Tetralogy of Fallot: Perioperative Management and Analysis of Outcomes

Neurological injury in pediatric heart disease: A review of developmental and acquired risk factors and management considerations

Medical and surgical advancements have improved survival in children with acquired and congenital heart disease (CHD), but the burden of neurological morbidity is high. Brain disorders associated with CHD include white matter injury, stroke, seizure, and neurodevelopmental delays. While genetics and disease-specific factors play a substantial role in early brain injury, therapeutic management of the heart disease intensifies the risk. There is a growing interest in understanding how to reduce brain injury and improve neurodevelopmental outcomes in cardiac diseases. Pediatric neurologists serve a vital role in care teams managing these complex patients, providing interpretation of neuromonitoring and imaging, managing neurologic emergencies, assisting with neuro prognostication, and identifying future research aims.

Aortic valve replacement in a 41-year-old woman with uncorrected tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collateral arteries: a case report

BACKGROUND

Tetralogy of Fallot (TOF) is a complex cyanotic congenital heart disease. As most patients with TOF undergo palliative or radical surgical repair during childhood, cardiac surgery under cardiopulmonary bypass (CPB) for adult survivors with unrepaired TOF is exceedingly rare.

CASE PRESENTATION

A 41-year-old woman with unrepaired TOF, pulmonary atresia (PA), and major aortopulmonary collateral arteries (MAPCAs) developed acute infectious endocarditis (IE). As vegetation gradually increased despite intravenous antibiotic administration, she was scheduled for urgent aortic valve replacement under CPB. Pulmonary blood flow was primarily provided by the MAPCAs originating from the descending aorta. Intra-aortic balloon occlusion for MAPCAs was performed to ensure a bloodless surgical field. Aortic valve replacement was successful.

CONCLUSION

An adult with uncorrected TOF developed acute IE and subsequently had successful cardiac surgery under CPB. Understanding TOF physiology with PA and MAPCAs, particularly pulmonary blood flow through MAPCAs, is crucial.

Managing Tetralogy of Fallot During Interhospital Transfers

Pediatric and neonatal critical care providers involved in transport run calls involving patients diagnosed with Tetralogy of Fallot, which can occasionally be a challenge for some providers. Making up around 10% of all congenital heart defects, inevitably makes Tetralogy of Fallot (TOF) the most common of all the cyanotic congenital heart diseases. There are some transport teams that do not have the capability and invasive equipment that a referring hospital may have to manage these high acuity low volume patients. This makes it imperative to have a good working knowledge of this condition, and more importantly, the ability to recognize it when encountered so that you will then be able treat these patients.

Preoperative Management of Neonates With Congenital Heart Disease

Clinicians caring for neonates with congenital heart disease encounter challenges in clinical care as these infants await surgery or are evaluated for further potential interventions. The newborn with heart disease can present with significant pathophysiologic heterogeneity and therefore requires a personalized therapeutic management plan. However, this complex field of neonatal-cardiac hemodynamics can be simplified. We explore some of these clinical quandaries and include specific sections reviewing the anatomic challenges in these patients. We propose this to serve as a primer focusing on the hemodynamics and therapeutic strategies for the preoperative neonate with systolic dysfunction, diastolic dysfunction, excessive pulmonary blood flow, obstructed pulmonary blood flow, obstructed systemic blood flow, transposition physiology, and single ventricle physiology.

Anaesthesia management for cleft lip in a child with unrepaired Tetralogy of Fallot in Malawi: a case report

Background

Children with clefts lips often present with cardiac abnormalities, among them the tetralogy of Fallot. Anaesthesia for patients with unrepaired Tetralogy of Fallot coming for a non-cardiac surgery represents an additional risk of increased perioperative morbidity and mortality.

Case presentation

We present a case of a 8 years old boy with unrepaired Tetralogy of Fallot scheduled for cleft lip repair. The Child was referred to Mercy James Centre for Paediatric Surgery and Intensive Care from an Operation Smile Mission campaign. Anaesthesia consisted of a balanced general anaesthesia combined with regional anaesthesia by an infraorbital nerve block. The child developed hypercyanotic spells postoperatively which were successfully managed with noradrenaline, morphine, fluid, and oxygen therapy.

Conclusion

Children with unrepair Tetralogy of Fallot coming for non-cardiac surgery have increased risk of complications during anaesthesia. The anaesthesia provider should be aware and ready to manage them promptly.

Preoperative Care of Neonates With Congenital Heart Disease

Congenital heart disease (CHD) is one of the most common types of birth defects, with 40,000 newborns diagnosed yearly in the United States. This article describes: (1) four common heart defects seen in neonatal intensive care units, (2) the typical medical/nursing care of these neonates, and (3) common surgical management for the defects. Hypoplastic left heart syndrome, dextro-transposition of the great arteries, tetralogy of Fallot, and pulmonary atresia with intact ventricular septum are four common types of CHD requiring NICU admission. Knowledge of these defects will help nurses to appropriately manage and treat neonates with these types of CHD.

Right-left ventricular shape variations in tetralogy of Fallot: associations with pulmonary regurgitation

BACKGROUND

Relationships between right ventricular (RV) and left ventricular (LV) shape and function may be useful in determining optimal timing for pulmonary valve replacement in patients with repaired tetralogy of Fallot (rTOF). However, these are multivariate and difficult to quantify. We aimed to quantify variations in biventricular shape associated with pulmonary regurgitant volume (PRV) in rTOF using a biventricular atlas.

METHODS

In this cross-sectional retrospective study, a biventricular shape model was customized to cardiovascular magnetic resonance (CMR) images from 88 rTOF patients (median age 16, inter-quartile range 11.8-24.3 years). Morphometric scores quantifying biventricular shape at end-diastole and end-systole were computed using principal component analysis. Multivariate linear regression was used to quantify biventricular shape associations with PRV, corrected for age, sex, height, and weight. Regional associations were confirmed by univariate correlations with distances and angles computed from the models, as well as global systolic strains computed from changes in arc length from end-diastole to end-systole.

RESULTS

PRV was significantly associated with 5 biventricular morphometric scores, independent of covariates, and accounted for 12.3% of total shape variation (p < 0.05). Increasing PRV was associated with RV dilation and basal bulging, in conjunction with decreased LV septal-lateral dimension (LV flattening) and systolic septal motion towards the RV (all p < 0.05). Increased global RV radial, longitudinal, circumferential and LV radial systolic strains were significantly associated with increased PRV (all p < 0.05).

CONCLUSION

A biventricular atlas of rTOF patients quantified multivariate relationships between left-right ventricular morphometry and wall motion with pulmonary regurgitation. Regional RV dilation, LV reduction, LV septal-lateral flattening and increased RV strain were all associated with increased pulmonary regurgitant volume. Morphometric scores provide simple metrics linking mechanisms for structural and functional alteration with important clinical indices.

Tetralogy of Fallot: stent palliation or neonatal repair?

Surgical repair of Tetralogy of Fallot has excellent outcomes, with over 90% of patients alive at 30 years. The ideal time for surgical repair is between 3 and 11 months of age. However, the symptomatic neonate with Tetralogy of Fallot may require earlier intervention: either a palliative intervention (right ventricular outflow tract stent, ductal stent, balloon pulmonary valvuloplasty, or Blalock-Taussig shunt) followed by a surgical repair later on, or a complete surgical repair in the neonatal period. Indications for palliation include prematurity, complex anatomy, small pulmonary artery size, and comorbidities. Given that outcomes after right ventricular outflow tract stent palliation are particularly promising - there is low mortality and morbidity, and consistently increased oxygen saturations and increased pulmonary artery z-scores - it is now considered the first-line palliative option. Disadvantages of right ventricular outflow tract stenting include increased cardiopulmonary bypass time at later repair and the stent preventing pulmonary valve preservation. However, neonatal surgical repair is associated with increased short-term complications and hospital length of stay compared to staged repair. Both staged repair and primary repair appear to have similar long-term mortality and morbidity, but more evidence is needed assessing long-term outcomes for right ventricular outflow tract stent palliation patients.

Critical Congenital Heart Disease in Neonates: A Review Article

Critical congenital heart defects (CCHDs) are serious malformations that remain to be an important cause of neonatal mortality and morbidity. The clinical presentations of CCHD are shock, cyanosis, or respiratory distress, which may be similar to that of other neonatal conditions. Failure to diagnose these conditions early on after birth may result in acute cardiovascular collapse and death. Screening with routine pulse oximetry is efficient in distinguishing newborns with CCHD and other hypoxemic illnesses, which may otherwise be potentially life-threatening. If the cardiovascular system cannot be observed by echocardiography, then treatment with continuous prostaglandin-E1(PGE1) infusion should be started in any newborn whose condition deteriorates in the first few days of life. This review aims to provide a concise summary of the presentation and management of various CCHDs and to emphasize the role of timely diagnosis in the management.