As originally published in 1988: Results of total correction of tetralogy of Fallot performed in adults. Updated in 1996

Adult case of tetralogy of Fallot associated with atrioventricular septal defect

The patient was a 28-year-old woman who was misdiagnosed with tetralogy of Fallot and straddling mitral valve after birth. She underwent a left modified Blalock-Taussig shunt at the age of 1 year. At age 28, she presented with fatigue and progressive cyanosis. Finally, she was diagnosed with tetralogy of Fallot and complete atrioventricular septal defect. To measure the exact biventricular volumes, we performed cardiac magnetic resonance imaging in addition to cardiac angiography and ensured adequate volume capacity. We eventually decided to perform biventricular repair. Her postoperative course was uneventful, and she returned to full-time work.

Tetralogy of Fallot, left ventricular clot, aortic dissection: rare association

Cases of uncorrected adult tetralogy of Fallot are rare and mostly manifest secondary to complications. A 30-year-old man presented with progressive breathlessness and severe chest discomfort. Echocardiography revealed tetralogy of Fallot with a left ventricular apical clot and DeBakey type I dissection of the aorta. The patient underwent successful surgical correction. The combination of preoperative complications in the setting of uncorrected tetralogy of Fallot, such as a left ventricular clot and DeBakey type I dissection of the aorta, is very rare.

Anesthetic Considerations for Adult Cardiac Surgery Patients with Congenital Heart Disease

The number of adults with congenital heart disease surviving into adulthood is increasing. The proportion of adults undergoing revision of a previous repair is increasing in comparison to those that present for a palliative or curative operation. At the Toronto Congenital Cardiac Centre for Adults, 528 patients underwent cardiac surgery between January 1, 1992 and December 31, 2001. The anesthetic management of the surgical correction of simple and complex congenital heart lesions includes general physiologic considerations such as dysrhythmias, hypoxemia, polycythemia, and pulmonary hypertension. Palliative shunts from early childhood have anatomical and physiologic implications for the adult. Preparation for the operating room and postoperative care are natural extensions of the anesthetic management of the surgical correction of the congenital heart lesions. Anesthetic management of septal lesions in the interventional suite and operating room is discussed. Complex lesions such as tetralogy of Fallot, transposition of the great arteries, Glenn anastomosis, and the Fontan operation are reviewed. The anesthetic management of these patients is rewarding but impossible without an integrated team approach involving cardiologists, surgeons, perfusionists, and nursing staff.

Surgical repair of tetralogy of fallot at age 83

Tetralogy of Fallot (TOF) is a cyanotic congenital heart defect typically diagnosed in infancy and treated with early surgical correction. We report a patient with TOF diagnosed at age 78. Successful surgical repair was performed at age 83, the oldest reported age of surgical correction of this condition. Despite a complicated surgical and postoperative course, the patient is doing well almost four years later.

Correction of tetralogy of Fallot in an adult using a stented bioprosthetic valved conduit

A 55-year-old man with tetralogy of Fallot successfully underwent correction using a valved conduit. He was diagnosed as having congenital heart disease during childhood, but no surgical intervention was performed. Cyanosis and dyspnea on effort had progressed gradually. Catheterization showed a left ventricular end diastolic volume of 126 ml, and the pulmonary arteries had sufficient diameters. To prevent postoperative pulmonary regurgitation, we planned to use a bioprosthetic valved conduit for right ventricular outflow tract reconstruction. At 4.5 years after the operation he is in New York Heart Association functional class I. The catheterization performed 1.5 years after the surgery showed no pressure gradient between the right ventricle and the pulmonary artery. Thus, total correction of tetralogy of Fallot in an adult can be achieved safely, and the use of a bioprosthetic stented valved conduit can be beneficial.

Surgical correction of congenital heart disease at 76 years of age

The management of adult congenital heart disease is challenging and poses specific problems. We report a patient with ventricular septal defect and pulmonary stenosis who underwent successful repair and coronary artery bypass grafting at the age of 76 years.

Complete surgical repair of Tetralogy of Fallot in adults, is it ever too late?

A minority of patients with Tetralogy of Fallot (TF) survive into adulthood. These patients have been subjected to a prolong period of cyanosis and hypoxia. The aim of this study is to assess the benefits of total correction of TF in this adult population. From August 1995 to March 2005, fifty one patients underwent total correction of TF. The mean age was 22.2 years (range 16 to 38 years). There were 31 males and 20 females. Twenty two percent of patients were in NYHA functional class III prior to the operation. The mean gradient across the right ventricular outflow tract was 81.7 mmHg (range 30 to 130 mmHg). The operation was performed through the right ventricle in the majority of patients. Transannular patch was used in 33 patients. The mean follow-up period was 42 months ranging from 1 to 116 months. Hospital mortality was 1.9% (1 patient), and one patient died three months after the operation. Post-operatively 87.3% of patients were in NYHA functional class I. During the follow-up period four patients required re-operation; two for residual ventricular septal defect, one for residual pulmonary stenosis and one had pulmonary valve replacement for severe pulmonary regurgitation. Complete repair of TF in adults is feasible with acceptable mortality and morbidity. The main benefit of the operation is functional improvement in this patient population.

Long-Term Functional Assessment After Correction of Tetralogy of Fallot in Adulthood

BACKGROUND

Tetralogy of Fallot presenting in adulthood is a surgical challenge. We present the long-term outcomes of surgical correction in this subset of patients, including results of postoperative effort tolerance as assessed by treadmill testing.

METHODS

Fifty-eight patients older than 18 years operated on between January 1995 and June 2004 are included in the study. Mean age at surgery was 22.5 +/- 5 years. Forty-seven patients were in New York Heart Association functional class II and 11 were in class III. Two patients had previous shunts. Forty-four patients received a transannular patch, and 14 had a right ventricular outflow tract patch. The prospective arm objectively assessed postoperative ventricular function by treadmill testing and echocardiography.

RESULTS

Hospital mortality was 6.9%. Follow-up was 89% complete, with mean follow-up of 69.9 +/- 43 months. Late mortality occurred in 2 patients, both with infective endocarditis. Significant improvement in functional class was demonstrated (p < 0.001). Eight patients had significant pulmonary regurgitation on follow-up. The probability of survival after repair was 89% at 15 years. Thirty-five of 36 patients who underwent treadmill testing had good effort tolerance, with an average of 10.47 +/- 1.4 metabolic equivalents achieved. None had a positive result. One patient with transannular patch, in functional class III, had fair exercise tolerance with severe pulmonary regurgitation on echocardiography.

CONCLUSIONS

Repair of adult tetralogy of Fallot has acceptable morbidity and mortality rates with good long-term surgical outcome in terms of effort tolerance as demonstrated by treadmill testing. Transannular patching does not appear to be a significant risk factor for right ventricular failure at long-term follow-up.

The Anesthesiologist's Role in Adults with Congenital Heart Disease

Anesthesia for adults with congenital heart disease has many challenging physiologic considerations. Collaborative relationships of a multidisciplinary team including cardiology, cardiac surgery, anesthesiology, and intensive care are essential to ensure positive outcomes in this population for noncardiac and cardiac surgery.

Correction of Tetralogy of Fallot and of Pulmonary Atresia with Ventricular Septal Defect in Adults

BACKGROUND

Early correction is regarded as the treatment of choice for patients with tetralogy of Fallot or pulmonary atresia with ventricular septal defect. Nevertheless, some of these patients reach adulthood without early correction. This study sought to assess risk factors for operative mortality and determine the benefit of total correction in adolescent and adult patients.

METHODS

A retrospective analysis of 52 patients (>16 years at the time of corrective surgery) for tetralogy of Fallot (n = 42) or pulmonary atresia with ventricular septal defect (n = 10) between 1974 and 2003 was performed.

RESULTS

Age at correction was 28.9 +/- 9.9 (16 to 57 years). There were 8 early deaths (15.4%). Preoperative hemoglobin concentration (p = 0.002) and reconstruction of the right ventricular outflow tract with a patch (p = 0.002) were correlated with a significantly higher early mortality. Mean follow-up time was 12.3 +/- 10.4 years. Late deaths (n = 6; 11.5%) were cardiac-related in 2 of 6 cases. At follow-up, 28 patients (87.5%) were assigned to the New York Heart Association functional class I. Twenty-four patients led a normal life with full-time work, 6 patients were able to do part-time work, and only 2 patients experienced noticeable limitation on activities.

CONCLUSIONS

Repair of tetralogy of Fallot and of pulmonary atresia with ventricular septal defect in this patient group is associated with a high early mortality. Preoperative chronic cyanosis, expressed by elevated hemoglobin concentration, is predictive for early mortality. Because cyanosis has been shown to lead to multiorgan dysfunction, we conclude that preoperative multiorgan dysfunction may be the intrinsic risk factor for perioperative mortality. Surgical correction in this patient group should still be recommended because the functional status considerably improves.

A Critical Increase in Right-to-Left Shunt After Acute Myocardial Infarction in a 68-year-old Male With Tetralogy of Fallot

A male patient with tetralogy of Fallot accompanied by aortic regurgitation had maintained sufficient exercise capacity for a number of decades with the status of acyanotic tetralogy of Fallot. When he was 67 years old, he suffered a posterior wall acute myocardial infarction and direct percutaneous coronary angioplasty successfully revascularised the target lesion in the left circumflex artery. However, a few months after the onset of the myocardial infarction, his shortness of breath became clinically significant and was associated with increased right-to-left shunt and increased right ventricular end-diastolic pressure, as well as hypoxia. At 68 years old, therefore, total corrective repair of the tetralogy with replacement of the aortic and pulmonary valves was performed. The patient was asymptomatic after the successful operation. This report suggests that coronary artery disease can be one of the potential factors in inducing critical hemodynamic changes in aging patients with congenital heart disease, especially those who have a shunt between the right and left chambers. The unique clinical course is described with some discussion of the repair of tetralogy in adults.

Cyanotic Tetralogy of Fallot With Its Infective Endocarditis Complication on the Tricuspid and Pulmonary Valves of a 55-Year-Old Man

A 55-year-old man had undiagnosed tetralogy of Fallot with the complications of decompensated heart failure and infective endocarditis, as well as pulmonic involvement secondary to the endocarditis. The patient had a massive hemoptysis and died. This case is a rare insight into the late outcome of this congenital heart disease.

Malformations in adult cases in Egypt

The pathologic patterns as an indication for cardiac surgery in adults with congenital heart diseases and subsequently the surgical techniques have changed greatly in the last decade. The presence of fully equipped pediatric cardiac units helped in early surgical repair in many lesions. However, this service is not always readily available in many parts of the world with the effect of seeing patients with congenital heart diseases latter on during their life needing intervention. Also, older surgical concepts (like considering a trileaflet mitral valve as normal) resulted in the presentation of a subgroup of patients who needed re-intervention latter during adulthood. Surgeons are also faced with the residual effects of putting in different kinds of prosthetic valves or homografts that degenerates or the child overgrows and need to be dealt with latter during the child life. Although the interventional transcatheter techniques helped in the closure of small atrial septal defects, patent ducti, pulmonary arteriovenous fistulas, and dilatation of coarctations, it helped in the emergence of a new pathologic entities like failed or complicated transcatheter closure or dilatations. As a result of competition with the cardiologists, minimal access cardiac surgery emerged. Upper and lower partial ministernotomies and right thoracotomy and fast-track congenital heart operation in some lesions had effectively decreased pain and discomfort, shortened the recovery period, and improved the cosmetic result.

Decreased left ventricular filling pressure 8 months after corrective surgery in a 55-year-old man with tetralogy of Fallot: adaptation for increased preload

A 55-year-old man with tetralogy of Fallot underwent corrective surgery. Left ventricular filling pressure increased markedly with increased left ventricular volume one month after surgery, then decreased over the next 7 months, presumably due to increased left ventricular compliance.

Total correction of tetralogy of Fallot in adults--surgical experience

A total of 100 patients of tetralogy of Fallot aged 13 years and over were operated upon at the All India Institute of Medical Sciences, New Delhi, India between January 1991 and December 1996. There were 69 males (69%) and 31 females (31%). Age ranged from 13 years to 43 years (mean 19.66 years). Twenty % of patients had preoperative complications like haemoptysis, cerebrovascular accidents, brain abscess and infective endocarditis. Twenty-two patients had previous palliative shunts. Fifteen patients had coil embolisation of major collaterals prior to surgery. In hospital mortality rate was 4%. Follow-up ranged from 1 month to 5 years (mean 3.4 years). There was one late death due to infective endocarditis. Postoperatively 93.6% patients were in NYHA class I. Significant residual defects warranting re-operation were present in three patients. Total correction of tetralogy of Fallot in older patients can be performed with acceptable results.

Cardiac surgery for grown-up congenital heart patients: survey of 307 consecutive operations from 1991 to 1994

The cardiac surgery performed from 1991 to 1994 in a unit dedicated specifically for grown-up congenital heart (GUCH) patients was reviewed to determine the frequency of various procedures, incidence of first and reoperations, early mortality, and its determinants. The 295 patients, aged 16 to 77 years (31 +/- 13), had 307 operations. First operations (n = 128, 42%) were most commonly for closure of atrial septal defect (n = 40), aortic valve replacement (n = 31) or repair of aortic coarctation (n = 14). Reoperations were more frequent (n = 179, 58%) and divided among first corrective repair (n = 49), reoperation after corrective repair (n = 115), and further palliation (n = 15). First corrective surgery was mainly for aortic valve disease (n = 17), Fallot (n = 7), and lesions needing a Fontan procedure (n = 5). Reoperations after corrective repair were needed for aortic valve disease (n = 43), right-sided conduit (n = 30), or recoarctation (n = 11). Early mortality was influenced by presence of central cyanosis (9 of 49, 18% in cyanotic patients; 12 of 258, 5% in acyanotic; p <0.001), increased number of previous operations (0 = 4%, 1 = 7%, 2 = 11%, >2 = 13%; p = 0.003), and increasing age of patients. Cyanotic patients had more serious postoperative complications: pleural and pericardial effusions, severe bleeding, renal insufficiency, and sepsis, and their hospital stay was longer compared with acyanotic patients (20 +/- 17 vs 11 +/- 8 days; p <0.001). In GUCH patients, reoperations cause the largest demand on cardiac surgical services. Increased survival of patients with complex cardiovascular malformations brings difficult challenges not only to cardiologists but also to cardiovascular surgeons. There is a need to provide continued highly specialized care. Resources, patients, and funding should be concentrated in a few designated centers.