Long-term follow-up studies in 211 patients with tetralogy of Fallot after corrective surgery over 10 years

A total number of 427 patients with tetralogy of Fallot who underwent corrective surgery between 1960 and March 1990, in whom 211 patients who survived the surgery over 10 years were evaluated for the follow-up studies. Hemodynamic and cardiac function studies were carried out in 101 patients at the mean interval of 15.7 years (ranges 2 to 21 years). Three methods indicated that patients with muscle resection and pulmonary valvulotomy without patch enlargement (NP) had worse results than the groups with RV patch below valve (RP) and with transannular patch (TP). Also, Holter ECG revealed ventricular arrhythmias in patients with NP were more common than the groups with RP and TP. Sixteen patients (13 with NP, 2 with TP and one with RP) were required reoperation for residual ventricular shunt in 13, residual pulmonary stenosis in 11 and tricuspid regurgitation in 2. All of these 16 patients survived operation and obtained excellent clinical status. It is concluded that patients with TOF after corrective surgery should be carefully followed with short term interval to prevent sudden death and postoperative complications.     

Ninety consecutive corrective operations for tetralogy of Fallot with or without minimal right ventriculotomy

Eighty-eight patients with tetralogy of Fallot and two patients with ventricular septal defect and pulmonary atresia underwent repair without right ventriculotomy (n = 43) or with a minimal right ventriculotomy (n = 47) of 10 to 15 mm. The ventricular septal defect was closed through the tricuspid valve in 75 patients. The pulmonary valve was either preserved or reconstructed to maintain its competence. The age at operation was 1 or 2 years in 51 patients. There was one operative death and there were no late deaths. The results of postoperative cardiac catheterization in the present series of patients (n = 34) were compared with those of control patients (n = 21) who had repairs with a conventional right ventriculotomy in the preceding period. There was no significant difference in right ventricular/left ventricular systolic pressure ratio or in cardiac index either at rest or during isoproterenol infusion between the two groups. The incidence of significant pulmonary regurgitation (Grade greater than or equal to 2/4) was less (p less than 0.05) in the present patients (47%, n = 34) than in the control patients (81%, n = 21). The right ventricular end-diastolic volume index (ml/m2) was smaller in the present patients than in the control patients both at rest (91 +/- 37 versus 142 +/- 28, p less than 0.01) and during isoproterenol infusion (81 +/- 21 versus 109 +/- 30, p less than 0.01). The right ventricular ejection fraction was higher in the present patients than in the control patients during isoproterenol infusion (57% +/- 4% versus 49% +/- 6%, p less than 0.01). The incidence of ventricular arrhythmias (Lown's grade greater than or equal to 2) was less in the present patients (6/35) than in the control patients (36/65) (p less than 0.005). This method of repair for tetralogy of Fallot carries no more risk than the conventional method, and the results are better with respect to postoperative right ventricular function and ventricular arrhythmia.     

Noninvasive and quantitative evaluation of pulmonary regurgitation by pulsed Doppler echocardiography--a study in patients with tetralogy of Fallot after corrective surgery

A noninvasive and quantitative evaluation of pulmonary regurgitation (PR) using pulsed Doppler echocardiography (PDE) was performed in 25 patients with tetralogy of Fallot (TOF) after corrective surgery. Considering a possibility of the presence of the difference in regurgitant flow velocity in pulmonary artery, four sampling points for detecting the pulmonary regurgitant flow were designed as follows: point 0 was positioned at the right ventricular outflow tract; point 1, at the pulmonary annulus; point 2, at mid-portion of the pulmonary trunk; point 3, at bifurcation of the pulmonary artery. The values of maximum Doppler shift determined by analysing the sonograms recorded at point 1, 2 and 3 were examined in comparison with the grades of PR estimated by pulmonary arteriography and the results obtained were as follows. In a retrospective study in 18 patients with PR, the values of maximum Doppler shift were highest at point 1, and followed by point 2 and point 3 in order (p less than 0.005), indicating that the velocity gradient of regurgitant flow existed in the pulmonary artery. The values of maximum Doppler shift were highest in the group of PR grade III estimated by pulmonary arteriography, and followed by the group of PR grade II and grade I in order. At point 2, the group of grade III-PR showed significantly higher Doppler shift than the group of grade I-PR (p less than 0.05). Following above data, a new criteria for estimating the severity of PR by PDE according to the velocity gradient of regurgitant flow in the pulmonary artery was proposed. In a prospective study in a separate group of other 7 patients, the grade of PR estimated by PDE corresponded well with these of pulmonary arteriography, with a significant Spearman rank correlation coefficient (rs = 0.90, p less than 0.01). An experimental study using a dog with surgically induced PR of different grades confirmed the presence of higher Doppler shift in pulmonary artery corresponding to the grade of PR. These results indicated the usefulness of a newly proposed method evaluating PR by PDE applying a concept of Windkessel model for PR regurgitant flow.     

Prediction of severe obstruction to right ventricular outflow after repair of tetralogy of Fallot and pulmonary atresia

Cineangiograms were available for a quantitative retrospective study along with complete clinical information in 96 patients who underwent intracardiac repair of tetralogy of Fallot with pulmonary atresia. Multivariate analysis determined that the risk factors for too high a ratio (greater than or equal to 1) between the peak pressure in the right ventricle and that in the left, in the operating room about 30 minutes after repair, were as follows: size of the patient, small size of the right and left pulmonary arteries, and a larger number of large aortopulmonary collateral arteries. When, according to the multivariate equation, the predicted probability of this ratio being equal to or greater than 1 is 50% or more, consideration may be given to preliminary operations before repair; when the predicted probability is 70% or more, complete repair at that stage may be unwise.     

The influence of pulmonary regurgitation on left ventricular function after repair of tetralogy of Fallot

The influence of right ventricular (RV) volume overload by pulmonary regurgitation (PR) on left ventricular (LV) function was evaluated postoperatively in 23 patients with tetralogy of Fallot (TF). The age at operation was 3.1 +/- 1.7 (mean +/- SD) years. The age at postoperative study was 5.9 +/- 2.0 years. We determined RV end-diastolic volume (%RVEDV), RV ejection fraction (EF), %LVEDV, LV end-systolic volume (%LVESV), LVEF, and LV end-systolic stress (ESS)/%LVESV. Patients were divided into 2 groups on the basis of presence or absence of RV volume overload by PR as follows: The %RVEDV (175 +/- 23%) of group 1 (n = 10) was 150% greater than normal RVEDV. Group 2 (n = 13) had normal %RVEDV (108 +/- 23%). Preoperatively, there had been no differences in hemoglobin, %RVEDV, RVEF, %LVEDV, LVEF, and in the ratio of average cross-sectional area of the left and right pulmonary arteries to cross-sectional area of the normal right pulmonary artery between the 2 groups. Moreover, there were no differences in age at repair, or during postoperative study, nor in the postoperative ratio of RV to LV systolic pressure between the 2 groups. RVEF was significantly less in group 1 than in group 2 (0.53 +/- 0.05 vs 0.58 +/- 0.05, p less than 0.05). %LVEDV and %LVESV in group 1, 138 +/- 10% and 171 +/- 30% respectively, were significantly greater than those in group 2, 116 +/- 11% and 133 +/- 20% respectively (p less than 0.001 in %LVEDV and p less than 0.01 in %LVESV).(ABSTRACT TRUNCATED AT 250 WORDS)     

右心室流出道的处理方法与法洛四联症矫治术后右心室功能的相关分析

目的 评价法洛四联症(TOF)右心室流出道(RVOT)处理方法与矫治术后右心功能变化的关系,以期提高矫治手术的中、远期效果.方法 2003年1月至2006年1月,125例TOF患儿接受矫治手术,其中男66例,女59例;手术年龄1～5岁,平均(3.4±1.1)岁;体质量7～26 kg,平均(15.2±5.7)kg.对照组选择20例同龄健康儿童.RVOT处理方法包括跨肺动脉瓣环补片加宽(M1组)67例,右心室漏斗部补片加宽(M2组)6例,经右心室切口非补片修复(M3组)18例,经右心房-肺动脉切口非补片修复(M4组)34例.采用脉冲多普勒(PDE)和组织多普勒超声心动图(TDI)评价右心室功能,选择三尖瓣环收缩期移位(TAPSE)、右心室心肌作功指数(MPI)作为右心室收缩功能指标,测定的三尖瓣瓣环处舒张早期峰速(Em),舒张晚期峰速(Am),计算Em/Am和E/Em比值作为右心室舒张功能指标.计量资料采用单因素方差分析,单因素分析有统计学意义的变量纳入logistic回归分析.计数资料采用x2检验.结果 术后5年随访检查心脏超声发现,M1和M2组的MPI和E/Em显著高于M3和M4组.单因素分析显示,术前Nakata指数、既往分流手术、手术方式、肺动脉瓣反流和术后QRS时间是影响术后MPI的危险因素;术前Nakata指数、手术方式、肺动脉瓣反流和术后QRS时间是影响术后E/Em的危险因素.二元logistic逐步回归分析结果显示,手术方式和术后QRS时间是影响术后MPI的独立因素;术后肺动脉瓣反流是影响术后E/Em的独立因素.结论 TOF术后右心室功能降低与RVOT处理方法有关,舒张功能的降低与术后肺动脉瓣的反流有明显的相关性,收缩功能的降低与手术中应用补片加宽右心室流出道和术后的QRS时间有明显的相关性.心脏超声多普勒技术在测定TOF术后右心室功能和评价术后中、长期疗效有重要的指导意义.     

Stability of right and left ventricular ejection fractions and volumes after heart transplantation.

BACKGROUND: The long-term stability of right ventricular (RV) and left ventricular (LV) volume and function after heart transplantation has not been well characterized. Accordingly, the objective of this study was to assess time- and rejection-dependent changes in RV and LV function and volume after cardiac transplantation by means of a recently validated 3-dimensional tomographic equilibrium radionuclide ventriculography approach. METHODS: A total of 71 consecutive patients (age, mean +/- SD, 57 +/- 12 years; 62 men; 9 women) were studied 5 +/- 4 years (range 1--16 years) after heart transplantation. The mean frequency of >Grade 2 rejection was 1.7 +/- 1.8 episodes (range 0--7 episodes). RV and LV ejection fraction (EF) and end-diastolic volume (EDV) in transplant patients were compared with data from 34 subjects at low likelihood for coronary artery disease. RESULTS: No significant differences in RV or LV EF or EDV compared with controls were observed (RV EF=54 +/- 9 vs 53 +/- 9; RV EDV [ml]=109 +/- 35 vs 120 +/- 32; LV EF=72 +/- 8 vs 73 +/- 9; and LV EDV [ml]=108 +/- 28 vs 98 +/- 20 for controls and patients with transplants, respectively; p=NS for all comparisons). There was no significant effect on RV or LV EF or volumes with rejection, or with time after transplantation. CONCLUSIONS: RV as well as LV EF and EDV are stable more than 1 year after heart transplantation for up to 16 years. Thus, changes in EF or EDV in the transplanted heart are abnormal and should prompt a clinical evaluation.