Tetralogy of Fallot: favorable outcome of nonneonatal transatrial, transpulmonary repair.

This report describes our experience with 366 patients who had a transatrial, transpulmonary repair of tetralogy of Fallot between December 1980 and December 1991. Included in this group are patients with tetralogy of Fallot plus atrioventricular septal defect as well as patients displaying all degrees of aortic override (in the presence of subaortic ventricular septal defect and right ventricular outflow tract obstruction). Median age was 15.3 months and median weight, 12.3 kg. Of the 366 patients, 72% required a pericardial patch to reconstruct the main pulmonary artery or right ventricular outflow tract. Serious coronary anomalies were seen in 11 patients, without influencing surgical approach. There were two hospital deaths (0.5%; 70% confidence limits, 0.2% to 1.2%). Actuarial survival was 97.5% at 42 months (95% confidence limits, 95% to 99%) reflecting four late deaths over 1,129 patient-years of follow-up. Postoperative cardiac catheterization studies were performed in 61 patients at a mean follow-up interval of 23 months. Mean right ventricular/left ventricular systolic pressure ratio after repair was 0.46 (standard deviation, 0.28), and mean gradient across the right ventricular outflow tract was 15 mm Hg (standard deviation, 24 mm Hg). Actuarial freedom from reoperation for any reason has been 95% (95% confidence limits, 92% to 97%) at 5-year and 10-year follow-up. These early and medium-term results encourage us to continue with transatrial, transpulmonary repair of tetralogy of Fallot. We believe that this approach has an operative risk similar to or lower than transventricular repair, and that it will result in better preservation of right ventricular function in the long term.     

Complete atrioventricular septal defect associated with tetralogy of Fallot. Favourable outcome of transatrial transpulmonary repair

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: The transatrial-transpulmonary approach for correction of AVSD with TOF contributes to improved results after repair of this rare combination of defects.     

Transatrial-Transpulmonary Repair of Atrioventricular Septal Defect with Right Ventricular Outflow Tract Obstruction

A bstract Twenty patients had a repair of an atrioventricular septal defect with tetralogy of Fallot (n = 13) or double outlet right ventricle (n = 7). Mean age was 3.5 years. Surgical technique included transatrial-transpulmonary resection of right ventricular outflow tract obstruction and transatrial two patch repair of the atrioventricular septal defect. Ten patients required a transannular patch and one patient had a right ventricle-pulmonary artery conduit placed. There was no hospital mortality, and mean hospital stay was 15 days. One patient had late sudden death of unknown cause. Six patients have required reoperation because of residual ventricular septal defect (VSD), mitral incompetence, residual right ventricular outflow tract obstruction, and/or conduit stenosis. No patient was reoperated on because of left ventricular outflow tract obstruction. Fifteen patients are asymptomatic, one has exertional dyspnea, and two have intermittent occasional bronchospasm. The transatrial-transpulmonary two patch repair and extensive relief of right ventricular outflow tract obstruction have given good immediate results. Reoperation rate has been high mainly due to residual VSD and mitral incompetence. ( J Card Surg 1993; 8:622–627 )     

Primary repair minimizing the use of conduits in neonates and infants with tetralogy or double-outlet right ventricle and anomalous coronary arteries

OBJECTIVE: The purpose of this study was to review our results with an approach of early primary repair for tetralogy of Fallot or double-outlet right ventricle with anomalous coronary arteries, using several techniques to minimize the use of a conduit. METHODS: Twenty consecutive neonates and infants with anomalous coronary arteries crossing an obstructed right ventricular outflow tract underwent primary repair. Median age was 5.5 months and mean weight 6.22 kg. The anomalous coronary arteries included the left anterior descending from the right coronary artery (n = 10), the right coronary artery from the left anterior descending (n = 1), the left anterior descending from the right sinus (n = 1), and a significant conal branch from the right coronary artery (n = 7) or left anterior descending (n = 1). Two neonates had pulmonary atresia. The right ventricular outflow tract was reconstructed without a conduit in 18 patients, including those with pulmonary atresia. Surgical techniques included main pulmonary artery translocation in 4 patients, transannular repair under a mobilized left anterior descending coronary artery in 2 patients, and displaced ventriculotomy with subcoronary suture lines in 8 patients. In 4 patients the right ventricular outflow tract was repaired via the ventriculotomy and/or pulmonary arteriotomy. A homograft was used as the sole right ventricle-pulmonary artery connection in 1 patient and in another a homograft was added to a hypoplastic native pathway. RESULTS: There have been no early or late deaths. The right ventricular/left ventricular pressure ratio within 48 hours of the operation was 0.47 +/- 0.10. There were 2 reoperations at 8 and 11 years after the operation, during a mean follow-up of 5.2 years (1-11.3 years). CONCLUSIONS: Primary repair of tetralogy of Fallot or double-outlet right ventricle with anomalous coronary arteries can be done in neonates and infants with excellent results. Alternative surgical techniques for right ventricular outflow tract reconstruction, such as main pulmonary artery translocation, can avoid the use of a conduit in most patients.     

Early primary repair of tetralogy of Fallot

Young age, low weight, and the requirement for transannular patch reconstruction of the right ventricular outflow tract (RVOT) are thought to adversely affect intracardiac repair of tetralogy of Fallot. Forty patients underwent complete repair between January, 1984, and January, 1987. Only infants with pulmonary atresia, complete atrioventricular canal, or coronary artery anomalies were shunted initially. The malalignment ventricular septal defect was closed with a Dacron patch. Infundibular resection was minimized. All atrial communications were left open. Thirty-four patients (85%) had a transannular RVOT patch, and 2 patients (5%) had a nontransannular patch. All 10 infants weighing 3.4 to 9.6 kg had a transannular RVOT patch at 7 weeks to 12 months of age. An RVOT patch was used in 26 of 30 children operated on between 1 and 6 years of age (median age, 24 months). No patient undergoing intracardiac repair died. Postoperative RVOT pullback gradients were between 0 and 35 mm Hg (mean, 18.5 mm Hg). Postoperative pulmonary artery saturation (mean, 73%) did not reveal any residual ventricular septal defect. The right ventricular/arterial pressure ratio was always less than 0.6 (mean, 0.4). All children are doing well at follow-up from two to 37 months. Serial echocardiograms reveal no residual ventricular septal defect and only 1 moderate RVOT gradient. Follow-up cardiac catheterization in 15 patients revealed no residual ventricular septal defect and RVOT gradients between 5 and 35 mm Hg. The right ventricular/left ventricular pressure ratio was always less than 0.6 (mean, 0.48). The early and late results justify continued primary repair of tetralogy of Fallot in symptomatic children, regardless of age or weight.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transatrial-transpulmonary repair of tetralogy of Fallot

Classical tetralogy of Fallot was repaired by a transatrial-transpulmonary approach in 61 of 70 patients treated surgically on one surgical service between July 1981 and December 1985. Their ages ranged from 2.5 months to 57 years (mean 52.9 +/- 104.2 months). The ventricular septal defect was closed through the right atrium and tricuspid valve in 60 patients and via the pulmonary artery in one patient with a subpulmonary defect. A pulmonary arteriotomy was made in 38 patients to expose the stenotic pulmonary valve for valvotomy and to begin the infundibular mobilization and resection. It was extended through a small pulmonary anulus primarily in 15 patients and secondarily in one, a minimal distance upon the right ventricular infundibulum to enlarge the outflow tract to 2 standard deviations larger than the mean normal pulmonary valve anulus diameter. There were no hospital or late deaths or reoperations among the entire group. The mean postrepair peak right ventricular/left ventricular pressure measured in the operating room was 0.52 +/- 0.165 for the entire group of 61 patients which indicates similar relief of pulmonary stenosis to that obtained by the classical transventricular repair. At follow-up between 2.3 and 53.8 months (mean 22.6) each patient was in New York Heart Association Class I and without cardiac medication. Postoperative cardiac catheterization studies performed in nine patients between 4 and 28 months after operation showed no residual ventricular septal defects and a mean peak right/left ventricular pressure of 0.42 +/- 0.13. This series indicates that successful repair of tetralogy of Fallot can be accomplished in most patients by a transatrial-transpulmonary approach, which may provide improved right ventricular function over the long term.     

Repair of complete atrioventricular septal defect with tetralogy of fallot: our experience and literature review

OBJECTIVES: The aim of this report is to describe the rationale of our surgical approach, to explore the best management for complete atrioventricular septal defect associated with the tetralogy of Fallot (CAVSD-TOF), and to present our outcome in relation to the previously reported series. MATERIALS AND METHODS: Between January 1990 and January 2002, 17 consecutive children with CAVSD-TOF underwent complete correction. Nine patients (53%) underwent previous palliation. Mean age at repair was 2.9 +/- 1.9 years. Mean gradient across the right ventricular outflow tract was 63 +/- 16 mmHg. All children underwent closure of septal defect with a one-patch technique, employing autologous pericardial patch. Maximal tissue was preserved for LAVV reconstruction by making these incisions along the RV aspect of the ventricular septal crest. LAVV annuloplasty was performed in 10 (59%) patients. Six patients (35%) required a transannular patch. RESULTS: Three (17.6%) hospital deaths occurred in this series. Causes of death included progressive heart failure in two patients and multiple organ failure in the other patient. Two patients required mediastinal exploration due to significant bleeding. Dysrhythmias were identified in 4 of 11 patients undergoing a right ventriculotomy versus none of the patients undergoing a transatrial transpulmonary approach (p = ns). The mean intensive care unit stay was 3.2 +/- 2.4 days. Two patients required late reoperation due to severe LAVV regurgitation at 8.5 and 21 months, respectively, after the intracardiac complete repair. The mean follow-up time was 36 +/- 34 months. All patients survived and are in NYHA functional class I or II. The LAVV regurgitation grade at follow-up was significantly lower than soon after operation, 1.1 +/- 0.4 versus 1.7 +/- 0.5 (p = 0.002). At follow-up, the mean gradient across the right ventricular outflow tract was 17 +/- 6 mmHg, significantly lower than preoperatively (p < 0.001). CONCLUSIONS: Complete repair in patients with CAVSD-TOF seems to offer acceptable early and mid-term outcome in terms of mortality, morbidity, and reoperation rate. Palliation prior to complete repair may be reserved in specific cases presenting small pulmonary arteries or severely cyanotic neonates. The RVOT should be managed in the same fashion as for isolated TOF; however, a transatrial transpulmonary approach is our approach of choice.     

Tetralogy of Fallot with anomalous coronary artery: double outflow technique.

A new technique to repair tetralogy of Fallot with an anomalous coronary artery crossing the right ventricular outflow tract is described, together with intermediate term follow-up. Using a pedicled flap of the anterior pulmonary artery wall as the floor, and a vascular or prosthetic patch as the roof, a composite conduit with the potential for growth is constructed. Together with the native outflow tract, this provides unobstructed egress from the right ventricle to the branch pulmonary arteries. Since 1990, 4 infants aged 2-weeks to 6-months have undergone primary repair using this technique. Intermediate term follow-up shows adequate durability of the repair.     

Slicing technique of the RV outflow tract in transatrial-transpulmonary repair for tetralogy of Fallot

The relief of a right ventricular outflow tract obstruction is a crucial step to successful transatrial-transpulmonary repair for tetralogy of Fallot. We here describe our technique for achieving good effective relief of a right ventricular outflow tract obstruction by slicing the wall without right ventriculotomy or with minimum transannular right ventriculotomy if necessary. The right ventricular outflow tract can be widely opened by slicing the inner half of the wall both through the tricuspid valve and the pulmonary valve. This procedure can be performed safely and effectively by detecting structural differences between the inner and outer half of the right ventricular wall, the former coarse and the latter dense.     

Evaluation of the growth of a new pulmonary trunk after the reconstruction of right ventricular outflow tract without using an external conduit

To evaluate the growth of a pulmonary trunk reconstructed without an extracardiac conduit, the hemodynamics and diameter of a new pulmonary trunk were measured in 5 patients from the right ventriculogram and MRI at postoperative follow-up periods. There were tetralogy of Fallot with pulmonary atresia in two patients, tetralogy of Fallot with single coronary in one, truncus arteriosus type I in one and transposition of the great arteries with ventricular septal defect and pulmonary stenosis in one. The age at operation ranged from 26 days to 4.5 years. The posterior wall continuity of the right ventricle and pulmonary artery was established by the direct pulmonary-right ventricular anastomosis in three patients and by the interposition of the left atrial appendage in two. Postoperative follow-up periods ranged from 2 years and 6 months to 3 years and 10 months (median: 2 years and 11 months). In four of them, the postoperative right ventricular to aortic or left ventricular systolic pressure ratios were less than 0.4 without any significant systolic pressure gradients between pulmonary artery and right ventricle. In these four patients, the diameters of the reconstructed pulmonary trunks grew from 10～18 mm to 18～21 mm postoperatively. These diameters were more than 100% of normal values. In the remaining patient with tetralogy of Fallot and single coronary artery, the obstruction of the new pulmonary trunk by a bulged left atrial appendage, which was used as the postoperior wall, was observed on the right ventricular outflow tract reconstruction without an extracardiac conduit has growth potential in the future.     

Reconstruction of the pulmonary valve and outflow tract with bicuspid prosthesis in tetralogy of Fallot

Background. Right ventricular outflow tract and pulmonary valve implant in patients with tetralogy of Fallot may be required to avoid late postoperative right ventricular impairment. The use of porcine bicuspid prosthesis might be a technical alternative, although comprehensive studies on the long-term use of these prostheses are not available.

Methods. Sixty-three patients (aged 5 months to 34 years; mean, 6 years) with tetralogy of Fallot and pulmonary hypoplasia underwent surgical repair and enlargement of the right ventricular outflow using preserved porcine pulmonary bicuspid prostheses. Fifty-two patients (82.5%) were followed and underwent clinical evaluation and serial Doppler echocardiography. The first 15 patients (29.4%), with ages ranging from 5 to 16 years (mean, 8.2 years) and postoperative follow-up of 48 to 87 months (mean, 65.1 months) underwent hemodynamic and cineangiographic evaluations.

Results. There were 11 deaths (17.4%) in the early postoperative period. Of the 52 surviving patients (82.5%), 51 (80.9%) were followed for 1 to 87 months (mean, 42.0 months). Four patients (7.6%) had additional treatment. Of the 15 patients (29.1%) undergoing hemodynamic evaluation, 9 (60%), had mild valvular pulmonary insufficiency and 6 (40%) had moderate insufficiency. Only the right ventricle-to-pulmonary artery pressure gradients and the right ventricular ejection fraction showed statistically significant differences between groups. Right ventricular dimension, although increased in all patients, did not show statistically significant differences.

Conclusions. Right ventricular outflow tract and pulmonary valve repair in patients with tetralogy of Fallot using a bicuspid porcine pulmonary prosthesis is a simple, reliable procedure with good results in postoperative medium term follow-up.     

Tetralogy of Fallot correction with transannular patch reconstruction in a patient with an anomalous right coronary artery and an unusual course of the right ventricular branch

Anomalous coronary arteries occur in as many as 12% of patients with tetralogy of Fallot (TOF). In patients with this condition, pulmonary hypoplasia can be prohibitive in performing a valve-sparing repair, subsequently resulting in various techniques to preserve the anomalous coronary artery. The management strategy is often complex in such a situation. We report on a case of TOF with an anomalous right coronary artery crossing the right ventricular outflow tract, with an unusual course of the right ventricular (RV) branch, which precluded placement of a valved conduit. In this case, we performed a successful repair with mobilization of the anomalous coronary artery and reconstruction of the right ventricular outflow tract with a limited transannular patch.     

Coronary artery anomalies in patients with tetralogy of Fallot.

A left anterior descending coronary artery arising from the right coronary artery can be easily injured during performance of a right ventriculotomy for correction of tetralogy of Fallot. This occurred in 2 of the 23 patients in this series, and both patients died from myocardial failure in the early period after operation. Of 19 patients who presented a combination of tetralogy of Fallot and unusual coronary artery distribution, injury to the abnormal coronary artery was avoided by a transverse right ventriculotomy either alone or combined with an upper vertical incision in 17 patients. In 2 patients a Dacron tube graft was inserted between the right ventricular outflow tract and the pulmonary artery. In 2 patients a right ventriculotomy was avoided by closing the ventricular septal defect through a transaortic approach. All 21 patients survived. Before a vertical or longitudinal incision in the right ventricular outflow tract is performed, the coronary artery distribution should always be checked and confirmation made of the normal origin of the left anterior descending branch from the left coronary artery to the left of the pulmonary artery.     

Right ventricular outflow tract reconstruction for tetralogy of fallot with abnormal coronary artery: experience with 35 patients

BACKGROUND: An abnormal coronary artery crossing the right ventricle outflow tract (RVOT) complicates complete repair of tetralogy of Fallot (TOF). We have evaluated surgical options for RVOT reconstruction for this group of patients. METHODS: Between 1984 and 2002, 35 TOF patients with abnormality of coronary arteries underwent total correction. Age of these patients ranged from 1 to 14 years (mean 5.8 +/- 2.8 years). All patients were diagnosed by echocardiography and 25 patients had cardiac catheterization. All the abnormal coronary arteries were spared at the operation. In 24 patients a transannular patch was applied for RVOT reconstruction. In three patients with an adequate pulmonary annulus, oblique ventriculotomy incisions, and in two patients, transatrial approaches were performed. "Two-patch" technique was chosen for two patients. In four patients placement of an extracardiac conduit was necessary. RESULTS: Mortality was observed in four patients, in two of them due to suspected myocardial ischemia. None of the surviving patients needed reoperation. All of them were in NYHA class I. The follow-up period for patients without extracardiac conduit was between 14 and 96 months (mean 50.2 months) and for the patients with extracardiac conduit ranged 36 to 98 months (63.5 months). The mean gradients measured by echocardiography were, respectively, 5 mmHg (range 0 to 35 mmHg) and 23.75 mmHg (range 20 to 25 mmHg). CONCLUSIONS: Definitive repair of TOF patients with abnormal coronary arteries can be performed in early childhood, but care should be taken to leave at least 1 cm of myocardium between the sutureline and the abnormal coronary artery. Detailed evaluation of the patients preoperatively is mandatory to identify the strategy and timing of the operation.     

Simplified technique for pericardial patch of the right ventricular outflow tract

Pericardial patching to enlarge the right ventricular outflow tract is often required in congenital cardiac surgery in lesions such as tetralogy of Fallot, pulmonary atresia, pulmonary stenosis, and pulmonary artery repair following removal of a palliative pulmonary artery band. A method of simplifying the attachment of the pericardial patch onto the right ventricular outflow tract is described.     

Repair of complete atrioventricular septal defect with tetralogy of Fallot

Repair of complete atrioventricular canal with tetralogy of Fallot was performed in 9 patients. Ventricular septal defect was closed through the right atrium using a single polytetrafluoroethylene patch with ample anterior extension to avoid subaortic obstruction. The atrial septal defect was closed with a separate patch. Undivided atrioventricular valve leaflets were sandwiched between the two patches. Right ventricular outflow tract stenosis was relieved by pulmonary valvotomy and an infundibular patch in 7, a supravalvar patch (none transannular) in 6, and right ventricle-to-pulmonary artery conduit in 2. There was one hospital death (1/9, 11%) in a patient with persistent clinically significant postoperative pulmonary stenosis and low cardiac output requiring reoperation and right ventricle-to-pulmonary artery conduit insertion. There was no late mortality. All patients are asymptomatic 0.3 to 5.6 years after operation. Follow-up right ventricular outflow tract gradient ranged from 11 to 43 mm Hg and was 70 mm Hg in 1 patient who later had successful relief of obstruction. Three patients had mitral valve insufficiency; 1 needed reoperation. Aggressive relief of right ventricular outflow tract stenosis with maintenance of pulmonary valve competence and use of two separate patches for closure of the septal defects contribute to optimum immediate and long-term results after repair of this lesion.     

Tetralogy of Fallot with anomalous origin of left anterior descending coronary artery. Surgical options

Anomalous origin of the left anterior descending coronary artery from the right coronary artery can interfere with the location of the usual ventriculotomy during repair of tetralogy of Fallot. The purpose of this study was to compare the results of two operative techniques: (1) a "tailored" right ventricular incision and outflow patch reconstruction and (2) placement of a conduit from the right ventricle to the main pulmonary artery. We reviewed the records of 416 patients who had complete repair of tetralogy of Fallot at the Mayo Clinic from 1973 through 1984. Twenty (5%) (median age 6.5 years) had anomalous origin of the left anterior descending coronary artery from the right coronary artery. Twelve of these patients had right ventricular outflow patch reconstruction, and eight had placement of a conduit from the right ventricle to the pulmonary artery. Three deaths occurred, all during hospitalization, two in the patch reconstruction group and one in the conduit group. The average reduction in right ventricular pressure postoperatively was slightly but not significantly greater for the conduit group. These data indicate that correction of tetralogy of Fallot with anomalous origin of the left anterior descending coronary artery can be done with either patch reconstruction or conduit placement. Selection of the more appropriate procedure depends on the exact location and degree of tortuosity of the anomalous artery and the level and severity of right ventricular outflow obstruction.     

Aneurysm of pericardial right ventricular outflow tract patches.

Among 1,022 patients who underwent repair of tetralogy of Fallot, 252 received a pericardial patch of the right ventricular outflow tract; of these, 10 subsequently developed an aneurysm of the right ventricular outflow tract. Cardiac catheterization and angiography revealed moderate pulmonary insufficiency in all patients, a residual pressure gradient in the right ventricular outflow tract in 7, and a residual ventricular septal defect in 2 patients. Reoperation was indicated in 8 patients because of progressive distention of the aneurysm, residual infundibular or pulmonary artery stenosis, and recurrent ventricular septal defect. Reconstruction of the right ventricular outflow tract was accomplished by resection of the aneurysm and insertion of a woven Dacron patch in 5 patients, primary suture of the pulmonary artery in 2, and implantation of a woven Dacron conduit containing a Björk-Shiley cardiac valve prosthesis in 1 patient. There were no early or late deaths. When reconstruction of the right ventricular outflow tract is necessary, we recommend a woven Dacron patch because pericardium may form an aneurysm.     

Reoperation of tetralogy of Fallot for the transannular patch neo-intimal stenosis: a case report]

A 3-year-old male patient underwent right ventricular outflow tract reconstruction with a glutaraldehyde-preserved equine pericardium for tetralogy of Fallot. Because of progressive severe pulmonary restenosis with over systemic right ventricular pressure, tricuspid regurgitation, and abnormal high echoic shadow in the distal main pulmonary artery on echocardiogram, he required reoperation a year after the first correction. In the reoperative findings, the pseudointima was thickened heavily and detached from glutaraldehyde-preserved equine pericardial patch. The patch was removed and the right ventricular outflow was reconstructed widely to the pulmonary bifurcation with porcine pericardial patch again. Patho-histological findings showed foreign body giant cells and macrophages in the pseudointima. Four years after the reoperation, echocardiogram shows 41 mmHg for the right ventricular pressure and 22 mmHg for the pressure gradient of right ventricular outflow tract, and the patient is doing well now.     

Reoperation in adults with repair of tetralogy of fallot: indications and outcomes.

OBJECTIVE: The purpose of this study is to review indications, surgical procedures, and outcomes in adults with repaired tetralogy of Fallot referred for reoperation. METHOD: Sixty consecutive adults (age >/= 18 years) who underwent reoperation between 1975 and 1997 after previous repair of tetralogy of Fallot were reviewed. Mean age at corrective repair was 13.3 +/- 9.6 years and at reoperation 33.3 +/- 9.6 years. Mean follow-up after reoperation is 5.0 +/- 4.9 years. RESULTS: Long-term complications of the right ventricular outflow tract (n = 45, 75%) were the most common indications for reoperation: severe pulmonary regurgitation (n = 23, 38%) and conduit failure (n = 13, 22%) were most frequent. Less common indications were ventricular septal patch leak (n = 6) and severe tricuspid regurgitation (n = 3). A history of sustained ventricular tachycardia was present in 20 patients (33%) and supraventricular tachycardia occurred in 9 patients (15%). A bioprosthetic valve to reconstruct the right ventricular outflow tract was used in 42 patients. Additional procedures (n = 115) to correct other residual lesions were required in 46 patients (77%). There was no perioperative mortality. Actuarial 10-year survival is 92% +/- 6%. At most recent follow-up, 93% of the patients are in New York Heart Association classification I or II. Sustained ventricular tachycardia occurred in 4 patients (7%) during follow-up. CONCLUSIONS: Long-term complications of the right ventricular outflow tract were the main reason for reoperation. Mid-term survival and functional improvement after reoperation are excellent.