Surgical management of tetralogy of Fallot in the first year of life

Pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals: collateral vessel disease burden and unifocalisation strategies

IntroductionThe optimal approach to unifocalisation in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (pulmonary artery/ventricular septal defect/major aortopulmonary collaterals) remains controversial. Moreover, the impact of collateral vessel disease burden on surgical decision-making and late outcomes remains poorly defined. We investigated our centre's experience in the surgical management of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals.Materials and methodsBetween 1996 and 2015, 84 consecutive patients with pulmonary artery/ventricular septal defect/major aortopulmonary collaterals underwent unifocalisation. In all, 41 patients received single-stage unifocalisation (Group 1) and 43 patients underwent multi-stage repair (Group 2). Preoperative collateral vessel anatomy, branch pulmonary artery reinterventions, ventricular septal defect status, and late right ventricle/left ventricle pressure ratio were evaluated.

RESULTS

Median follow-up was 4.8 compared with 5.7 years for Groups 1 and 2, respectively, p = 0.65. Median number of major aortopulmonary collaterals/patient was 3, ranging from 1 to 8, in Group 1 compared with 4, ranging from 1 to 8, in Group 2, p = 0.09. Group 2 had a higher number of lobar/segmental stenoses within collateral vessels (p = 0.02). Group 1 had fewer catheter-based branch pulmonary artery reinterventions, with 5 (inter-quartile range from 1 to 7) per patient, compared with 9 (inter-quartile range from 4 to 14) in Group 2, p = 0.009. Among patients who achieved ventricular septal defect closure, median right ventricle/left ventricle pressure was 0.48 in Group 1 compared with 0.78 in Group 2, p = 0.03. Overall mortality was 6 (17%) in Group 1 compared with 9 (21%) in Group 2.DiscussionSingle-stage unifocalisation is a promising repair strategy in select patients, achieving low rates of reintervention for branch pulmonary artery restenosis and excellent mid-term haemodynamic outcomes. However, specific anatomic substrates of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals may be better suited to multi-stage repair. Preoperative evaluation of collateral vessel calibre and function may help inform more patient-specific surgical management.

Tetralogy of Fallot repair in patients presenting after Infancy: A single surgeon experience

Objective:

To determine the early surgical outcomes of Tetralogy of Fallot (TOF) repair in children and young adults operated after the age of one year.

Methods:

In this retrospective study, 307 cases of primary repair of Tetralogy of Fallot were done between September 2012 to February 2017, at CPE Institute of cardiology, Multan. Out of 307 operated patients, 4 (1.3%) patients had previous modified Blalock Taussig shunts, 2 (0.6%) associated ASD with TOF, 3 (0.9%) co-association of TOF with PDA, 2 (0.6%) had large conal arterial branch crossing the annulus, 3 (0.9%) had dextrocardia with situs inversus, 12 (3.9%) TOF with double outlet right ventricle (DORV), 2 (0.6%) were associated with complete AV canal defect, 8 (2.60%) with absent pulmonary valve syndrome, 15 (5.5%) with left pulmonary artery stenosis. Data of post-operative complications and operative parameters was recorded for all patients.

Results:

Mean age of operated patients was 9.56±4.89 years. Post-operative complications occurred in 7.8% of patients. Most common post-operative complications were pleural effusion with a frequency of 12(3.9%) patients, and complete heart block in one patient. Insignificant small residual VSD was diagnosed in 8 (2.6%) patients. One moderately large VSD was closed surgically after one year of 1^st surgery. Moderate to severe pulmonary valve regurgitation was diagnosed in 114 (37.1%) patients. Mild to moderate tricuspid regurgitation in 15 (4.8%) patients and moderate right ventricular outflow tract obstruction (RVOT) in 16 (5.2%) patients. Thirty-day mortality was only four (1.3%).

Conclusion:

Surgical correction of Tetralogy of Fallot (TOF) in children after one year carries good operative outcomes with minimum morbidity and mortality.

The Changing Epidemiology of Pediatric Endocarditis

The epidemiology of infective endocarditis (IE) appears to be related to changes in the management of children with congenital heart disease (CHD) and the virtual disappearance of rheumatic heart disease. To better understand these changes, we divide the history into: I. The pre-surgical era, II. The early years of CHD surgical intervention, correlated with introduction of antibiotics, III. The modern era of cardiac interventions. Microbiologic changes include an early predominance of viridans streptococci and an overtaking by staphylococci. Additionally, there have been advances in imaging that allow earlier detection of IE and a reduction in IE-related mortality.

Repair of Tetralogy of Fallot in Infancy via the Atrioventricular Approach

Background

Tetralogy of Fallot (TOF) is a well-recognized congenital heart disease. Despite improvements in the outcomes of surgical repair, the optimal timing of surgery and type of surgical management of patients with TOF remains controversial. The purpose of this study was to assess outcomes following the repair of TOF in infants depending on the surgical procedure used.

Methods

This study involved the retrospective review of 120 patients who underwent TOF repair between 2010 and 2013. Patients were divided into three groups depending on the surgical procedure that they underwent. Corrective surgery was done via the transventricular approach (n=40), the transatrial approach (n=40), or a combined atrioventricular approach (n=40). Demographic data and the outcomes of the surgical procedures were compared among the groups.

Results

In the atrioventricular group, the incidence of the following complications was found to be significantly lower than in the other groups: complete heart block (p=0.034), right ventricular failure (p=0.027) and mediastinal bleeding (p=0.007). Patients in the atrioventricular group had a better postoperative right ventricular ejection fraction (p=0.001). No statistically significant differences were observed among the three surgical groups in the occurrence of tachycardia, renal failure, and tricuspid incompetence. The one-year survival rates in the three groups were 95%, 90%, and 97.5%, respectively (p=0.395).

Conclusion

Combined atrioventricular repair of TOF in infancy can be safely performed, with acceptable surgical risk, a low incidence of reoperation, good ventricular function outcomes, and an excellent survival rate.

Tetralogy of Fallot with atrioventricular septal defect: surgical strategies for repair and midterm outcome of pulmonary valve-sparing approach

Repair for tetralogy of Fallot (TOF) with complete atrioventricular septal defect (CAVSD) has been reported with good early and intermediate outcomes. Morbidity, however, remains significantly high. To date, repair of CAVSD/TOF using a pulmonary valve-sparing technique (PVS) and freedom from valve reoperation are not well defined. A study was undertaken to investigate outcomes. This study was conducted in as a retrospective investigation. Between January 1988 and December 2008, 13 consecutive patients with CAVSD/TOF were identified, and their records were reviewed retrospectively. Of these 13 patients, 9 had Rastelli type C CAVSD. Trisomy 21 was present in 9 cases (69 %; 7 with type C). Five patients had received a systemic-to-pulmonary shunt (SPS) before complete repair at a mean age 1.7 ± 0.6 months. All the patients survived until complete repair. At complete CAVSD/TOF repair, AVSD was corrected with a two-patch technique in all patients. For eight patients (61.5 %), PVS was used. The remaining five patients had transannular patch (TAP) repair. The mean age at complete repair was 6.3 ± 2.4 months. At complete repair, the mean cardiopulmonary bypass time was 173.5 ± 30.6 min, and the cross-clamp time was 134.7 ± 28.8 min. There was one hospitalization and no late deaths. The median follow-up period was 9.2 years [interquartile range (IQR), 4.7-13.3 years]. The actuarial survival was 90.0 ± 9.5 % at 1 year, 90 ± 9.5 % at 5 years, and 90 ± 9.5 % at 8 years. Of the 12 survivors, 6 had some reintervention during the follow-up period. Within the first 11 years after complete repair, two patients underwent left atrioventricular (AV) valve repair, and one patient had right AV valve repair. Two patients had residual VSD closure. Four patients underwent the first right ventricular outflow tract (RVOT) reintervention for critical insufficiency or stenosis at a mean interval of 6 ± 21) months. One patient had a second RVOT reoperation. Findings showed that CAVSD/TOF with PVS was related to significantly higher freedom from RVOT reintervention (100 % at 1, 5, and 8 years compared with 80 ± 17.9 % at 1 year, 60 ± 21.9 % at 5 years, and 40 ± 21.9 % at 8 years for CAVSD/TOF using TAP; P < 0.05). No patient who underwent PVS had left ventricular outflow tract obstruction requiring reoperation. Overall freedom from any reintervention was 90.9 ± 8.6 % at 1 year, 71.6 ± 14.0 % at 5 years, and 53.7 ± 8.7 % at 8 years in this group of patients. Correction of TOF with CAVSD can be performed at low risk with favorable intermediate-term survival and satisfactory freedom from reoperation. Use of TAP can be avoided in almost two thirds of patients and may influence freedom from early RVOT reintervention.

Conal septal morphometrics can identify higher risk neonates with tetralogy of Fallot

BACKGROUND

Some neonates with tetralogy of Fallot (TOF) have rapid progression of right ventricular outflow tract obstruction, requiring early repair irrespective of Doppler gradient as measured in the neonatal period. The aim of this study was to test the hypothesis that infundibular morphology in neonates with TOF is associated with the occurrence of hypercyanotic spells and need for neonatal surgery.

METHODS

Fifty patients with TOF undergoing surgical repair from 2003 to 2009 were studied. Neonatal echocardiograms were retrospectively analyzed to measure conal septal angle (the angle between the conal septum and the horizontal plane passing through the center of the aortic valve in the parasternal short-axis view, with a larger angle denoting more anterocephalad deviation of conal septum), conal septal thickness and length, the degree of aortic dextroposition, and sizes and Z scores of the pulmonary annulus and the main and branch pulmonary arteries. Outcomes included the occurrence of hypercyanotic spells and the need for neonatal surgery.

RESULTS

The median age at first echocardiogram was 2 days (range, 0-12 days). The median age at surgery was 94 days (range, 5-282 days); hypercyanotic spells occurred in 17 patients (34%), and nine (18%) underwent neonatal repair. The presence of a wider conal septal angle was significantly associated with the occurrence of hypercyanotic spells (59 ± 21° vs 48 ± 13°, P = .023) and the need for neonatal surgery (67 ± 13° vs 48 ± 16°, P = .004). The positive and negative predictive values of hypercyanotic spells for conal septal angles ≥60° were 64% and 78%, respectively. Importantly, Doppler right ventricular outflow tract gradient at initial echocardiography, degree of aortic dextroposition, and pulmonary or aortic valve size were not associated with these outcomes.

CONCLUSIONS

A wider conal septal angle is associated with the occurrence of hypercyanotic spells and the need for neonatal surgery.

Heart rate variability and exercise capacity of patients with repaired tetralogy of Fallot

Heart rate variability (HRV) has been used as a reliable method to detect cardiac autonomic nervous system activity. Peak oxygen uptake (VO(2) peak) has been a predictor of death for adults with repaired tetralogy of Fallot (TOF). This study investigated the correlation between HRV and exercise capacity in 30 patients with TOF after surgery for total correction. The median age of the patients was 14 years (range, 9-25 years), and the median follow-up period was 11.6 months (range, 5.3-20.2 months). Low- and high-frequency-domain HRV significantly correlated with VO(2) peak (r = 0.56, P = 0.001 and r = 0.44, P = 0.02, respectively). After the 1-year follow-up evaluation, VO(2) peak and HRV analysis did not differ from those at entry to the study. However, low- and high-frequency-domain HRV still correlated significantly with VO(2) peak (r = 0.43, P = 0.03 and r = 0.52, P = 0.007, respectively). Left ventricular early diastolic myocardial velocity was most closely correlated with the VO(2) peak (r = 0.51, P = 0.005). Impaired cardiovascular autonomic control and left ventricular diastolic dysfunction may be responsible for exercise intolerance in patients with repaired TOF. Long-term follow-up evaluation with exercise testing and 24-h Holter monitoring are warranted.

Late surgical treatment of tetralogy of Fallot

Aim

To study early post-operative results and follow up of patients over a year old, operated on for tetralogy of Fallot (ToF).

Methods

This retrospective analysis included 22 patients (14 male and eight female) with a mean age of 9.18 ± 6.5 years (range 13.5 months to 26 years), who underwent complete repair of ToF between April 2003 and June 2009. Data from patients’ records, pre-operative cardiac catheterisation studies, operative intervention, and pre-operative and postoperative two-dimensional echocardiographic studies were reviewed. All patients underwent complete repair including closure of ventricular septal defect (VSD). A trans-annular patch was used in 12 patients while an infundibular patch was used in 10 others. Patients were evaluated one, three, six and 12 months after surgery, and annually thereafter. The duration of follow up was from eight months to six years post surgery.

Results

Classical ToF was found in 10 patients. Twelve cases had associated anomalies: two patients with hypoplastic pulmonary artery branches, two with arterial duct malformations, and eight had proximal stenosis of the left branch of the pulmonary artery. NHYA class distribution was as follows: class I: two patients; class II: five subjects; class III: 10 patients; class IV: five subjects. The mean stay in hospital was 15 ± 7 days. Two patients (9%) died during the early post-surgical period. At a mean follow-up interval of 32 ± 9 months, all patients were asymptomatic and in NYHA class I. No late deaths occurred. In three patients, we registered isolated monomorphic ventricular extrasystoles. The right ventricle outflow tract (RVOT) pressure gradient was 29 ± 1.5 mmHg in the acute post-surgical period and it did not change significantly during follow up. The right ventricular function was defined as normal in 95% of the patients in the study and was mildly depressed in 5%.

Conclusion

Even if treated later in life, our study showed very good surgical results of patients with ToF.

Effects of left ventricular function on the exercise capacity in patients with repaired tetralogy of Fallot

BACKGROUND

Tissue Doppler imaging has been recently used to evaluate ventricular function. Peak oxygen uptake (V•O2peak) has been demonstrated as a predictor for death in adults with repaired tetralogy of Fallot (TOF). The aim of this study was to determine which Doppler parameters correlated with V•O2peak in patients with repaired TOF.

METHOD AND RESULTS

Doppler echocardiography, tissue Doppler imaging, and exercise test were performed in 30 patients with TOF after surgical repair. In 30 patients with repaired TOF (median age 14 years, range 9-25 years), 11 patients (37%) were female. Seven patients (median age 12 years) had normal left ventricular diastolic function, whereas the rest of the patients were classified as diastolic dysfunction grade II (median age 15 years; n=15) and III and IV (median age 18 years; n=8). The oxygen uptake at anaerobic threshold (V•O2AT) and peak exercise in patients with left ventricular diastolic dysfunction was significantly lower than that in those with normal diastolic function. Also, V•O2AT and V•O2 peak in patients with diastolic dysfunction grade III and IV were significantly lower than that in those with diastolic dysfunction grade II. Left ventricular early diastolic myocardial velocity was most closely correlated to V•O2peak (r=0.51; P=0.005). Peak early ventricular filling velocity to early diastolic myocardial velocity ratio was significantly correlated with V•O2peak (r=-0.50; P=0.006).

CONCLUSION

Left ventricular diastolic dysfunction is correlated with V•O2peak. Left ventricular diastolic function should be a routine echocardiographic assessment in patients with repaired TOF.

Pulmonary Segmental Artery Ratio An Alternative to the Pulmonary Artery Index in Patients With Tetralogy of Fallot

The objective of this study was to determine a reliable, alternative ratio to the pulmonary artery (PA) index, which will help to estimate the adequacy of postoperative pulmonary blood flow in patients with tetralogy of Fallot. We propose the pulmonary segmental artery ratio (PSAR), which is an angiographic measure for the quantitative standardization of the total number of pulmonary segmental arteries in a patient. The expected value of the PSAR is 1 and it is constant after the 16(th) week of intrauterine life. Retrospective analysis of the PSAR and PA index calculations in patients with tetralogy of Fallot was conducted. Sixty-one patients were assigned to a moderate or low risk group according to their PSAR; the low risk group included 31 patients whose PSAR was between 0.75-1 (group 1) while the moderate risk group included 30 patients whose PSAR was between 0.50-0.75 (group 2). High risk patients whose PSAR was less than 0.50 were excluded from the study. Postoperative peak right ventricular pressure, the pulmonary artery to systemic pressure ratio, and peripheral arterial oxygen saturation preoperatively after cardiopulmonary bypass were analyzed separately in groups 1 and 2. Postoperative peak right ventricular pressure was lower in group 1 than group 2, while the pulmonary artery to systemic pressure ratio and peripheral arterial oxygen saturation were higher in group 1 than group 2 (P < 0.01). Based on the present findings, it is concluded that PSAR is not as reliable as the Nakata index. However, in cases in which the PSAR and PA index are not correlated, PSAR may be helpful for determining the adequacy of postoperative pulmonary blood flow and postoperative outcomes of patients with hypoplastic pulmonary arteries.

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

BACKGROUND

Our surgical strategy for repair of tetralogy of Fallot has focused on preserving the pulmonary valve. The purpose of this review was to identify pulmonary valve characteristics that mark the limits of this strategy.

METHODS

From 1997 through 2004, 102 consecutive patients underwent repair of tetralogy of Fallot at a median age of 5.9 months. Twenty-five patients had a prior shunt. Eighty-two patients (80%) had pulmonary valve-sparing procedures, predominantly through a transatrial and transpulmonary approach (n = 52). Twenty patients had a transannular patch (20%). Intraoperative measurements included the pulmonary valve annulus size and the postoperative pressure ratio between the right and left ventricles.

RESULTS

Eighty of 85 (94%) patients with z-score greater than -4 had a pulmonary valve-sparing procedure compared with 2 of 17 patients (12%) with pulmonary valve annulus z-scores less than -4 (p < 0.0001). All patients with a tricuspid pulmonary valve (n = 26) had a pulmonary valve-sparing procedure compared with 56 of 76 (74%) patients with a bicuspid pulmonary valve (p = 0.0016). Five patients with initial pulmonary valve-sparing operations required reoperation for residual stenoses; 4 pulmonary valve-sparing right ventricular outflow tract resections and 1 transannular patch. The only death occurred after reoperation elsewhere. Three of 9 patients (33%) who had a postoperative pressure ratio between the right and left ventricles greater than 0.7 after their initial pulmonary valve-sparing procedure required reoperation compared with 2 of 73 with postoperative pressure ratio between the right and left ventricles less than 0.7 (3%; p = 0.008). Fifteen of 25 patients (60%) with prior shunts had pulmonary valve-sparing procedures.

CONCLUSIONS

A pulmonary valve-sparing approach to the repair of tetralogy of Fallot was applied successfully in 80% of patients. Significant markers for success were a measured pulmonary annulus z-score of -4 or larger, a tricuspid pulmonary valve, and a postoperative pressure ratio between the right and left ventricles less than 0.7.

Long-Term Outcome After Total Correction of Tetralogy of Fallot in Adolescent and Adult Age

Although most patients with tetralogy of Fallot (TOF) undergo radical repair during infancy and childhood, patients remaining undiagnosed and untreated until adulthood can still be treated. These patients have either a previous palliative or natural collateral circulation to the lung or a mild form of right ventricular outflow tract (RVOT) obstruction. The aim of this study is to analyze the perioperative and long-term results of radical corrective procedures in patients who reached adult ages. Two hundred and seven patients with TOF underwent complete correction between 1985-and 2002, 64 (30.9%) of whom were aged 14 years or more. The mean age at corrective repair for this group was 20.6 +/- 7.5 years (range 14 to 49 years). Only two patients had previous modified Blalock-Taussig shunts. In 44 patients (68.7%) besides infundibular resection, a transannular gluteraldehyde-treated pericardial patch was used to reconstruct right ventricular outflow tract (RVOT). Only infundibular patching was used in 15 patients (23.4%) and infundibular muscular resection with primary closure of right ventricle was performed in five patients (7.8%). Hospital mortality was 3.1% with two patients. Four patients (6.2%) underwent reoperation because of recurrent ventricular septal defect (VSD) with/without residual obstruction or pulmonary regurgitation. All survivors were in NYHA class I (42) or II (17). Late mortality was recorded in two patients and 16-year actuarial survival was 89.2%+/- 4.9%. The significant negative predictors of late survival determined by univariate analysis were reoperation <0.018) and associated cardiac anomalies <0.011). Multivariate analysis showed that there was no negative predictor of late-term mortality. Corrective procedures in adult patients with TOF can be performed successfully compared to patients who underwent operation during infancy and childhood.

The influence of perioperative factors on outcomes in children aged less than 18 months after repair of tetralogy of Fallot

OBJECTIVES

To determine the impact of age at repair in patients with tetralogy of Fallot on early postoperative morbidity.

METHODS

All patients less than 19 months of age (median age, 8 months; range, 36 days-18.5 months) who underwent complete repair of tetralogy of Fallot between January 1997 and December 1999 were reviewed. Data were analyzed on the preoperative clinical and anatomical characteristics, operative procedure and postoperative course in the intensive care unit. Independent factors associated with intensive care unit stay were sought using Cox's proportionate hazard modeling. In addition, independent factors associated with an intensive care unit stay of more than 2 days were sought in multiple logistic regression analysis.

RESULTS

Seventy-eight patients underwent surgical repair; 3 had (4%) had a previous systemic to pulmonary arterial shunt. There was no operative mortality. One late death occurred. The median intensive care unit length of stay and mechanical ventilation time were 2 days (range, 1-14) and 16.2 hours (range, 0-267), respectively. Age less than 3 months was associated with increased use of vasoactive drugs, higher postoperative fluid requirement, and a higher incidence of organ dysfunction but no patient required renal replacement therapy. The duration of ventilator support and the intensive care unit length of stay were also longer in this age group.

CONCLUSIONS

Primary repair at an early age has excellent short-term outcome. Patients less than 3 months of age have an increased but transient intensive care unit morbidity.

Total correction of tetralogy of Fallot in the first year of life: late results

BACKGROUND

Correction of tetralogy of Fallot in patients less than 1 year of age offers the advantage of a more normal development; but in the majority of cases exposes the patient to the possibly of a higher mortality with one-stage primary repair, and to the long-term effects of a transannular patch, which is often necessary.

METHODS

A retrospective review of total correction of tetralogy of Fallot performed in 63 consecutive patients at less than 1 year of age was made. Risk factors for operative mortality and functional status at follow-up were analyzed. Follow-up was obtained from clinic appointments and telephone questionnaires.

RESULTS

The operative mortality was 6%, with three late deaths. Aortic cross-clamp time more than 60 minutes (p = 0.023), cardiopulmonary bypass time more than 90 minutes (p = 0.016), and frequent preoperative respiratory tract infection symptoms (p = 0.008) affected operative survival; whereas age less than 3.0 months or weight less than 6.0 kg did not. Mean follow-up is 11.6 years (+/- 0.6 years, standard error). Actuarial survival is 89% (+/- 4%) and freedom from reoperation is 96% (+/- 4%) at up to 20 years after correction. Eighty-seven percent of patients have normal echocardiographic right ventricular function. Only 4 patients have greater than moderate pulmonary regurgitation by echocardiography. Three of these four patients are asymptomatic. At more than 15 years postoperatively, 88% of patients have good-to-excellent functional status.

CONCLUSIONS

Early correction of tetralogy of Fallot at less than 1 year of age can have a low operative mortality and provide excellent asymptomatic long-term survival.

How to diminish reoperation rates after initial repair of tetralogy of Fallot?

BACKGROUND

Complete correction of tetralogy of Fallot has good long-term results. Right ventricular outflow tract obstruction and pulmonary insufficiency occur which require reintervention. The present study evaluated the efficacy of reoperation following complete correction of tetralogy of Fallot, the sites of recurrences and impact of techniques used at first operation.

METHODS

Between 1980 and 1999, 501 patients underwent complete correction of tetralogy of Fallot. Reoperation rate was 7.4%. Residual or recurrent right ventricular outflow tract stenosis was seen in 25 patients (68%), and 7 patients (19%) had severe pulmonary insufficiency. Age at redo was 9.1+/-6.4 years. Restenosis was most frequently observed (75%) at the bifurcation of the pulmonary artery. Extended 1-patch enlargement was used until 1989 and thereafter changed to a 2-patch technique.

RESULTS

Valvar-supravalvar 1-patch technique had a redo rate of 33.3%, compared with 4.3% for the 2-patch technique, p = 0.0264, with excellent freedom from reoperation rate. At reoperation right ventricular-pulmonary artery (RV-PA) conduits managed 29 patients and 3 had supravalvar patch enlargement. Hospital mortality was 5.4% (2 of 37). Twenty-five patients (68%) were in New York Heart Association functional class I to II at end of the follow-up, and none required further interventions.

CONCLUSIONS

Redo rate following complete correction of tetralogy of Fallot was 7.4%. Right ventricular outflow tract pathology was the dominant reason for reoperations (86%). At reoperation, RV-PA conduits was the most frequently used technique. Reoperation was efficient in reducing the RV-PA gradient, had low hospital and late mortality. A 2-patch valvar-supravalvar enlargement at first operation reduced the risk for redo in long-term follow-up.

Early and late results of total correction of congenital cardiac anomalies in infancy

OBJECTIVE

We evaluated long-term results of surgical correction of congenital cardiac anomalies in infancy.

METHODS

We reviewed cases of 856 patients who underwent complete correction of major cardiac anomalies in the first year of life during last 24 years at our institution, and analyzed results. Surgery involved ventricular septal defect (n = 453), tetralogy of Fallot (n = 92), atrioventricular canal defect (n = 93), and complete transposition of the great arteries (n = 218).

RESULTS

Operative mortality was 2.2% in ventricular septal defect, 0% in tetralogy of Fallot, 8.6% in atrioventricular canal defect, and 4.1% in complete transposition of the great arteries. Freedom from reoperation at 20 years was 96.5 +/- 2.0% and actuarial survival was 94.2 +/- 1.3% in ventricular septal defect. Freedom from reoperation at 15 years was 90.5 +/- 3.9% in tetralogy of Fallot and 86.6 +/- 4.4% in atrioventricular canal defect. Actuarial survival at 15 years was 97.8 +/- 1.6% in tetralogy of Fallot, 85.7 +/- 3.7% in atrioventricular canal defect, and 89.9 +/- 2.2% in complete transposition of the great arteries. Actuarial survival in complete transposition of the great arteries was significantly better in arterial than in atrial switch operations.

CONCLUSIONS

Total correction of ventricular septal defect, tetralogy of Fallot, atrioventricular canal defect, and complete transposition of the great arteries in infancy was conducted safely, but the incidence of reoperation in late follow-up must be reduced.

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.

Outcome after repair of tetralogy of Fallot in the first year of life

BACKGROUND

The purpose of this study was to evaluate the early and late outcome after repair of tetralogy of Fallot in the first year of life.

METHODS

Between 1974 and 2000, 89 consecutive infants with a mean age of 6.3 +/- 2.6 months (range, 15 days to 12 months) underwent repair of tetralogy of Fallot (ventricular septal defect and pulmonary stenosis) by one surgeon (J.L.M.). Three infants had previous palliative operations. Sixty-seven procedures were urgent or emergency. A transannular patch was inserted in 69 patients (77.5%). Follow-up was complete, averaging 13.4 +/- 5.6 years (range, 0 to 25.4 years).

RESULTS

There was one operative death (1.1%). Mean right ventricular to left ventricular pressure ratio postoperatively was 0.4 +/- 1.1 (in 79 patients, < 0.5). Fourteen patients underwent reoperations or reinterventions. There were no reoperations for residual or recurrent ventricular septal defect. Kaplan-Meier freedom from reoperation or reintervention for any cause at 20 years was 85% +/- 4.4%, for relief of right ventricular outflow tract obstruction it was 94% +/- 3.1%, and for pulmonary valve replacement this was 95.4% +/- 2.6%. Use of a transannular patch did not significantly affect the need for reoperation or reintervention. There was one late death (leukemia). Kaplan-Meier 20-year survival was 97.8% +/- 1.9%. On latest echocardiography, 42 patients had moderate pulmonary regurgitation, 4 had a right ventricular outflow tract gradient more than 40 mm Hg, and 86 had good biventricular function. Twelve-lead electrocardiography was performed in all and 24-hour electrocardiography in 61 patients. One patient (1.1%) exhibited late recurrent ventricular tachycardia requiring implantation of a defibrillator. The remaining 86 patients are in New York Heart Association class I with none of them receiving antiarrhythmic medications.

CONCLUSIONS

These data strongly support the concept of early repair of tetralogy of Fallot. It is associated with an acceptable operative risk and a low incidence of significant arrhythmias, and provides long-term survival similar to that observed in the general population. Late complications may, however, develop, and long-term follow-up for their early recognition is essential.

Tetralogy of Fallot: what operation, at which age

BACKGROUND

The optimal management of tetralogy of Fallot is still under debate, particularly with respect to surgical approach and the age of operation. In recent times a transatrial-transpulmonary approach and primary repair in younger patients is favoured. The purpose of the present study was to analyze the result of our current surgical management by assessing the perioperative and intermediate term follow up in order to define the optimal strategy and timing of operation for our institution.

METHODS

One hundred and thirty two patients with tetralogy of Fallot who underwent definitive repair between May 1993 and December 1998 were analyzed by reviewing their medical records and follow-up. Median age was 15. 5 (2.3-68.6) months and median weight was 8.8 (5-16) kg. Ten (7.57%) patients were under 6 months, 38 (28.78%) were between 6 and 12 months, 36 (27.27%) were between 12 and 18 months, 23 (17.42%) were between 18 and 24 months and 25 (18.93%) were more than 24 months age. During the study period there was a move to earlier surgery and differing methods of repair depending on the anatomy observed. Follow up was conducted by the referring cardiologist. Median follow up was 35.48 (8.07-74.93) months.

RESULTS

Forty-two (31.8%) patients required a palliative procedure before total correction due to unfavourable anatomy. Subpulmonary infundibular obstruction with a fibrous component increased significantly with age (P<0.05). Operations were entirely transatrial in 14 (10.6%), transatrial and transpulmonary in 69 (52.2%), transatrial and transventricularly in 42 (31.8%) and a homograft conduit was used in seven (5.3%) patients. Younger patients had narrower pulmonary valves and required a transannular patch more frequently. All patients were in sinus rhythm, 28 (21.1%) showing right bundle branch block. Median hospital stay was 8 (5-54) days. No patient required reintervention during follow up and there was no early or late mortality.

CONCLUSION

Correction of tetralogy of Fallot at younger age does not increase morbidity or mortality and has potential advantages. A surgical technique adapted to the anatomy of the right ventricular outflow tract, achieves the best results.