Hostname: page-component-586b7cd67f-rdxmf Total loading time: 0 Render date: 2024-11-27T01:26:35.995Z Has data issue: false hasContentIssue false
  • English
  • Français

The current strategy of repair of tetralogy of Fallot in children and adults*

Published online by Cambridge University Press:  01 December 2008

Guo-Wei He ,
Xiao-Cheng Liu ,
Xiang-Rong Kong ,
Li-Xin Liu ,
Ying-Qun Yan ,
Bao-Jun Chen ,
Zong-Xiao Li ,
Wen-Bin Jing ,
Zheng-Qing Wang  and
Kai Wang
...Show all authors
Guo-Wei He*
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China Wuhan Heart Institute, The Central Hospital of Wuhan, Wuhan, China Department of Surgery, Starr Academic Center, St. Vincent Heart & Vascular Institute, Oregon Health and Science University, Portland, Oregon, United States of America Department of Surgery, The Chinese University of Hong Kong, Hong Kong
Xiao-Cheng Liu
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Xiang-Rong Kong
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Li-Xin Liu
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Ying-Qun Yan
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Bao-Jun Chen
Affiliation:
Wuhan Heart Institute, The Central Hospital of Wuhan, Wuhan, China
Zong-Xiao Li
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Wen-Bin Jing
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Zheng-Qing Wang
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Kai Wang
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Wei Zhang
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Tie-Nan Chen
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Ping-Shan Wang
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Wan-li Lu
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Jian-Liang Zhang
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Zhi-Peng Guo
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Lan-Gang Xue
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Yu-Xiang Zhu
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Xiu-Li Wang
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
Lei Xi
Affiliation:
TEDA International Cardiovascular Hospital, Nankai University, Tianjin, China
*
Correspondence to: Professor Guo-Wei He, MD, PhD, DSc., Senior Cardiac Surgeon, Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, 61, Third Avenue, TEDA, Tianjin, China, Post code: 300457. Tel: (Hong Kong ) – (852) 2645 0519; Fax: (852) 2645 1762; E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives

The strategies of repair of tetralogy of Fallot change with the age of patients. In children older than 4 years and adults, the optimal strategy may be to use different method of reconstruction of the right ventricular outflow tract from those followed in younger children, so as to avoid, or reduce, the pulmonary insufficiency that is increasingly known to compromise right ventricular function.

Methods

From April, 2001, through May, 2008, we undertook complete repair in 312 patients, 180 male and 132 female, with a mean age of 11.3 years ±0.4 years, and a range from 4 to 48 years, with typical clinical and morphological features of tetralogy of Fallot, including 42 patients with the ventriculo-arterial connection of double outlet right ventricle. The operation was performed under moderate hypothermia using blood cardioplegia. The ventricular septal defect was closed with a Dacron patch. When it was considered necessary to resect the musculature within the right ventricular outflow tract, or perform pulmonary valvotomy, we sought to preserve the function of the pulmonary valve by protecting as far as possible the native leaflets, or creating a folded monocusp of autologous pericardium.

Results

The repair was achieved completely through right atrium in 192, through the right ventricular outflow tract in 83, and through the right atrium, the outflow tract, and the pulmonary trunk in 36 patients. A transjunctional patch was inserted in 169 patients, non-valved in all but 9. There were no differences regarding the periods of aortic cross-clamping or cardiopulmonary bypass. Of the patients, 5 died (1.6%), with no influence noted for the transjunctional patch. Of those having a non-valved patch inserted, three-tenths had pulmonary regurgitation of various degree, while those having a valved patch had minimal pulmonary insufficiency and good right ventricular function postoperatively, this being maintained after follow-up of 8 to 24-months.

Conclusions

Based on our experience, we suggest that the current strategy of repair of tetralogy of Fallot in older children and adults should be based on minimizing the insertion of transjunctional patches, this being indicated only in those with very small ventriculo-pulmonary junctions. If such a patch is necessary, then steps should be taken to preserve the function of the pulmonary valve.

Keywords

Cyanotic congenital heart diseaseright ventricular outflow tractsurgical correctioncardiopulmonary bypassopen heart surgery
Type
Original Article
Information
Cardiology in the Young , Volume 18 , Issue 6 , December 2008 , pp. 608 - 614
Copyright
Copyright © Cambridge University Press 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

*

The presentation on which this work is based was given at the Inaugural Meeting of the World Society for Pediatric and Congenital Heart Surgery, held in Washington, District of Columbia, May 3 and 4, 2007.

References

1.Bove, EL, Byrum, CJ, Thomas, FD, et al. . The influence of pulmonary insufficiency on ventricular function following repair of tetralogy of Fallot. Evaluation using radionuclide ventriculography. J Thorac Cardiovasc Surg 1983; 85: 691–696.CrossRefGoogle ScholarPubMed
2.Oku, H, Shirontani, H, Sunakawa, A, Yokoyama, T. Postoperative long-term results in total correction of tetralogy of Fallot: hemodynamics and cardiac function. Ann Thorac Surg 1986; 41: 413–418.CrossRefGoogle ScholarPubMed
3.d’Udekem, Y, Rubay, J, Shango-Lody, P, et al. Late homograft valve insertion after transannular patch repair of tetralogy of Fallot. J Heart Valve Dis 1998; 7: 450–454.Google ScholarPubMed
4.Giannopoulos, NM, Chatzis, AK, Karros, P, et al. Early results after transatrial/transpulmonary repair of tetralogy of Fallot. Eur J Cardiothorac Surg 2002; 22: 582–586.CrossRefGoogle ScholarPubMed
5.Roughneen, PT, DeLeon, SY, Parvathaneni, S, Cetta, F, Eidem, B, Vitullo, DA. The pericardial membrane pulmonary monocusp: surgical technique and early results. J Card Surg 1999; 14: 370–374.CrossRefGoogle ScholarPubMed
6.Borowski, A, Ghodsizad, A, Litmathe, J, Lawrenz, W, Schmidt, KG, Gams, E. Severe pulmonary regurgitation late after total repair of tetralogy of Fallot: surgical considerations. Pediatr Cardiol 2004; 25: 466–471; Epub 2004 Mar 4.CrossRefGoogle ScholarPubMed
7.Conte, S, Jashari, R, Eyskens, B, Gewillig, M, Dumoulin, M, Daenen, W. Homograft valve insertion for pulmonary regurgitation late after valveless repair of right ventricular outflow tract obstruction. Eur J Cardiothorac Surg 1999; 15: 143–149.CrossRefGoogle ScholarPubMed
8.Giannopoulos, NM, Chatzis, AC, Bobos, DP, Kirvassilis, GV, Tsoutsinos, A, Sarris, GE. Tetralogy of Fallot: influence of right ventricular outflow tract reconstruction on late outcome. Int J Cardiol 2004; 97: 87–90.CrossRefGoogle ScholarPubMed
9.Bigras, JL, Boutin, C, McCrindle, BW, Rebeyka, IM. Short-term effect of monocuspid valves on pulmonary insufficiency and clinical outcome after surgical repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 1996; 112: 33–37.CrossRefGoogle ScholarPubMed
10.Rao, V, Kadletz, M, Hornberger, LK, Freedom, RM, Black, MD. Preservation of the pulmonary valve complex in tetralogy of fallot: how small is too small? Ann Thorac Surg 2000; 69: 176–179; discussion 179–80.CrossRefGoogle Scholar
11.Pozzi, M, Trivedi, DB, Kitchiner, D, Arnold, RA. Tetralogy of Fallot: what operation, at which age. Eur J Cardiothorac Surg 2000; 17: 631–636.CrossRefGoogle ScholarPubMed
12.Brizard, CP, Mas, C, Sohn, YS, Cochrane, AD, Karl, TR. Transatrial-transpulmonary tetralogy of Fallot repair is effective in the presence of anomalous coronary arteries. J Thorac Cardiovasc Surg 1998; 116: 770–779.CrossRefGoogle ScholarPubMed
13.He, GW, Kuo, CC, Mee, RB. Pulmonic regurgitation and reconstruction of right ventricular outflow tract with patch. An experimental study. J Thorac Cardiovasc Surg 1986; 92: 128–137.Google ScholarPubMed
14.Bogers, AJ, Roofthooft, M, Pisters, H, Spitaels, SE, Bos, E. Long-term results of the gamma-irradiation-preserved homograft monocusp for transannular reconstruction of the right-ventricular outflow tract in tetralogy of Fallot. Thorac Cardiovasc Surg 1994; 42: 337–339.CrossRefGoogle ScholarPubMed
15.Sievers, HH, Lange, PE, Regensburger, D, et al. Short-term hemodynamic results after right ventricular outflow tract reconstruction using a cusp-bearing transannular patch. J Thorac Cardiovasc Surg 1983; 86: 777–783.CrossRefGoogle ScholarPubMed
16.Noera, G, Gatti, M, Massini, C, Medici, SI, Fattori, G. Experimental right ventricular outflow tract reconstruction with a composite mitrathane monocusp patch: preliminary results. Thorac Cardiovasc Surg 1988; 36: 89–95.CrossRefGoogle ScholarPubMed
17.Marchand, P. The use of a cusp-bearing homograft patch to the outflow tract and pulmonary artery in Fallot’s tetralogy and pulmonary valve stenosis. Thorax 1967; 22: 497–509.CrossRefGoogle Scholar
18.Trusler, GA, Iyengar, SR, Mustard, WT. Reconstruction of the pulmonary valve and outflow tract. J Thorac Cardiovasc Surg 1973; 65: 245–251.CrossRefGoogle ScholarPubMed
19.Revuelta, JM, Ubago, JL, Duran, CM. Composite pericardial monocusp patch for the reconstruction of right ventricular outflow tract. Thorac Cardiovasc Surg 1983; 31: 156–159.CrossRefGoogle ScholarPubMed
20.Abdulali, SA, Silverton, NP, Yakirevich, VS, Ionescu, MI. Right ventricular outflow tract reconstruction with a bovine pericardial monocusp patch. J Thorac Cardiovasc Surg 1985; 89: 764–771.CrossRefGoogle ScholarPubMed
21.Gundry, SR, Razzouk, AJ, Boskind, JF, Bansal, R, Bailey, LL. Fate of the pericardial monocusp pulmonary valve for right ventricular outflow tract reconstruction. J Thorac Cardiovasc Surg 1994; 107: 908–913.CrossRefGoogle ScholarPubMed
22.Ross, D, Somerville, J. Fascia-lata reconstruction of the right ventricular outflow tract. Lancet 1971; 1: 941–943.CrossRefGoogle ScholarPubMed
23.Ionescu, MI, Macartney, FJ, Wooler, GH, Gerbode, F. Reconstruction of the right ventricle outlet with fascia lata composite graft. J Thorac Cardiovasc Surg 1972; 63: 60–74.CrossRefGoogle Scholar
24.Trusler, GA, Ishizawa, E, Echevarre, E. Use of autogenous pericardium and homograft aortic valves in pulmonary valve reconstruction: an experimental study. Can J Surg 1974; 17: 16–19.Google ScholarPubMed
25.Egloff, L, Turina, M, Senning, Å. An experimental study on transannular patching of the right ventricular outflow tract with and without a pulmonary valve monocusp mechanism. Thorac Cardiovasc Surg 1981; 29: 246–251.CrossRefGoogle Scholar
26.Sievers, HH, Storde, U, Rohwedder, EB, et al. Superior function of a bicuspid over a monocuspid patch for reconstruction of a hypoplastic pulmonary root in pigs. J Thorac Cardiovasc Surg 1993; 105: 580–590.CrossRefGoogle Scholar
27.Shatapathy, P, Aggarwal, BK, Kamath, SG, Sai, S. Pulmonary valve reconstruction in absent pulmonary valve syndrome: a new technique. J Card Surg 1997; 12: 180–184.CrossRefGoogle ScholarPubMed
28.Yamagishi, M, Kurosawa, H. Outflow reconstruction of tetralogy of Fallot using a Gore-Tex valve. Ann Thorac Surg 1993; 56: 1414–1417.CrossRefGoogle ScholarPubMed
29.Turrentine, MW, McCarthy, RP, Vijay, P, Fiore, AC, Brown, JW. Polytetrafluoroethylene monocusp valve technique for right ventricular outflow tract reconstruction. Ann Thorac Surg 2002; 74: 2202–2205.CrossRefGoogle ScholarPubMed
30.Quintessenza, JA, Jacobs, JP, Chai, PJ, Morell, VO, Giroud, JM, Boucek, RJ. Late replacement of the pulmonary valve: when and what type of valve? Cardiol Young 2005; 15 (Suppl 1): I58–63.CrossRefGoogle ScholarPubMed
31.Quintessenza, JA, Jacobs, JP, Morell, VO, Giroud, JM, Boucek, RJ. The initial experience with a bicuspid polytetrafluoroethylene pulmonary valve in 41 children and adults: a new option for right ventricular outflow tract reconstruction. Ann Thorac Surg 2005; 79: 924–931.CrossRefGoogle ScholarPubMed
32.He, GW. A new technique of transannular monocusp patch-repair of the right ventricular outflow tract in repair of tetralogy of Fallot. Heart Lung Circ 2007; 16: 107–112; Epub 2007 Feb 20.CrossRefGoogle ScholarPubMed
33.He, GW, Mee, RB. Complete atrioventricular canal associated with tetralogy of Fallot or double-outlet right ventricle and right ventricular outflow tract obstruction: a report of successful surgical treatment. Ann Thorac Surg 1986; 41: 612–615.Google ScholarPubMed
34.Ilbawi, MN, Idriss, FS, DeLeon, SY, et al. Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair. Surgical implications. J Thorac Cardiovasc Surg 1987; 93: 36–44.CrossRefGoogle ScholarPubMed
35.Singh, GK, Greenberg, SB, Yap, YS, Delany, DP, Keeton, BR, Monro, JL. Right ventricular function and exercise performance late after primary repair of tetralogy of Fallot with the transannular patch in infancy. Am J Cardiol 1998; 81: 1378–1382.CrossRefGoogle ScholarPubMed
36.Norgard, G, Gatzoulis, MA, Moraes, F, et al. Relationship between type of outflow tract repair and postoperative right ventricular diastolic physiology in tetralogy of Fallot. Implications for long-term outcome. Circulation 1996; 904: 3276–3280.CrossRefGoogle Scholar
37.de Ruijter, FT, Weenink, I, Hitchcock, FJ, Meijboom, EJ, Bennink, GB. Right ventricular dysfunction and pulmonary valve replacement after correction of tetralogy of Fallot. Ann Thorac Surg 2002; 73: 1794–1800; discussion 1800.CrossRefGoogle ScholarPubMed
38.Faidutti, B, Christenson, JT, Beghetti, M, Friedli, B, Kalangos, A. How to diminish reoperation rates after initial repair of tetralogy of Fallot? Ann Thorac Surg 2002; 73: 96–101.CrossRefGoogle ScholarPubMed
39.d’Udekem, Y, Ovaert, C, Grandjean, F, et al. Tetralogy of Fallot: transannular and right ventricular patching equally affect late functional status. Circulation 2000; 102: III116–III122.CrossRefGoogle ScholarPubMed
40.Yankah, AC, Lange, PE, Sievers, HH, et al. Late results of valve xenograft conduits between the right ventricle and the pulmonary arteries in patients with pulmonary atresia and extreme tetralogy of Fallot. Thorac Cardiovasc Surg 1984; 32: 250–252.CrossRefGoogle ScholarPubMed