Determinants and Clinical Outcomes of Patients With Tetralogy of Fallot Lost to Cardiology Follow-up

BACKGROUND

Various rates of loss to follow-up (LTFU) have been reported in patients with congenital heart disease, but return to follow-up is rarely considered in those analyses. Outcomes of LTFU patients are difficult to assess because the patients no longer attend cardiac care. We leveraged data from the TRIVIA cohort, which combines more than 30 years of clinical and administrative data, allowing us to study outcomes even after LTFU.

METHODS

This population-based cohort included 904 patients with tetralogy of Fallot (TOF) born from 1982 to 2015 in Québec, Canada. Risk factors for LTFU and outcomes were calculated by Cox models and marginal means/rates models. Outcomes of LTFU patients were compared with propensity score-matched non-LTFU patients.

RESULTS

The cumulative risk of experiencing 1 episode of LTFU was 50.3% at 30 years. However, return to follow-up was frequent and the proportion of patients actively followed was 85.9% at 10 years, 76.4% at 20 years, and 70.6% at 30 years. Factors associated with a reduced risk of LTFU were primary repair with conduit (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.15-0.58) and transannular patch (HR 0.60, 95% CI 0.46-0.79). LTFU patients had lower rates of cardiac hospitalisations (HR 0.49, 95% CI 0.42-0.56) and cardiac interventions (HR 0.32, 95% CI 0.25-0.42), but similar rates of cardiac mortality (HR 0.95, 95% CI 0.24-3.80).

CONCLUSIONS

There was a lower proportion of LTFU patients compared with previous studies. Factors associated with lower rates of LTFU were conduits and non-valve-sparing surgery. LTFU patients had lower rates of cardiac procedures and cardiac hospitalisations.

Characterizing the Use of Exercise Testing in Repaired Tetralogy of Fallot Patients: A Multi-Institutional Survey

Cardiopulmonary exercise testing (CPET) is an important tool used in the management of patients with congenital heart disease. However, there are no clear guidelines for its use in specific populations, such as repaired Tetralogy of Fallot (rTOF). We sought to characterize current practice patterns and attitudes regarding exercise testing in the rTOF population using an online survey distributed to pediatric cardiologists. Analyses were performed using qualitative statistics, Wilcoxon rank-sum, Kruskal-Wallis test, and chi-squared analysis. 103 clinicians completed the survey with 83% routinely sending symptomatic rTOF patients for exercise testing and 59% for asymptomatic patients. Respondents who routinely test asymptomatic patients reported higher levels of perceived helpfulness of exercise testing (p < 0.01) and comfort with CPET interpretation (p < 0.01). Although a large majority of respondents found exercise testing to be helpful (81% either "somewhat" or "very" helpful"), a considerably smaller portion indicated comfort with CPET interpretation (49% either "comfortable" or "very comfortable"). Nearly all respondents (92%) reported changing management primarily based on exercise testing results. However, the frequency of changes varied, with 10% "frequently", 62% "occasionally", 19% "rarely" changing management. There was a statistically significant relationship between the perceived helpfulness of exercise testing and the likelihood of management changes (p < 0.01). While exercise testing is used to make clinical decisions, our findings suggest that in some cases, management changes may be made without a similar degree of confidence in interpreting CPET findings. The variability in attitudes and practices highlights the need for evidence-based guidelines addressing exercise testing in rTOF, particularly for asymptomatic patients.

Genetic Risk Score Constructed from Polymorphisms in the VEGFA, TBX5, and SMAD7 Genes Provides Novel Insights into the Molecular Mechanisms of the Tetralogy of Fallot and Ventricular Septal Defect (Case-Control Study from the Pakistani Population)

Congenital heart defects are common and complex birth-defect malformations in developed and developing countries. It is a multifactorial disease that involves the interaction of either gene-gene or gene-environment. This comparative study was the first report on the genotypic-phenotypic correlation in the Pakistani population. The single nucleotide polymorphisms (SNPs) were further tested for association with maternal diabetes mellitus or hypertension. In addition, the cumulative genetic risk score (GRS) for low to moderately-associated SNPs was calculated for each study subject, which can ultimately guide us for better therapeutic options and prevention strategies. According to the predefined selection criteria, 376 subjects were recruited. The multiplex mini-sequencing genotyping technique opted for the cost-effective genotyping of selected loci. The association of variants with the disease was examined using logistic regression analysis. The statistical and graphical analysis was conducted using SPSS, Haploview, SNPStats, and GraphPad Prism. The results for all SNPs analysis suggested a nonsignificant association with overall congenital heart defect risk except rs3809923. However, interestingly on stratified analysis variants, rs3809923 and rs3809922 showed an association only with tetralogy of Fallot. The remaining risk factor analysis for maternal hypertension and diabetes mellitus association with SNPs were nonsignificant. The GRS was the first time constructed for this low to moderately-associated variants. Interestingly, the cumulative GRS was significantly different from the control group revealing the cumulative effect of these polymorphisms panel in patients. In conclusion, the use of GRS in the clinical setting can predict better risk association and patient outcomes.

Long-term follow-up and sex differences in adults operated for tetralogy of Fallot

OBJECTIVE

Adults operated for tetralogy of Fallot (TOF) have high risk of ventricular arrhythmias (VA). QRS duration >180 ms is an established risk factor for VA. We aimed to investigate heart function, prevalence of arrhythmias and sex differences in patients with TOF at long-term follow-up.

METHODS

We included TOF-operated patients≥18 years from our centre's registry. We reviewed medical records and the most recent echocardiographic exam. VA was recorded on ECGs, 24-hour Holter registrations and from implantable cardioverter defibrillator.

RESULTS

We included 148 patients (age 37±10 years). Left ventricular global longitudinal strain (LV GLS, -15.8±3.1% vs -18.8±3.2%, p=0.001) and right ventricular (RV) GLS (-15.8±3.9% vs -19.1±4.1%, p=0.001) were lower in men at all ages compared with women. Higher RV D1 (4.3±0.5 cm vs 4.6±0.6 cm, p=0.01), lower ejection fraction (55%±8% vs 50%±9%, p=0.02), lower RV GLS (-18.1±4.0 ms vs -16.1±4.8 ms, p=0.04) and N-terminal pro-brain natriuretic peptide (NT-proBNP) over reference range (n=27 (23%) vs n=8 (77%), p<0.001) were associated with higher incidence of VA. QRS duration was longer in men (151±30 ms vs 128±25 ms, p<0.001). No patients had QRS duration >180 ms. QRS duration did not differ in those with and without VA (143±32 ms vs 137±28 ms, p=0.06).

CONCLUSIONS

Our results confirmed reduced RV function in adults operated for TOF. Male patients had impaired LV and RV function expressed by lower LV and RV GLS values at all ages. Reduced cardiac function and elevated NT-proBNP were associated with higher incidence of VA and may be important in risk assessment.

[Epidemiological surveillance of congenital heart defects: the Tetralogy of Fallot in the Valencian Region, 2007-2017.]

OBJECTIVE

Tetralogy of Fallot is characterized by the presence of four congenital heart defects. Objective: to describe the temporal trend and distribution of Tetralogy of Fallot, in children under one year in the Valencian Region.

METHODS

Cases with Tetralogy of Fallot (code Q21.3 from the ICD10-British Paediatric Association) were selected from the Congenital Anomalies Population-based Registry between 2007-2017. Prevalence per 10,000 births with 95%CI was calculated, and a descriptive analysis of sociodemographic and clinical variables was made.

RESULTS

165 cases were identified (43.6% male, 30.9% female and 25.5% unknown). The overall prevalence was 3.1/10,000 births (95%CI:2.6-3.6), being 2015 and 2017 the years with the highest (4.3/10,000 births and 4.7/10,000 births respectively) and 2011 with the lowest (1.8/10,000 births). 72.1% were live births, 24.8% Termination of Pregnancy for Fetal Anomaly (TOPFA) and 3.0% stillbirths. The prevalence in live births was 2.2/10,000 births (95%CI:1.8-2.7) and in TOPFA it was 0.8/10,000 births (95%CI:0.5-1.0), identifying an increasing trend along the period in the last one. 10.1% of live births died during the first year of life and 55.8% were diagnosed prenatally. Mothers younger than 20 years had the highest prevalence (4.8/10,000 births).

CONCLUSIONS

The prevalence obtained in the Valencian Region was slightly lower than EUROCAT's but coincides with that of the registries that are closer geographically, and in all of them it is noted that their increasing trend specifically affects cases ending in TOPFA.

Pattern of congenital heart disease among children presenting to the Uganda Heart Institute, Mulago Hospital: a 7-year review

BACKGROUND

Congenital heart disease (CHD) is the most common congenital anomaly in children. Over half of the deaths due to CHD occur in the neonatal period. Most children with unrepaired complex heart lesions do not live to celebrate their first birthday. We describe the spectrum of congenital heart disease in Uganda.

METHODS

We retrospectively reviewed the data of children with CHD who presented to the Uganda Heart Institute (UHI), Mulago Hospital Complex from 2007 to 2014.

RESULTS

A total of 4621 children were seen at the UHI during the study period. Of these, 3526 (76.3%) had CHD; 1941(55%) were females. Isolated ventricular septal defect (VSD) was the most common CHD seen in 923 (27.2%) children followed by Patent ductus arteriosus (PDA) 760 (22%) and atrial septal defects (ASD) 332 (9.4%). Tetralogy of Fallot (TOF) and Truncus arteriosus were the most common cyanotic heart defects (7% and 5% respectively). Dysmorphic features were diagnosed in 185 children, of which 61 underwent genetic testing (Down syndrome=24, 22q11.2 deletion syndrome n=10). Children with confirmed 22q11.2 deletion had conotruncal abnormalities.

CONCLUSION

Isolated VSD and Tetralogy of Fallot are the most common acyanotic and cyanotic congenital heart defects. We report an unusually high occurrence of Truncus arteriosus.

Prevalence and management of coronary artery anomalies in tetralogy of Fallot at Cheikh Zaid Hospital's Pediatric Cardiac Surgery Department in Morocco: retrospective study

INTRODUCTION

Tetralogy of Fallot (TOF) is one of the most common cyanogenic congenital heart defects. It represents 10% of congenital heart diseases in children. Coronary artery anomalies (CAA) have been reported in 2% to 14% of cases in patients with TOF, according to angiographic, surgical and autopsy series. Many of these anomalies are difficult to detect during surgery. The objective of this article is to study the prevalence of the coronary artery anomalies in patients with TOF as well as their surgical management in our hospital between 2007 and 2015.

METHODS

A retrospective study was conducted on 90 patients with TOF aged 1 month to 10 years who were operated on in the Department of Paediatric Cardiac Surgery of Cheikh Zaid Hospital between 2007 and 2015. None of the patients had preoperative coronary angiography and all the anomalies were diagnosed during surgery. Patient clinical data were collected from patient records and from the hospital information system. The qualitative variables are expressed as mean and standard deviation and the quantitative variables are expressed as a percentage. Statistical analyses were performed using SPSS 13.0 software.

RESULTS

Of the 90 patients with TOF followed in the study period, 9 (10%) patients had coronary artery anomalies. We found in 3 (33%) patients an anomalous origin of the left anterior descending coronary artery (LAD) from the right coronary artery (RCA), an anomalous origin of the RCA from the left coronary trunk (LCT) in 1 (11%) patient and a large infundibular branch blocking the pulmonary infundibulum in 5 (56%) patients. All the patients underwent a complete surgical treatment (closure of the ventricular septal defect (VSD) by patch plus stenosis resection plus infundibular enlargement by patch). Eight (89%) patients progressed well in postoperative care and 1 (11%) died immediately after surgery in intensive care.

CONCLUSION

The coronary anomalies detected in patients with TOF are rare but represent a challenge for the surgical team because of the difficulty of diagnosing them pre-operatively. The management of these anomalies is mainly surgical and the technique used by our team is proved to be safe and effective.

Determinants of Left Ventricular Dysfunction and Remodeling in Patients With Corrected Tetralogy of Fallot

Background

The aim of this study was to identify in asymptomatic patients with repaired tetralogy of Fallot the prevalence and determinants of impaired left‐sided cardiac function and adverse ventricular remodeling and the relation of left ventricular (LV) dysfunction and remodeling with cardiopulmonary exercise capacity.

Methods and Results

In a cross‐sectional study, 103 patients with tetralogy of Fallot (median age, 16.3 years) in New York Heart Association class 1, with surgical repair at a median age of 1.1 years, and 63 age‐matched controls were studied. LV, right ventricular function and geometry, LV myocardial extracellular volume (n=57), and left atrial function were quantified with cardiac magnetic resonance. Peak oxygen consumption was measured by a standardized cardiopulmonary exercise test (n=70). Patients with tetralogy of Fallot had lower LV ejection fraction (P=0.001; 49% below age‐adjusted fifth percentile for controls), lower LV mass index (P=0.003), lower LV mass/volume ratio (P<0.01), and impaired left atrial function. Right ventricular mass/volume ratio was the best predictor for LV systolic dysfunction and for a lower LV mass/volume ratio. Compared with controls, LV extracellular volume was higher (P<0.001), particularly in female patients, and associated with subnormal peak oxygen consumption (P=0.037). A peak oxygen consumption below the third percentile reference level was more likely with decreasing LV ejection fraction (P=0.008), and lower LV mass index (P=0.024), but independent of right ventricular ejection fraction.

Conclusions

In New York Heart Association class 1 patients with tetralogy of Fallot, frequent impaired systolic and diastolic LV function, LV adverse remodeling with LV atrophy, a decreased mass/volume ratio, and extracellular matrix expansion suggest cardiomyopathic changes. The best predictor for LV systolic dysfunction was the right ventricular mass/volume ratio. The subnormal peak oxygen consumption indicates that monitoring of LV status may be important for long‐term prognosis.

Trends and Outcomes of Infective Endocarditis in Adults With Tetralogy of Fallot: A Review of the National Inpatient Sample Database

BACKGROUND

Lesion complexity and prosthetic valves are known risk factors for infective endocarditis in patients with congenital heart disease. Tetralogy of Fallot (TOF) is the most common complex/cyanotic congenital heart disease and often requires prosthetic valve implantation. Population-based risk of endocarditis in TOF patients is unknown.

METHODS

We reviewed the National Inpatient Sample (NIS) and identified admissions in TOF patients (>18 years), 2000 to 2014. The primary outcome was to describe incidence of endocarditis-related admissions. To assess trends, we divided the study period into tertiles: early (2000 to 2004), mid (2005 to 2009) and late (2010 to 2014) eras. The secondary outcome was to compare in-hospital mortality, complications, and health care resource utilization between admissions with and without endocarditis.

RESULTS

There were 393 (2.1%) endocarditis-related admissions among 18,353 admissions, and the incidence of endocarditis-related admissions increased over time: 1.9% (early era) vs 2.2% (mid-era) vs 2.4% (late era), P < 0.001. Overall in-hospital mortality was 6%. In addition to previously described risk factors for endocarditis, such as previous pacemaker/defibrillator or prosthetic valve implantation, we observed an association between endocarditis-related admissions and male gender, black race, and lower socioeconomic class. In comparison with admissions without endocarditis, the endocarditis-related admissions had higher in-hospital mortality, complications, and health care resource utilization measured by length of stay, inflation-adjusted hospitalization cost, and type of hospital discharge.

CONCLUSIONS

Incidence of endocarditis-related admissions increased over time and was associated with higher mortality, complications, and health care resource utilization. Further studies are required to investigate the observed temporal increase in incidence of endocarditis and explore new strategies to improve outcomes.

GATA4 molecular screening and assessment of environmental risk factors in a Moroccan cohort with tetralogy of Fallot

Background

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect (CHD) with an incidence of 1/3600 live births. This disorder was associated with mutations in the transcription factors involved in cardiogenesis, like Nk2 homeobox5 (NKX2-5), GATA binding protein4 (GATA4) and T-BOX1 (TBX1). GATA4 contributes particularly to heart looping and differentiation of the second heart field.

Objectives

The aim of this study was to screen a Moroccan cohort with tetralogy of Fallot for GATA4 mutations, and to assess environmental risk factors that could be involved in the occurrence of this disorder.

Methods

Thirty-one non-syndromic TOF patients, enrolled between 5^th April 2014 and 18^th June 2015, were screened for GATA4 mutations using direct sequencing of GATA4 coding exons. Statistical assessment of different risk factors, which is a retrospective study, was carried out using Chi-square and Fisher's exact tests.

Results

We identified seven exonic variants in nine patients (two missense and five synonymous variants); in addition of eight intronic variants. Assessment of environmental risk factors shows significant association of maternal passive smoking with TOF in the Moroccan population.

Conclusion

The present study allowed, for the first time, the molecular and environmental characterisation of Moroccan TOF population. Our findings emphasise particularly the strong association of passive smoking with the emergence of tetralogy of Fallot.

Absent pulmonary valve syndrome - diagnosis, associations, and outcome in 71 prenatally diagnosed cases

OBJECTIVE

The objective of this study was to analyze the spectrum of prenatally diagnosed absent pulmonary valve syndrome (APVS) and the outcome from diagnosis onwards. Fetuses with APVS and tetralogy of Fallot (TOF/APVS) and with APVS and intact ventricular septum (APVS/IVS) were included.

METHOD

Multicenter retrospective study of the International Prenatal Cardiology Collaboration Group. Clinical and echocardiographic databases of nine referral centers were reviewed from 2012-2016.

RESULTS

The cohort included 71 cases, 59 with TOF/APVS and 12 with APVS/IVS. In 18.3% of cases, diagnosis was achieved within first trimester. Association with hydrops fetalis was high within first trimester (69%). No fetus with known outcome survived after first trimester diagnosis. Karyotype anomalies occurred in 45% of cases with known karyotype. Intrauterine fetal demise occurred in 14.3%. Overall survival after initial diagnosis in the total cohort was 28.1% (28.8% TOF/APVS and 25.0% APVS/IVS). Survival to birth was 50% in TOF/APVS and 44.4% in APVS/IVS. Survival of subjects born alive beyond neonatal period was 84.6% in TOF/APVS and 100% in APVS/IVS.

CONCLUSION

Diagnosis of APVS is feasible within first trimester. Outcomes remain guarded, especially if first trimester diagnosis is included into the analysis because of associated karyotypic anomalies, the presence of hydrops fetalis, and patent ductus arteriosus. © 2017 John Wiley & Sons, Ltd.

National Trends in Hospitalizations of Adults With Tetralogy of Fallot

The population of adults with tetralogy of Fallot (TOF) is growing, and it is not known how the changes in age distribution, treatment strategies, and prevalence of co-morbidities impact their interaction with the health care system. We sought to analyze the frequency and reasons for hospital admissions over the past decade. We extracted serial cross-sectional data from the United States Nationwide Inpatient Sample on hospitalizations including the diagnostic code for TOF from 2000 to 2011. From 2000 to 2011, there were 20,545 admissions for subjects with TOF, with a steady increase in annual number. The most common primary admission diagnoses were heart failure (HF; 17%), arrhythmias (atrial 10% and ventricular 6%), pneumonia (9%), and device complications (7%). The rates of co-morbidities increased significantly, particularly diabetes (4.5% to 8.1%), obesity (2.1% to 6.5%), hypertension, and renal disease. The number of pulmonic valve replacements increased (6.8% to 11.3% of TOF admissions, p <0.001), with an increase in median age at surgery from 16 to 19 years old (p = 0.036). The cost per TOF admission was more than double that of noncongenital HF admissions and rose significantly, reaching $21,800 ± 46,000 in 2011. In conclusion, hospitalized patients with TOF have become significantly more medically complex and are growing in number. The increase in the prevalence of obesity, hypertension, and diabetes in this young population supports the need for prevention efforts focused on modifiable risk factors, in addition to HF and arrhythmia treatment. The increase in cost of care calls for further analysis of areas in which efficiency can be increased to ensure high quality of care and lifelong follow-up of patients with TOF.

Associated Coronary Anomalies in 135 Iranian Patients with Tetralogy of Fallot

Coronary artery anomalies are common among patients with tetralogy of Fallot. One hundred and thirty-five patients (80 males and 55 females) with tetralogy of Fallot who underwent repair between 1995 and 2002 were studied to determine the incidence of coronary anomalies in Iranian patients. Eight (5.9%) patients (4 males and 4 females) had a surgically relevant coronary artery anomaly: single coronary ostium in 5, origin of the left anterior descending artery from the right coronary artery in 2, and origin of the right coronary artery from the left coronary artery in 1. The surgical technique in 3 of these patients was repair of the ventricular septal defect with a transverse incision on the right ventricle, without damage to the coronary arteries. In another patient, an allograft aortic valve cylinder was inserted. In the other 4 patients with a single coronary ostium, placement of a limited transannular patch was adequate. Consideration of these anomalies during primary repair could decrease the risk of operation in such patients. However, it seems that the presence of anomalous coronary arteries does not affect incremental risk after surgical repair.

A systematic review of trends and patterns of congenital heart disease in children in Nigeria from 1964-2015

BACKGROUND

Congenital heart diseases cause significant childhood morbidity and mortality. Several restricted studies have been conducted on the epidemiology in Nigeria. No truly nationwide data on patterns of congenital heart disease exists.

OBJECTIVES

To determine the patterns of congenital heart disease in children in Nigeria and examine trends in the occurrence of individual defects across 5 decades.

METHOD

We searched PubMed database, Google scholar, TRIP database, World Health Organisation libraries and reference lists of selected articles for studies on patterns of congenital heart disease among children in Nigeria between 1964 and 2015. Two researchers reviewed the papers independently and extracted the data. Seventeen studies were selected that included 2,953 children with congenital heart disease.

RESULTS

The commonest congenital heart diseases in Nigeria are ventricular septal defect (40.6%), patent ductus arteriosus (18.4%), atrial septal defect (11.3%) and tetralogy of Fallot (11.8%). There has been a 6% increase in the burden of VSD in every decade for the 5 decades studied and a decline in the occurrence of pulmonary stenosis. Studies conducted in Northern Nigeria demonstrated higher proportions of atrial septal defects than patent ductus arteriosus.

CONCLUSIONS

Ventricular septal defects are the commonest congenital heart diseases in Nigeria with a rising burden.

Prenatal and Postnatal Survival of Fetal Tetralogy of Fallot: A Meta-analysis of Perinatal Outcomes and Associated Genetic Disorders

OBJECTIVES

The aim of this systematic review was to compare the postnatal outcomes, genetic testing results, and sonographic findings in 3 subtypes of tetralogy of Fallot.

METHODS

Thirty-six articles from the MEDLINE and EMBASE databases were selected for this review. The postnatal outcomes, karyotyping results, and sonographic findings of fetal tetralogy of Fallot with pulmonary stenosis, tetralogy of Fallot with pulmonary atresia, and tetralogy of Fallot with an absent pulmonary valve were collected and compared.

RESULTS

The survival rates (termination of pregnancy was considered fetal death) for prenatally diagnosed tetralogy of Fallot with pulmonary atresia and tetralogy of Fallot with an absent pulmonary valve at the end of neonatal period were significantly lower than the rate for tetralogy of Fallot with pulmonary stenosis (P < .05). The survival rate for tetralogy of Fallot with pulmonary atresia was also lower at birth (P < .001). Major chromosomal anomalies were more frequently detected in tetralogy of Fallot with pulmonary stenosis (P< .05); conversely, 22q11 deletion was present more often in fetuses with tetralogy of Fallot with pulmonary atresia and tetralogy of Fallot with an absent pulmonary valve (P < .001). Compared to tetralogy of Fallot with pulmonary stenosis, a right aortic arch was more associated with tetralogy of Fallot with pulmonary atresia (32.6%; P < .05), and the ductus arteriosus was almost always absent in tetralogy of Fallot with an absent pulmonary valve (87.5%; P < .001).

CONCLUSIONS

The postnatal outcomes, genetic testing results, and sonographic findings are different among subtypes of tetralogy of Fallot. Documenting those details at diagnosis can help specialists better counsel their patients.

A single misstep in cardiac development explains the co-occurrence of tetralogy of fallot and complete atrioventricular septal defect in Down syndrome

Tetralogy of Fallot and a complete atrioventricular septal defect are thought to arise by distinct mechanisms, yet their co-occurrence is a recognized association. Analysis of the prevalence of co-occurrence in Down syndrome suggests a common developmental basis. Trisomy 21 may perturb cardiac progenitor cells before they enter the heart tube.

Use of oral fluconazole during pregnancy and the risk of birth defects

BACKGROUND

Case reports suggest that long-term, high-dose fluconazole treatment for severe fungal infections during pregnancy causes a pattern of birth defects. It is unclear whether commonly used lower doses increase the risk of specific birth defects.

METHODS

In a registry-based cohort of liveborn infants in Denmark, we evaluated first-trimester oral fluconazole exposure and the risk of birth defects overall and of birth defects previously linked to azole antifungal agents.

RESULTS

The majority of fluconazole-exposed pregnancies were in women who received common therapeutic doses of 150 mg (56% of pregnancies) or 300 mg (31%). Oral fluconazole exposure was not associated with an increased risk of birth defects overall (210 birth defects among 7352 fluconazole-exposed pregnancies [prevalence, 2.86%] and 25,159 birth defects among 968,236 unexposed pregnancies [prevalence, 2.60%]; adjusted prevalence odds ratio, 1.06; 95% confidence interval [CI], 0.92 to 1.21). In addition, oral fluconazole exposure was not associated with a significantly increased risk of 14 of 15 types of birth defects previously linked to azole antifungal agents: craniosynostosis, other craniofacial defects, middle-ear defects, cleft palate, cleft lip, limb defects, limb-reduction defects, polydactyly, syndactyly, diaphragmatic hernia, heart defects overall, pulmonary-artery hypoplasia, ventricular septal defects, and hypoplastic left heart. A significantly increased risk of tetralogy of Fallot was observed (7 cases in fluconazole-exposed pregnancies [prevalence, 0.10%] as compared with 287 cases in unexposed pregnancies [prevalence, 0.03%]; adjusted prevalence odds ratio, 3.16; 95% CI, 1.49 to 6.71).

CONCLUSIONS

Oral fluconazole was not associated with a significantly increased risk of birth defects overall or of 14 of the 15 specific birth defects of previous concern. Fluconazole exposure may confer an increased risk of tetralogy of Fallot. (Funded by the Danish Medical Research Council.).

Cardiovascular disease in late survivors of tetralogy of fallot: a tertiary care center experience

Patients with tetralogy of Fallot can survive to late adulthood; however, there are few data on cardiovascular outcomes in this population. We conducted a single-center retrospective analysis of cardiovascular outcomes and risk factors in 208 patients with tetralogy of Fallot to better evaluate the burden of cardiovascular disease in this group. Descriptive statistics were used to determine the prevalence of relevant cardiovascular risk factors and outcomes, including a composite analysis of cardiovascular disease. Rates and mean values from the American Heart Association 2011 Heart Disease and Stroke Statistics Update were used as population estimates for comparison. In tetralogy of Fallot patients, cardiovascular disease prevalence was not different from that found in the general population (40% vs. 36%, P=0.3). However, there was significantly more cardiovascular disease in tetralogy of Fallot men aged 20 to 39 years (30% vs. 14%, P < 0.05) and in tetralogy of Fallot men aged 40 to 59 years (63% vs. 29%, P < 0.0001). This was due to higher prevalence of coronary disease (12% vs. 7%, P < 0.05) and heart failure (16% vs. 2%, P < 0.0001). In particular, the increased prevalence of heart failure (regardless of pulmonary valve disease) accounts for the frequency of cardiovascular disease in tetralogy of Fallot men aged 20 to 59 years. These data support the need to routinely screen young adult male survivors of tetralogy of Fallot for asymptomatic heart failure. Further studies are needed to determine the incidence, severity, and long-term effects of cardiovascular disease in the adult congenital heart disease population.

Population-based review of tetralogy of Fallot with absent pulmonary valve: is prenatal diagnosis really associated with a poor prognosis?

OBJECTIVES

Tetralogy of Fallot with absent pulmonary valve syndrome (TETAPV) is reported in obstetric literature to have an extremely poor prognosis. We sought to determine the clinical outcome associated with TETAPV and whether prenatal diagnosis confers a poor prognosis.

METHODS

All cases of TETAPV diagnosed in British Columbia between 1980 and 2009 were reviewed and grouped according to time of diagnosis, either prenatal or postnatal. The groups were compared with respect to mortality, respiratory problems, number of interventions and functional capacity at last follow-up.

RESULTS

Eight and 11 patients were included in the prenatally and postnatally diagnosed groups, with overall long-term survival of 71% and 82%, respectively. There was no significant difference in mortality, frequency of preoperative intubation, number of interventions or functional capacity between groups.

CONCLUSION

From a population-based retrospective analysis of TETAPV cases identified over three decades it is concluded that the prognosis for TETAPV is better than that previously reported in the obstetric literature. This information should be used to guide prenatal counseling.

Tetralogy of Fallot: fetal diagnosis to surgical correction

Tetralogy of Fallot is one of the most common forms of cyanotic congenital heart disease. The diagnosis consists of four main anatomic features: a large ventricular septal defect (anterior malaligned), overriding aorta, right ventricular outflow obstruction and right ventricular hypertrophy. The refinement of fetal screening and echocardiography has led to an increase in prenatal diagnosis. Prenatal diagnosis along with the recognition of extracardiac anomalies and genetic abnormalities, including 22q11 deletion, sets the framework for prenatal counseling and can help predict the postnatal course and surgical repair. After birth, the degree of cyanosis and the presence of other extracardiac and cardiac abnormalities will direct the timing of surgical repair. Full surgical repair within the first year of life, either primary or after a palliative procedure, is the mainstay of therapy. Our understanding of the consequences of prior era surgeries and the detrimental effects of long standing pulmonary insufficiency has led to newer surgical and interventional techniques. Tetralogy of Fallot is a lifelong disease that requires careful follow up through adulthood with the potential for additional surgical and interventional procedures later in life.

[Analysis of microdeletions in 22q11 in Colombian patients with congenital heart disease]

Cardiac defects are the most frequent congenital malformations, with an incidence estimated between 4 and 12 per 1000 newborns. Their etiology is multifactorial and might be attributed to genetic predispositions and environmental factors. Since 1990 these types of pathologies have been associated with 22q11 microdeletion. In this study, the frequency of microdeletion 22q11 was determined in 61 patients with non-syndromic congenital heart disease. DNA was extracted from peripheral blood and TUPLE1 and STR D10S2198 genes were amplified by multiplex PCR and visualized in agarose gels. Gene content was quantified by densitometry. Three patients were found with microdeletion 22q11, representing a 4.9% frequency. This microdeletion was associated with two cases of Tetralogy of Fallot and a third case with atrial septal defect (ASD). In conclusion, the frequency for microdeletion 22q11 in the population analyzed was 4.9%. The cases that presented Teratology of Fallot had a frequency for this microdeletion of 7.4% and for ASD of 11.1%.

Clinical profile of patients with tetralogy of Fallot admitted for surgery at a cardiac surgical centre

INTRODUCTION

Tetralogy of Fallot (TOF), a conotruncal defect, has been documented to be associated with chromosome abnormalities, single gene syndrome (22q11 microdeletion), known teratogens, with the rest associations being multifactorial. This study was carried out to determine the clinical profile and associated risk factors in patients with TOF admitted for surgical repairs.

METHODS

Case files of all patients admitted for Tetralogy of Fallot over a period of one year were retrieved from the Medical Records Department and reviewed. Data on the patients' and their family history and associated cardiac anomalies were noted.

RESULTS

There were 54 patients, 37 males and 17 females, with a mean age of 6.8 years +/- 7.1. Sixty percent were born between July and December, 81.5% as full term and 44% as first born. Twenty-six percent were born into consanguineous marriages. Five patients had dysmorphic features. Associated cardiac anomalies included right aortic arch, pulmonary atresia, dextrocardia and left superior vena cavae.

CONCLUSION

The associated risk factors noted in this study were male sex, birthdates between July and December, first born and increased paternal age. Other risk factors were consanguinity and specific patterns of cardiovascular diseases associated with 22q 11 deletions. This suggests a multifactorial etiology for TOF.

[Clinical epidemiological retro prospective studies on the incidence and prevalence of cardiac congenital abnormalities in a group of 1570 children, born in Iaşi between 2000-2009]

MATERIAL AND METHOD

The study has been conducted on a period of ten years and it included 1570 children with congenital abnormalities (CA), of which 371 (24%) were cardiac abnormalities, 312 (20%) were skeletal abnormalities, 55 (3%) were Down Syndrome and 832 (53%) were other pathologies.

RESULTS

48% of the 371 children that were diagnosed with cardiac CA were males, while 52% were females; 52% of the children were from the city, while 48% were from the country-side; 42% of the children have been born prematurely, while 58% of them have been born at normal term. 38% of the children had an APGAR score lower than 7 and 62% of them had an APGAR score higher than 7. Of the total number of births, 72% were caesarian births and 28% were natural births. The different types of Cardiac CA that have been encountered in the study were atrioventricular canal (56%), transposition of the great vessels (18%), common arterial trunk (10%), atrial septal defect (8%), ventricular septal defect (5%) and tetralogy of Fallot (3%). 66% of the total number of deaths were represented by those with cardiac pathology, 21% were caused by hydrocephalus, 7% were caused by diaphragmatic hernia, 4% had renal CA, while 2% were caused by other pathologies.

Association of consanguinity with congenital heart diseases in a teaching hospital in Western Iraq

OBJECTIVE

To study the association of consanguinity as a risk factor for congenital heart diseases (CHDs).

METHODS

Patients with suggestive signs of CHD admitted to the Al-Ramadi Maternity and Children Hospital, Al-Anbar Governorate, Iraq from January 2009 to January 2010 were subject to diagnostic investigations. Case data includes: name, age, gender, and cause of admission. Parents data includes: age, residence, degree of consanguinity, and history of family recurrent CHDs. Three controls to one case (3:1) were selected to compare their consanguinity with the CHD cases. Odds ratio was used for the measurement of consanguinity and other variable risks on CHD occurrence.

RESULTS

The CHD cases were 86. Selected controls were 258 non-CHD cases. The most recorded subtypes were ventricular septal defect (VSD), atrial septal defect (ASD), and tetralogy of fallot (ToF). Consanguinity was found in 78% of cases and 43.3% in controls. First cousin consanguinity comprised 66.2% in cases and 35.6% in controls from all their marriages. Consanguinity was found a significant risk factor, more affecting the VSD and ASD than ToF subtypes, while parental age and infant gender were not found as risk factors.

CONCLUSION

Consanguinity proved to be a risk factor for CHD. Further social education of the risks of consanguineous marriages in this tribal population is needed to reduce the prevalence of these morbid and mortal anomalies.

The challenge of congenital heart disease worldwide: epidemiologic and demographic facts

Congenital heart disease (CHD) afflicts a large number of children every year. The incidence of CHD is generally considered to be 8 per 1,000 live births. However, this estimate is perhaps inaccurate and does not take into consideration regional differences. A large review of the literature was performed to establish the true incidence of CHD and geographical variations. Data on the incidence of specific lesions and their geographical variation, as well as on mortality from CHD, was also reviewed. Taking into consideration the available data on incidence, mortality, and access to care, the global challenge that CHD represents was analyzed. Insight into how to confront this challenge is given.

Tetralogy of Fallot

Tetralogy of Fallot is the most common form of cyanotic congenital heart disease, and one of the first to be successfully repaired by congenital heart surgeons. Since the first procedures in the 1950s, advances in the diagnosis, perioperative and surgical treatment, and postoperative care have been such that almost all those born with tetralogy of Fallot can now expect to survive to adulthood. The startling improvement in outcomes for babies born with congenital heart disease in general-and for those with tetralogy of Fallot in particular-is one of the success stories of modern medicine. Indeed, in many countries adults with tetralogy of Fallot outnumber children. Consequently, new issues have emerged, ranging from hitherto unpredicted medical complications to issues with training for caregivers and resource allocation for this population of survivors. Therefore, evolution of treatment, recognition of late complications, research on disease mechanisms and therapies-with feedback to changes in care of affected children born nowadays-are templates on which the timely discussion of organisation of care of those affected by congenital heart diseases from the fetus to the elderly can be based. Here, we focus on new developments in the understanding of the causes, diagnosis, early treatment, and late outcomes of tetralogy of Fallot, emphasising the continuum of multidisciplinary care that is necessary for best possible lifelong treatment of the 1% of the population born with congenital heart diseases.

Frequency of 22q11.2 microdeletion in sporadic non-syndromic tetralogy of Fallot cases

BACKGROUND

Tetralogy of Fallot (TOF) is a congenital conotruncal heart defect commonly found in DiGeorge (DGS) and velocardiofacial (VCFS) syndromes. The deletion of chromosome 22q11 has also been demonstrated in sporadic or familial cases of TOF. The aim of the present study was to investigate the frequency of del22q11 in patients with non-syndromic TOF seen at a tertiary Pediatric Cardiology care center.

METHOD

One hundred and twenty three non-syndromic TOF patients were selected and evaluated by history, physical examination and review of medical records. Venous blood was drawn for genomic DNA extraction after informed consent 22q11 microdeletion diagnosis was conducted through a standardized SNP genotyping assay and consecutive homozygosity mapping. Phenotype-genotype correlations regarding cardiac anatomy were conducted.

RESULTS

We evaluated 123 non-syndromic TOF patients for a 22q11 deletion. 105 (85.4%) patients presented pulmonary stenosis and 18 (14.6%) had pulmonary atresia. Eight patients (6.5%) were found to have a deletion. Of the deleted patients, three (37.5%) presented pulmonary atresia. We have verified a tendency towards a higher prevalence of pulmonary atresia when comparing TOF patients with and without 22q11 microdeletion.

CONCLUSIONS

22q11.2 deletion in non-syndromic TOF patients is present in approximately 6% of patients. We suggest a tendency towards a higher prevalence of pulmonary atresia in non-syndromic TOF patients with 22q11 microdeletion. Molecular genetic screening of non-syndromic TOF patient may be important for the correct care of these patients and a more specific genetic diagnostic and counseling.

Prevalence of congenital heart disease, Kanpur, India

Our aim was to study the prevalence, age-wise distribution, and clinical spectrum of congenital heart disease (CHD) at a multi-speciality corporate hospital in North India. A retrospective analysis of records of 10,641 patients over a five-and-a-half year period was done. Clinical examination, echocardiography and color doppler were used as diagnostic tools. A prevalence of 26.4 per 1000 patients was observed. VSD (ventricular septal defect) was the commonest lesion (21.3%), followed by ASD (atrial septal defect) in 18.9% and PDA (patent ductus arteriosus) in 14. 6%. Tetralogy of Fallot was the commonest cyanotic heart disease (4.6%). Maximum number of children with heart disease (82.9%) were diagnosed between 0-3 years of age.

The utility of the general practice research database to examine selected congenital heart defects: a validation study

OBJECTIVE

The purpose of this research was (1) to validate that ventricular septal defect (VSD), tetralogy of Fallot (TOF), and coarctation of the aorta (COA) can be studied in the UK General practice research database (GPRD) and (2) to understand which of the available GPRD components (computerized medical records, questionnaires, and maternal/infant free text) provide maximal information about these heart defects.

METHODS

Using a practitioner questionnaire, the positive predictive value (PPV) of the computerized medical record for VSD, TOF, and COA were determined. Both infant and maternal free text was examined. Concordance between the infant free text information and questionnaires was calculated. The proportion of infant information captured in the maternal free text was determined.

RESULTS

A 93% response rate was achieved. Based on questionnaire responses, an overall PPV of 93.5% was achieved (VSD = 95%, TOF = 90%, COA = 100%). Approximately half of the records contained infant free text information including information on the type and size of VSD, echocardiogram findings, and surgery. Concordance between the infant's free text and questionnaire information occurred in most of the cases (92-100%). The proportion of infant information in the maternal free text was low (4-19%).

CONCLUSION

The GPRD computerized medical records are sufficient to assess VSD, TOF, and COA. This study confirms that maternal free text provides a low yield of limited information pertaining to the infants' defect, while the infant free text may provide an additional information usually obtainable from practitioner questionnaires. The information provided by an infant free text may limit the need for practitioner questionnaire validation.

Tetralogy of Fallot in teenagers and adults: surgical experience and follow-up

OBJECTIVE

The aim of this study was to review short- and long-term outcomes following total correction in patients with tetralogy of Fallot that presented during adulthood.

METHODS

It was a retrospective analysis of 284 patients (aged 14-50 years, mean 19.4 +/- 2.5 years) with tetralogy of Fallot who underwent total correction at our institution between January 1991 and December 2001. Thirty patients were subjected to postoperative first-pass radionuclide angiocardiography scans. A Hindi version of the standard World Health Organization quality of life proforma was mailed to 120 patients operated on during the first half of the study period.

RESULTS

Altogether, 45 (15.8%) patients had palliative shunts, and 32 (11%) had preoperative coil embolization. The transatrial/transpulmonary artery approach was used in 62 (22%) patients, the transventricular approach in 86 (30%) patients, and a combined approach in 136 (48%) patients. A transannular pericardial patch was used in 200 (70%) patients. A total of 61 (21%) patients had nonfatal complications. There were 28 hospital deaths. Follow-up ranged from 1 month to 10 years (mean 4.6 +/- 2.3 years). There were 7 (2.5%) late deaths and 6 (2.1%) reoperations. Altogether, 94% of patients were in New Yk Heart Association (NYHA) class I. Radionuclide angiocardiography showed normal right ventricular and left ventricular function in 18 (60%) and 22 (73%) patients, respectively. All of the 66 respondents perceived an improved quality of life. The actuarial survival and freedom from reoperation at 10 years were 82.88% +/- 3.80% and 92.82% +/- 3.40%, respectively.

CONCLUSION

Total correction in this subset of patients offers the best option for long-term symptom-free survival.

Outcome of pregnancy in women with congenital heart disease: a literature review

A search of peer-reviewed literature was conducted to identify reports that provide data on complications associated with pregnancy in women with structural congenital heart disease (CHD). This review describes the outcome of 2,491 pregnancies, including 377 miscarriages (15%) and 114 elective abortions (5%). Important cardiac complications were seen in 11% of the pregnancies. Obstetric complications do not appear to be more prevalent. In complex CHD, premature delivery rates are high, and more children are small for gestational age. The offspring mortality was high throughout the spectrum and was related to the relatively high rate of premature delivery and recurrence of CHD.

Postoperative retrograde intussusception in an infant: a rare occurrence

Retrograde intussusception is a rare postoperative complication, most commonly after gastric resection or gastrojejunostomy. This report describes a case of retrograde jejunojejunal intussusception after duodenal atresia repair.

Surgical repair of atrioventricular septal defect with common atrioventricular junction when associated with tetralogy of Fallot or double outlet right ventricle

The association of atrioventricular septal defect with common atrioventricular junction and malformations of the ventricular outflow tracts presents a significant challenge for the surgeon. In the most common of these, the association with tetralogy of Fallot, several surgical techniques have been described, and shown to deliver excellent results.1–10On the other hand, in the setting of more extreme malformations, such as double-outlet right ventricle, discordant ventriculo-arterial connections, or common arterial trunk, albeit rare lesions, the combination presents a more formidable surgical challenge, as evidenced by the few reports of successful repair of these lesions. This challenge is both physiological, when dealing with a very sick neonate or infant, as well as anatomical in terms of the complexity of the malformation and the ability to achieve a successful biventricular repair. Our goal in this review is to discuss the surgical treatment in the setting of tetralogy of Fallot and double outlet right ventricle, with emphasis on biventricular repair.

Congenital cardiac malformations in relation to central venous access

During the third and seventh weeks of gestation, teratogenic exposure may lead to fetal abnormality such as congenital heart defects or intrauterine death. Congenital heart defects are present from birth, but may appear at any time, or only revealed postmortem. Often defects are present by degree. Some defects are life-threatening, while other, less severe conditions, may have minimal physiological impact. Left superior vena cava exists in early embryonic development, but the vessel degenerates as the cardiovascular system matures. When not associated with other malformations, an incidence of persistent left-sided superior vena cava (PLSVC) has no clinical signs or symptoms. However, it may not be as innocuous as it appears due to its association with the cyanotic defect, tetralogy of Fallot (TOF). Using a case history as an illustration it can be shown that all cases of defect or chromosomal suspicion should be documented as there may be implications for future interventions.

Outcomes After Late Reoperation in Patients With Repaired Tetralogy of Fallot: The Impact of Arrhythmia and Arrhythmia Surgery

BACKGROUND

We evaluated outcomes in patients requiring late reoperation after tetralogy of Fallot (ToF) repair to identify risk factors for arrhythmia and determine whether arrhythmia surgery decreased the risk of subsequent death or recurrent arrhythmia.

METHODS

Review was performed of all ToF patients from 1969 to 2005 undergoing reoperation late (> 1 year) after repair. Patients with associated lesions, except pulmonary atresia, were included. A total of 249 patients had 278 reoperations. Procedures at initial reoperation included pulmonary valve replacement (PVR) in 217, ablation in 63, and tricuspid valve repair/replacement in 46. Pre-reoperative arrhythmias were present in 75, including supraventricular tachycardia (SVT) in 31, ventricular tachycardia (VT) in 34, and SVT+VT in 10 patients.

RESULTS

Median age at reoperation was 23 years (range, 1 to 63). Ten-year survival after reoperation was 93%, and was independent of arrhythmia status (p = 0.86). Arrhythmia patients were characterized by older age at initial repair and at late reoperation, tricuspid and pulmonary regurgitation, and longer QRS duration (p < 0.001 for all). Risk factors for post-reoperative recurrent arrhythmia were longer QRS duration and not having PVR. Longer QRS duration, with a cut-point of more than 160 msec, was associated with recurrent SVT (p = 0.004). Supraventricular tachycardia ablation improved arrhythmia-free survival (75% versus 33%, p < 0.001) but VT ablation did not (96% versus 95%, p = 0.50). However, recurrent VT occurred in only 3 patients (10%).

CONCLUSIONS

Late mortality in patients undergoing reoperation after ToF repair is not impacted by pre-reoperative arrhythmia. Prolongation of QRS identifies patients at risk for recurrent VT and SVT, but recurrent VT is uncommon. Early PVR, and surgical ablation in patients with SVT, decreases arrhythmic risk.

Tetralogy of Fallot with congenital aortic valvar stenosis: the tetralogy-truncus interrelationship

Two rare patients are reported with tetralogy of Fallot and congenital aortic valvar stenosis. The anatomic and developmental interrelationship between tetralogy of Fallot and truncus arteriosus is summarized. A study of 100 randomly selected postmortem cases of tetralogy revealed aortic valve pathology in 8%, myxomatous aortic valve leaflets without stenosis in 4%, bicuspid aortic valves without stenosis in 3%, and congenital aortic valvar stenosis in 1%. The frequency of systemic semilunar valve pathology in truncus was much higher (66%): moderate to marked myxomatous change in 44%, mild myxomatous change in 22%, truncal valvar stenosis in 11%, and truncal valvar regurgitation in 15%. Being aware of the tetralogy-truncus interrelationship and knowing that myxomatous aortic valves are prone to premature calcific aortic stenosis and/or regurgitation, physicians should follow the aortic valves of surgically repaired patients with tetralogy of Fallot and truncus arteriosus long term with great care. Timely aortic valvuloplasty or replacement may well prove life-saving in such patients.

Ventricular fibrosis suggested by cardiovascular magnetic resonance in adults with repaired tetralogy of fallot and its relationship to adverse markers of clinical outcome

BACKGROUND

Late morbidity and mortality remain problematic after repair of tetralogy of Fallot (TOF). We hypothesized that fibrosis detected by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) would be present in adults with repaired TOF and would be related to adverse markers of outcome.

METHOD AND RESULTS

LGE was scored in the right and left ventricles (RV and LV) of 92 adult patients who had undergone TOF repair. RV LGE was seen in all patients at surgical sites located in the outflow tract (99%) or the site of ventricular septal defect patching (98%) and in the inferior RV insertion point (79%) and trabeculated myocardium (24%). LV LGE (53%) was located at the apex consistent with apical vent insertion (49%), in the inferior or lateral wall consistent with infarction (5%), or in other areas (8%). Patients with supramedian RV LGE score were older (38 versus 27 years, P<0.001) and more symptomatic (38% versus 8% in New York Heart Association class II or greater, P=0.001), had increased levels of atrial natriuretic peptide (7.3 versus 4.9 pmol/L, P=0.041), and had a trend to higher brain natriuretic peptide (12.3 versus 7.2 pmol/L, P=0.086), exercise intolerance (maximum VO2 24 versus 28 mL.min(-1).kg(-1), P=0.021), RV dysfunction (RV end-systolic volume 61 versus 55 mL/m2, P=0.018; RV ejection fraction 50% versus 56%, P=0.007), and clinical arrhythmia (26% versus 10%, P=0.039). Non-apical vent LV LGE also correlated with markers of adverse outcome. In a multivariate model, RV LGE remained a predictor of arrhythmia.

CONCLUSIONS

RV and LV LGE were common after TOF repair and were related to adverse clinical markers, including ventricular dysfunction, exercise intolerance, and neurohormonal activation. Furthermore, RV LGE was significantly associated with clinical arrhythmia.

Outcome after one-stage repair of tetralogy of Fallot

AIM

The purpose of this study was to evaluate the outcome after one-stage repair of tetralogy of Fallot (TOF).

METHODS

Between May 1997 and December 2002, 240 patients with a median age of 9 months (1 month-48 years) underwent one-stage repair of TOF. Closure of ventricular septal defect (VSD) was accomplished through the right atrium in 171 (71.3%) patients and through the right ventricle in 69 (28.7%) patients. For the reconstruction of the right ventricular outflow tract (RVOT), transannular repair was performed in 151 (62.9%) patients, and non-transannular repair was performed in 89 (37.1%) patients. Follow-up was complete, averaging 40+/-17.6 months (3 months-5.8 years).

RESULTS

There were 2 (0.8%) operative deaths. Between early repair group (age under 6 months) and late repair group (age above 6 months), there were no differences in the method of RVOT reconstruction (transannular vs non-transannular) and the need for branch pulmonary artery angioplasty. Early repair group had more transventricular VSD closure than late repair group (46% vs 22%, P < 0.05). Duration of inotropic support and intensive care unit (ICU) stay were longer in the early repair group (P < 0.05). Five patients required reoperations due to RVOT obstruction (n = 3), and residual VSD (n = 2). Kaplan-Meier freedom from reoperation at 5 years was 98.3+/-1%. Nine patients underwent catheter intervention for branch pulmonary artery stenosis. Freedom from reintervention at 5 years was 95.4+/-1.5%. All survivors are currently asymptomatic.

CONCLUSIONS

One-stage repair of TOF could be performed with low mortality and morbidity. Especially, early one-stage repair in symptomatic infant could be performed with low risk, eliminating the need for palliative procedures.

Pregnancy Outcomes in Women With Congenital Heart Disease

Background— Pregnant women with congenital heart disease are at increased risk for cardiac and neonatal complications, yet risk factors for adverse outcomes are not fully defined.

Methods and Results— Between January 1998 and September 2004, 90 pregnancies at age 27.7±6.1 years were followed in 53 women with congenital heart disease. Spontaneous abortions occurred in 11 pregnancies at 10.8±3.7 weeks, and 7 underwent elective pregnancy termination. There were no maternal deaths. Primary maternal cardiac events complicated 19.4% of ongoing pregnancies, with pulmonary edema in 16.7% and sustained arrhythmias in 2.8%. Univariate risk factors included prior history of heart failure (odds ratio [OR], 15.5), NYHA functional class ≥2 (OR, 5.4), and decreased subpulmonary ventricular ejection fraction (OR, 7.7). Independent predictors were decreased subpulmonary ventricular ejection fraction and/or severe pulmonary regurgitation (OR, 9.0) and smoking history (OR, 27.2). Adverse neonatal outcomes occurred in 27.8% of ongoing pregnancies and included preterm delivery (20.8%), small for gestational age (8.3%), respiratory distress syndrome (8.3%), intraventricular hemorrhage (1.4%), intrauterine fetal demise (2.8%), and neonatal death (1.4%). A subaortic ventricular outflow tract gradient >30 mm Hg independently predicted an adverse neonatal outcome (OR, 7.5). Cardiac risk assessment was improved by including decreased subpulmonary ventricular systolic function and/or severe pulmonary regurgitation (OR, 10.3) in a previously proposed risk index developed in pregnant women with acquired and congenital heart disease.

Conclusions— Maternal cardiac and neonatal complication rates are considerable in pregnant women with congenital heart disease. Patients with impaired subpulmonary ventricular systolic function and/or severe pulmonary regurgitation are at increased risk for adverse cardiac outcomes.

[Early one-stage repair of tetralogy of Fallot]

OBJECTIVE

To evaluate the outcome after early, primary repair of Tetralogy of Fallot (TOF) in children under 6 months of age.

METHODS

74 infants, who underwent repair of TOF between 1992 and 2003, aged from 1.5 to 6 months, were investigated. 32 (43%) patients were cyanotic, 14 (18%) had anoxemic spells. Most of them were qualified for surgical procedure by echocardiographic study only, 26 patients required cardiac catheterisation. Two had balloon angioplasty prior to primary repair. None of them underwent initial palliation. Mean follow-up was 4.9 years (1 -9.5 years).

RESULTS

71 children survived and they were in good condition. 3 patients died (mortality 3.6%). One child required reoperation. Transannular patch (TAP) was inserted in 66% of patients. Right ventricular outflow tract obstruction (RVOTO) more than 40 mmHg occurred in 2 infants. Moderate pulmonary insufficiency was present in 38 infants (25%). None of the patients had QRS complex longer than 140 msec.

CONCLUSIONS

Early one-stage repair of TOF was achieved with low mortality rate and low risk for reoperation (1.5%). It eliminates initial palliation and drug therapy.

Prevalence and clinical manifestations of 22q11.2 microdeletion in adults with selected conotruncal anomalies

OBJECTIVES

This study was designed to determine the prevalence and clinical manifestations of 22q11.2 microdeletion in adults with selected conotruncal anomalies and to assess the clinician's ability to predict the presence or absence of 22q11.2 microdeletion on the basis of clinical features.

BACKGROUND

It is known that 22q11.2 microdeletion is a chromosomal anomaly with cardiac and extracardiac manifestations. The prevalence and manifestations in adults have not been well characterized.

METHODS

A total of 103 consecutive adults with either tetralogy of Fallot (TOF), pulmonary atresia/ventricular septal defect (PA/VSD), or truncus arteriosus (TA) were prospectively screened for 22q11.2 microdeletion using a fluorescence in situ hybridization (FISH) assay. Clinicians were asked to predict 22q11.2 microdeletion status on the basis of clinical features. A geneticist blinded to FISH assay results reviewed photographs of the patients for typical dysmorphic features of 22q11.2 microdeletion.

RESULTS

Six patients (prevalence 5.8%, 95% confidence interval 1.3 to 10.3) had 22q11.2 microdeletion (3 with TOF, 2 with PA/VSD, 1 with TA). In two of these patients, the clinician incorrectly predicted absence of the deletion. In three, typical dysmorphic features of 22q11.2 microdeletion were absent.

CONCLUSIONS

Our work showed that 22q11.2 microdeletion is under-recognized in adults with congenital heart disease. The absence of typical phenotypic features makes it difficult to correctly predict if the deletion is present. Screening for 22q11.2 microdeletion should be considered in adults with high-risk cardiac lesions, as it has important implications in reproductive counseling and surveillance for associated extracardiac manifestations.

Clinical presentation, natural history, and outcome of patients with the absent pulmonary valve syndrome

So-called 'absent pulmonary valve syndrome' is a rare cardiac malformation, usually associated with tetralogy of Fallot. Congenital absence of the leaflets of the pulmonary valve is less common when the ventricular septum is intact. Characteristic features of the syndrome include dysplasia or absence of the pulmonary valvar leaflets, permitting severe pulmonary regurgitation, and aneurysmal dilation of the pulmonary arteries. The purpose of our study was to review our experience with patients diagnosed as having the absent pulmonary valve syndrome, and to describe their clinical presentation, natural history, and outcome. We reviewed retrospectively data from 18 patients with absent pulmonary valve syndrome, 10 boys and eight girls, treated between March 1983 and May 2003. We identified two groups of patients, one made up of 11 patients with a ventricular septal defect, in whom the morphology of the subpulmonary outflow tract was phenotypic for tetralogy of Fallot, and another group, with seven patients, having an intact ventricular septum. Family history of congenital heart disease was common only in patients with ventricular septal defect, being found in 73%, all of whom were diagnosed during infancy with variable respiratory distress. Diagnosis was delayed in 43% of the patients with an intact ventricular septum. Cardiac surgery was performed in eight patients with ventricular septal defect (73%), compared to only two patients (28%) with an intact ventricular septum. Overall mortality was 28%, with five patients dying. Although our sample was small, two clinical patterns emerged depending on the presence or absence of a ventricular septal defect. Patients with a ventricular septal defect and phenotypic features of tetralogy of Fallot have a strong family history of congenital cardiac disease, develop respiratory symptoms during infancy and exhibit a variable prognosis, despite cardiac surgery. Patients with an intact ventricular septum are usually asymptomatic, present later in life, and show a relatively benign prognosis.

Myocardial acceleration during isovolumic contraction as a new index of right ventricular contractile function and its relation to pulmonary regurgitation in patients after repair of tetralogy of Fallot

BACKGROUND

Myocardial acceleration during isovolumic contraction (IVA) by Doppler tissue imaging has been proposed to be a new index of right ventricular contractile function that is unaffected by ventricular shape or loading conditions.

OBJECTIVES

We sought to assess the use of IVA to evaluate right ventricular contractile function.

METHODS

In all, 22 pediatric patients with pulmonary regurgitation (PR) after repair of tetralogy of Fallot (TOF) (8 +/- 3 years) and 27 age-matched children were examined. The degree of PR (mild, moderate, and severe) for patients with TOF was on the basis of pulsed and color Doppler findings. Using Doppler tissue imaging, the peak myocardial velocities during early diastole, late diastole, systole, and isovolumic contraction were recorded.

RESULTS

Compared with healthy children, Doppler tissue imaging velocities for patients with TOF showed decreased myocardial velocities during early diastole (P =.007), late diastole (P <.0001), systole (P <.0001), and isovolumic contraction (P <.0001). Patients with TOF had a lower IVA when compared with healthy children (P <.0001). There was a stepwise decrease in the IVA from mild to severe PR. We found a significant relationship between the IVA and the degree of PR (r = -0.86, P <.0001).

CONCLUSION

The analysis of IVA allows the assessment of right ventricular contractile function for patients with repaired TOF and various degrees of PR.

Right ventricular strain rate and strain analysis in patients with repaired tetralogy of Fallot: possible interventricular septal compensation

BACKGROUND

Indices such as strain rate (SR) and strain (epsilon) are free of geometric assumptions and, thus, may provide new insights into right ventricular (RV) function and compensatory mechanisms in repaired tetralogy of Fallot (TOF).

METHODS

All those with postoperative (>1 year) TOF had echocardiography evaluation of SR and epsilon indices along the RV lateral free wall (RVFW) and the interventricular septum (IVS) in the apical 4-chamber view. Pulmonary regurgitation, pulmonary stenosis, QRS duration, RV ejection fraction, and RV dimension were also measured and compared with control subjects.

RESULTS

There were 15 patients with TOF (7 +/- 4 years old) 6 +/- 3 years remote from surgical repair and 25 control subjects (10 +/- 5 years old). In the patients with TOF, systolic and diastolic SR and epsilon in the RVFW were significantly reduced but were normal in the IVS. In the RVFW, reduced systolic SR and epsilon correlated with reduced RV ejection fraction (r = -0.7 [P <.01] and -0.6 [P <.03], respectively), and poorer early diastolic SR correlated with poorer RV ejection fraction (r = 0.7, P <.01).

CONCLUSIONS

In patients with postoperative TOF, systolic and diastolic RV SR and epsilon were impaired in the RVFW but preserved in the IVS. We speculate that IVS myocardial function is preserved as a compensatory mechanism for impaired RVFW function.

Right ventricular myocardial activation delay in adult patients with right bundle branch block late after repair of Tetralogy of Fallot

Electromechanical interaction, with prolonged QRS duration due to right ventricular (RV) overload, has been described as a predictor of unfavorable outcome in patients late after correction of Tetralogy of Fallot (TOF). Aim of our study was to evaluate myocardial function and activation delay of both left and right ventricles in TOF patients. Doppler echo, treadmill test and pulsed Tissue Doppler (TD) were performed in 25 healthy subjects and in 30 adult patients who had undergone surgery for TOF, all with right bundle branch block on ECG. Exclusion criteria were evidence of residual pulmonary either stenosis or regurgitation. By use of TD, the level of both LV mitral and RV tricuspid annulus were measured: systolic (Sm), early- and late-diastolic (Em and Am) regional peak velocities. The indexes of myocardial systolic activation were calculated: precontraction time (PCTm) and interventricular activation delay (InterV-del) (difference of PCTm between RV and LV segments). The two groups were comparable for LV diameters and for Doppler indexes, while QRS duration was prolonged and RV end-diastolic diameter was increased in TOF. By TD analysis, only at the level of tricuspid annulus TOF patients had lower Sm and Em, and increased RV PCTm ( p<0.001 ) and InterV-del ( p<0.0001 ), even after adjustment for heart rate (HR) and QRS duration. By treadmill test, TOF showed reduced cardiac functional reserve. In seven patients non-sustained ventricular tachycardia was documented during physical effort. By multivariate analysis, RV Em ( p<0.001 ), and InterV-del ( p<0.01 ) were independently associated to maximal workload at peak effort. The same InterV-del was an independent determinant of risk of ventricular arrhythmias during effort ( p<0.01 ). A cut-off point of Em peak velocity of tricuspid annulus <0.13 m/s at rest showed a sensitivity of 91% and a specificity of 88% in identifying TOF patients with submaximal exercise test. A cut-off point of InterV-del >55 ms showed 87% sensitivity and 88% specificity to detect increased risk of ventricular arrhythmias during effort. In TOF patients, TD analysis at rest may be taken into account as a non-invasive and easy-repeatable tool to predict cardiac performance during physical effort, and to select subgroups of patients at increased risk of ventricular arrhythmias.

Transcatheter closure of a Potts' shunt with subsequent surgical repair of tetralogy of fallot

Closure of a Potts' aortopulmonary anastomosis during repair of a congenital heart malformation has been associated with high morbidity and mortality, especially due to technical problems encountered at closure of the shunt. A case is presented of a 40-year-old patient with tetralogy of Fallot and pulmonary atresia after palliation during infancy with a Potts' shunt. The anastomosis was successfully occluded using an Amplatzer ventricular septal defect occluder, immediately followed by complete surgical repair of his tetralogy of Fallot.

Pressure half-time predicts hemodynamically significant pulmonary regurgitation in adult patients with repaired tetralogy of fallot

Pulmonary regurgitation (PR) is associated with adverse outcomes late after tetralogy of Fallot repair. Accurate assessment of PR in these patients is, therefore, fundamental to their clinical treatment; however, accurate ultrasound markers of severity are as yet poorly defined. This is a prospective study of 34 adult patients with repaired tetralogy of Fallot. Cardiac magnetic resonance imaging was used to assess the PR fraction and its hemodynamic significance on the right ventricular volumes. Regurgitant fractions >/= 20% were associated with significant increases in right ventricular end-diastolic volumes. Echocardiographic continuous wave Doppler profiles of the PR jet were used to calculate pressure half-time. Pulmonary pressure half-time < 100 milliseconds was found to be a good indicator of hemodynamically significant regurgitation. This measure is highly reproducible and easily accessible.