Abstract
Background and Objective: We compared trans-right atrial (t-RA) versus combined (trans-right-atrial and trans-ventricular (t-RA/RV) approaches for intra-cardiac repair of Tetralogy of Fallot (TOF) for the pre-operative and post-operative right ventricular (RV) function. The RV function was calculated using a tricuspid annular plane systolic excursion (TAPSE) using two-dimensional (2-D) echocardiography.
 Materials and Methods: This was a retrospective study. Fifty-three patients operated for the intra-cardiac repair of TOF between August 2019 and March 2021 were included in the study and divided into two groups based on the approach for repair as follows: t-RA or combined (t-RA/RV) approach. The first group (t-RA) had twenty-one patients, and the second group (combined t-RA/RV approach) had thirty-two patients. The assessment of pre-operative and post-operative RV function was done using TAPSE. Records of follow-up at 1 month and 3 months were evaluated.
 Results: Age, body surface area (BSA), preoperative saturation, cardiopulmonary bypass time, aortic cross?clamp time, postoperative intensive care unit (ICU) stay, and hospital stay
 were similar in both groups. However, t?RA/RV group had more pleural effusions (9 vs. 1 patients, P < 0.05), but had more improvements in Right Ventricular outflow tract (RVOT) gradients. There were no differences in arrhythmias in either group. Pre-operative TAPSE for both groups was similar (1.46 ± 0.27 vs. 1.61 ± 0.31, P > 0.05) and so was the post?operative TAPSE at discharge (1.54 ± 0.31 vs. 1.49 ± 0.33, P > 0.05), at 1 months (1.64 ± 0.25 vs. 1.48 ± 0.32, P > 0.05) and 3months (1.75 ± 0.19 vs. 1.7 ± 0.15, P > 0.05).
 Conclusion: Both approaches provide adequate palliation with effective improvements in RVOT gradients for patients with TOF. A limited right ventriculotomy does not adversely affect early RV function or increase the incidence of arrhythmias at the immediate post-operative period and early follow-up. More extensive studies with prospective randomized design and longer follow-ups are needed to address these issues further.
 Keywords: Tetralogy of Fallot, transatrial approach, intracardiac repair.
Highlights
Tetralogy of Fallot (TOF) is the most common cyanotic congenital cardiac anomaly.[1]
Intra-cardiac repairs of TOF were undertaken through a right ventriculotomy incision with or without the use of a transannular patch.[2,3]
With increasing expertise of infundibular resection and ventricular septal defect (VSD) closure through the transseptal right atrial approach, more and more intracardiac repairs for TOF were advocated through a trans-right atrial (t-RA) approach.[4]
Summary
Tetralogy of Fallot (TOF) is the most common cyanotic congenital cardiac anomaly.[1]. The t‐RA approach supposedly has a longer learning curve and leaves residual RVOT obstruction than a t‐RV approach.[5]. Both approaches are popular depending on the anatomical subset and surgeon preference and experience. Comparative studies to determine the immediate and early postoperative RV function using either approach are very few.[6] Because of the more complicated anatomy of the RV and failure to trace its endocardial surface completely, assessment of the RV function is difficult.[7]. Various studies have validated it as a reliable measure of the systolic function of the RV.[8] The present study compares the preoperative and immediate post-operative RV function between t-RA versus t-RA/RV approach for TOF repair using the TAPSE
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