Tetralogy of Fallot with anomalous coronary artery: double outflow technique

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot

OBJECTIVE

Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice.

METHODS

The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement.

RESULTS

In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation.

CONCLUSIONS

Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.

Tetralogy of Fallot with coronary crossing the right ventricular outflow tract: A tale of a bridge and the artery

A coronary artery crossing the right ventricular outflow tract is a subset of a larger pathomorphological cohort known as an anomalous coronary artery (ACA) in the tetralogy of Fallot (TOF). The best possible outcome in a patient with TOF and ACA is decided by judicious selection of optimum preoperative investigative information, the timing of surgery, astute assessment of preoperative surgical findings, and appropriate surgical technique from a wide array of choices. In most instances, the choice of surgical technique is determined by the size of the pulmonary annulus and the anatomical relation of ACA to the pulmonary annulus. In the present era, complete, accurate preoperative diagnosis and primary repair is a routine procedure with strategies to avoid a right ventricle-to-pulmonary artery conduit.

Alternative techniques of right ventricular outflow tract reconstruction for surgical repair of truncus arteriosus

OBJECTIVES

This study aimed to evaluate the outcomes and feasibility of different techniques of reconstruction of the right ventricular outflow tract (RVOT) in surgical repair of truncus arteriosus.

METHODS

We retrospectively reviewed all consecutive patients with truncus arteriosus who underwent successful surgical repair in our centre between 1994 and 2017. We analysed late results according to the type of RVOT repair.

RESULTS

We collected data from 29 survivors after truncus arteriosus repair. Six (20%) of them were affected by DiGeorge syndrome. The RVOT reconstruction was achieved using a valved conduit in 58.6%, while a direct right ventricle-pulmonary artery (RV-PA) anastomosis, with or without the interposition of the left atrial appendage, was performed in the remaining. At a median follow-up time of 7.9 years (interquartile range 1.8-13.1), 6 patients (3 affected by DiGeorge syndrome) died. Between the 2 groups, there were no differences in terms of the late mortality and onset of adverse events. However, the use of a conduit seemed more prone to reintervention and onset of adverse events.

CONCLUSIONS

Different RVOT reconstruction techniques are safe and have similar late outcomes. However, use of a direct RV-PA anastomosis and left atrial appendage interposition may reduce the need for reoperation in the long term.

Closure of insufficient, native right ventricular outflow tract with AMPLATZER™ muscular ventricular septal defect occluder in a patient with tetralogy of Fallot post-Melody® valve

AMPLATZER™ muscular ventricular septal defect occluder is used commonly for off-label purposes. We describe an unusual case of a patient with tetralogy of Fallot who underwent repair with a right ventricle to pulmonary artery homograft due to abnormal coronary artery pattern. During the initial surgery, the native right ventricular outflow tract was left open. At 30 years of age, he was symptomatic due to severe native right ventricular outflow tract insufficiency. Cardiac MRI confirmed a dilated right ventricle and pulmonary insufficiency through the native right ventricular outflow tract, despite no significant homograft insufficiency due to previous Melody^® valve placement. The right ventricular outflow tract was closed successfully using an 18 mm AMPLATZER™ muscular ventricular septal defect occluder. At 5-year follow-up, there is no native right ventricular outflow tract insufficiency and no additional arrhythmia. We suggest that percutaneous closure of the insufficient; native right ventricular outflow tract using a septal occluder is an alternative to surgical management.

Post Melody valve implant in a conduit with regurgitant native outflow tract successful closure by Amplatzer muscular device

We describe the technique of closure of native right ventricular outflow tract by Amplatzer muscular ventricular septal defect device because of severe regurgitation in a patient who had tetralogy of Fallot repair with conduit at 3 years of age followed by percutaneous Melody valve implant 6 years later.

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.

Double-outlet technique for tetralogy of Fallot-type disease with an anomalous coronary artery

To reduce the right ventricular (RV) pressure and the pressure gradient between the RV and the pulmonary artery (PA) in Tetralogy of Fallot (TOF) with small pulmonary annulus, it is inevitable to enlarge the small annulus by incising and patching from RV to PA via PA annulus. If the anomalous coronary artery exists in the RV outflow tract, the procedure can not be done.

Repair of tetralogy of Fallot with anomalous coronary arteries coursing across the obstructed right ventricular outflow tract

Anomalous coronary artery (ACA) anatomy occurs in 2-9% of patients with tetralogy of Fallot (TOF), in which the left anterior descending coronary artery (LAD) originates from the right coronary artery (RCA) crossing the right ventricular outflow tract. The purpose of this study was to review our results of repair for TOF with ACA. Between 1978 and 2001, 43 ACA patients (mean age, 4.8 years; range, 5 months-41 years) underwent repair for TC. The ACA anatomy was classified as the single LAD from the RCA (n = 20), a significant conal branch (dual LAD) from the RCA (n = 13), paired anterior descending arteries originating from the left and right coronary arteries (n = 7), and single RCA from the LAD (n = 3). In cases in which the anomalous LAD crossed the obstructed infundibulum, thinning or coring of the endocardium was done. Patch infundibuloplasty was performed in 39 patients, with 10 needing separate RV and pulmonary artery patches, and the pulmonary valve was preserved. Nine patients had the addition of a monocusp to a transannular incision. Two patients had a main pulmonary arterioplasty alone. There was one early (2.3%) and no late deaths. Mean early and late postoperative gradients were 21.5 +/- 10.5 mmHg (4 patients had > or =30 mmHg) and 27.1 +/- 13.7 mmHg (5 patients had >30 mmHg; p = 0.12), respectively. There were four reoperations during a mean follow-up of 4.8 years (range, 6 months to 18 years). Actuarial freedom from reoperation was 90% at 5, 10, and 15 years. At the latest follow-up, all patients were in NYHA functional class I. TOF repair for an ACA can be performed without disturbing the native coronary anatomy and without the use of conduits in most cases. Outcomes are similar to those of other patients with TOF. The presence of ACA does not impose increased risk after this surgical strategy.

Left atrial appendage insertion for right ventricular outflow tract reconstruction

BACKGROUND

The left atrial appendage (LAA) may serve as an alternative to the pulmonary arterial wall for right ventricular outflow tract (RVOT) reconstruction without an extracardiac conduit.

METHODS

Five consecutive patients with pulmonary atresia or severe stenosis underwent corrective (n = 4) or palliative (n = 1) RVOT reconstruction using an LAA insertion. Surgery was performed to treat tetralogy of Fallot, double-outlet right ventricle, or transposition of the great arteries. By inserting the LAA into the obstructed portion, the width of the posterior wall of the RVOT was 20 mm or more. The anterior half of the RVOT was then augmented with pericardial patch.

RESULTS

There were no early or late postoperative deaths, and no major complications (arrhythmias, thrombo-embolic episodes, infective endocarditis, need for reoperation). The postrepair systolic right ventricular-to-systemic arterial pressure ratio was 0.61 +/- 0.26. Color Doppler flow mapping revealed that the reconstructed RVOT was nonobstructive and had nonturbulent flow. No thrombus or pseudoneointimal formation was observed in the RVOT.

CONCLUSIONS

LAA insertion in the RVOT is an effective alternative to, or adjunct of, direct anastomosis. It offers several advantages, including fewer early and midterm complications and avoiding the use of an extracardiac conduit.

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.