Surgery for tetralogy of fallot in adults: early outcomes

Abstract Objective: To study the in-hospital outcome of adult patients who had undergone surgical repair for Tetralogy of Fallot. Methods: A retrospective descriptive study was conducted at the Punjab Institute of Cardiology searching the hospital records. All those adult patients who had undergone repair for Tetralogy of Fallot from January 2012 to December 2014 were included in the study. All the patients were operated by the same surgical team. Patients who underwent primary repair as well as those with previous palliative procedures were included in the study. Thirty days outcome was studied by recording variables from the database. Data was analysed using Statistical Package for Social Sciences version 16. Results: A total of 80 patients was included in the study, in which there were 48 (60%) male patients and 32 (40%) female patients. Mean age was 21±0.21 years. Those with previous palliation were 15 (18.75%). The associated problems observed were: atrial septal defect 27 (33.75%), right aortic arch 30 (37.5%), patent ductus arteriosus 6 (7.5%) and double outlet right ventricle 3 (3.75%). In-hospital mortality recorded was 7 (8%). Postoperative complications encountered were low cardiac output syndrome 9 (11.25%), pleural effusion requiring tapping 3 (3.75%), reoperation for bleeding 3 (3.8%), pulmonary regurgitation (moderate to severe) 20 (25%) which occurred in the transannular patch group only and atrial arrhythmia 4 (5%). Conclusion: A large number of adult patients are still operated for tetralogy of Fallot in Pakistan. With increasing experience in the technique the mortality and morbidity is comparable to international literature.

Resultados quirúrgicos y factores de riesgo relacionados a mortalidad operatoria en la corrección quirúrgica de 276 pacientes consecutivos con tetralogía de Fallot / Surgical outcomes and risk factors of operative mortality in 276 consecutives patients with tetralogy of Fallot

La tetralogía de Fallot es una de las cardiopatías congénitas cianógenas más frecuentes. A pesar de ello no existen en Venezuela reportes actualizados de los resultados de su corrección quirúrgica. Describir los resultados obtenidos en la reparación quirúrgica de pacientes con tetralogía de Fallot y evaluar los factores de riesgo de mortalidad operatoria relacionados así como describir la sobrevida actuarial y la libertad de reoperación del tracto de salida del ventrículo derecho. Se incluyeron en forma restrospectiva a todos aquellos pacientes intervenidos de corrección total de tetralogía de Fallot entre octubre 2006 a mayo 2010. Se evaluó el tiempo de by-pass cardiopulmonar, tiempo de pinzamiento aórtico, edad, peso, talla, relación de presiones entre el ventrículo derecho e izquierdo después de la corrección. Adicionalmente se trazaron las curvas actuariales para sobrevida y libertad de reoperación para el tracto de salida derecho. Solo el tiempo de circulación extracorporea mayor a 100 minutos estuvo relacionado a mortalidad operatoria. La mortalidad operatoria global fue de 5,8%. La sobrevida actuarial a los 4 años fue de 92,5%, y la libertad de reoperación por obstrucción del tracto de salida derecho fue de 98,4%. Los resultados obtenidos son similares a los observados en la literatura mundial en relación con la mortalidad operatoria y libertad de reoperación del tracto de salida derecho. Los tiempos de circulación extracorporea mayores a 100 minutos podrían estar relacionados a una mayor dificultad técnica de la corrección y esto a su vez estar relacionado a mortalidad.

Tetralogy of Fallot is one of the most common cyanotic congenital heart defects. However, in Venezuela there are no current reports of results of its surgical correction. To describe the results of surgical repair of Tetralogy of Fallot patients and evaluate the risk factors related to operative mortality and to describe the actuarial survival curves and freedom from reoperation for the right ventricule outflow tract obstruction. We included retrospectively all patients undergoing total correction of tetralogy of Fallot from October 2006 to May 2010. We evaluated time of cardiopulmonary bypass, aortic cross-clamp time, age, weight, height, and pressure ratio between right and left ventricle after correction. Additionally actuarial curves were plotted for survival and freedom from reoperation for right outflow tract obstruction. Cardiopulmonary by-pass times longer than 100 minutes was related to operative mortality. The overall operative mortality was 5.8%. The actuarial survival at 4 years was 92.5%, and freedom from reoperation for right outflow tract obstruction was 98.4%. These results are similar to those observed in the literature regarding the operative mortality and freedom from reoperation for right outflow tract obstruction. Cardiopulmonary by-pass times longer than 100 minutes could be related to increased technical difficulties during correction and this in turn be related to mortality.

Mortalidade hospitalar na cirurgia de reconstrução da via de saída do ventrículo direito com homeonxerto pulmonar / Hospital mortality in surgery for reconstruction outflow right ventricle with pulmonary homograft

FUNDAMENTO: Mortalidade hospitalar na cirurgia de reconstrução da via de saída do ventrículo direito com homoenxerto pulmonar é variável. OBJETIVOS: Identificar os fatores de risco associados à mortalidade hospitalar e ao perfil clínico dos pacientes. MÉTODOS: Estudo de crianças submetidas à reconstrução da via de saída do ventrículo direito com homoenxerto pulmonar. Analisados como fatores de risco as variáveis clínicas, cirúrgicas e de aspectos morfológicos da prótese. RESULTADOS: Noventa e dois pacientes foram operados entre 1998 e 2005, apresentando principalmente atresia pulmonar com comunicação interventricular e a tetralogia de Fallot. Quarenta pacientes foram atendidos no primeiro mês de vida. Necessitaram de 38 cirurgias de Blalock Taussig devido à gravidade clínica. A idade mediana na cirurgia de correção total foi de 22 meses, variando de 1 mês a 157 meses. O tamanho homoenxerto pulmonar variou de 12 a 26 mm e o tempo de extracorpórea foi 132 ± 37 minutos. Após a cirurgia houve 17 óbitos (18 por cento casos), em média 10,5 ± 7,5 dias após. A causa predominante foi falência de múltiplos órgãos. Na análise univariada entre os tipos de cardiopatia, estas deferiram na idade, momento da cirurgia, tamanho do homoenxerto, valor Z da valva pulmonar, tempo de circulação extracorpórea, manutenção da integridade do homoenxerto e alteração da árvore pulmonar. Não houve diferença estatística com relação à mortalidade hospitalar entre as variáveis e o tipo de cardiopatia. CONCLUSÃO: As cardiopatias obstrutivas do lado direito necessitam de atendimento cirúrgico nos primeiros dias de vida. A cirurgia de correção total apresenta risco de mortalidade de 18 por cento, mas não houve associação com nenhuma variável estudada.

BACKGROUND: Hospital mortality for surgical reconstruction of the outflow of the right ventricle with pulmonary homograft is variable. OBJECTIVES: To identify risk factors associated with hospital mortality and clinical profile of patients. METHODS: Children underwent reconstruction of the outflow tract of right ventricle with pulmonary homograft. Analyzed as risk factors for the clinical, surgical and morphological aspects of the prosthesis. RESULTS: Ninety-two patients operated on between 1998 and 2005 presented mainly pulmonary atresia with ventricular septal defect and tetralogy of Fallot. Forty patients were treated in the first month of life. He needed 38 surgeries to Blalock Taussig due to clinical severity. The median age at surgery for total correction was 22 months, ranging from 1 to 157 months. Size pulmonary homograft ranging from 12 to 26 mm and length of bypass was 132 ± 37 minutes. After surgery there were seventeen deaths (18 percent cases) on average 10.5 ± 7.5 days. The predominant cause was multiple organ failure. In the univariate analysis between the types of heart disease, they found in favor of age at surgery, size of homograft, pulmonary valve Z value, CPB time, maintaining the integrity of the homograft and pulmonary tree change. There was no statistical differencein hospital mortality between the variables and the type of heart disease. CONCLUSION: The congenital obstructive right requires surgical care in the first days of life. The total correction surgery has a risk rate of 18 percent but there was no association with any variable studied.

Correção intracardíaca da tetralogia de Fallot no primeiro ano de vida: resultados a curto e médio prazos / Intracardiac correction of tetralogy of Fallot in the first year of life: short-term and midium-term results

OBJETIVO: Avaliar os resultados a curto e médio prazos da correção intracardíaca da tetralogia de Fallot no primeiro ano de vida. MÉTODOS: De janeiro de 1996 a outubro de 2004, 67 crianças com idade variando de 1 a 11 meses (média: 7,2 meses) e pesando entre 4 a 10 quilos (média: 7,1 kg) foram eletivamente submetidas a correção intracardíaca da tetralogia de Fallot. A cirurgia foi realizada com circulação extracorpórea convencional e hipotermia moderada. Ventriculotomia direita foi realizada em 60 (89,5 por cento) casos e em sete (10,5 por cento) utilizou-se a abordagem do defeito pela via atriopulmonar. RESULTADOS: O tempo de circulação extracorpórea variou de 35 a 147 minutos (média:78,8 ± 21 minutos), e o tempo de pinçamento da aorta variou de 25 a 86 minutos (média: 51,8 ± 15,6 minutos). Ampliação transanular da via de saída do ventrículo direito foi necessária em 50 (64,1 por cento) casos. O gradiente entre o ventrículo direito e a artéria pulmonar, após a correção, variou de 0 a 54 mmHg (média: 15,5 ± 10,8 mmHg). Ocorreram dois (2,98 por cento) óbitos no pós-operatório imediato. O seguimento tardio variou de 7 a 115 meses (média: 44,0 ± 35 meses). Houve uma morte tardia não-cardíaca. Todos os outros pacientes estão assintomáticos. A curva de sobrevida actuarial, incluindo a mortalidade operatória, revelou que a probabilidade de sobrevida, 12 anos após a operação, é de 97 por cento. Dez pacientes foram avaliados por angiorresonânia magnética nuclear. CONCLUSÕES: A correção intracardíaca da tetralogia de Fallot no primeiro ano de vida pode ser feita com baixas morbidade e mortalidade e bons resultados tardios.

OBJECTIVE: To evaluate short-term and medium-term results of intracardiac correction of Tetralogy of Fallot in the first year of life. METHODS: From January 1996 to October 2004, 67 consecutive infants ranging in age from 1 to 11 months (mean: 7.2 months) and weighing from 4 to 10 kilograms (mean: 7.1 kilograms) underwent elective total correction of Tetralogy of Fallot. The surgery was accomplished with conventional cardiopulmonary bypass and moderate hypothermia. Right ventriculotomy was performed in 60 (89.5 percent) cases and an atriopulmonary approach was used in the other seven (10.5 percent) cases. RESULTS: Cardiopulmonary bypass time ranged from 35 to 147 minutes (mean: 78.8 ± 21 minutes), and aortic clamping time ranged from 25 to 86 minutes (mean: 51.8 ± 15.6 minutes). Transannular enlargement of the right ventricular outflow tract was needed in 50 (64.1 percent) patients. Gradient between the right ventricle and pulmonary artery after correction varied from 0 to 54 mmHg (mean: 15.5 ± 10.8 mmHg). There were two (2.98 percent) early deaths. Follow-up of the 65 survivors ranged from 7 to 115 months (mean:44.0 ± 35 months). There was one late noncardiac death. All other patients are asymptomatic. The actuarial survival curve at 12 years, including operative mortality, was 97 percent. Ten patients were evaluated by magnetic nuclear angioresonance. CONCLUSIONS: Intracardiac correction of Tetralogy of Fallot in the first year of life may be performed with low morbidity and mortality and good late results.

Management of tetralogy of Fallot with absent pulmonary valve: early and mid-term results of a uniform approach.

The operative management of absent pulmonary valve syndrome remains controversial regarding palliative or one-stage correction, the need for pulmonary valve implantation and pulmonary arterioplasty. This retrospective report summarises the experience of a single centre with a view to provide some answers to this controversy. Forty-six consecutive patients including five infants, aged 2 months to 43 years, underwent primary surgical correction during the last 8.5 years. All the patients underwent two-dimensional echocardiography and cardiac catheterisation. Nine patients had mild and 10 moderate pulmonary artery hypertension. Repair consisted of patch closure of the ventricular septal defect and reconstruction of the right ventricular outflow tract. A valve was incorporated in the pulmonary position in 19 patients. Pulmonary arterioplasty was performed only in infants. Overall hospital mortality was 4 out of 46 patients (8.6%). Two out of five infants died accounting for 40 percent mortality. Forty-two survivors were followed up from 4 to 101 months; 40 patients are in functional class I and two in class II. Actuarial survival at 8.5 years was 91 percent. It is concluded that reconstruction of the right ventricular outflow tract with a transannular patch is sufficient in majority of patients. A selective approach to pulmonary valve insertion is recommended in patients with pulmonary hypertension or other anomalies. Pulmonary arterioplasty should be performed as the primary treatment in infants.

Tratamento cirúrgico da tetralogia de Fallot no adulto / Surgical treatment of tetralogy of Fallot in adult

Vinte e nove pacientes com tetralogia de Fallot, cujas idades variaram de 16 a 43 anos (média:21 anos), foram submetidos à correçao total. Somente dois (6,8 por cento) tinham uma operaçao de Blalock-Taussig prévia. A técnica clássica de correçao intracardíaca foi usada em todos os casos. Em 13,7 por cento (4 casos) dos pacientes foi necessário reconstruir a via de saída do ventrículo direito. Houve quatro (l3,75) óbitos operatórios. Todas as mortes ocorreram no início da experiência (l967-1977), quando oxigenadores descartáveis e proteçao miocárdica nao foram usados. O seguimento dos sobreviventes foi de 1.560 pacientes- meses (média: 62 meses). Houve uma morte tardia de causa nao cardíaca. Exceto em dois doentes, a evoluçao clínica foi boa. Dois pacientes foram reoperados com sucesso para correçao de defeitos residuais, ll anos e seis meses, respectivamente, após a operaçao inicial. Acredita-se que a idade avançada nao é contra-indicaçao para correçao total da tetralogia de Fallot, sobretudo porque os portadores desta anomalia que sobrevivem à idade adulta, geralmente apresentam anatomia favorável.