Transatrial-transpulmonary Approach Research Articles

Long-term Outcomes of Transatrial-Transpulmonary Repair of Tetralogy of Fallot With Anomalous Coronary Arteries

Repair of tetralogy of Fallot (TOF) can be complicated by the presence of an anomalous coronary artery (ACA) crossing the right ventricular outflow tract (RVOT). This study sought to evaluate the late outcomes of a policy of transatrial-transpulmonary repair for this condition. The transatrial-transpulmonary approach was used in 864 consecutive TOF repairs between 1993 and 2018 at a single institution, of which 55 (6%) patients had an ACA. Nineteen (35%,19/55) patients underwent prior palliation. Late survival and freedom from reoperations were compared with the general cohort of 809 patients who underwent complete repair during the same period. Early mortality was 2% (1/55). Median follow-up was 15.6 years. Late mortality was 6% (3/54). Absence of a preoperative diagnosis of ACA was not a risk factor for worse outcomes in terms of late re-interventions, acute coronary syndrome, residual RVOT gradient, and late mortality. Survival was 91% (95% confidence interval [CI]: 77-96%) at 20 years and was comparable to the general TOF cohort (95%, 95% CI: 90-98%, P = 0.12). Actuarial freedom from any re-intervention was 46% (95% CI: 27-62%) at 20 years, which was also comparable to the general cohort (31%, 95% CI: 20-42%, P = 0.19). The presence of an ACA does not appear to affect late survival or re-intervention rates in patients undergoing transatrial-transpulmonary repair of TOF.

Transatrial-transpulmonary correction of tetralogy of Fallot: experience of a developing country.

IntroductionRight ventricular dysfunction is a cause of morbidity and mortality after surgical correction of tetralogy of Fallot. The transatrial-transpulmonary approach allows preservation of right ventricular function.AimTo report the immediate and long-term results of surgical treatment of tetralogy of Fallot using the transatrial-transpulmonary approach.Material and methodsThis is a retrospective study including cases of tetralogy of Fallot operated on by the transatrial-transpulmonary approach between April 2009 and October 2010 in our institution.ResultsThere were 19 patients including 10 girls and 9 boys with a mean age of 7.4 years (extremes: 3 and 19 years). All our patients benefited from closure of the ventricular septal defect by a right atrial approach and enlargement of the pulmonary pathway. In the immediate postoperative period, the pressure gradient between the pulmonary artery and the right ventricle was 18.77 mm Hg. We had 2 deaths (10.5%). Complications were dominated by conduction disorders (100%) such as right bundle branch block and pleuropulmonary complications (41.20%). After a mean follow-up of 11.43 ±0.81 years, no patient died and all were asymptomatic, without significant residual lesion.ConclusionsComplete cure of tetralogy of Fallot by the transatrial-transpulmonary route is associated with low morbidity and mortality in our experience. The long-term results are satisfactory.

Early outcome of total correction in adult tetralogy of fallot patients.

Objectives: To detect the early outcome of total correction of Tetralogy of Fallot (TOF) in adult patients of age 16 years or above. Study Design: Retrospective descriptive case series. Setting: Paediatric Cardiac Surgery Department of Faisalabad Institute of Cardiology, Faisalabad. Period: October 2016 to June 2019. Material & Methods: All consecutive patients of age 16 years or above who underwent total correction for TOF during study period were included. Surgical procedure and early outcome measures were recorded and analyzed. Results: Sixty nine patients underwent total correction for TOF during the study period. Majority of patients (n=55, 79.7%) were between16 to 25years of age. Male dominated the study population (56.5%, n=39) with male to female ratio 1.3: 1. Nine patients (13%) had coiling of MAPCA before surgery while prior palliation with Blalock Taussig shunt (BT Shunt) was seen in 5.8 % patients (n=4). All patients were operated with trans-atrial trans-pulmonary approach (n=69, 100%). Pulmonary artery was augmented with pericardial patch in 22 cases (32%) while left pulmonary artery (LPA) augmentation was done in two patients. Pulmonary valve annulus divided in 22 % of patients (n=15), RVOT was reconstructed with trans-annular pericardial patch in 10.1% patients (n=7) while Pulmonary valve was replaced with tissue valve in 7 patients (10.1%). In one patient RV to PA continuity was established with contegra. Post operatively Inotropic support was given for initial 39 ±45 hours, mean ICU stay was 39±75 hours, mean chest drainage 1086±741 ml and mean requirement for blood transfusion was 2.2 ±2.4 units. As regard early complications, six patients had tiny to small residual VSD (8.7%) while no patient developed complete heart block. Two patients had neurological damage (2.9%), one patient developed renal failure (1.45%) while chest reopening was done in two patients due to postoperative bleeding and/ or tamponade (2.9%). There was death of two patients (2.9%), one had renal failure due to low cardiac output (LCOS) and the other had stroke. Conclusion: The early outcome of complete repair of TOF in patients 16 years and above is good with a negligible mortality and limited number of complications.

Intracardiac Repair of the Tetralogy of Fallot Using Trans-right Atrial and Transpulmonary Approach: A Video Presentation

AbstractTetralogy of Fallot (TOF) is one of the common cyanotic heart diseases. Now total repair is increasingly being used to save children at younger age and having lower body weight. The aim of this study was to evaluate the results of the two different surgical techniques used for total repair of TOF: transatrial-transpulmonary approach and transventricular approach with special emphasis on pre- and intraoperative risk factors that affect the prognosis of patients, and with analysis of postoperative short-term results.

Tetralogy of Fallot in the Current Era

Only few studies have reported long-term outcome of the transatrial-transpulmonary approach in the current era of management of tetralogy of Fallot (ToF). We investigated 15-year outcome of correction via a transatrial-transpulmonary approach in a large cohort of successive patients operated in the 21st century. All infant ToF patients undergoing transatrial-transpulmonary ToF correction between 2000 and 2015 were included (N = 177, 106 male, median follow-up 7.1 (interquartile range 3.0-10.9) years. Data regarding postoperative complications, reinterventions, development of atrial and ventricular arrhythmia, cardiac function, and survival were evaluated. Prior shunting was performed in 10 patients (6%). The transatrial-transpulmonary approach resulted in valve-sparing surgery in 57 patients (32%). Postoperative surgical complications included junctional ectopic tachycardia (N = 12, 7%), pericardial (N = 10, 6%) or pleural effusion (N = 7, 3%), chylothorax (N = 7, 4%), bleeding requiring reoperation (N = 4, 3%), and superficial wound infection (N = 1). Fifty-one patients underwent 68 reinterventions, mainly due to pulmonary restenosis (PS) (N = 57). ToF correction at age <2 months and double outlet or double-chambered right ventricle variants of the ToF spectrum were independent predictors for reintervention. Patients undergoing valve-sparing ToF correction had a significant longer PR-free survival than those with a transannular patch (8.5 [95% confidence interval 6.8-10.3] years vs 1.1 [95% confidence interval 0.8-1.5] years; P < 0.001). Overall mortality was 2.8%; mortality rates were higher in premature/dysmature newborns (0.7% vs 9.5%; P < 0.001). Although the 15-year outcome of the transatrial-transpulmonary approach in terms of postoperative complications and mortality rates is excellent, the high incidence of moderate and severe PR is worrisome. Valve-sparing surgery was associated with a substantially lower incidence of PR, yet was surgically not possible in the majority of patients.

Surgical strategies protecting against right ventricular dilatation following tetralogy of Fallot repair

BackgroundRight ventricular (RV) volume overload increases morbidity and mortality after tetralogy of Fallot (TOF) repair. Surgical strategies like pulmonary leaflets sparing and tricuspid valve repair at time of primary repair may decrease RV overload. Our objective is to evaluate early and midterm results of pulmonary leaflets sparing with infundibular preservation and tricuspid valve repair in selected TOF patients with moderate pulmonary annular hypoplasia.MethodsFrom 2011 to 2016; 46 patients with TOF and moderate pulmonary annular hypoplasia had surgical repair with sparing of the pulmonary valve leaflets. Concomitant tricuspid valve repair was performed in 33 patients (71.8%). Mean age was 13.1 ± 4.8 months, 68% were males (n = 31) and mean weight was 9.5 ± 2.3 kg. Preoperative McGoon ratio was 1.9 ± 0.4 and pulmonary valve z-score ranges from − 2 to − 3. Preoperative pressure gradient of RVOT was 80.9 ± 7.7 mmHg and 10.9% had minor coronary anomalies (n = 5).ResultsAll repairs were performed through trans-atrial trans-pulmonary approach. 87% had pulmonary valve commissurotomy (n = 40). Mean cardiopulmonary bypass time was 71 ± 6.3 min and ischemic time 42.4 ± 4.9 min. Hospital mortality occurred in 4.3% (n = 2). Mean RVOT pressure gradient decreased significantly postoperatively (28.8 ± 7.2 mmHg, p-value< .001) and at the last follow up (23.6 ± 1.8 mmHg, p-value< .001). Pulmonary regurgitation progressed by one grade in 2 patients compared to the postoperative grade. 1 patient (2.5%) had late mortality and reintervention was required in 5 patients (12.5%).ConclusionPulmonary leaflets sparing, and tricuspid valve repair are safe for TOF repair with no added morbidity or mortality. These procedures could contribute to reducing right ventricular volume overload over time after TOF repair.

Total Repair of Tetralogy of Fallot: Trans-Atrial Trans-Pulmonary Approach Versus Trans-Ventricular Approach

1. Abstract 1.1. Background: <span style=font-size:10.0pt; font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>Tetralogy of Fallot (TOF) is one of the common cyanoticheart diseases.Now total repair is spreading to save children at younger age and lower body weight.The aim of this study was to evaluate the results of the two different surgical techniques used for total repair of tetralogy of Fallot:transatrial-transpulmonary approach and transventricular approach with special emphasis on preoperative and intraoperative risk factors that affecting the prognosis of patients,and with analysis of postoperative short-term results. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.2. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>Patients and Methods: Between January 2014 and December 2016,sixty patients withTOF were randomly collected in a prospective study. Children divided into two groups,GroupAincluded 30 patients repaired through transatrial-transpulmonary approach.GroupBincluded30 patients repaired through transventricular approach. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman;letter-spacing:= -.3pt=>1.3. Results: <span style=font-size:10.0pt; font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>Preoperative characteristics and variables of patients were similar.As regard to cardiopulmonary bypass time,cross-clamp timethere were no significant differences(p>0.05).There were significant differences in ventilation time(p 0.023),inotropic support(p 0.001)and duration of stay in the ICU(p0.001).The incidence of arrhythmia2 patients (6.7%)vs.5 patients (16.7%)]with non- <span style=font-size: 10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:arial;= mso-font-width:99%=>significant difference.There is significant difference in right/left ventricular pressure ratio(p At follow up,Comparisons between both groups showed no significantdifferences as regard to RV pressure and PG across the RVOT(P>0.05).None of our children needed reintervention for residual VSD or significant RVOTO.There were three mortalities(5%),one in group A due to RV dysfunction and two in group B due toventricular arrhythmia and RV dysfunction. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.4. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>Conclusion: Total repair is the primary choice for management of FallotTetralogy.We encourage transatrial-transpulmonary repair to avoid ventricular incisions, otherwise a limited ventriculotomy is sufficient rather than extended ventriculotomy with transannular repair. 2. Keywords: Congenital Heart Disease; Surgical Techniques; Tetralogy of Fallot

Long-term outcomes of transatrial-transpulmonary repair of tetralogy of Fallot.

The surgical approach to repair of tetralogy of Fallot (ToF) has shifted over the years. We aimed to report the long-term follow-up after ToF repair with the transatrial-transpulmonary approach and to determine predictors of long-term outcomes. Retrospective analysis of patients operated on in two tertiary referral centres. Primary outcome measures were: death, pulmonary valve replacement (PVR), reintervention for other reasons, internal cardiodefibrillator and/or pacemaker placement. Kaplan-Meier assessment of overall and event-free survival as well as uni- and multivariate analyses of risk factors for outcomes were performed. Four hundred and fifty-three patients were included. Median age at operation was: 0.6 years (range 0-19.6) and median age at the last follow-up was 14.3 years (range 0.1-42.1). Median age at repair decreased from 1.2 years (range 0.6-5.8) (1970-80) to 0.3 years (range 0-4.7) (2000-12). A transannular patch (TP) was used in 65% of all patients. The use of a TP showed a decline from 89% in the initial years of the cohort to 64% in 2000-12. Early mortality was 1.1% (5 patients) for the entire cohort and late mortality 2.4% (11 patients). Overall survival for the entire cohort was 97.3% (95% CI 95.7-98.8) and 91.8% (95% CI 85.9-97.7) at 10 and 25 years, respectively. For patients with a TP (n = 294) vs non-TP (n = 159), this was 97.2% (95% CI 95.2-99.2) vs 97.5% (95% CI 95.1-99.9) at 10-year and 91.0% (95% CI 83.9-98.1) vs 96.3% (95% CI 93.0-99.6) at 25-year follow-up (P = 0.958). Fifty-two patients underwent PVR, and in 5 a pacemaker was inserted. Event-free survival for TP versus non-TP patients was 80.2% (95 CI% 75.5-84.9) vs 81.7% (95% CI 75.2-88.2) at 10-year and 27.9% (95% CI 17.7-38.1) vs 78.5% (95% CI 71.4-85.6) at 25-year follow-up (P = 0.016). In multivariate analysis, both the use of a TP (HR 1.705, 95% CI 1.023-2.842) and the year of surgical repair of tetralogy of Fallot (HR 1.039, 95% CI 1.006-1.073) were associated with a higher probability of an event. ToF patients corrected with the transatrial-transpulmonary approach have good long-term survival. PVR is a frequent event at longer follow-up, and other events are limited. The use of a TP is a predictor for poorer event-free outcomes, increasing the risk of the composite endpoint 1.7 times.

Repair of Atrioventricular Septal Defect Associated With Tetralogy of Fallot or Double-Outlet Right Ventricle: 30 Years of Experience

The surgical outcomes of atrioventricular septal defect (AVSD) associated with tetralogy of Fallot (TOF) or double-outlet right ventricle (DORV) have improved in recent times. However, high mortality and reoperation rates are still reported. This study reviews our surgical experience in patients with complete AVSD and TOF or DORV. Between 1980 and 2010, 48 consecutive patients with AVSD associated with TOF (n = 26) or DORV (n = 22) underwent complete repair; of which, 19 had staged repair. A transatrial-transpulmonary approach with the 2-patch technique was the preferred surgical technique. Data were obtained from inpatient and outpatient medical files. The mortality rates were 8.3% (4 of 48) for in-hospital death and 13.6% (6 of 44) for late death. Mean follow-up was 8.0 ± 8.7 years (median 10.8 years; range from 2 months to 30 years). Actuarial survival was 76% at 5 years and 71% at 20 years. No deaths occurred after 2001. Reoperations were required in 16 of 48 patients (33%). The overall freedom from reoperation was 55% at 5 and 20 years. Down syndrome was protective for reoperation (p = 0.022). Complete AVSD associated with TOF or DORV can be repaired with good survival. Detachment of the superior bridging leaflet provided excellent exposure. However, reoperation rate remains high.

Results of the probe technique for transatrial repair of tetralogy of Fallot.

Total correction of classical tetralogy of Fallot (TOF) by transatrial approach has become a standard procedure in the goal to minimize structural damage to the pulmonary pump. The most critical point in transatrial repair of TOF is infundibular dissection. Right atrial approach provides better surgical exposure for parietal extension of the infundibular septum when compared to the right ventricular approach. However it is not always easy to determine the localization and amount of muscle bundles to be resected and this surgical maneuver requires experience. Nineteen patients who had repair of isolated TOF using this technique from 1993 to 2001 were reviewed. The mean age of patients were 5 +/- 2 years. Transatrial-transpulmonary approach were performed for all patients. To make easier the infundibular muscle bundles resection and to determine the localization and amount of muscle bundle to be resected, we placed a Hegar dilator into the right ventricle through pulmonary arteriotomy. The muscle bundles between the dilator and the anterior leaflet annulus of the tricuspid valve were totally excised until the intraventricular part of the dilator and pulmonary annulus became completely visible. The area between the Hegar dilator and the margins of the ventricular septal defect (VSD) was left untouched. None of the patients had transannular patch. To improve exposure, tricuspid valve detachment was performed in 11 patients. All patients were followed-up in our clinic every 6 months using echocardiography. There were no early or late deaths, and no reoperation for residual VSD or residual right ventricle (RV) outflow obstruction. All patients were in NYHA Class I. RV on the echocardiography was spared late dilatation and had a good late functional status. Eighteen patients had no or mild pulmonary regurgitation. One patient who had undergone tricuspid anterior leaflet detachment showed mild tricuspid insufficiency. On the basis of hemodynamic outcomes, this procedure for elective repair of TOF in selected cases shows excellent early and mid-term results.

A Symptomatic Neonate With Tetralogy of Fallot, an Absent Pulmonary Valve, and a Single Coronary Artery With a Major Fistula

We present a case with a rare combination of tetralogy of Fallot with an absent pulmonary valve, and a single coronary artery with a major fistula to the main pulmonary artery. Myocardial ischemia developed in response to increasing shunt flow through the coronary fistula, resulting in heart failure. We ligated the coronary fistula and plicated the anterior wall of the dilated pulmonary arteries during the neonatal period. Complete repair through a transatrial-transpulmonary approach was performed at the age of 17 months. The postoperative course was excellent and the patient maintained a stable hemodynamic and respiratory state with no evidence of myocardial ischemia.

Transatrial-Transpulmonary Repair of Tetralogy of Fallot

Routine early transatrial-transpulmonary repair of tetralogy of Fallot (TOF) has been performed at our institution since 1990. A transatrial-transpulmonary approach implies a minimal or no ventriculotomy and therefore it is expected to improve the right ventricular performance in the long term. Early transatrial-transpulmonary repair has been used for avoiding the deleterious effects of preoperative chronic cyanosis and spells, surgery for systemic-to-pulmonary artery shunts and their consequences, chronic right ventricular systolic pressure, and myocardial compensatory hypertrophy, with the aim of achieving better preservation of the right ventricular function in the long term. In our experience, transatrial-transpulmonary repair of TOF has been feasible at any age with immediate results that are comparable to those performed later in infancy.

Invited Commentary

Invited Commentary

28 Years' Experience With Transatrial-Transpulmonary Repair of Atrioventricular Septal Defect With Tetralogy of Fallot

The outcome of surgical correction of atrioventricular septal defect and tetralogy of Fallot has improved in recent years but is still reported to be associated with high mortality. Controversy exists about the need of a right ventriculotomy or a right ventricular to pulmonary artery conduit. The purpose of this study was to evaluate our results of atrioventricular septal defect and tetralogy of Fallot repair by transatrial-transpulmonary approaches. Between 1979 and 2007, 20 consecutive patients underwent correction of atrioventricular septal defect and tetralogy of Fallot. Five patients had undergone prior palliative shunts. In all patients, a transatrial-transpulmonary approach was used and repair was accomplished without a conduit. The two-patch technique was used to correct the atrioventricular septal defect. Clinical data were obtained by retrospective review of inpatient and outpatient clinical charts. There was no in-hospital mortality and one late, noncardiac death. Six patients required eight reoperations, six for left atrioventricular valve insufficiency (repair: n = 4; replacement: n = 2), one for residual ventricular septal defect, and one for pulmonary artery branch obstruction. Follow-up was complete for all patients (median, 17 years; range, 1.5 to 28 years). All 19 survivors were in good clinical condition at last control, without medication, and in New York Heart Association class I (n = 18) or II (n = 1). Transesophageal echocardiography revealed good right ventricular function, low right ventricular outflow tract gradients (mean, 9 +/- 7.4 mm Hg), and trace pulmonary valve insufficiency (n = 11). Atrioventricular septal defect and tetralogy of Fallot can be repaired with low mortality by the transatrial-transpulmonary approach without the use of a conduit.

Diastolic Function in Repaired Tetralogy of Fallot at Rest and during Stress: Assessment with MR Imaging

To prospectively assess, with magnetic resonance (MR) imaging, right ventricular (RV) diastolic function after repair of tetralogy of Fallot (TOF) at rest and during pharmacologic stress and to study relationship between main pulmonary artery end-diastolic forward flow (EDFF) (indicative of restrictive RV physiology) and clinical status. Institutional medical ethics committee approval and patient or parent informed consent were obtained. Patients with TOF corrected through the transatrial-transpulmonary approach underwent MR imaging at rest and during dobutamine stress and maximal exercise testing. Two-dimensional (2D) cine volumetric data were acquired. Flow measurements were performed with a standard 2D flow-sensitized sequence. MR imaging flow curves for tricuspid and pulmonary valves were combined into RV time-volume change curves, from which indexes of RV filling were derived. Patient results were compared with published data in control subjects. Student t tests, Mann-Whitney U tests, analysis of covariance, and paired and one-sample t tests were used. Thirty-six patients (mean age at repair, 0.9 year +/- 0.5 [standard deviation]; median age at study inclusion, 17 years [range, 7-23 years]; 26 male and 10 female patients) were included. Abnormalities in RV filling included impaired relaxation (prolonged deceleration time, P = .002; smaller early filling fraction, P = .02) in the entire group compared with published data in healthy control subjects and signs of restriction to RV filling (smaller atrial filling fraction and higher early filling/atrial filling peak ratio, P < .05 for both) in patients with EDFF (n = 24) compared with patients without EDFF (n = 12). Stress response was abnormal in patients with EDFF, who developed impaired RV relaxation not appreciated at rest. Patients with EDFF had more severe pulmonary regurgitation (P < .05) and poorer exercise performance (P < .001). In patients with TOF corrected with currently widely accepted surgical strategies, pulmonary artery EDFF relates to worse clinical state at mid- to long-term follow-up. Dobutamine stress imaging may unmask abnormalities in RV diastolic filling not appreciated with rest imaging alone.

Clinical condition at mid-to-late follow-up after transatrial–transpulmonary repair of tetralogy of Fallot

To assess the clinical condition at mid-to-late follow-up in tetralogy of Fallot corrected by a transatrial-transpulmonary approach at a young age and to identify risk factors associated with right ventricular dilation/dysfunction and with decreased exercise tolerance. Patients with tetralogy of Fallot underwent cardiac magnetic resonance imaging, maximal bicycle ergometry, electrocardiography, Holter monitoring, and spirometry. Multivariate linear regression analyses were used to determine independent predictors for selected clinical parameters. Fifty-nine patients (mean +/- SD), age at repair 0.9 +/- 0.5 years, interval since repair 14 +/- 5 years, were included. The median pulmonary regurgitant fraction was 32% (0%-57%). Compared with published data on healthy controls, Fallot patients had significantly larger right ventricular end-diastolic and end-systolic volumes and smaller right ventricular and left ventricular ejection fractions. Maximum oxygen consumption was 97% +/- 17% and maximum workload 89% +/- 13% of predicted. Median QRS duration was 110 ms (82-161 ms). No important ventricular arrhythmias were found. Compared with patients without a transannular patch, patients with a patch had more pulmonary regurgitation, a larger right ventricle, worse right ventricular and left ventricular ejection fractions, but comparable exercise capacity. Multivariate regression analysis identified the following independent determinants for larger right ventricular volumes: longer interval since repair, longer QRS duration, and higher pulmonary regurgitation percentage. The following were independent determinants for smaller right ventricular ejection fraction: abnormal right ventricular outflow tract wall motion, longer interval since repair, and longer QRS duration. For smaller maximum oxygen consumption, the independent determinants were smaller right ventricular ejection fraction and longer QRS duration. At mid-to-late follow-up, clinical condition in tetralogy of Fallot corrected according to contemporary surgical approaches appears well preserved. However, even these patients show right ventricular dilation and dysfunction associated with impaired functional capacity. Abnormalities relate to right ventricular outflow tract motion abnormalities, longer interval since repair, longer QRS duration, and more severe pulmonary regurgitation.

Tetralogy of Fallot

Background —In tetralogy of Fallot, transannular patching is suspected to be responsible for late right ventricular dilatation. Methods and Results —In our institution, 191 patients survived a tetralogy of Fallot repair between 1964 and 1984. Transannular patching was used in 99 patients (52%), patch closure of a right ventriculotomy in 35, and direct closure of a right ventriculotomy in 55. Two had a transatrial-transpulmonary approach. To identify predictive factors of adverse long-term outcome related to right ventricular dilatation, the following events were investigated: cardiac death, reoperation for symptomatic right ventricular dilatation, and NYHA class II or III by Cox regression analysis. Mean follow-up reached 22±5 years. The 30-year survival was 86±5%. Right ventricular patching, whether transannular or not, was the most significant independent predictor of late adverse event (improvement χ 2 =16.6, P &lt;0.001). In patients who had direct closure, the ratio between end-diastolic right and left ventricular dimensions on echocardiography was smaller (0.61±0.017 versus 0.75±0.23, P =0.007), with a smaller proportion presenting severe pulmonary insufficiency (9% versus 40%, P =0.005). There was no difference between right ventricular and transannular patching concerning late outcome (log rank P value=0.6), right ventricular size (0.70±0.28 versus 0.76±0.26, P =0.4), or incidence of severe pulmonary insufficiency (30% versus 43%, P =0.3). Conclusions —In tetralogy of Fallot, transannular patching does not result in a worse late functional outcome than patching of an incision limited to the right ventricle. Both are responsible for a similar degree of long-term pulmonary insufficiency and right ventricular dilatation.

Tetralogy of Fallot: transannular and right ventricular patching equally affect late functional status.

In tetralogy of Fallot, transannular patching is suspected to be responsible for late right ventricular dilatation. In our institution, 191 patients survived a tetralogy of Fallot repair between 1964 and 1984. Transannular patching was used in 99 patients (52%), patch closure of a right ventriculotomy in 35, and direct closure of a right ventriculotomy in 55. Two had a transatrial-transpulmonary approach. To identify predictive factors of adverse long-term outcome related to right ventricular dilatation, the following events were investigated: cardiac death, reoperation for symptomatic right ventricular dilatation, and NYHA class II or III by Cox regression analysis. Mean follow-up reached 22+/-5 years. The 30-year survival was 86+/-5%. Right ventricular patching, whether transannular or not, was the most significant independent predictor of late adverse event (improvement chi(2)=16.6, P:<0.001). In patients who had direct closure, the ratio between end-diastolic right and left ventricular dimensions on echocardiography was smaller (0.61+/-0.017 versus 0. 75+/-0.23, P:=0.007), with a smaller proportion presenting severe pulmonary insufficiency (9% versus 40%, P:=0.005). There was no difference between right ventricular and transannular patching concerning late outcome (log rank P: value=0.6), right ventricular size (0.70+/-0.28 versus 0.76+/-0.26, P:=0.4), or incidence of severe pulmonary insufficiency (30% versus 43%, P:=0.3). In tetralogy of Fallot, transannular patching does not result in a worse late functional outcome than patching of an incision limited to the right ventricle. Both are responsible for a similar degree of long-term pulmonary insufficiency and right ventricular dilatation.

Right ventricular outflow tract after non-conduit repair of tetralogy of Fallot with coronary anomaly

Background. A total of 25 patients with tetralogy of Fallot and an important coronary artery crossing the right ventricular outflow tract underwent complete repair without use of an extracardiac conduit between January 1990 and December 1994. Repair was exclusively done by the transatrial or transatrial-transpulmonary approach. Age of these patients ranged from 1 to 12 years (mean 3.6 years). Three of the patients had already received a systemic to pulmonary artery shunt. Methods. All patients reporting for follow-up (n = 18) were subjected to transthoracic echocardiography and, if required, cardiac catheterization and angiography. Right ventricle to pulmonary artery gradients were noted preoperatively, at discharge following repair and at follow-up study. Results. Mean follow-up was 40.6 months (24 to 62 months). Mean early postoperative gradient was 23.5 ± 13.4 mm Hg and 4 patients had significant (> 30 mm Hg) gradients. Mean late postoperative gradient was 20.6 ± 12.4 mmHg and 2 patients had gradients greater than 30 mmHg. All the patients were in New York Heart Association functional class I at the time of last follow-up. Conclusions. Acceptable gradients across the right ventricular outflow tract are achievable following repair of tetralogy of Fallot in the presence of anomalous coronary artery across the right ventricular outflow tract using the transatrial or transatrial-transpulmonary approach. Most gradients were found not to vary significantly on subsequent follow-up.

Complete Atrioventricular Septal Defect Associated with Tetralogy of Fallot. Favourable Outcome of Transatrial Transpulmonary Repair

Complete correction of atrioventricular septal defect (AVSD) associated with tetralogy of Fallot (TOF) has been reported to account for an increased surgical risk. Impaired right ventricular function after classic transventricular repair, residual outflow tract stenosis, and incompetence of the pulmonary or atrioventricular valves are considered to be essential factors affecting the results.From 3/95 to 6/98 six consecutive patients with AVSD and TOF underwent repair (age 18 months to 7.3 years) using a combined transatrial-transpulmonary approach. RV outflow tract balloon dilatation preceded transatrial correction in 4 patients. Pulmonary annulotomy but not transanular patching was necessary in 4 cases. The septal defects were closed by two separate patches using a Dacron patch with short depth and anterior extension for the ventricular component.All patients survived and had stable sinus rhythm. Echocardiography demonstrated mild, but hemodynamically insignificant mitral regurgitation in two and tricuspid regurgitation in four patients. Right ventricle to pulmonary artery gradients ranged from 5 to 35 mmHg (mean 24.2 mmHg) without progression. During follow-up ranging from 4 months to 3.5 years (mean 16.8 months) no reoperation was necessary.The transatrial-transpulmonary approach for correction of AVSD with TOF contributes to improved results after repair of this rare combination of defects.