Hemoptysis in a patient with a previous surgical correction of a tetralogy of Fallot

Aorto-bronchial fistula is a rare but associated with a height rare of mortality. Although most reported cases are secondary to infectious aneurysms, cases arising after surgery to correct congenital cardiovascular abnormalities have recently been described. We report the case of a 41-year-old patient with recurrent hemoptysis and a history of Fallot's tetralogy corrected in childhood. Given such a case of hemoptysis in a patient with a history of cardiovascular surgery, the correct diagnostic approach includes fiberoptic bronchoscopy, helicoidal CAT and/or NMR, and aortography. Diagnostic confirmation should be followed soon by corrective surgery.     

Unusual interventional management in an adult with tetralogy of Fallot

A 53-year-old man with tetralogy of Fallot had been palliated with two classic Blalock-Taussig shunts. Cardiac catheterization in our center revealed acquired atresia of the pulmonary valve. We perforated and dilated the valve as a palliative procedure with a new system using radiofrequency energy.     

Late surgical treatment of tetralogy of Fallot

Aim

To study early post-operative results and follow up of patients over a year old, operated on for tetralogy of Fallot (ToF).

Methods

This retrospective analysis included 22 patients (14 male and eight female) with a mean age of 9.18 ± 6.5 years (range 13.5 months to 26 years), who underwent complete repair of ToF between April 2003 and June 2009. Data from patients’ records, pre-operative cardiac catheterisation studies, operative intervention, and pre-operative and postoperative two-dimensional echocardiographic studies were reviewed. All patients underwent complete repair including closure of ventricular septal defect (VSD). A trans-annular patch was used in 12 patients while an infundibular patch was used in 10 others. Patients were evaluated one, three, six and 12 months after surgery, and annually thereafter. The duration of follow up was from eight months to six years post surgery.

Results

Classical ToF was found in 10 patients. Twelve cases had associated anomalies: two patients with hypoplastic pulmonary artery branches, two with arterial duct malformations, and eight had proximal stenosis of the left branch of the pulmonary artery. NHYA class distribution was as follows: class I: two patients; class II: five subjects; class III: 10 patients; class IV: five subjects. The mean stay in hospital was 15 ± 7 days. Two patients (9%) died during the early post-surgical period. At a mean follow-up interval of 32 ± 9 months, all patients were asymptomatic and in NYHA class I. No late deaths occurred. In three patients, we registered isolated monomorphic ventricular extrasystoles. The right ventricle outflow tract (RVOT) pressure gradient was 29 ± 1.5 mmHg in the acute post-surgical period and it did not change significantly during follow up. The right ventricular function was defined as normal in 95% of the patients in the study and was mildly depressed in 5%.

Conclusion

Even if treated later in life, our study showed very good surgical results of patients with ToF.     

Complete atrioventricular canal and tetralogy of Fallot: surgical considerations

Nine patients with complete atrioventricular canal and tetralogy of Fallot underwent intracardiac repair of both anomalies between 1982 and 1989. The ages of the patients ranged from 6 months to 7 years. Six of the 9 had one or more previous systemic-pulmonary artery shunts. Two-dimensional echocardiography showed diagnostic characteristics of both malformations in all patients. The diagnosis was confirmed by cardiac catheterization and cineangiography. The ventricular septal defect was repaired by a combined right atrial and ventricular approach in every patient. Outflow tract reconstruction was performed with the use of a transannular patch (4), infundibular patch (4), and a valved conduit (1). There were no hospital deaths. Meningitis was responsible for the death of a patient 2 years after repair. We recommend early palliation, complete repair in those older than 4 or 5 years, surgical technique depending on the anatomical findings, combined atrial and ventricular approach, 2 separate patches to close the ventricular septal defect in required cases, adjusted correction of the right ventricular outflow tract, and careful postoperative care.     

法洛四联症外科矫治手术前后的介入干预治疗

目的:评价经导管介入治疗措施对法洛四联症(tetralogy of Fallot,TOF)外科矫治术的辅助治疗价值。方法:对我科2010年10月至2013年12月住院的27例,和作者在外院完成的3例TOF经导管介入治疗进行总结分析。结果:男性20例,女性10例,年龄8个月~49岁,平均4.3岁。外科矫治术前行体-肺侧枝血管(major aorto-pulmonary collateral arteries,MAPCAs)栓塞术17例、肺动脉瓣球囊扩张术(percutaneous balloon pulmonary valvuloplasty PBPV)4例;因术后肺出血急诊行MAPCAs栓塞术4例,术后左心衰行MAPCA-肺静脉瘘瘘口封堵1例、肺动脉分支狭窄球囊扩张(percutaneous balloon pulmonary arterioplasty PBPA)3例、PBPV1例。介入治疗均达到预期效果,未发生与操作相关的并发症,1例根治术后,肺出血患者行MAPCAs栓堵术后肺出血改善,但死于感染性心内膜炎,其他病例均痊愈出院。结论:TOF外科矫治术前、术后的介入治疗,可减少TOF根治手术风险并改善预后。     

成人法乐氏四联症的外科治疗

目的 总结成人法乐氏四联症外科手术治疗的经验。 方法 从1996年10月至2003年12月对82例18周岁以上成人法乐氏四联症实施根治手术,最大年龄48岁。所有病例均经右室流出道切口完成疏通及室缺修补,室缺全部使用涤纶片修补,27例行跨环补片术,53例单纯补片加宽流出道,1例补片分别加宽主肺动脉和流出道,另有1例直接缝合流出道。 结果住院死亡1例,死亡率为1.2％。16例发生了并发症,包括因肺部感染二次气管插管1例,二次开胸止血6例,残余分流7例(均≤5mm),右室流出道残留梗阻2例(压差>60mmHg)。结论成人法乐氏四联症的根治手术可取得满意的临床结果。     

Reoperations after surgical correction of tetralogy of Fallot

Between 1970 and 1981, 40 patients (6%) were reoperated after surgical correction of Fallot's tetralogy. The average age of these patients was 7,5 years (range 2 months to 37 years). The usual anatomical form was present in 30 cases and severe forms accounted for the other 10 cases (pulmonary atresia with septal defect were excluded). The 40 patients were divided into 3 groups according to the anatomical lesions corrected at reoperation: Group I: 16 patients with a residual isolated VSD; Group II: 14 patients with one or two residual right heart anomalies (RRHA) but without a septal defect; Group III: 10 patients with a residual VSD and RRHA. The only clinical difference between the patients of these 3 groups was the delay of onset of symptoms: the patients with residual VSD (Groups I and III) often developed cardiac failure immediately, whilst in those without residual VSD (Group II) cardiac failure was usually observed secondarily. Four patients (10%) died early after reoperation (less than 1 month). Three others died later, two during a third operation. The total mortality was similar in the three groups. The surgical result was assessed clinically after an average follow-up of 4,5 +/- 3 years: patients with a residual isolated VSD (Group I) had the best long-term results. In 12 patients, M mode and 2D echocardiography showed normal left ventricular function but the ratio of end diastolic right ventricular and left ventricular dimensions was increased to an average of 0,72 +/- 0,2.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transvenous approach to coronary angiography in infants with tetralogy of Fallot

A new technique is offered for selective imaging of the coronary arterial system from a transvenous approach in patients with tetralogy of Fallot as an alternative to other traditional approaches. This technique should identify important coronary anomalies while avoiding femoral arterial cannulation and compromise.     

Uncorrected tetralogy of Fallot in an 86-year-old patient

This report describes the presentation and evaluation of an elderly man with uncorrected tetralogy of Fallot. The patient had remained fairly asymptomatic for much of his life. He presented to the hospital at age 86 with new-onset atrial fibrillation with rapid ventricular response and a non-ST-segment elevation myocardial infarction. Transthoracic and transesophageal echocardiography revealed infundibular pulmonic stenosis with a ventricular septal defect, overriding aorta, and right ventricular hypertrophy, findings consistent with unrepaired tetralogy of Fallot. Severe right ventricular pressure overload was also present. Coronary angiography revealed nonobstructive coronary artery disease. It was felt that the rapid atrial fibrillation resulted in right ventricular subendocardial ischemia that improved following restoration of sinus rhythm. After a systematic literature search, the authors believe this case represents the oldest reported patient with the diagnosis of uncorrected tetralogy of Fallot and serves as an example of a well-balanced congenital shunt.     

The surgical decision in tetralogy of Fallot: weighing risks and benefits with decision analysis

The preferred management of the symptomatic infant less than 2 years of age with tetralogy of Fallot remains unsettled. In this study decision analysis was used to assess the risks and benefits of three courses of action: (1) primary intracardiac repair; (2) palliative operation in infancy and delayed intracardiac repair; and (3) treatment with propranolol in infancy and delayed intracardiac repair. For each action the likelihood was determined of three possible outcomes for the patient: (1) death, (2) poor surgical result, or (3) good surgical result. Each outcome was associated with an estimated life expectancy. The best action was defined as that resulting in the longest life expectancy. With use of previously reported data and those from experience at one institution, a range of probabilities was estimated for death before operation, surgical mortality, success of propranolol treatment and hemodynamic result of operation. The choice of action was affected most by the mortality of primary intracardiac repair and the likelihood of a good hemodynamic result from intracardiac repair. Less important factors were the outcome of a palliative operation and the likelihood of success with propranolol therapy. It was found that in the institution studied if the mortality rate of primary intracardiac repair is 10 percent or less, intracardiac repair should be performed; otherwise propranolol treatment, which allows delay in intracardiac repair, should be selected. Both alternatives are preferable to palliative operation. With decision analysis, the clinician can use probabilities and life expectancy appropriate to a given clinical setting in determining the best management for the infant with tetralogy of Fallot.     

Late results of surgical repairs of tetralogy of Fallot

The late results of 115 children with tetralogy of Fallot born and corrected between 1969 and 1988 are analyzed; the patients were distributed into 3 anatomical groups: normal pulmonary annulus (group A, 49 patients) annular stenosis (group B, 56 patients) and pulmonary atresia (group C, 10 patients). The probability of survival 15 years after correction is 97 p. 100 in cumulated groups A and B and 72 p. 100 in group C (p = 0.005). The probability of reoperation ten years after correction is 4 p. 100 in cumulated groups A and B without a previous shunt, 20 p. 100 in A and B with a previous shunt (p less than 0.05) and 55 p. 100 in group C (p = 0.0004). The proportion of serious cardiac sequellae amounts to 17 p. 100 in group A, 55 p. 100 in group B and 100 p. 100 in group C (p = 0.0005). As a whole, 55 p. 100 of the adolescents operated on for tetralogy of Fallot during infancy present a residual problem of some severity.