The angiocardiogram in Fallot's tetralogy

The aortic arch in tetralogy of Fallot: types of branching and clinical implications

INTRODUCTION

Tetralogy of Fallot is the most common form of cyanotic CHD, with an incidence of 421 cases per million live births, constituting around 10% of CHD. Variations in aortic arch anatomy associated with tetralogy of Fallot, other than the incidence of right aortic arch (13-34%), are not frequently reported. A comprehensive analysis of a large number of tetralogy of Fallot cases is required to arrive at a compendious description of aortic arch anatomy.

MATERIALS AND METHODS

All patients with a diagnosis of tetralogy of Fallot who had CT or MRI either pre or post procedures between 1 January 2010 and 31 December 2019 at our hospital were included in the study. Using radiology consultants' reports and analysis of individual images, we identified the various morphological patterns of aortic arches prevalent in these patients.

RESULT

Out of 2684 patients who met the inclusion criteria, 1983 patients had left aortic arch (73.9%), 688 patients had right aortic arch (25.7%), four patients had cervical aortic arch (0.15%), eight patients had double aortic arch (0.3%), one patient had an aorto-pulmonary window (0.04%), and none of the patients had interrupted aortic arch. Sub-classification and clinical implications of the arch variations are described.

CONCLUSION

Up to 10% of tetralogy of Fallot patients may have significant anatomical variations of aortic arch that would necessitate changes or additional steps in their surgical or interventional procedures.

The role of auscultation in the differentiation of Fallot's tetralogy from severe pulmonary stenosis with intact ventricular septum and right-to-left interatrial shunt

A clinical and phonocardiographic study has been made of the murmurs and heart sounds in the differentiation of Fallot's tetralogy from severe pulmonary stenosis with intact septum and right-to-left interatrial shunt. A striking difference in the behaviour of the systolic murmur was found in the two conditions and this affords a new, simple bedside method of diagnosis. Important differences in the behaviour of the heart sounds were also found, but these are usually more difficult to evaluate clinically and may require special study.

Confirmation that the velo-cardio-facial syndrome is associated with haplo-insufficiency of genes at chromosome 22q11

The velo-cardio-facial syndrome (VCFS) and DiGeorge sequence (DGS) have many similar phenotypic characteristics, suggesting that in some cases they share a common cause. DGS is known to be associated with monosomy for a region of chromosome 22q11, and DNA probes have been shown to detect these deletions even in patients with apparently normal chromosomes. Twelve patients with VCFS were examined and monosomy for a region of 22q11 was found in all patients. The DNA probes used in this study could not distinguish the VCFS locus and the DGS locus, indicating that the genes involved in these haploinsufficiencies are closely linked, and may be identical. The phenotypic variation of expression in VCFS and DGS may indicate that patients without the full spectrum of VCFS abnormalities but with some manifestations of the disorder may also have 22q11 deletions.

Surgical management in tetralogy of Fallot and vascular ring

The management of three infants born with a combination of tetralogy of Fallot and a vascular ring causing tracheoesophageal compression is described. There was a double aortic arch in two patients and an aberrant left subclavian artery with left ligamentum arteriosum and right aortic arch in one. Single-stage corrective surgery of both lesions during infancy, performed under profound hypothermia and circulatory arrest, was successful. In our opinion, this is the treatment of choice, when the anatomy of the tetralogy is favorable for primary correction.

Two-dimensional echocardiographic recognition of the right aortic arch

A mirror-image right aortic arch (RAA) is frequently associated with congenital heart disease. The chest roentgenogram with or without contrast remains the noninvasive diagnostic method of choice. While 2-dimensional (2-D) echocardiography has been used to elucidate the left aortic arch (LAA), detailed description of the technique for RAA has not been reported. This study was pursued to delineate the 2-D echocardiographic approach to the patient with RAA. Twenty-seven patients in this study had LAA (Group A) and 27 had RAA (Group B). The 2-D echocardiographic examinations concentrated on the standard suprasternal long-axis (SSNL), parasternal long and short axes, and the subcostal abdominal short-axis views. When the SSNL failed to demonstrate LAA, an alternate position for RAA was utilized. The SSNL correctly identified the LAA in all Group A patients, but in Group B it located only the ascending aorta. This simulated an interrupted aortic arch anomaly. Transducer realignment to position 2 confirmed RAA in all Group B patients. In the parasternal axes, the left descending aorta was detected posterior to the atrioventricular groove or the left ventricle in every Group A patient but in no Group B patient. The descending aorta was found to the left of the spine on the abdominal short-axis view in both groups. The 2-D echocardiographic technique proposed for RAA is simple, rapid, and definitive. It should be pursued whenever LAA cannot be demonstrated, especially in children suspected of having a congenital heart defect. Anticipation of RAA can expedite chest and cardiovascular surgery.

Congenital extracardiac shunts with tetralogy of Fallot

Congenital extracardiac shunts in tetralogy of Fallot may significantly alter the history and clinical findings and also have significant management implications. An unusual variant of severe tetralogy of Fallot in a 54-year-old man enabled long survival with minimal symptoms. The patient had pulmonary valvular and infundibular stenosis, a large ventricular septal defect, an overriding aorta, and large volume systemic-to-pulmonary artery shunting from his right internal mammary and accessory internal mammary arteries to his right pulmonary artery.

Right-sided aorta. I. Occurrence of right aortic arch in various types of congenital heart disease. II. Right aortic arch, right descending aorta, and associated anomalies

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UNILATERAL RIB-NOTCHING FROM THE COLLATERAL CIRCULATION AFTER DIVISION OF THE SUBCLAVIAN ARTERY

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The aorta and pulmonary arteries in Fallot's tetralogy

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Absence of the left pulmonary artery in Fallot's tetralogy

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Results of pulmonary valvotomy and infundibular resection in 100 cases of Fallot's tetralogy

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Rapid biplane angiocardiography in the tetralogy of Fallot

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