of a right-ventricular infundibulum-sparing approach in transatrial-transpulmonary repair of tetralogy of Fallot

OBJECTIVE

The study aimed to evaluate the outcome of transatrial-transpulmonary repair of tetralogy of Fallot in relation to a right-ventricular outflow tract (RVOT)-sparing surgery.

METHODS

Based on the surgical management of right-ventricular outflow tract obstruction (RVOTO) at repair of tetralogy of Fallot, 140 children were retrospectively divided into three groups: (1) pulmonary valve (PV)-sparing, (2) infundibulum-sparing and (3) extended trans-annular patch (TAP). Clinical and echocardiographic outcome was assessed with regards to three equally divided study time eras between January 1994 and June 2010.

RESULTS

Over a 15-year study period, median age decreased from 11 (2-101) to 5 (1-11) months (p<0.001), whereas type of RVOT repair changed significantly between the first and the last era (group 1: 18-40%, group 2: 25-40% vs group 3: 57-20% (p=0.002)). Mortality was 0%. Complications were mainly related to clinical restrictive RV physiology (27%) and arrhythmia (10%). This cardiac morbidity remained constant over the eras and was associated with younger age (p=0.04), increased postoperative right ventricle/left ventricle (RV/LV) pressure ratio (p=0.01) and type of RVOT repair at the cost of TAP (p=0.03). Median follow-up of 8 years (1-16 years) showed an overall freedom from RVOT re-operation of 84% and 73%, respectively at 5 and 10 years. Most re-operations were for residual/recurrent RVOTO (12%) occurring more frequently in the latter era: 16% versus 7% in era 1 (p=0.08). Late echocardiographic evaluation revealed a strong correlation between severity of pulmonary regurgitation and increased RV/LV size ratio, which was mainly determined by increased TAP length (p<0.001) and duration of follow-up (p=0.06).

CONCLUSION

In a 15-year's experience with transatrial-transpulmonary correction of tetralogy of Fallot, a valve- and infundibulum-sparing approach has been advanced by lowering the age for elective repair. This change has been performed without compromising immediate clinical outcome, despite an increased early re-operation rate for residual obstruction. However, longer follow-up will disclose whether this approach is protective against progressive and late RV dysfunction.

Transesophageal Echocardiography in Tetralogy of Fallot

Transesophageal echocardiography (TEE) plays an important role in the anatomical, functional, and hemodynamic assessment of patients with congenital heart disease (CHD). This imaging approach has been applied to both children and adults with a wide range of cardiovascular malformations. Extensive clinical experience documents significant contributions, particularly in the perioperative setting. In fact, in the current medical era, many consider this technology to be an essential adjunct to surgical and anesthetic management in CHD. This review focuses on the applications of TEE in patients with tetralogy of Fallot (TOF), the most common form of cyanotic heart disease. Emphasis is given to the perioperative use of this imaging modality and benefits derived during the prebypass and postbypass periods. Limitations and pitfalls relevant to the TEE assessment in patients with this anomaly are also addressed.

Deformities of pulmonary and aortic annulus 42 years after repair of tetralogy of Fallot

We report an extremely rare case of deformity of the pulmonary sinus of Valsalva with pulmonary valvular stenosis 42 years after a pulmonary annular-sparing operation for tetralogy of Fallot. Aortic regurgitation with deformity of the sinus is also noted. At the previous operation, the right ventricular outflow tract was augmented by a prosthetic subvalvular patch. Through the years, the pulmonary valve and sinus were distorted because the patch was pulled over toward the right ventricle.

Balloon pulmonary valvotomy as interim palliation for symptomatic young infants with tetralogy of Fallot

Objectives:

To describe the case selection, technique and immediate and short-term results of balloon pulmonary valvotomy (BPV) in young infants with tetralogy of Fallot (TOF).

Background:

Symptomatic young infants with TOF can either undergo corrective surgery or Blalock-Taussig (BT) shunt. Corrective surgery in early infancy is associated with significant morbidity and is not a realistic option in many centers. BT shunt carries the risk of branch pulmonary artery distortion and shunt occlusion.

Methods:

Infants less than three months with a significant valvar pulmonary stenosis (with or without associated infundibular and annular component) and oxygen saturation ≤80% were offered BPV. The right ventricular outflow tract (RVOT) was crossed with 4F Judkin's right coronary catheter and the valve was crossed with 0.014” coronary guide wire. Serial balloon dilatations were done with over the wire coronary balloons (3-4 mm) and Mini Tyshak balloons up to a balloon annulus ratio of 2:1, depending upon the improvement in saturation and formation of annular waist.

Results:

Seventeen infants less than three months of age with tetralogy of Fallot (median age: 33 days, range: 10-90 days, weight: 3.47 ± 0.87 kg, pulmonary annulus Z score: -5.59 ± 1.04) including eight neonates underwent palliative BPV between May 2004 and March 2007. The mean balloon annulus ratio was 1.4 ± 0.28 and fluoroscopy time was 26.18 ± 20.2 minutes. The mean oxygen saturation increased significantly from 73 ± 7% to 90 ± 3.68% following BPV (p = 0.0001). The only major complication was RVOT perforation and pericardial tamponade in one infant. The mean follow-up period was 23 ± 12 months. Two babies developed significant desaturation requiring surgery in the six months following BPV. There was a significant increase in pulmonary annulus. The z score for the pulmonary annulus improved from -5.59 ±1.04 before BPV to - 4.31 ± 1.9 at the time of last follow-up (p = 0.018). The mean Z score of hilar right pulmonary artery (RPA) increased significantly from -1.19 ± 1.78 before BPV to 0.7 ± 0.91 after BPV (p = 0.001). The mean Z score of hilar left pulmonary artery (LPA) increased significantly from -1.28 ± 1.41 to 0.03 ± 1.29 after BPV (p = 0.005). Eight patients underwent corrective surgery.

Conclusions:

Balloon pulmonary valvotomy is safe and effective. It significantly improves the growth of pulmonary annulus and branch pulmonary arteries. Thus it can be considered as an interim palliative procedure for symptomatic young infants with TOF and predominant valvar pulmonary stenosis.

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.

Perioperative care of children with tetralogy of fallot

OPINION STATEMENT

Complete surgical repair of tetralogy of Fallot (TOF) around 3 months of age is the commonly undertaken management strategy in many centers and has excellent outcomes. Intervention at an earlier age, including the newborn period, may be required for children with symptoms. Early extubation from mechanical ventilation where possible may help improve outcomes for children undergoing complete repair of TOF.

Outcomes of prenatally diagnosed tetralogy of Fallot: Implications for valve-sparing repair versus transannular patch

OBJECTIVES

To assess outcomes of prenatally diagnosed tetralogy of Fallot and determine factors associated with the choice to undergo a valvesparing repair versus transannular patch, and the use of prostaglandins at birth.

METHODS

All cases at The Hospital for Sick Children (Toronto, Ontario) with a fetal diagnosis of tetralogy of Fallot from 1998 to 2006, were reviewed for demographic and fetal echocardiographic data to determine factors associated with the valve-sparing repair and need for perinatal support.

RESULTS

Sixty-four fetuses met inclusion criteria (median gestational age 22 weeks) with 47 live births. Twenty-six underwent valve-sparing repair (median age 5.7 months) and 14 underwent transannular patch repair (median age 4.5 months). There were seven deaths before surgery and one post-transannular patch repair. One patient required a transannular patch repair after the initial valve-sparing repair. Twelve of 29 (41%) patients received prostaglandins at birth. Type of surgical repair, use of prostaglandins and postnatal death were among the outcomes investigated. The mean pulmonary valve (PV) z-score was -3.0+/-2.0 and the mean PV/aortic valve (AoV) ratio was 0.65+/-0.10. Lower PV z-score (P=0.04), smaller PV/AoV ratio (P=0.04) and the presence of nonantegrade arterial duct flow (P=0.02) were associated with prostaglandin use. A higher PV/AoV ratio was associated with valvesparing repair (P=0.04). Fetal z-scores of the PV, AoV and right pulmonary artery at 29 to 32 weeks gestational age correlated with respective postnatal z-scores (P=0.01).

CONCLUSION

Fetal echocardiographic variables were associated with the use of prostaglandins and valve-sparing repair in fetuses with tetralogy of Fallot, and at 29 weeks, correlated with postnatal valve diameters.

Early outcome of tetralogy of Fallot repair in the current era of management

BACKGROUND

Traditional use of trans-annular patch (TAP) to release right ventricular outflow tract (RVOT) obstruction during tetralogy of Fallot (TOF) repair may lead to a harmful pulmonary regurgitation. Different approaches have been used to release RVOT obstruction and spare the pulmonary valve (PV) function. In this study, we aim to evaluate the post-operative course of patients who had TOF repair in the current era that emphasizes on protective strategy of releasing RVOT obstruction and preserving PV function.

METHODS

A retrospective study of all TOF cases repaired in our institute between March 2002 and December 2007 was conducted. Cases were classified into two groups; group I included patients that had a TAP, while group II included cases that had simple TOF repair without TAP. Group I was subdivided into two groups, group (A) which include patients who had TAP without a valve. Group (B) includes those who had TAP with a monocuspid valve (Contegra). We compared post-operative care and outcome of all groups.

RESULTS

Eighty-three patients fulfilled the study criteria. There were 64 cases (77%) in group I, and 19 cases (23%) in group II. All children tolerated surgical repair and did well. We observed no statistically significant difference in the post-operative ICU care, complications rates and morbidity between all groups. There was no surgical mortality in all groups.

CONCLUSION

Children undergoing TOF repair had excellent short-term outcome with the current protective strategy aiming to spare valvular function, and conserving myocardial function. Applying a monocuspid patch technique did not show clear short-term benefits. Long term follow up is needed to evaluate future difference in different techniques.

Tetralogy of Fallot

Tetralogy of Fallot is a congenital cardiac malformation that consists of an interventricular communication, also known as a ventricular septal defect, obstruction of the right ventricular outflow tract, override of the ventricular septum by the aortic root, and right ventricular hypertrophy. This combination of lesions occurs in 3 of every 10,000 live births, and accounts for 7-10% of all congenital cardiac malformations. Patients nowadays usually present as neonates, with cyanosis of varying intensity based on the degree of obstruction to flow of blood to the lungs. The aetiology is multifactorial, but reported associations include untreated maternal diabetes, phenylketonuria, and intake of retinoic acid. Associated chromosomal anomalies can include trisomies 21, 18, and 13, but recent experience points to the much more frequent association of microdeletions of chromosome 22. The risk of recurrence in families is 3%. Useful diagnostic tests are the chest radiograph, electrocardiogram, and echocardiogram. The echocardiogram establishes the definitive diagnosis, and usually provides sufficient information for planning of treatment, which is surgical. Approximately half of patients are now diagnosed antenatally. Differential diagnosis includes primary pulmonary causes of cyanosis, along with other cyanotic heart lesions, such as critical pulmonary stenosis and transposed arterial trunks. Neonates who present with ductal-dependent flow to the lungs will receive prostaglandins to maintain ductal patency until surgical intervention is performed. Initial intervention may be palliative, such as surgical creation of a systemic-to-pulmonary arterial shunt, but the trend in centres of excellence is increasingly towards neonatal complete repair. Centres that undertake neonatal palliation will perform the complete repair at the age of 4 to 6 months. Follow-up in patients born 30 years ago shows a rate of survival greater than 85%. Chronic issues that now face such adults include pulmonary regurgitation, recurrence of pulmonary stenosis, and ventricular arrhythmias. As the strategies for surgical and medical management have progressed, the morbidity and mortality of those born with tetralogy of Fallot in the current era is expected to be significantly improved.

Tetralogy of Fallot

Tetralogy of Fallot is a congenital cardiac malformation that consists of an interventricular communication, also known as a ventricular septal defect, obstruction of the right ventricular outflow tract, override of the ventricular septum by the aortic root, and right ventricular hypertrophy. This combination of lesions occurs in 3 of every 10,000 live births, and accounts for 7-10% of all congenital cardiac malformations. Patients nowadays usually present as neonates, with cyanosis of varying intensity based on the degree of obstruction to flow of blood to the lungs. The aetiology is multifactorial, but reported associations include untreated maternal diabetes, phenylketonuria, and intake of retinoic acid. Associated chromosomal anomalies can include trisomies 21, 18, and 13, but recent experience points to the much more frequent association of microdeletions of chromosome 22. The risk of recurrence in families is 3%. Useful diagnostic tests are the chest radiograph, electrocardiogram, and echocardiogram. The echocardiogram establishes the definitive diagnosis, and usually provides sufficient information for planning of treatment, which is surgical. Approximately half of patients are now diagnosed antenatally. Differential diagnosis includes primary pulmonary causes of cyanosis, along with other cyanotic heart lesions, such as critical pulmonary stenosis and transposed arterial trunks. Neonates who present with ductal-dependent flow to the lungs will receive prostaglandins to maintain ductal patency until surgical intervention is performed. Initial intervention may be palliative, such as surgical creation of a systemic-to-pulmonary arterial shunt, but the trend in centres of excellence is increasingly towards neonatal complete repair. Centres that undertake neonatal palliation will perform the complete repair at the age of 4 to 6 months. Follow-up in patients born 30 years ago shows a rate of survival greater than 85%. Chronic issues that now face such adults include pulmonary regurgitation, recurrence of pulmonary stenosis, and ventricular arrhythmias. As the strategies for surgical and medical management have progressed, the morbidity and mortality of those born with tetralogy of Fallot in the current era is expected to be significantly improved.

Tetralogy of Fallot repair: the Right Ventricle Infundibulum Sparing (RVIS) strategy

Despite the excellent operative survival for tetralogy of Fallot (TOF) repair, well-documented long-term complications and reduced life expectancy remain challenges for these patients and their clinicians. In an attempt to change the natural history of repaired TOF, we at Texas Children's Hospital (Houston, TX) have developed a management strategy not focused on age, but rather focused on preserving the right ventricular (RV) infundibulum. The RV infundibulum sparing (RVIS) repair of TOF consists of a transatrial and transpulmonary approach to close the ventricular septal defect and resect RV infundibular muscle coupled with a mini (< 5 mm) transannular patch or no ventricular incision. This strategy is applied with the ambition of decreasing the well-documented, long-term complications of TOF repair with large right ventriculotomies such as RV dilation, arrhythmias, need for pulmonary valve replacement, and RV failure. The RVIS strategy is an attempt based on our current knowledge and experience to optimize the time of repair so that we can not only maximize the early operative results but the long-term effects of this approach as these children mature into adolescents and adults. We have uniformly applied the RVIS strategy since 1995, which includes over 320 isolated TOF patients. We are currently reviewing this cohort in hopes that it will strengthen our beliefs and known results as well as give us more insight into whether the RVIS strategy can change the natural history of repaired TOF.

Primary early correction of tetralogy of Fallot irrespective of age

OBJECTIVE

The policy of early repair of patients with tetralogy of Fallot, irrespective of age, as opposed to initial palliation with a shunt, remains controversial. The aim of our study was to analyze the midterm outcome of primary early correction of tetralogy of Fallot.

METHODS

Between 1996 and 2005, a total of 61 consecutive patients less than 6 months of age underwent primary correction of tetralogy of Fallot in two institutions. The median age at surgery was 3.3 months, and 27 patients (44%) were younger than 3 months of age, including 12 (20%) newborns. We analyzed the patients in 2 groups: those younger than 3 months of age, and those aged between 3 and 6 months.

RESULTS

There was one early (1.6%), and one late death. Actuarial survival was 98.4%, 96.7%, 96.7% at 1, 5, and 10 years respectively, with a median follow up of 4.5 years. There was no difference in survival, bypass time, lengths of ventilation, and hospital stay between the groups. A transjunctional patch was placed significantly more often in the patients younger than 3 months (p = 0.039), with no adverse effect on survival and morbidity during the follow-up. Freedom from reoperation was 98.2%, 92.2%, and 83% at 1, 5, and 10 years respectively, with no difference between the groups.

CONCLUSION

Elective primary repair of tetralogy of Fallot in asymptomatic patients is delayed beyond 3 months of age. In symptomatic patients, primary repair of tetralogy of Fallot is performed irrespective of age, weight and preoperative state. This approach is safe, and provides an excellent midterm outcome with acceptable morbidity and rates of reintervention. The long-term benefits of this approach must be established by careful follow-up, with particular emphasis on arrhythmias, right ventricular function, and exercise performance.

Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot

OBJECTIVES

The transannular patch used to relieve right ventricular outflow tract obstruction in children with tetralogy of Fallot may result in pulmonary insufficiency. We hypothesized that pulmonary valve cusp augmentation with pericardium would decrease pulmonary insufficiency and improve the early outcome for transatrial-transpulmonary tetralogy of Fallot repair requiring transannular patch.

METHODS

Since November 2001, 41 patients with tetralogy of Fallot and 2 patients with isolated pulmonary valve stenosis had relief of right ventricular outflow tract obstruction with either a transannular patch plus pulmonary valve cusp augmentation (n = 18) or a transannular patch alone (n = 25). Data were retrospectively collected.

RESULTS

The median age (5.3 vs 3.2 months; P = .09) and weight (6.4 vs 5.2 kg; P = .3) were similar for the cusp augmentation and transannular patch groups, respectively. The diameter of the pulmonary valve annulus (6.4 vs 6.0 mm; P = .57) and the McGoon index (1.47 vs 1.69, P = .75) were also similar. The mean aortic clamp time (48 +/- 18 minutes vs 52 +/- 19 minutes; P = .46) and median cardiopulmonary bypass time (89 vs 91 minutes; P = .9) did not differ. One patient with a transannular patch died of multiorgan system failure. Patients with a pulmonary valve cusp augmentation had a shorter duration of intubation (1 vs 3 days; P < .001) and intensive care unit stay (2 vs 8 days; P < .001). Thirteen patients with a transannular patch and 1 patient with a pulmonary valve cusp augmentation required inotropic support for more than 72 hours (P = .001). Discharge echocardiograms demonstrated moderate or severe pulmonary insufficiency in 5 patients with a pulmonary valve cusp augmentation and in 21 patients with a transannular patch (P < .001). At 7.5 months, 3 patients (17%) with a pulmonary valve cusp augmentation had progression of pulmonary insufficiency.

CONCLUSIONS

Augmentation of a pulmonary valve cusp reduces the incidence of clinically significant postoperative pulmonary insufficiency. This technique may improve the early outcome for children with tetralogy of Fallot requiring a transannular patch.

Total Transatrial Correction of Tetralogy of Fallot: No Outflow Patch Technique

BACKGROUND

The aim of this study was to analyze the feasibility and early results of transatrial total correction of tetralogy of Fallot (TOF).

METHODS

Of the 860 patients undergoing total correction for TOF between January 2000 and July 2005, 334 patients were considered morphologically suitable for transatrial total correction. The ventricular septal defect (VSD) closure, infundibular resection, and pulmonary valvotomy were performed through the right atrium without a right ventriculotomy. Age ranged from 6 months to 40 years (median, 2.8 years), and weight ranged from 5.5 to 70 kg (median, 14 kg).

RESULTS

Peroperatively, 34 patients required right ventriculotomy and transannular patch; hence, they were excluded from the study. In addition, pulmonary arteriotomy was required in 71 patients (22.9%). There were 4 hospital deaths. There were 4 early reoperations (residual/additional VSD in 3 and tricuspid regurgitation in 1). Two patients had complete heart block requiring permanent pacemaker. Echocardiography at discharge showed a peak right ventricular outflow tract gradient of 20 +/- 5.2 mm Hg. Mean follow-up was 26.8 +/- 4.2 months (range, 1 to 52 months). The right ventricular outflow tract gradients reduced to 13 +/- 4.2 mm Hg after a mean interval of 18.8 +/- 5.2 months. Follow-up New York Heart Association class was I in 240 cases (82%), II in 49 (16%), and III in 7 (2%). There were no late deaths or reoperations.

CONCLUSIONS

Transatrial total correction of TOF can be accomplished in selected patients with good early results. In 300 cases (90%), the feasibility of transatrial total correction could be predicted accurately.

Tetralogy of fallot

The optimal management of patients with tetralogy of Fallot has to consider the individual intra-cardiac anatomy as the most important variable, together with the age and the body weight of the patient. In any case the potential advantages of a primary early repair should be weighted against the experience and expertise of the individual centre and/or surgical team in dealing with tetralogy of Fallot and with neonates and infants. The best results are achieved by very carefully adapting the surgical technique to the individual morphology of the right ventricular outflow tract and of the pulmonary arteries. The details of the established surgical management for each component of the surgical repair are analysed and described. Over a period of 12 years (from 1993 to 2005) 318 consecutive patients with tetralogy of Fallot underwent repair with one hospital death (1/318=0.3% mortality).