Valve-sparing options in tetralogy of Fallot surgery

Given late outcomes of patients with tetralogy of Fallot repaired in the 1970s and 1980s, as well as a better understanding of the late deleterious effects of pulmonary regurgitation, there is a tendency toward preservation of the pulmonary valve function during primary repair of tetralogy of Fallot. The bar keeps moving downward, to include smaller and more dysmorphic pulmonary valves. This article reviews some useful indications and techniques for valve-sparing options, including intraoperative balloon dilation and cusp reconstruction using a patch. Just like other valve repair techniques, no one technique can be applied uniformly, and surgeons must master a wide armamentarium of techniques.     

Pulmonic valve annular enlargement with valve repair in tetralogy of Fallot

We present an operative technique of pulmonic valve annular enlargement with concomitant valve repair using two pericardial patches to reduce pulmonary regurgitation after complete repair of tetralogy of Fallot. We have used this technique in 18 patients with tetralogy of Fallot with excellent results.     

Late repair of the native pulmonary valve in patients with pulmonary insufficiency after surgery for tetralogy of Fallot

Pulmonary regurgitation developing late after tetralogy of Fallot repair is now recognized as a serious threat to the long-term welfare of these patients. This article summarizes our experience with 5 patients who underwent reoperations for treatment of severe pulmonary regurgitation after transannular patch repair of tetralogy of Fallot. In each case, the intraoperative findings revealed anatomy favorable for valve repair and enabled preservation of the native pulmonary valves.     

Two cases of tetralogy of Fallot with absent pulmonary valve repaired by modified Kreutzer’s technique

Two severely symptomatic infants of tetralogy of Fallot with absent pulmonary valve successfully repaired by a modified Kreutzer’s technique are described. In addition to the standard repair of tetralogy of Fallot, our surgical technique consists of extensive pulmonary reduction arterioplasty, which allows tracheobronchial decompression. Both patients tolerated surgery and showed significant relief of airway compression and clinical symptoms, although they required prolonged mechanical ventilatory support. The modified Kreutzer’s technique is relatively simple and could be sufficiently efficacious even for symptomatic infants of tetralogy of Fallot with absent pulmonary valve.     

Transcatheter pulmonary valve implantation in native pulmonary outflow tract using the Edwards SAPIEN? transcatheter heart valve

Percutaneous pulmonary valve implantation (PPVI) is now an accepted alternative option to conventional surgery for patients with dysfunctional conduits between the right ventricle and pulmonary artery. PPVI will reduce the total number of repeat operations in such patients. However, surgery remains the primary option in postoperative tetralogy of Fallot patients with severe pulmonary regurgitation who underwent transannular patch reconstruction of their right ventricular outflow tract (RVOT). Traditionally, an RVOT patch is considered a relative contraindication to PPVI, however, in selected patients PPVI was successfully performed. We report the case of a 12-year-old patient after neonatal repair of tetralogy of Fallot and pulmonary atresia, who developed advanced liver disease and severe pulmonary regurgitation. In this patient, the risk for surgical valve replacement was considered too high and he was treated with percutaneous implantation of the Edwards SAPIEN? transcatheter heart valve.     

法洛四联症术后肺动脉瓣置换术的中期效果评价

目的 评价法洛四联症根治术后患者行外科肺动脉瓣置换术的中期效果.方法 纳入2010年1月至2020年1月于我院接受外科肺动脉瓣置换术的法洛四联症术后患者73例,其中男42例、女31例.行法洛四联症根治术时中位年龄为3.9(0.2～42.8)岁,行肺动脉瓣置换术时中位年龄为20.0(2.0～50.0)岁.记录并分析患者的...     

Tetralogy of Fallot: Late outcome after repair and surgical implications

Cardiac surgery has transformed the outcome for patients with tetralogy of Fallot. Repair has conveyed excellent long-term results with most patients remaining well and leading normal lives. However, there are problems with late morbidity and mortality primarily due to right ventricular dysfunction, exercise intolerance, arrythmia, and sudden cardiac death. There has been a dynamic shift in our surgical approach to managing patients with tetralogy over the past 5 decades. This in part accounts for persisting difficulties in predicting late outcome for evry single patient with repaired tetralogy of Fallot. There are, however, several confounding variables, influencing long-term outcome for these patients, namely the underlying anatomical substrate, age at repair, surgical approach to repair, and residual hemodynamic abnormalities. It is gratifying to see that recent knowledge accumulated from long-term follow-up studies is influencing contemporary surgical practice. Individualized strategies aiming to minimize the potential for free pulmonary regurgitation, and the long-term detrimental effects associated with it, need to continue to develop. Preservation of right ventricular and pulmonary valve function combined with early restoration of normal pulmonary blood flow are likely to convey an even better long-term outlook for these patients. Further follow-up studies with assessment of bi-venticular function, however, are needed in both our older and contemporary cohorts with repaired tetralogy of Fallot. Copyright © 2000 by W.B. Saunders Company     

Congenital quadricuspid aortic valve with tetralogy of Fallot and pulmonary atresia

We report the case of a 4-year-old girl who had quadricuspid aortic valve regurgitation with tetralogy of Fallot and pulmonary atresia. This combination is very uncommon. Aortic valve replacement was performed successfully due to aortic regurgitation which had progressed one year after the total repair. The dilated aortic annulus plus quadricuspid aortic valve may result in progressive aortic regurgitation for a short period.     

Tetralogy of Fallot and Pulmonary Valve Replacement: Timing and Techniques in the Asymptomatic Patient

An increasing number of survivors of congenital heart disease will require repeat surgical intervention. In the tetralogy of Fallot population, the primary indication is for pulmonary valve replacement secondary to pulmonary regurgitation. Although pulmonary valve disruption during repair is initially well tolerated, by the second decade following repair, patients develop increased right ventricular size with potentially decreased function. It is now well accepted that patients experiencing symptoms of heart failure secondary to chronic pulmonary insufficiency undergo pulmonary valve replacement. However, in the asymptomatic population, indications and timing of valve replacement are less clear. This article examines the current literature and presents guidelines regarding pulmonary valve replacement in the asymptomatic patient. Also, in the current era of percutaneous valve replacement, certain technical considerations should be given toward valve replacement and are discussed as well.     

Pulmonary valve replacement long after repair of tetralogy of Fallot

Purpose  

Pulmonary valve replacement long after repair of tetralogy of Fallot can improve cardiac function, functional status, and arrhythmia propensity. This has not been reported in Japan. We aim to evaluate the effects of pulmonary valve replacement in repaired tetralogy of Fallot.     

Valve‐sparing repair with skeletonization of the pulmonary annulus for tetralogy of Fallot

Pulmonary valve preservation in tetralogy of Fallot (TOF) repair is one of the most challenging issues. Herein, we describe a novel valve‐sparing technique for TOF repair that primarily consists of skeletonization of the anterior part of the pulmonary annulus and gentle dilatation by preserving the pulmonary valve and annulus integrity. With encouraging early results, this technique is suggested to prevent severe pulmonary regurgitation and provide acceptable relief of pulmonary stenosis in patients with TOF.     

Follow-up of tetralogy of Fallot after repair

Repair of tetralogy of Fallot (TOF) exists for more than 40 years. This repair results in a pulmonary regurgitation, which is usually well tolerated for two decades or so, but eventually this is injurious for the right ventricle (RV). The RV enlargement and severe RV dysfunction increase risk for ventricular tachycardia (VT) and sudden death in the long-term. The pulmonary valve replacement (PVR) is shifting earlier to preserve RV function before patients develop symptoms. Several parameters have to be considered to facilate correct timing for PVR (surgically of by catheterization)?: echocardiography, magnetic resonance imaging, electrocardiogram and cardiopulmonary exercise. All patients should have regular follow-up in a specialized grown-up congenital heart disease (GUCH) center to detect as soon as possible pathological signs of RV enlargement. Implantable cardioverter-defibrillator (ICD) implantation for primary prevention and programmed ventricular stimulation in repaired TOF remain controversal.     

Expanding the indications for pulmonary valve replacement after repair of tetralogy of fallot

BACKGROUND: Insertion of a competent pulmonary valve has been advocated to reduce right ventricular volume overload associated with pulmonary regurgitation (PR) after repair of tetralogy of Fallot. However the indications, proper timing, and long-term benefits of restoring pulmonary valve function remain controversial. METHODS: Thirty-six patients (aged 15.2 +/- 9.2 years) underwent pulmonary valve implantation (31 homografts, 5 heterografts) 12.2 +/- 6.9 years after tetralogy repair. Additional surgical procedures included pulmonary artery augmentation (n = 14), closure of septal defects (n = 10), and cryoablation and endocardial resection of ventricular tachycardia (n = 2). RESULTS: All patients have had clinical improvement in their exercise capacity. Preoperative and postoperative bicycle ergometry tests in 6 patients demonstrated significant improvement in the percent of predicted peak workload (68.5% +/- 19.8% to 80.7% +/- 17.4%, p < 0.015). One midterm death occurred in a 38-year-old patient with a history of ventricular tachycardia who died suddenly 2 years after pulmonary valve insertion. Postoperative echocardiographic measurements were available in 34 patients at a mean follow-up of 5 years. There was a 30% reduction in right ventricular end-diastolic diameter indexed to body surface area after surgery (30.1 +/- 10.2 to 18.6 +/- 6.0 mm/m(2), p < 0.0001). Two patients required conduit replacements at 1 and 9 years postoperatively. CONCLUSIONS: Timely insertion of a competent pulmonary valve in children, adolescents, and young adults with significant PR after tetralogy of Fallot repair results in subjective and objective improvement in exercise capacity and is associated with reduction in right ventricle size.     

Reoperation of tetralogy of Fallot long after correction with aortic homograft: a case report

Late results in the surgery for congenital heart disease repaired with external conduit have not yet been fully elucidated. We experienced a reoperation of tetralogy of Fallot (TF) that was previously repaired with an aortic homograft pretreated with beta-propiolactone for the reconstruction of right ventricular outflow tract. Ten years after correction of TF, right ventricular failure developed due to the regurgitation of tricuspid valve. At reoperation tricuspid annuloplasty was performed, and the valve of aortic homograft was also replaced with xenograft because of its uncertain durability. However, the resected valve had pliability with least degenerative change macroscopically. The postoperative course was smooth. The case was a rare one of late reoperation of TF due to the tricuspid valve regurgitation, and the case also indicated unexpected long durability of the valve cusp of the aortic homograft.     

Right ventricular myxoma in a patient with tetralogy of Fallot

INTRODUCTION

Cardiac myxoma is the most common primary cardiac tumour in adulthood and may present in the context of Carney''s complex.

PRESENTATION OF CASE

A 32-year-old male with a history of repaired tetralogy of Fallot in childhood was admitted with severe pulmonary valve regurgitation and a mobile mass in the right ventricle. The patient underwent pulmonary valve replacement and mass excision. Pathology examination showed myxoma.

DISCUSSION

In the majority of cases myxomas originate in the atria, nevertheless they can also be found in a ventricular cavity. Myxoma is a prevalent feature of Carney''s complex, an inherited, autosomal disease, characterised by multiple tumours in several organs. Tetralogy of Fallot has also been described in association with Carney''s complex.

CONCLUSION

Coexistence of tetralogy of Fallot with a cardiac ventricular myxoma in a patient not affected from Carney''s complex or other familial syndrome.     

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.     

Reoperation for tricuspid regurgitation after total correction of tetralogy of Fallot.

BACKGROUND: The aim of this study is to review the outcome of reoperation for severe tricuspid regurgitation after repair of tetralogy of Fallot. METHODS: Between 1972 and 2000, 12 patients underwent reoperation on the tricuspid valve after total correction of tetralogy of Fallot. The mean age at the time of reoperation was 17 years (range, 1 to 39 years). The mean interval between the initial correction and the reoperation was 7.8 years (range, 10 days to 19 years). The functional class was New York Heart Association class II in 2 patients and class III or IV in 10. Six patients underwent tricuspid valve repair, and the others underwent tricuspid valve replacement. RESULTS: Hospital mortality was 16.7% (2/12). Three patients (30%, 3/10) required a second reoperation 1.6, 9.2, and 15.6 years after the most recent reoperation with no deaths. The reasons for second reoperation were failure of the tricuspid valve repair in two and a thrombosed valve in one. There were two late deaths. Mean overall event-free actuarial survival at 10 years was 46.3%. CONCLUSION: Reoperation for severe tricuspid regurgitation after total correction of tetralogy of Fallot was associated with a high operative mortality and disappointing long-term results. Tricuspid regurgitation after corrective surgery for tetralogy of Fallot must be diagnosed promptly and cured, as tolerance is poor because of postoperative right ventricular insufficiency.     

Semilunar Valve Replacement with a Cylindrical Valve

A bstract A cylindrical valve was designed to prevent regurgitation of the semilunar valve. The valve is made of a sheet of polytetrafluoroethylene (PTFE) or porcine pericardium, and has three cusps and three commissures. The diameter of the valve is equal to the height of the cusps. We have used these valves in pulmonary stenosis after Jatene's operation and total correction of tetralogy of Fallot, and for truncal valve regurgitation. Regurgitation was trivial on color Doppler echocardiography in all cases. Advantages in comparison with the implantation of commercially available artificial valves include the ability to insert a larger size and no compression of the valve ring when closing the sternum. Outflow tract obstruction does not occur even when the valve is implanted in a small infant. In the present report, we describe this simple technique.     

Successful repair of tetralogy of Fallot combined with aortic valve replacement in a 65-year-old woman]

Survival to seventh decade with tetralogy of Fallot is uncommon. Herein we report a successful repair of tetralogy of Fallot combined with aortic valve replacement for concomitant aortic valve regurgitation in a 65-year-old woman. She had been in severe congestive heart failure and respiratory failure, and also showed liver and renal dysfunction preoperatively. Postoperative course has been good but ventricular arrhythmia of Lown grade II persisted.     

Deformities of pulmonary and aortic annulus 42 years after repair of tetralogy of Fallot

We report an extremely rare case of deformity of the pulmonary sinus of Valsalva with pulmonary valvular stenosis 42 years after a pulmonary annular-sparing operation for tetralogy of Fallot. Aortic regurgitation with deformity of the sinus is also noted. At the previous operation, the right ventricular outflow tract was augmented by a prosthetic subvalvular patch. Through the years, the pulmonary valve and sinus were distorted because the patch was pulled over toward the right ventricle.