Tetralogy of fallot surgical techniques: Difference between revisions
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(/* Surgery for adults with previous repair of Tetralogy of Fallot (DO NOT EDIT){{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with con...) |
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==Overview== | ==Overview== | ||
Repair of | Repair of tetralogy of Fallot reduces [[mortality]]. we can either perform palliative [[surgery]] which involves forming an [[anastomosis]] between the [[subclavian artery]] and the [[pulmonary artery]]. This redirected a large portion of the partially [[oxygenated blood]] leaving the [[heart]] for the body into the [[lung]]s, increasing flow through the [[Pulmonary circulation|pulmonary circuit]], and greatly relieving [[symptoms]] in [[patients]] or total [[Surgery|surgical]] repair which involves making incisions into the [[heart muscle]], relieving the [[Right ventricular outflow tract obstruction|right ventricular outflow tract stenosis]] by careful resection of [[muscle]], repairing the [[VSD]] using a Gore-Tex or Dacron patch or a homograft. Additional reparative or reconstructive work may be done on [[patients]] as required by their particular [[anatomy]].The repair could be done by either of the approaches i.e.transatrial or transpulmonary. | ||
==Surgery== | ==Surgery== | ||
===Palliative | ===Palliative Surgery=== | ||
*The condition was initially thought untreatable until surgeon [[Alfred Blalock]], cardiologist [[Helen B. Taussig]], and lab assistant [[Vivien Thomas]] at Johns Hopkins University developed a surgical procedure. It was actually Helen Taussig who convinced Alfred Blalock that the shunt was going to work. | *The condition was initially thought untreatable until surgeon [[Alfred Blalock]], cardiologist [[Helen B. Taussig]], and lab assistant [[Vivien Thomas]] at Johns Hopkins University developed a surgical procedure. It was actually Helen Taussig who convinced Alfred Blalock that the shunt was going to work. | ||
*The surgery involved forming an anastomosis between the subclavian artery and the pulmonary artery. This redirected a large portion of the partially oxygenated blood leaving the heart for the body into the | *The surgery involved forming an [[anastomosis]] between the [[subclavian artery]] and the [[pulmonary artery]]. This redirected a large portion of the partially oxygenated blood leaving the [[heart]] for the body into the [[lung]]s, increasing flow through the pulmonary circuit, and greatly relieving symptoms in patients. | ||
*The first [[Blalock-Thomas-Taussig shunt]] surgery was performed on 15-month old Eileen Saxon on November 29, 1944 with dramatic results. | *The first [[Blalock-Thomas-Taussig shunt]] surgery was performed on 15-month old Eileen Saxon on November 29, 1944 with dramatic results. | ||
*The Pott shunt and the Waterson procedure are other shunt procedures which were developed for the same purpose. | *The Pott shunt and the Waterson procedure are other shunt procedures which were developed for the same purpose. | ||
* Waterson shunt: Shunt between right pulmonary artery and ascending aorta. | * Waterson shunt: Shunt between [[right pulmonary artery]] and [[ascending aorta]]. | ||
* Potts shunt: Shunt between left pulmonary artery and descending aorta. | * Potts shunt: Shunt between [[left pulmonary artery]] and [[descending aorta]]. | ||
*The technique has been modified and is usually performed using a Gortex tube to create the connection. | *The technique has been modified and is usually performed using a Gortex tube to create the connection. | ||
*Currently, Blalock-Thomas-Taussig shunts are not normally performed on infants with TOF except for some conditions like- | *Currently, Blalock-Thomas-Taussig shunts are not normally performed on infants with TOF except for some conditions like- | ||
**Severe variants such as | **Severe variants such as tetralogy of Fallot with [[pulmonary atresia]] | ||
**Premature babies | **[[Premature]] babies | ||
**Coronary artery origin anomalies | ** Coronary artery origin anomalies | ||
*The Blalock-Taussig procedure was the only surgical treatment until the first total repair was performed in 1954. | *The Blalock-Taussig procedure was the only surgical treatment until the first total repair was performed in 1954. | ||
* They are usually performed through lateral thoracotomy. | * They are usually performed through lateral [[thoracotomy]]. | ||
===Disadvantages=== | |||
* Shunt placement causes pulmonary artery distortion such as kink, thrombosis and occlusion | * Shunt placement causes [[pulmonary artery]] distortion such as kink, [[thrombosis]] and [[occlusion]] | ||
* Large shunt produces pulmonary hypertension and pulmonary vascular disease | * Large shunt produces [[pulmonary hypertension]] and pulmonary vascular disease. | ||
* Large shunt causes volume overload of left ventricle. | * Large shunt causes volume overload of [[left ventricle]]. | ||
===Total | ===Total Surgical Repair=== | ||
*The total repair was performed by [[C. Walton Lillehei]] at the University of Minnesota in 1954 on a 10-month boy. | *The total repair was performed by [[C. Walton Lillehei]] at the University of Minnesota in 1954 on a 10-month boy. | ||
*Total repair initially carried a high mortality risk which has consistently improved over the years. | *Total repair initially carried a high [[mortality]] risk which has consistently improved over the years. | ||
*Surgery is now often carried out in infants 1 year of age or younger with a <5% perioperative mortality. | *[[Surgery]] is now often carried out in infants 1 year of age or younger with a <5% perioperative [[mortality]]. | ||
*The surgery generally involves | *The [[surgery]] generally involves | ||
**Making incisions into the heart muscle, relieving the right ventricular outflow tract stenosis by careful resection of muscle | **Making incisions into the [[Myocardium|heart muscle]], relieving the [[Right ventricular outflow tract obstruction|right ventricular outflow tract stenosis]] by careful resection of [[muscle]] | ||
**Repairing the VSD using a Gore-Tex or Dacron patch or a homograft. | **Repairing the [[VSD]] using a Gore-Tex or Dacron patch or a homograft. | ||
**Additional reparative or reconstructive work may be done on patients as required by their particular anatomy. | **Additional reparative or reconstructive work may be done on [[patients]] as required by their particular [[anatomy]]. | ||
**The repair could be done by either of the approaches i.e.transatrial or transpulmonary | **The repair could be done by either of the approaches i.e.transatrial or transpulmonary | ||
*Patients who have undergone "total" repair of tetralogy of Fallot often have good to excellent cardiac function after the operation with some to no exercise intolerance and have the potential to lead normal lives. Surgical success and long-term outcome greatly depends on the particular anatomy of the patient and the surgeon's skill and experience with this type of repair. | *[[Patients]] who have undergone "total" repair of tetralogy of Fallot often have good to excellent cardiac function after the operation with some to no [[exercise intolerance]] and have the potential to lead normal lives. Surgical success and long-term [[outcome]] greatly depends on the particular [[anatomy]] of the [[patient]] and the surgeon's skill and experience with this type of repair. | ||
* Pulmonary valve should be replaced before right ventricle dysfunction occurs. | *[[Pulmonary valve]] should be replaced before [[right ventricle]] dysfunction occurs. | ||
==Video== | ==Video== | ||
{{#ev:youtube|Sl6RoaLyIgw}} | {{#ev:youtube|Sl6RoaLyIgw}} | ||
===After Repair=== | |||
Arrythmia may occur after the surgical repair of TOF. | |||
==2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677 }} </ref> == | ==2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677 }} </ref> == | ||
=== Evaluation and | === Evaluation and Follow-up in the Repaired Patients of Tetralogy of Fallot (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677 }} </ref> === | ||
{|class="wikitable" | {|class="wikitable" | ||
| Line 53: | Line 56: | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1'''. Patients with repaired tetralogy of Fallot should have at least annual follow-up with a [[cardiologist]] who has expertise in adult [[congenital heart disease]] (ACHD).''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1'''. Patients with repaired tetralogy of Fallot should have at least annual follow-up with a [[cardiologist]] who has expertise in adult [[congenital heart disease]] (ACHD). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2'''. Patients with tetralogy of Fallot should have [[echocardiographic]] examinations and/or [[magnetic resonance imaging]]s (MRIs) performed by staff with expertise in ACHD.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2'''. Patients with tetralogy of Fallot should have [[echocardiographic]] examinations and/or [[magnetic resonance imaging]]s (MRIs) performed by staff with expertise in ACHD. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3'''. Screening for [[heritable]] causes of their condition (e.g., 22q11 deletion) should be offered to all patients with tetralogy of Fallot.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3'''. Screening for [[heritable]] causes of their condition (e.g., 22q11 deletion) should be offered to all patients with tetralogy of Fallot. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4'''. Before [[pregnancy]] or if a [[genetic]] syndrome is identified, consultation with a [[geneticist]] should be arranged for patients with tetralogy of Fallot.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''4'''. Before [[pregnancy]] or if a [[genetic]] syndrome is identified, consultation with a [[geneticist]] should be arranged for patients with tetralogy of Fallot. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5'''. Patients with unrepaired or palliated forms of tetralogy should have a formal evaluation at an ACHD center regarding suitability for repair.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''5'''. Patients with unrepaired or palliated forms of tetralogy should have a formal evaluation at an ACHD center regarding suitability for repair. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|} | |} | ||
=== Surgery for | === Surgery for Adults with Previous Repair of Tetralogy of Fallot (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677 }} </ref> === | ||
{|class="wikitable" | {|class="wikitable" | ||
| Line 70: | Line 73: | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Surgeons with training and expertise in [[congenital heart disease]] (CHD) should perform operations in adults with previous repair of tetralogy of Fallot.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Surgeons]] with training and expertise in [[congenital heart disease]] (CHD) should perform operations in adults with previous repair of tetralogy of Fallot. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Pulmonary valve]] replacement is indicated for severe [[pulmonary regurgitation]] and symptoms or decreased exercise tolerance.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Pulmonary valve]] replacement is indicated for severe [[pulmonary regurgitation]] and symptoms or decreased exercise [[tolerance]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Coronary artery]] anatomy, specifically the possibility of an anomalous anterior descending coronary artery across the [[RVOT]], should be ascertained before operative intervention.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Coronary artery]] anatomy, specifically the possibility of an anomalous anterior descending [[coronary artery]] across the [[RVOT]], should be ascertained before operative intervention. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''Pulmonary valve replacement is reasonable in adults with previous tetralogy of Fallot, severe pulmonary regurgitation, and any of the following: | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Pulmonary valve]] replacement is reasonable in adults with previous tetralogy of Fallot, severe [[pulmonary regurgitation]], and any of the following:<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''a.'''Moderate to severe right ventricular | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''a.''' Moderate to severe [[right ventricular dysfunction]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''b.'''Moderate to severe RV enlargement.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''b.''' Moderate to severe [[RV]] enlargement. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''c.'''Development of symptomatic or sustained atrial and/or ventricular arrhythmias.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''c.''' Development of [[symptomatic]] or sustained [[atrial]] and/or [[ventricular]] [[arrhythmias]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''d.'''Moderate to severe tricuspid regurgitation (TR).''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''d.''' Moderate to severe [[tricuspid regurgitation]] (TR). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.'''Collaboration between ACHD surgeons and ACHD interventional | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Collaboration between ACHD [[surgeons]] and ACHD interventional [[cardiologist]]s, which may include preoperative [[stenting]], intraoperative stenting, or intraoperative patch [[angioplasty]], is reasonable to determine the most feasible treatment for [[pulmonary artery stenosis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.'''Surgery is reasonable in adults with prior repair of tetralogy of Fallot and residual RVOT obstruction (valvular or subvalvular) and any of the following indications: | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Surgery]] is reasonable in adults with prior repair of tetralogy of Fallot and residual [[RVOT]] obstruction (valvular or subvalvular) and any of the following indications:<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''a.'''Residual RVOT obstruction (valvular or subvalvular) with peak instantaneous echocardiography gradient greater than 50 mm Hg.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''a.''' Residual [[RVOT]] obstruction (valvular or subvalvular) with peak instantaneous [[echocardiography]] gradient greater than 50 mm Hg. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''b.'''Residual RVOT obstruction (valvular or subvalvular) with RV/LV pressure ratio greater than 0.7.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''b.''' Residual [[RVOT]] obstruction (valvular or subvalvular) with RV/LV pressure ratio greater than 0.7. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''c.'''Residual RVOT obstruction (valvular or subvalvular) with progressive and/or severe dilatation of the right ventricle with dysfunction.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''c.''' Residual RVOT obstruction (valvular or subvalvular) with progressive and/or severe dilatation of the [[right ventricle]] with dysfunction. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''d.'''Residual ventricular septal defect (VSD) with a left-to-right shunt greater than 1.5:1.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''d.''' Residual [[ventricular septal defect]] (VSD) with a [[left-to-right shunt]] greater than 1.5:1. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''e.'''Severe aortic regurgitation (AR) with associated symptoms or more than mild LV dysfunction.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''e.''' Severe [[aortic regurgitation]] (AR) with associated symptoms or more than mild [[LV dysfunction]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''f.'''A combination of multiple residual lesions (e.g., VSD and RVOT obstruction) leading to RV enlargement or reduced RV function.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''f.''' A combination of multiple residual lesions (e.g., [[VSD]] and [[RVOT]] obstruction) leading to RV enlargement or reduced RV function. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
|} | |} | ||
==References== | ==References== | ||
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[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Congenital heart disease]] | [[Category:Congenital heart disease]] | ||
[[Category:Pediatrics]] | |||
[[Category:Disease]] | |||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
Latest revision as of 18:30, 14 April 2020
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Tetralogy of fallot Microchapters |
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Diagnosis |
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Treatment |
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Tetralogy of fallot surgical techniques On the Web |
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American Roentgen Ray Society Images of Tetralogy of fallot surgical techniques |
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Risk calculators and risk factors for Tetralogy of fallot surgical techniques |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [2]; Cafer Zorkun, M.D., Ph.D. [3]; Keri Shafer, M.D. [4]; Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [5]
Overview
Repair of tetralogy of Fallot reduces mortality. we can either perform palliative surgery which involves forming an anastomosis between the subclavian artery and the pulmonary artery. This redirected a large portion of the partially oxygenated blood leaving the heart for the body into the lungs, increasing flow through the pulmonary circuit, and greatly relieving symptoms in patients or total surgical repair which involves making incisions into the heart muscle, relieving the right ventricular outflow tract stenosis by careful resection of muscle, repairing the VSD using a Gore-Tex or Dacron patch or a homograft. Additional reparative or reconstructive work may be done on patients as required by their particular anatomy.The repair could be done by either of the approaches i.e.transatrial or transpulmonary.
Surgery
Palliative Surgery
- The condition was initially thought untreatable until surgeon Alfred Blalock, cardiologist Helen B. Taussig, and lab assistant Vivien Thomas at Johns Hopkins University developed a surgical procedure. It was actually Helen Taussig who convinced Alfred Blalock that the shunt was going to work.
- The surgery involved forming an anastomosis between the subclavian artery and the pulmonary artery. This redirected a large portion of the partially oxygenated blood leaving the heart for the body into the lungs, increasing flow through the pulmonary circuit, and greatly relieving symptoms in patients.
- The first Blalock-Thomas-Taussig shunt surgery was performed on 15-month old Eileen Saxon on November 29, 1944 with dramatic results.
- The Pott shunt and the Waterson procedure are other shunt procedures which were developed for the same purpose.
- Waterson shunt: Shunt between right pulmonary artery and ascending aorta.
- Potts shunt: Shunt between left pulmonary artery and descending aorta.
- The technique has been modified and is usually performed using a Gortex tube to create the connection.
- Currently, Blalock-Thomas-Taussig shunts are not normally performed on infants with TOF except for some conditions like-
- Severe variants such as tetralogy of Fallot with pulmonary atresia
- Premature babies
- Coronary artery origin anomalies
- The Blalock-Taussig procedure was the only surgical treatment until the first total repair was performed in 1954.
- They are usually performed through lateral thoracotomy.
Disadvantages
- Shunt placement causes pulmonary artery distortion such as kink, thrombosis and occlusion
- Large shunt produces pulmonary hypertension and pulmonary vascular disease.
- Large shunt causes volume overload of left ventricle.
Total Surgical Repair
- The total repair was performed by C. Walton Lillehei at the University of Minnesota in 1954 on a 10-month boy.
- Total repair initially carried a high mortality risk which has consistently improved over the years.
- Surgery is now often carried out in infants 1 year of age or younger with a <5% perioperative mortality.
- The surgery generally involves
- Making incisions into the heart muscle, relieving the right ventricular outflow tract stenosis by careful resection of muscle
- Repairing the VSD using a Gore-Tex or Dacron patch or a homograft.
- Additional reparative or reconstructive work may be done on patients as required by their particular anatomy.
- The repair could be done by either of the approaches i.e.transatrial or transpulmonary
- Patients who have undergone "total" repair of tetralogy of Fallot often have good to excellent cardiac function after the operation with some to no exercise intolerance and have the potential to lead normal lives. Surgical success and long-term outcome greatly depends on the particular anatomy of the patient and the surgeon's skill and experience with this type of repair.
- Pulmonary valve should be replaced before right ventricle dysfunction occurs.
Video
{{#ev:youtube|Sl6RoaLyIgw}}
After Repair
Arrythmia may occur after the surgical repair of TOF.
2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[1]
Evaluation and Follow-up in the Repaired Patients of Tetralogy of Fallot (DO NOT EDIT)[1]
| Class I |
| "1. Patients with repaired tetralogy of Fallot should have at least annual follow-up with a cardiologist who has expertise in adult congenital heart disease (ACHD). (Level of Evidence: C)" |
| "2. Patients with tetralogy of Fallot should have echocardiographic examinations and/or magnetic resonance imagings (MRIs) performed by staff with expertise in ACHD. (Level of Evidence: C)" |
| "3. Screening for heritable causes of their condition (e.g., 22q11 deletion) should be offered to all patients with tetralogy of Fallot. (Level of Evidence: C)" |
| "4. Before pregnancy or if a genetic syndrome is identified, consultation with a geneticist should be arranged for patients with tetralogy of Fallot. (Level of Evidence: B)" |
| "5. Patients with unrepaired or palliated forms of tetralogy should have a formal evaluation at an ACHD center regarding suitability for repair. (Level of Evidence: B)" |
Surgery for Adults with Previous Repair of Tetralogy of Fallot (DO NOT EDIT)[1]
| Class I |
| "1. Surgeons with training and expertise in congenital heart disease (CHD) should perform operations in adults with previous repair of tetralogy of Fallot. (Level of Evidence: C)" |
| "2. Pulmonary valve replacement is indicated for severe pulmonary regurgitation and symptoms or decreased exercise tolerance. (Level of Evidence: B)" |
| "3. Coronary artery anatomy, specifically the possibility of an anomalous anterior descending coronary artery across the RVOT, should be ascertained before operative intervention. (Level of Evidence: C)" |
| Class IIa |
| "1. Pulmonary valve replacement is reasonable in adults with previous tetralogy of Fallot, severe pulmonary regurgitation, and any of the following:" |
| "a. Moderate to severe right ventricular dysfunction. (Level of Evidence: B)" |
| "b. Moderate to severe RV enlargement. (Level of Evidence: B)" |
| "c. Development of symptomatic or sustained atrial and/or ventricular arrhythmias. (Level of Evidence: C)" |
| "d. Moderate to severe tricuspid regurgitation (TR). (Level of Evidence: C)" |
| "2. Collaboration between ACHD surgeons and ACHD interventional cardiologists, which may include preoperative stenting, intraoperative stenting, or intraoperative patch angioplasty, is reasonable to determine the most feasible treatment for pulmonary artery stenosis. (Level of Evidence: C)" |
| "3. Surgery is reasonable in adults with prior repair of tetralogy of Fallot and residual RVOT obstruction (valvular or subvalvular) and any of the following indications:" |
| "a. Residual RVOT obstruction (valvular or subvalvular) with peak instantaneous echocardiography gradient greater than 50 mm Hg. (Level of Evidence: C)" |
| "b. Residual RVOT obstruction (valvular or subvalvular) with RV/LV pressure ratio greater than 0.7. (Level of Evidence: C)" |
| "c. Residual RVOT obstruction (valvular or subvalvular) with progressive and/or severe dilatation of the right ventricle with dysfunction. (Level of Evidence: C)" |
| "d. Residual ventricular septal defect (VSD) with a left-to-right shunt greater than 1.5:1. (Level of Evidence: B)" |
| "e. Severe aortic regurgitation (AR) with associated symptoms or more than mild LV dysfunction. (Level of Evidence: C)" |
| "f. A combination of multiple residual lesions (e.g., VSD and RVOT obstruction) leading to RV enlargement or reduced RV function. (Level of Evidence: C)" |
References
- ↑ 1.0 1.1 1.2 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.