Total Repair of Tetralogy of Fallot: Trans-Atrial Trans-Pulmonary Approach Versus Trans-Ventricular Approach
Mohamed Saffan1,2, Yousry El-Saed1, Mohamed Elahabet2, Moataz Rizk1, Yousry Shaheen1, Mohamed Alassal1*
1Department of Cardiothoracic Surgery, Benha
University, Benha, Egypt
2Department of Cardiothoracic Surgery, Egypt Children hospital, Cairo, Egypt
*Corresponding author: Mohamed Alassal, Department of Cardiothoracic Surgery, Benha University, Faculty of medicine, Cardiothoracic surgery department, Benha, Egypt. Tel: +966539417103;Email: dmohamedabdelwahab@gmail.com
Received Date: 18 October, 2017; Accepted Date: 04 November, 2017; Published Date: 13 November, 2017
1. Abstract
1.1. Background: 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.
1.2. 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.
1.3. Results: 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-significant difference.There is significant difference in right/left ventricular pressure ratio(p<0.05).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.
1.4. 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
Introduction
Tetralogy of Fallot is considered to
be one of the common cardiac malformations [1]. The first complete description was
publishedby the French physician Etienne Louis Arthur Fallot in 1888 when he
described the four features of congenital anomaly:Ventricular Septal Defect,
Pulmonary Stenosis, Right Ventricular Hypertrophy and dextro-position of the aorta [2].
The natural history was changed with the introduction of the surgical
management of Tetralogy of Fallot which was first done by Blalock and Taussig
in 1945,who performed a palliative procedure by anastomosing the left
subclavian artery to left pulmonary artery to increase the pulmonary blood flow
and hence,improve patient's oxygen saturation [3].
The first successful correction through a right ventriculotomy was
achieved by Lillehei and Varco using "Controlled cross circulation"
in 1954.The first who used a pump oxygenator for the repair of tetralogy of
Fallot wasKirklin et al.one year later [3].
Thesurgical approach and optimal age for correction of tetralogy of
Fallot have been debated for several decades [4].
Current evidence supports early repair of tetralogy of Fallot to minimize
the adverse effects of hypoxia, reduce ventricular arrhythmias,prevent organ
damage and optimize functional and cardiac outcomes [5].
Improvements in CPB technology,surgical technique and perioperative care made
early correction feasible with low morbidity and mortality [6].
Traditionally,Tetralogy of Fallot was repaired through a right
ventriculotomy providing an excellent exposure for VSD closure and relief of RVOT
obstruction but there were concerns that the right ventricular scar may impair
the right ventricular function,increase the incidence of ventricular
arrhythmias and sudden deat h [7].
The first transatrial-transpulmonary repair of tetralogy of Fallot which
reported by Hudspeth et al in1963, had considered an important step in the
evolution of tetralogy of Fallot surgery.Edmunds et al introduced it in 1976
and popularized in recent years.The benefits of transatrial-transpulmonary
correction are believed to drive from eliminate a right ventricular incision
which may lead to late right ventricular dysfunction and diltationand increased
risk of ventricular arrhythmias [3].
The aim of this work is to evaluate the results of the two surgical approaches used for total repair of tetralogy of Fallot: transatrial-transpulmonary approach and transventricular approach with special emphasis on preoperative and intraoperative risk factors that affect the prognosis of patients undergoing total repair, and with full analysis of postoperative short-term results.
4. Patients and Methods
Between January 2014 and december
2016, 60 patients with TOF were collected in a randomized prospective study.We
excluded Patients withpulmonary atresia,absent pulmonary valve,absence of one
branch pulmonary artery, previous palliative procedures and TOF with atrioventricular
septal defects.
All children included underwent
total repair in two hospitals in Egypt (Benha university hospital and Children of
Egypt hospital) after obtaining informed patient consent.
According to surgical approach,Patients
were divided into two groups:Group A,included
30 patients repaired through transatrial-transpulmonary approach alone
orcombined with transannular patch.Two patches above and below the annulus
usedin patients when an infundibular patch was required,andare preferable to a
single patch across the annulus.
Group B,included
30 patients repaired through transventricular approach alone orcombined with transannular
patch.
All children were studied for the following variables:age,
sex, weight, and cyanosis.Full laboratory works up,chest X ray andECG done.
Echocardiography done describing detailed cardiac anatomy:size and position of
the VSD, diameters of main pulmonary artery and its branches,Mc-Goon ratio,
degree and level of RVOTO,degree of aortic overriding,cardiac dimensions,and
presence of other anomalies.Multisclice CT done,if
needed,to verifying echocardiography Findings.
4.1. Surgical Technique
Median sternotomy incision was the
standard incision, cardiopulmonary bypass was instituted.PDA is looked for
routinely, CPB was commenced with systemic cooling to moderate levels of
hypothermia (28C).In group A, the Rt atriotomy and the tricuspid valve were the
standard access to the VSD and RVOT,the intracardiac anatomy was then inspected
carefully.Dissection ofobstructing parietal muscles from the ventriculoinfundibular
fold and transected 4 to 5 mm away from the VSD and aortic annulus,then
dissection was carried upwards towards the pulmonary valve, assessment of RVOTO
is made by probing the PV with graded Hegar's dilators.
When the pulmonary annulus is
smaller,the main pulmonary artery openedand the PV is inspected and dealt with
according to its nature.If the pulmonary valve cusps are normal and either
bi-cuspid or tri-cuspid, full commissurotomies are performed.If the PV annulus
was narrow, the annulus is incised through the most anterior commissure without
Ventricular incision or by limiting the Ventricular incision to 3 to 5mm below
the annulus, just enough to put a pericardial patch to suffiecently enlarge the
annulus.
We measured the left and right
pulmonary arteries and the incision in the MPA, if necessary extended into
either pulmonary artery to augment an origin stenosis.The VSD closed with patch
material of either Poly-Tetra-Fluoro-Ethylene (PTFE) or Hemasheild.
In cases with combined
approaches,the pulmonary artery and RVOT were reconstructed using untreated
autologous pericardial patch
Group B: we made longitudinal incision in the
right ventricle,a few millimeters away from the pulmonary valve.Then excision
of obstructing muscles in the RVOT until detection of the VSD clearly.The VSD closed with patch material.The sutures were continued in a clockwise direction, keeping it on the
right side of the septum and the other end of the suture run around in an
anticlockwise manner. If the annulus was smaller,the incision carried upward
through the pulmonary valve to the bifurcation of the main pulmonary
artery.Hegar’s dilators were introduced through RVOT to assess the adequacy of it.
We use untreated autologous pericardial patch to enlarge the pulmonary annulus
when necessary.
Atrial septal defects and patent foramen ovale
were closed if found,thenassessment oftricuspid valve for competence done and
repaired if required.
After stabilization of
haemodynamics,patients were weaned from CPB.Direct measurements of pressure were
used to rule out residual pressure gradients between RV and PA, and also the
ratio between the RV and LV pressures(RVp/LVp ratio).Patient was then
transferred to ICU ventilated and on calculated doses of inotropes.
4.2.
Postoperative Data Include
Full ICU monitoring, Mechanical
ventilation, inotropic support and CXR daily in the ICU.Early postoperative echocardiography
done to evaluate anyresidual RVOT obstruction,residual VSD,pulmonary and/or
tricuspid valve insufficiency andassessment of overall RV and LV function.
The end points for early outcome were duration of mechanical
ventilation,inotropes and ICU stay,mortalityand morbidity defined by
complications affecting one of the former end points.
4.3.
Follow up
Up
to six months follow up by clinical examination,chest X ray, echocardiography
and need for medications.Follow up depended on clinical evolution and need forreintervention
for VSD and RVOT related issues as residual gradient across RVOTand grade of pulmonary
insufficiency.
4.4. Statistical Analysis
Data were analyzed
using Statistical Program for Social Science (SPSS) version 20.0. Quantitative
data were expressed asmean±Standard Deviation (SD).
Qualitative data were expressed as frequency and percentage.
The following tests
were done
·
Independent-samples
t-test of significance was used when comparing between two means.
·
Chi-square (X2) test of significance was used in order to
compare proportions between two qualitative parameters.
·
Probability (P-value)
–
P-value <0.05 was considered significant.
–
P-value <0.001 was considered as highly significant.
–
P-value >0.05 was
considered insignificant.
5.
Results
5.1. Demographic and Clinical Characteristics
60 patients divided into two groups each group
included 30patients.Group A (transatrial-transpulmonary approach, 20 males and
10 female),and group B (trans ventricular approach, 17 males and 13 female).
Our study showed that there was no significant
statistical difference between both groups regarding age, sex, body weight or
preoperative O2 saturation and hematocrit ratio with p value >0.05 (Table 1).
There was no significant statistical
difference between both groups regarding preoperative Echocardiographic data:RV
pressure,McGoon ratioand PG across the RVOT with p value >0.05 (Table 1).
Perioperative Data
there was no significant
statistical difference between both groups regarding associated cardiac
anomalies and intraoperative findings with p value >0.05 (Table 2).
Our study showed no significant statistical
difference between both groups regarding,the CPB time,the aortic cross clamp
time with p value >0.05 (Table 3).
Our data showed that there were significant
statistical differences among the two groups regarding the ventilation time,the
need of inotropic support and the ICU stay,with P value 0.023, 0.001and 0.001
respectively (Table 3) (Figure 1).
Early post-operative
complications include bleeding 1 (3.3%),arrhythmias 2 (6.7%), LCOP syndrome 1
(3.3%),Transient seizures 1 (3.3%) and Diaphragmatic paralysis 1 (3.3%)as shown
in group A.
In group B complications
include Bleeding 1(3.3%), arrythmias 5(16.7%), Chest infection 2 (6.7%), LCOP
syndrome 4 (13.3%),Wound infection 1(3.3%)and Transient seizures 2 (6.7%). (Table4) (Figure2)
Echocardiography was done postoperative,
showed no residual VSDs.
Our data showed that there were significant
statistical differences among the two groups regarding mean RV pressure(49.77±8.29 vs 44.37±7.59),mean
PG across the RVOT(31.5±8.37vs 27.4±9.76)and Mean RVp/LVp ratio in early
postoperative(0.52±0.17vs 0.44±0.14)with P value 0.009,0.036and 0.019 respectively.
(Table 5)
Early postoperative
echocardiographic data of assessment of pulmonary regurge and tricuspid regurge
are summarized in (Table 5), showed that the
number of patients who had moderate and sever pulmonary regurge more in group B
than group A.
More patients who repaired through
transventricular approach developed arrhythmias than those who repaired through
transatrial-transpulmonary approach.
In the follow up period,the comparison between
both groups as regard PG across the RVOT and the RV pressure was insignificant
(p>0.05). (Table 6) (Figure3).
6.
Discussion
Tetralogy of Fallot is considered to be one of the most common cardiac
malformations, representing approximately around 3 to 5 per 10,000 live births.
In this study we had 60 patients with TOF divided into two groups, 30
patients in each group according to the surgical approach used.
In this study,the age group ranged between 9 months and 68 months
compared to Ujjwal et al;who preferred early correction of Tetralogy of
Fallotto reduce long standing pressure overload of the right ventricleand to
minimize organ damage due to chronic hypoxia and arrhythmia [8] (Table 1).
As regards to pulmonary valve pathology, Brian et al;reported the
pulmonary valve stenosis in 75% of cases and in two thirds of cases,the valve
is bicuspid,where in our series,the PV was stenotic in 55 patients (91.7%),and
33 patients (55%) had tricuspid valve and 26 patients (43.3%) had a bicuspid
leaflet and one patient had monocuspid valve(1.6%).This reflects that the main
pathology of RVOT is more on the infundibular level rather than the valve
level [9] (Table 2).
Among our series, we encountered 5 cases(8.3%)with left pulmonary artery
branch origin stenosis that required concomitant repair,compared to Bove et al,
who published that, branch pulmonary artery abnormalities occurred in 10% of
cases of his patients,approximately less than 5% of them have bilateral branch
pulmonary artery stenosis [10].
The incidence of associated anomaliesof the coronary arteries is around
5% of patients with TOF as reported by Chiu et al. [11]. More
incidences were reported by Elisabeth et al, who reported coronary anomalies in
10 patients (13%) out of 78 patients [12]. In the
present study,only 2 patients out of sixty (3.33%)showed abnormal course of
their coronary arteries. Both cases were repaired through
transatrial-transpulmonary approach with no need for ventricular incision.
In the present study,in group A we closed the VSDs through the right
atrium.In group B,the VSDs were closed through the ventriculotomyin contrast to
Pozzi,who reported that all VSDs could be repaired through the right atrium whether
a transannular patch is used or not, to minimize the length of the right
ventricular incision (length necessary to relieve the RVOT obstruction only and
not for the VSD closure) [13].
No planned approaches decided for patients before surgeryin order to
relieve the RVOTO, but patients classified after correction into two groups:
Group A patients repaired
through transatrial-transpulmonary approach alone(group A1,23 patient (76.7%)
orcombined with Transannular Patch(TAP)(group A2, 7 patients (23.3).
Group B patients repaired
through transventricular approach alone(group B1 ,18 patients (60%) orcombined
with transannular patch (group B2, 12 patients (40%).
In our series 19 (36.67%) cases had TAP repair compared to Jacek Kolcz
and Christian Pizarro,who had 58 patients (88%) out of 66 received a
transannular patch [14].
The degree of right ventricular failure and exercise performance
correlate with the severity of pulmonary incompetence.The chronic volume load
to the right ventricle leads to ventricular dilatation and predisposes to late
ventricular arrhythmias and sudden death [15].
In the correction of tetralogy of Fallot,transannular patch is a
critical decision and is clearly the most likely causefor reoperation [16].
Our data showed that there were significant statistical differences
among the two groups regarding the ventilation time,the need of cardiac
inotropes and ICU stay,with P value 0.023, 0.001 and 0.001 respectively.
That means artificial ventilation time, cardiac support time and ICU
stay was longer in patients in group B compared to patients in group A.
The postoperative complications in both groups showed in (Table 4).
In our patients early, postoperative arrhythmias were noted in 7
patients(11.67%), 2patients(3.3%) in group A and 5 patients(8.3%) in group B.In
group A arrhythmias included Junctional Ectopic Tachycardia (JET) in one
patient, temporary atrioventricular block in one patient.In group B arrhythmias
included Junctional Ectopic Tachycardia (JET) in 4 patients, temporary
atrioventricular block in one patient.In the follow up all patients in group A
were in sinus rhythm and 3 patients on nodal rhythm in group B.
These results were similar to others who reported that the right atrial
approach seems to significantly reduce the risk of lifethreatening ventricular
arrhythmias after repair of tetralogy of Fallot without increasing the
incidence of supraventricular arrhythmias [17].
Sun et al, reported that after right ventricular incision,transmural
myocardial scarring is an important factor in the development of malignant
ventricular arrhythmias and the most sensitive predictor of its development is
the prolongation of the QRScomplex(>180ms).
Transatrial-transpulmonary repair of tetralogy of Fallot limits the
right ventricular incisionand reduce the incidence of ventricular arrhythmias [18].
During the postoperative period Our data showed that there were
significant statistical differences among the two groups regarding mean RV
pressure,mean PG across the RVOT and Mean RVp/LVp ratio in early postoperative
with P value 0.009, 0.036 and 0.019 respectively (Table
5).
These results showed the RV pressure and gradients across the RVOT
postoperatively in group A was higher than that of group B.At follow up, there
were progressive decrease of RV pressure and gradients across RVOT with no
significant difference between both groups.This observation goes with results
by Wensley et al. and Bove et al. [19] (Table 6).
The intraoperative RV/LV ventricular pressure ratio,is an important
indicator for morbidity and mortality after correction of Fallot tetralogy.
In our patients there were significant comparisons between both groups
depending on the RVp/LVp ratio(p< 0.05) in the early post-operative period.
Theseresults are similar toAlexiou et al.patients in group B (transventricular aapproach) had a significantly lowerRV/LV pressure ratio and they were less likely to have further procedures to relieve residual RVOTO. These differences were due to a higher rate of transannular patch in the RV group [20,21].
In our
group of patients,early echocardiography revealed no pulmonary regurge in 22
patients (36.7%), mild PR in 16 patients (26.7%),moderate PR in 13 (21.7%)
patients and severe PR in 9 patients (15%), It is to be noted that a
transannular patch was used in 19(31.66%) patients.In our series,we did find
the use of a transannular patch to influence the incidence of significant
postoperative pulmonary insufficiency.
The significant PR(sever), seen in 9 cases in the early postoperative examination decreased gradually and persist in only 6 cases where the right ventricle and pulmonary annulus were opened.
These results are similar to Rao et al.; used pulmonary valve preservation techniques in 89% of 50 operated patients and he reported pulmonary valve competence in 68% of children with 5 children (16%) had severe regurgitation at follow up [22].
This copes with De Reijter et al.;who followed up 171 patients after repair of Fallot Tetralogy, 92% through right ventriculotomy,and they concluded that right ventriculotomy is associated with a bad prognosis for the right ventricular function especially when it is associated with transannular patch with resultant pulmonary regurgitation [23].
In the follow up periodno one of our children needed reintervention for residual VSD or gradients over RVOT and all patients were in NYHA functional class I.Comparing our own results to those of Alexiou,who reported a 20 years survival of 98% after TOF repair,with 99% of survivors in New York Heart Association (NYHA) functional class I.
7. Conclusion
We encourage to start TOF repair through transatrial, followed by transpulmonary approach if it was not enough to relief the RVOTO.But when ventriculotomy is no way should be performed,we advise to make it limited rather than being extended.Also, to have a ventriculotomy with intact pulmonary annulus is much better than to have it with TAP.
1: Shows Postoperative Ventilation Time, Duration of Inotropic
Support and ICU Stay Needed for both Groups.
.
: Early Postoperative Complications.
Figure 3: RV pressure and PG across RVOT in the Follow up Period.
Pvalue |
t/ x2 |
GroupB (n=50) |
GroupA (n=50) |
Variables
|
0.072 NS |
1.006 |
35.88±11.76 |
39.36±16.68
|
Mean age (months) mean±SD |
0.203 NS
|
0.320 |
12.9±7 |
13.75±8.58
|
Bodyweight(kg)Mean ±SD |
0.472 |
2.682
|
17(56.67 %) 13(43.33 %) |
20(66.67 %) 10(33.33 %) |
Sex ratio:
Male Female
|
0.153 |
0.218
|
84±9.3%, |
86±9.56%, |
O2 Saturation(%) |
0.085 |
1.053 |
43.71±4.85%, |
45.88±5.1%, |
Hematocrite (%)
|
0.747 |
0.104 |
7(23.33) |
5(16.67) |
Cyanotic spells
|
0.549 NS |
0.214 |
1.84±0.39 |
1.86±0.31 |
McGoon ratio Mean±SD |
0.473 NS |
0.163 |
102.11±13.04 |
97.5±12.13 |
RV pressure Mean±SD |
0.528 NS |
0.097 |
86.15±15.79 |
84.13±11.74 |
PG RVOT Mean±SD |
: Clinical characteristics and preoperative data.Table 1
P value |
t/ x2 |
Group B |
Group A |
Variables
|
0.729 |
0.120 |
6(20%) |
4(13.33) |
PDA |
0.579 |
0.308 |
8(26.67) |
11(36.67%) |
PFO |
|0.478 |
0.518 |
0 |
2(6.67%) |
ASD |
0.505 |
0.445 |
4(13.33%) |
7(23.33%) |
RT sided aortic arch |
0.892 |
0.019 |
3(10%) |
2(6.67%) |
MAPCAs |
0.472 |
0.518 |
0 |
2(6.67%) |
Lt SVC |
0.472 |
0.518 |
0 |
2(6.67%) |
Coronary artery anomalies |
0.892 |
0.019 |
2(6.67%) |
3(10%) |
LT pulmonary artery origin stenosis |
0.531 |
0.393 |
8(26.67) |
5(16.67%) |
Overriding aorta >50% |
0.938 0.794 0.791 |
0.006 0.068 0.070 |
16(53.33%) 14(46.67%) 0 |
17(56.67%) 12(40%) 1(3.33%) |
Pulmonary valve: -tricusped -bicusped -monocusp |
Table 2:Associated Congenital Anomalies and Operative Findings.
P value |
t/x2 |
Group B |
Group A |
Variables
|
||||
0.143 |
1.042 |
79.4±16.3 |
77.51±13.4 |
CPB time Mean±SD |
||||
0.129 |
1.069 |
52.5±10.58 |
49.52±9.5 |
ACX time Mean±SD |
||||
0.267 |
1.233 |
12(40%) |
7(23.33%) |
TAP(transannular patch) |
||||
0.023 |
3.245 |
26.68±11.8 |
18.5±6.6 |
Ventilation time Mean±SD |
||||
<0.001 |
7.052 |
4.09±1.36 |
2.44±0.85 |
Inotropes Mean±SD |
||||
<0.001 |
5.147 |
3.85±1.43 |
3.15±1.18 |
ICU Stay Mean±SD |
Table 3: Perioperative Data.
Complications
|
Group A |
Group B |
t/x2 |
p-value |
Bleeding |
1 (3.3%) |
1 (3.3%) |
0.000 |
1.000 |
Arrhythmias |
2 (6.7%) |
5 (16.7%) |
0.654 |
0.422 |
Chest infection |
0 (0.0%) |
2 (6.7%) |
0.525 |
0.467 |
LCOP syndrome |
1 (3.3%) |
4 (13.3%) |
0.876 |
0.349 |
Wound infection |
0 (0.0%) |
1 (3.3%) |
0.003 |
0.999 |
Transient seizures |
1 (3.3%) |
2 (6.7%) |
0.003 |
0.999 |
Diaphragmatic Paralysis |
1 (3.3%) |
0 (0.0%) |
0.003 |
0.999 |
Mortality |
1 (3.3%) |
2 (6.7%) |
0.029 |
0.866 |
Table 4:Postoperative Complications and Mortality.
P value |
t/x2 |
Group B |
Group A |
Variables
|
|||
0.009 |
3.876 |
45.37±7.59 |
49.77±8.29 |
RVP |
|||
0.036 |
2.217 |
25.4±9.76 |
31.5±8.37 |
RVOT PG |
|||
0.019 |
3.076 |
0.44±0.14 |
0.46±0.17 |
RV/LV pressure ratio |
|||
|
|
|
|
PR: |
|||
0.382 |
0.762 |
6(20.0%) |
10(33.3%) |
-mild |
|||
0.531 |
0.392 |
8(26.7%) |
5(16.7%) |
-moderate |
|||
0.469 |
0.523 |
6(20.0%) |
3(10.0%) |
-sever |
|||
|
|
|
|
TR: |
|||
0.997 |
0.002 |
6 (20.0%) |
4 (13.3%) |
-mild |
|||
0.999 |
0.003 |
1 (3.3%) |
0 (0.0%) |
-moderate |
Table 5:Postoperative Echocardiography Data.
P value |
t/x2 |
Group B |
Group A |
Variables
|
||||
0.205 |
1.608 |
3(10.7%) |
0 |
Arrytmias |
||||
0.189 NS |
0.098 |
39.33±8.94 |
43.17±9.71 |
RV pressure |
||||
0.243 NS |
0.087 |
19.84±6.55 |
21.77±8.57 |
RVOT PG |
||||
|
|
|
|
PR |
||||
0.556 |
0.346 |
5 (17.9%) |
8 (27.6%) |
-mild |
||||
0.772 |
1.181 |
8 (28.6%) |
4 (13.8%) |
-moderate |
||||
0.956 |
0.003 |
4 (14.3%) |
2 (6.9%) |
-sever |
||||
|
|
|
|
TR |
||||
0.937 |
0.006 |
4 (14.3%) |
3 (10.3%) |
-mild |
||||
0.714 |
0.134 |
1 (3.6%) |
0 (0.0%) |
-moderate |
Table 6: Follow up Data.
- Martin AN, Poul l, Morten H, Gosta P (1999)Twenty to thirty-seven years follow up after repair for tetralogy of Fallot. Eur J Cardiothorac Surg 16: 125-130.
- Van Arsdell GS, Maharaj GS, Tom J, Rao VK, Coles JG, et al. (2000) What is the optimal age for repair of tetralogy of Fallot?. Circulation 102: 123-129.
- Giannopoulos NM, ChatzisAk, Karros P, Zavaropoulos P, Rammos S, et al. (2002) Early results after transatrial-Transpulmonary repair of tetralogy of Fallot. Eur J Cardio-thorac Surg 22: 582-586.
- Alassal M, Ibrahim BM, Elrakhawy HM, Elsadeck N, Sayed S, et al. (2017) Total Correction of Tetralogy of Fallot at Early Age: A Study of 183 Cases. Heart Lung CircApr 27. pii: S1443-9506 (17) 30329-3.30333
- Christos A, Qiang C, Maria G, James G, Salmon AP, et al (2002) Repair of tetralogy of Fallot in infancy with a transventricular or a transatrial repair.Eur J Cardiothorac Surg 22: 174-183.
- Adnan C, Jess MS (2002) Total correction of Fallot in the first year of life, late results.Ann Thorac Surg 74:133-138.
- Evgenij VP, Vladimir VA, Ingo D, Ekaterina AI, Peter EL, et al. (2001) Development of pulmonary arteries after central aorto-pulmonary shunt in newborns. Ann Thorac Surg 71: 899-906.
- Ujjwal K Chowdhury, Siddharth Sathia,Ruma Ray, MRCPath, Rajvir Singh, et al. (2006) Histopathology of the right ventricular outflow tract and its relationship to clinical outcomes and arrhythmias in patients with tetralogy of Fallot. J Thorac Cardiovasc Surg 132: 270-277.
- Brian W Duncan, Roger BB Mee (2005) Tetralogy
of Fallot with Pulmonary Stenosis in Sellke, Sabiston & Spencer Surgery of the
Chest, 7th ed 114: 1150.
- Bove EL, Hirsch JC (2006) Tetralogy of
Fallot in Surgery for Congenital heart defects 3rd ed by J Stark, M. de Leval
and V. Tsang 29: 399- 410.
- Chiu IS, Wu CS, Wang JK, Mei-Hwan Wu, Shu-Hsun Chu, et al. (2000) Influence of Aorto-Pulmonary rotation on the anomalous coronary artery pattern in tetralogy of Fallot. Am J Cardiol 85: 780-784.
- Elisabeth I van Dongen, Angelique GGlansdorp, Reinout JMildner, McCrindle BW, Sakopoulos AG, et al. (2003) The influence of perioperative factors on outcomes in children aged less than 18 months after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 126: 703-710.
- Pozzi M, Trivedi DB, Kitchiner D, Arnold
RA (2000) Tetralogy of Fallot: what operation, at which age. Eur J
Cardiothorac Surg 17: 631-636.
- Jacek Kolcz, Christian Pizarro (2005) Neonatal repair of tetralogy of Fallot results in improved pulmonary artery development without increased need for re-intervention. Eur J Cardio-Thorac Surg 28: 394-399.
- Anagnostopoulos P, Azakie A, Natarajan S, Alphonso N, et al. (2007) Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot. J Thorac Cardiovasc Surg 133: 640-647.
- Ooi A, Moorjani N, Baliulis G, Keeton BR, Salmon AP, et al. (2006) Medium term outcome for infant repair in tetralogy of Fallot: indicators for timing of surgery. Eur J Cardiothorac Surg 30: 917-922.
- Dietl CA, Cazzaniga ME, Dubner SJ, Perez
BN, Torres AR, et al. (1994) Life-threatening arrhythmias and RV dysfunction
after surgical repair of tetralogy of Fallot. Comparison between
transventricular and transatrial approaches. Circulation 90(5 Part 2): II7-
II12.
- Sun G, Wang X, Chen J, Ma R, Li F, Chen L, et al. (2013) Primary repair of tetralogy of Fallot in infants: Transatrial/transpulmonary or transventricular approach. Asian Journal of Surgery 36: 137-143.
- Wensley DF, Karl T, Deanfield J, de Leval MR, Macartney FJ, et al. (1987) Assessment of residual right ventricular outflow tract obstruction following surgery using the response to intravenous propranolol. Ann Thorac Surg 44: 633-636.
- Alexiou C, Chen Q, Galogavrou M, Gnanapragasam J, Salmon AP, et al. (2002) Repair of tetralogy of Fallot in infancy with a transventricular or a transatrial approach. Eur J Cardiothorac Surg 22: 174-183.
- Alexiou C, Mahmoud H, Al-Khaddour A, Salmon AP, Keeton BR, et al. (2001) Outcome after repair of tetralogy of Fallot in the first year of life. Ann Thorac Surg 71: 494-500.
- Rao V, Kadletz M, Momberger LK, Freedom RM, Black MD (2000) Preservation of the pulmonary valve complex in tetralogy of fallot: how small is too small?. Ann Thorac Surg 69: 176-179.
- De Ruijter FT, Weenink I, Hitchcock FJ, Meijboom EJ, Bennink GB (2002) Right ventricular dysfunction and pulmonary valve replacement after correction of tetralogy of Fallot. Ann Thorac Surg 73: 1794-1800.