Tetralogy of Fallot Associated with Aortic Insufficiency

Five patients with tetralogy of Fallot associated with aortic insufficiency were studied. They ranged from 6 to 34 years old (mean, 14 years), and 2 patients had a history of subacute bacterial endocarditis. Four patients had a bulboventricular type of ventricular septal defect. Prolapse of the right coronary cusp was the main cause of aortic insufficiency. Deformed valve secondary to subacute bacterial endocarditis and severe dilatation of the aortic annulus were the other causes. In addition to repair of the tetralogy defect, aortic valvuloplasty was performed in 2 patients. In the remaining 3 patients, the ventricular septal defect was closed with a relatively small-sized patch and no aortotomy was made. Four patients survived the operation, and no residual aortic insufficiency was observed in 3 of them. The etiology and the method of operation are discussed.     

Congenital Intercostal Lung Herniation Combined with an Unusual Morgagni's Hernia

A 70-year-old male visited urgent care due to coughing for 1 month and left chest pain. He had no history of trauma. The initial chest computed tomography (CT) showed the 7th left intercostal lung herniation. A follow-up CT showed an intercostal lung herniation combined with a bowl herniation, which had developed due to a Morgagni's hernia. An emergency operation was performed due to the incarceration of the bowl and lung. The primary repair of the diaphragm was performed and the direct approximation of the 7th intercostal space was determined. We concluded that the defect of the diaphragm and the intercostal muscle was a congenital lesion, and the recurrent coughing was the aggravating factor of herniation.     

Tetralogy of Fallot with subarterial ventricular septal defect

BACKGROUND: Tetralogy of Fallot with subarterial ventricular septal defect is frequently seen among Asians. Compared with infracristal ventricular septal defect, postoperative right ventricular outflow obstruction is more likely because of subpulmonary extension of the defect. Moreover the incidence of aortic regurgitation is a concern because of the absence of a supporting infundibulum. METHODS: Four hundred cases of classic tetralogy were reviewed, 61 of which had subarterial ventricular septal defect. RESULTS: Aortic regurgitation (of more than mild degree) was identified in 7 cases with subarterial and 7 with infracristal ventricular septal defects. The mechanism of infracristal defect was predominantly an annular dilation before surgery. In contrast 5 cases with subarterial defect had progression of aortic regurgitation after operation yielding an actuarial incidence of 29.7% at 20 years. In 2 patients the cause seemed to be fixation or plication of the aortic valve annulus by the ventricular septal patch. Compared with infracristal defect, subarterial defect was associated with increased incidence of reoperation (12.0% versus 1.9% at 10 years, p = 0.01), frequent use of transannular patch (70.5% versus 45.7%, p = 0.0004), and worse New York Heart Association (NYHA) functional class (p = 0.007). Right ventricular outflow obstruction was the reason for reoperation in 3 patients with subarterial defect and was associated with worse NYHA classification in the long-term, on multivariate analysis (p = 0.0002). CONCLUSIONS: Tetralogy with subarterial ventricular septal defect was associated with worse functional outcome. To prevent adverse outcomes, precise suturing of the distal ventricular septal patch, extensive infundibulectomy, lower threshold for transannular incision, and smaller-sized ventricular septal patch placement are warranted.     

Postoperative Studies in Patients with Tetralogy of Fallot

The present series demonstrates that hemodynamic abnormalities persist following intracardiac repair of tetralogy of Fallot despite clinical improvement. The incidence of residual ventricular communication and residual outflow obstruction is consistent with previous reports. The pulmonary incompetence is well tolerated when it exists as an isolated residual abnormality. The use of Teflon cloth to relieve the outflow obstruction has not led to aneurysm formation. This report calls attention to the occurrence of tricuspid insufficiency in patients with tetralogy of Fallot and the increased postoperative morbidity with this combination. Finally, aortic regurgitation is part of the pathophysiology of tetralogy of Fallot and may well affect the results of the intracardiac repair. The long-term consequences of these abnormalities are left to future consideration.     

Tetralogy of Fallot Associated with Complete Atrioventricular Canal

A 6-year-old girl had the clinical appearance of tetralogy of Fallot but was found at cardiac catheterization to have tetralogy of Fallot associated with complete atrioventricular canal. She underwent repair, and at recatheterization two years later, the hemodynamic result was excellent. Proper angiography is necessary to diagnose this combination, and correct preoperative diagnosis is necessary to plan a rational operative approach.     

Tetralogy of Fallot with subpulmonary ventricular septal defect

Among a total of 608 patients with tetralogy of Fallot, 35 with tetralogy and subpulmonary ventricular septal defect (VSD) have undergone intracardiac repair at the Children's Hospital, Buenos Aires. The crista supraventricular was absent in 62.9% of these patients; it was hypoplastic in 37.1%. Only 3 patients (8.6%) were severely cyanotic and required operation in infancy. The main and left and right pulmonary arteries were relatively large in all but 1 patient. Nevertheless, patch-graft enlargement across the pulmonary valve ring was necessary in 20 (57.1%). We believe that closure of the subpulmonary VSD increase the apparent severity of the pulmonary stenosis and necessitates patch-graft enlargement in patients in whom the appearance of the right ventricular outflow tract before repair would not have suggested its need.     

Transventricular Repair of Tetralogy of Fallot

When the preoperative assessment suggests that the pulmonary valve annulus is of adequate size, repair through the right atrium seems the best option. However, when the annulus is obviously small and a transannular patch will be needed, a ventriculotomy will be needed, and a small extension allows an adequate view of the VSD. This is a very satisfactory approach, and particularly when the repair is performed in infancy (which seems to be the current trend), late arrhythmias are very infrequent. When the annulus size is equivocal, either approach can be used and even a combination of ventricular and transatrial methods used to close the VSD.The results with both approaches are now very good, but an increased recurrence of RVOTO has been reported with the transatrial approach, presumably because of inadequate resection of obstructing muscle in the RVOT.¹⁰ Because transannular patches cause pulmonary regurgitation, many patients will come to late pulmonary valve replacement. However, even when the pulmonary valve is preserved, late regurgitation may occur and all these patients need careful follow-up.     

法乐四联症伴肺动脉闭锁的外科治疗(附14例报告)

报告外科治疗法乐四联症伴肺动脉闭锁１４例。肺动脉瓣水平膜状闭锁１３例，主肺动脉干闭锁１例。肺动脉发育好，肺血由一粗大的动脉导管供给者９例；肺动脉发育不良、无动脉导管，肺血由体肺侧支供给者１例；肺动脉发育不良，由细的动脉导管和体肺侧支共同供给者４例。姑息性手术５例，一期根治９例，二期根治２例；死亡３例。作者对法乐四联症伴肺动脉闭锁的手术适应证、姑息性手术方法的应用及体肺侧支的外科处理原则进行了探讨。     

Tetralogy of Fallot Repair with Minimal or No Ventriculotomy

Twenty-four consecutive patients with the tetralogy of Fallot underwent repair from March 25, 1985 to March 24, 1986. Correction was achieved without a ventriculotomy in 8 patients, necessitated a minimal ventriculotomy in 8, and a formal right ventriculotomy incision was required in the other 8. There were no early or late phase deaths-0% (70% C.L. 0%-7%). Post repair right ventricular to left ventricular pressure ratios were not significantly different between the three groups (p = 0.85). The 16 patients (66%) who underwent repair without a formal ventriculotomy were found to have severe hypertrophy of the infundibular septum as the primary etiology for right ventricular outflow tract obstruction. The other 8 patients (34%), who required a transventricular approach to the repair, were all found to have predominantly hypoplasia of the outflow tract and not hypertrophy. We conclude that repair of the tetralogy of Fallot can frequently be accomplished with no or a minimal ventriculotomy, and the results are satisfactory. Herein is described the operative approach to this procedure.