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

Development of a double-chambered right ventricle after repair of tetralogy of Fallot

OBJECTIVES

We sought to determine the frequency, etiology and progressive nature of midcavity obstruction in patients after primary repair of tetralogy of Fallot (TOF).

BACKGROUND

Midcavity obstruction (double-chambered right ventricle [DCRV]) represents a significant portion of reoperations in patients who have had TOF repair. This group is still poorly defined.

METHODS

A retrospective review of clinical, echocardiographic and catheterization data for all patients with TOF who later underwent reoperation for DCRV was performed.

RESULTS

Between 1973 and 1995, 552 children <2 years of age underwent primary TOF repair (median age 6.7 months). Long-term follow-up (median 50 months) was available in 308 children. Of these, 17 children subsequently developed DCRV requiring reoperation. The median age at initial operation was 7.9 months. During a median follow-up interval of 43.2 months, murmur intensity increased in all patients, and the average subpulmonary gradient at catheterization increased from 24+/-10 to 80+/-27 mm Hg in seven children (p = 0.002) and at Doppler echocardiography from 14+/-16 to 89+/-18 mm Hg in five children (p = 0.002). Before reoperation, 6 of the 17 children were symptomatic. During the operation (median age 55.4 months), obstruction was relieved by incision of hypertrophied anomalous muscle bundles in all 17 patients, with prominent fibrosis noted in 8 patients. Excessive septal and parietal hypertrophy was noted in one child. No new transannular patches were required. Recurrent obstruction has reappeared in 3 of these 17 children during follow-up.

CONCLUSIONS

DCRV is a medium-term complication of TOF repair in infants, with a minimal incidence of 3.1% (95% CI 1.8% to 4.9%). The condition is progressive and is due to anomalous muscle bundle hypertrophy or fibrosis, or both, which may represent displaced insertion of a moderator band. Further reobstruction does occur; continued careful follow-up is therefore essential.

Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot

OBJECTIVES

We sought to determine the features associated with sustained monoform ventricular tachycardia (VT) in adult patients late after repair of tetralogy of Fallot (TOF) and to review their management.

BACKGROUND

Patients with repair of TOF are at risk for sudden death. Risk factors for ventricular arrhythmia have been identified from patients with ventricular ectopic beats because of the low prevalence of sustained VT.

METHODS

From a retrospective chart review of patients assessed between January 1990 and December 1994, 18 adult patients with VT were identified and compared with 192 with repaired TOF free of sustained arrhythmia.

RESULTS

There was no significant difference in age at repair, age at follow-up or operative history. Patients with VT had frequent ventricular ectopic beats (6 of 9 vs. 21 of 101), low cardiac index ([mean +/- SD] 2.4 +/- 0.4 vs. 3.0 +/- 0.8) and more structural abnormalities of the right ventricle (outflow tract aneurysms and pulmonary or tricuspid regurgitation) than control patients. Electrophysiologic map-guided operation was performed in 10 of 14 patients who required reoperation. VT has reoccurred in three of these patients. Four patients did not undergo operation (three received amiodarone; one underwent defibrillator implantation). Two patients with VT also had severe heart failure and died.

CONCLUSIONS

Most patients with VT late after repair of TOF have outflow tract aneurysms or pulmonary regurgitation, or both. These patients have a greater frequency of ventricular ectopic beats than arrhythmia-free patients after repair of TOF. A combined approach of correcting significant structural abnormalities (pulmonary valve replacement or right ventricular aneurysmectomy, or both) with intraoperative electrophysiologic-guided ablation may reduce the potential risk of deterioration in ventricular function and enable arrhythmia management to be optimized.

Pulmonary valve replacement late after repair of tetralogy of Fallot

BACKGROUND

Pulmonary valve incompetence is usually well tolerated after tetralogy of Fallot repair but may result in late progressive right heart failure as manifested by increasing fatigue, dyspnea, and frequently arrhythmias.

METHODS

All patients who underwent pulmonary valve replacement in our center late after repair of tetralogy of Fallot were reviewed.

RESULTS

Eighty-five patients had elective pulmonary valve replacement late (median, 9.3 years) after repair. Operative risk was low (1.1%). Ninety percent of survivors are in New York Heart Association class I. Survival 10 years after pulmonary valve replacement is 95%, with 86% of the patients free of reoperation for valve failure.

CONCLUSIONS

Pulmonary valve replacement is infrequently required after repair of tetralogy of Fallot. Pulmonary valve replacement may be performed electively with little risk; it improves symptoms of right heart failure and provides satisfactory long-term survival with low risk of early valve failure. As the population of patients who have had repair of tetralogy of Fallot ages, pulmonary valve replacement will become a more frequent consideration.

The long-term influence of pulmonary valve regurgitation following repair of tetralogy of Fallot: does preservation of the pulmonary valve ring affect quality of life?

The transannular patch (TAP) repair used in the correction of tetralogy of Fallot (TOF) inevitably causes pulmonary regurgitation. We report herein the results of a long-term follow-up study conducted on 50 patients who had undergone a TAP repair 20-29 years earlier to evaluate the influence of pulmonary regurgitation on their late outcome and quality of life. As a control, 26 patients with an intact pulmonary valve ring and right ventricular outflow patch (RVP) confined to the subvalvular region were also studied. The 25-year survival rates of the TAP and RVP groups were 88.5% and 95.7%, respectively, and the event-free rates at 25 years were 73.3% and 90.9%, respectively. Although the absolute values of these rates were higher in the RVP group, there were no statistically significant differences between the two groups. To assess quality of life, the occupational status, childbearing ability, and late symptoms were evaluated, and found to be comparable between the two groups. Moreover, a treadmill submaximal stress test did not show any differences in exercise capacity between the two groups. In conclusion, the presence of a TAP does not significantly alter the late results or quality of life of patients who have undergone repair of TOF.

Mechanoelectrical interaction in tetralogy of Fallot. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death

BACKGROUND

Life-threatening ventricular arrhythmia and sudden death remain serious late complications after tetralogy of Fallot repair. Nevertheless, there remains no clear way of predicting which patients are at risk.

METHODS AND RESULTS

The study population included a total of 178 adult survivors (mean follow-up, 21.4 years) of tetralogy of Fallot repair who were currently attending our clinic. Mechano-electrical relations were sought in 41 of the patients (mean follow-up, 23.6 years) who were operated on by one surgeon and who were prospectively studied with a 12-lead ECG, chest radiography, and two-dimensional and Doppler echocardiography. Nine patients (mean follow-up, 17 years) from the total group of 178 were identified as having had sustained ventricular tachycardia (8 with near-miss sudden death), and their ECGs, Holter monitor readings, electrophysiological studies, and chest radiographs were reviewed. The case notes of an additional 4 patients with postoperative sudden cardiac death also were available for review. QRS duration in the 41 patients in whom mechanoelectrical interaction was sought ranged between 90 and 200 milliseconds and correlated with cardiothoracic ratio (CTR) on chest radiography (r = .64, P < .001) and with right ventricular size on echocardiography (r = .43, P < .02). Twenty of the 41 patients had restrictive right ventricular Doppler physiology (reduced ventricular compliance) with mean QRS duration of 129.3 +/- 20 milliseconds and mean CTR of 0.51 +/- 0.03. The remaining 21 patients with no evidence of right ventricular restriction had prolonged QRS duration of 157.5 +/- 13.2 milliseconds (P < .001) and CTR of 0.55 +/- 0.04 (P < .04) compared with the restrictive. In the 9 patients with ventricular tachycardia, the QRS duration ranged from 180 to 230 milliseconds (mean, 198.9 +/- 17.6 milliseconds), and the CTR ranged from 0.54 to 0.9 (mean, 0.67 +/- 0.12) (P < .0001 and P < .01, respectively, compared with patients without life-threatening arrhythmias). All patients with documented sustained ventricular tachycardia and the 4 patients with sudden death had a QRS duration of > or = 180 milliseconds (100% sensitivity).

CONCLUSIONS

Chronic right ventricular volume overload after tetralogy of Fallot repair is related to diastolic function and correlated with QRS prolongation. The risk of symptomatic arrhythmia is high when marked right ventricular enlargement and QRS prolongation develop. A QRS duration on the resting ECG of > or = 180 milliseconds is the most sensitive predictor of life-threatening ventricular arrhythmias yet described.

Unexpected extraction of a ventricular septal defect patch without an interventricular shunt

We report the case of a mediastinocutaneous fistula, 13 years after the total correction of tetralogy of Fallot. During a fistula curettage operation, we unexpectedly extracted a ventricular septal defect patch. An interventricular shunt was not detected after the operation. The patient is well 3 years after the last operation.

Cardiovascular health and disease in children: current status. A Special Writing Group from the Task Force on Children and Youth, American Heart Association

More than 600,000 children in the United States have a congenital or acquired cardiac abnormality, and millions more are at risk of developing atherosclerotic disease in adulthood, a risk made particularly evident by the prevalence of cardiovascular risk factors in the young. There are barriers to optimum prevention and treatment of these conditions in children and youth. The AHA's Task Force on Children and Youth has described these barriers and outlined a series of recommendations and strategies to meet the challenges they impose. More research is needed, and research initiatives will be developed at scientific conferences designed to review critical areas of cardiac development and etiology of disease in children. Financial support for such research initiatives must be increased. Educational programs on cardiovascular risk factors will be extended to children and their families. When these programs are coordinated with efforts in the community and in schools, they will reduce the prevalence of cardiovascular risk factors. The task force recommends that various departments and committees of the AHA use their resources for the benefit of children: for example, by developing more research initiatives for funding by the AHA or NHLBI and increasing legislative and regulatory efforts in the areas such as mandatory school health programs and tobacco advertising. It is hoped that in the next decade, through research and educational efforts, many advances in the prevention and treatment of cardiovascular diseases in the young will be realized.

Long-term outcome in patients undergoing surgical repair of tetralogy of Fallot

BACKGROUND

Although corrective surgery for tetralogy of Fallot has been available for more than 30 years, the occurrence of late sudden death in patients in whom surgery was apparently successful remains worrisome.

METHODS

We studied long-term survival among 163 patients who survived 30 days after complete repair of tetralogy of Fallot, examining follow-up hospital records and death certificates when relevant.

RESULTS

The overall 32-year actuarial survival rate among all patients who survived surgery was 86 percent, as compared with an expected rate of 96 percent in a control population matched for age and sex (P < 0.01). Thirty-year actuarial survival rates were calculated for the patient subgroups. The survival rates among patients less than 5 years old, 5 to 7 years old, and 8 to 11 years old were 90, 93, and 91 percent, respectively--slightly less than the expected rates (P < 0.001, P = 0.06, and P = 0.02). Among patients 12 years old or older at the time of surgery, the survival rate was 76 percent, as compared with an expected rate of 93 percent (P < 0.001). The performance of a palliative Blalock-Taussig shunt procedure before repair, unlike the performance of a Waterston or Potts shunt procedure, was not associated with reduced long-term survival, nor was the need for a trans-annular patch at the time of surgery. Independent predictors of long-term survival were older age at operation (P = 0.02) and a higher ratio of right ventricular to left ventricular systolic pressure after surgery (P = 0.008). Late sudden death from cardiac causes occurred in 10 patients during the 32-year period.

CONCLUSIONS

Among patients with surgically repaired tetralogy of Fallot, the rate of long-term survival after the postoperative period is excellent but remains lower than that in the general population. The risk of late sudden death is small.

Hemodynamic status in repaired tetralogy of Fallot assessed by Doppler echocardiography and cardiac catheterization. Comparisons with healthy subjects and elucidation of factors associated with cardiorespiratory function

Thirty-four patients were studied after corrective surgery for tetralogy of Fallot (mean follow-up 10 years) and compared with healthy matched controls. All underwent Doppler echocardiography, spirometry and treadmill exercise test. Post-operative cardiac catheterization had been performed on 26 (76%) of the patients and showed poor hemodynamic results in four (15%). Significant correlations of pressure gradients obtained from catheterization and estimated by Doppler echocardiography were right ventricular to right atrial (r = 0.77), pulmonary outflow (r = 0.75), pure valvular pulmonary outflow (r = 0.94) and diastolic pulmonary pressure gradients (r = 0.53). Pulmonary outflow gradients and right ventricular to right atrial pressure gradients estimated from tricuspid regurgitation jets were significantly increased in the patients. Diastolic pulmonary artery pressure, vital capacity and ventilatory anaerobic threshold were independent factors of maximal oxygen consumption. It is suggested that Doppler-derived diastolic pulmonary artery pressure, lung function studies and exercise testing with assessment of the ventilatory anaerobic threshold should be included in follow-up after repair of Fallot's tetralogy.

Long-term results of total repair of tetralogy of Fallot in childhood

Between 1958 and 1977, 170 children aged 10 years or less underwent total repair of tetralogy of Fallot at The Johns Hopkins Hospital. Follow-up data were obtained on 128 (90%) of the 143 who survived the operation at 10 to 28 years postoperatively (mean follow-up, 18 years). All patients completed an extensive questionnaire, and 59 returned for a thorough evaluation consisting of a history and physical examination, electrocardiogram, 24-hour Holter monitoring, exercise stress testing, pulmonary function testing, and two-dimensional and Doppler echocardiography. Late survival was excellent with only two of four known late deaths due to cardiac-related causes and with all 59 patients in New York Heart Association class I or II. None had cyanosis or clubbing. Normal sinus rhythm was present in 90%. One patient had complete heart block, and 75% had right bundle-branch block on the electrocardiogram. Right ventricular function was normal by echocardiography in 78%. Residual mild to moderate pulmonary stenosis was noted by Doppler study in 8 patients. Pulmonary regurgitation was present in 78%, but in only 11 patients was it graded as moderate and in none was it severe. Stress testing documented the excellent functional status of most patients, with 92% of predicted exercise time and 94% of maximum heart rate being attained. In the few who had impaired cardiac performance, this correlated best with moderate pulmonary regurgitation. Although the overall late functional status of patients undergoing repair in the first decade of life was very good, these patients need continued follow-up to assess the severity of pulmonary regurgitation and the need of possible intervention.

C. Walton Lillehei and total correction of tetralogy of Fallot

In March 1954, an operating team headed by C. Walton Lillehei introduced the technique of cross circulation for the first-ever total corrections of ventricular septal defect, tetralogy of Fallot, and atrioventricular canal. Ten of 45 patients operated on with this technique of cardiopulmonary bypass had correction of tetralogy of Fallot, and the results with these 10 patients were reported in a landmark article. The operative results achieved in 1954 and 1955 by Lillehei and his team using cross circulation were truly remarkable. In addition, the University of Minnesota team concomitantly developed a host of new techniques and biomedical devices that made subsequent cardiac operative procedures safer and simpler to perform. These techniques and devices included the first ventricular septal defect prosthetic patch, the first right ventricular outflow patch, the first clinically applicable bubble oxygenator, and the first intramyocardial electrode used in combination with an external pacemaker for a patient with complete heart block.

Exercise after surgical repair of congenital cardiac lesions

Congenital heart defects arise in approximately 1% of all live births, independent of ethnic and geographical considerations. With the development of new surgical procedures and current technologies a large number of these heart lesions can be surgically corrected in infancy. In the majority of cases patients evaluated some 10 to 20 years after surgery are asymptomatic and can lead a normal life. Despite their satisfactory clinical outcome patients may, nevertheless, show an abnormal pattern of physiological responses when submitted to dynamic exercise. This paper reviews the scientific literature concerning the exercise capabilities and the cardiorespiratory adjustments to exercise in patients surgically corrected for 4 of the most common congenital heart lesions: isolated atrial septal defect, isolated ventricular septal defects, pulmonary stenosis and tetralogy of Fallot. The maximal exercise tolerance of postoperative congenital heart defect patients may usually be related to: (a) the age of the patients at the time of surgery; (b) the severity of the lesions remaining after surgery; and (c) the age of the patients at the time of investigation. Although normal maximal exercise capabilities may be found in a good number of patients operated for either of the 4 lesions considered, this does not imply normal exercise haemodynamics. A general observation made in these 4 groups of patients is that of a subnormal exercise cardiac output which may or may not be fully compensated by an increase in peripheral oxygen extraction. The limitation in exercising cardiac output may, in turn, be attributed to either a subnormal stroke volume or a limitation in the chronotropic response to exercise or a combination of both factors. Residual pulmonary stenosis, increased pulmonary vascular resistance, increased myocardial stiffness are all factors that may contribute to the cardiac output limitation. A thorough explanation of underlying causes for the abnormal haemodynamic response to exercise, however, still remains to be provided.

Long-term outcome of patients undergoing surgical repair of isolated pulmonary valve stenosis. Follow-up at 20-30 years

In a group of 191 consecutive patients who underwent operation at the Mayo Clinic for isolated pulmonary valve stenosis between 1956 and 1967, late results were excellent. In patients surviving operation before the age of 21 years, long-term survival was similar to that in an age- and sex-matched control population. In the other patients, late survival and functional status were good, but survival was poorer than in the control population. This late attrition, most likely due to the sequelae of long-standing right ventricular hypertrophy, suggests the need for continued surveillance. Late sudden death occurred in only three patients, between 10 and 21 years postoperatively. The finding of normal life expectancy for such patients who survive operation before age 21 is important for actuarial purposes and for the patients' career and employment plans.