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Tetralogy of Fallot

  • Viktor Hraška
  • Peter Murín

Abstract

Evidence suggests that early correction minimizes secondary damage to the heart or other organ systems due to chronic hypoxia, promotes pulmonary artery growth, and alleviates the stimulus for continuous right ventricular hypertrophy, thus preserving the mechanical and electrical stability of the heart. In the majority of centers, therefore, primary repair is electively performed before 6 months of age. The strategy of primary repair provides excellent outcomes, with mortality approaching zero, and acceptable morbidity. Avoidance of a shunt also has economical and psychosocial advantages. A combination of transatrial and transpulmonary approach is the preferred method. An effort is made to preserve the pulmonary valve, thus potentially limiting the negative impact of pulmonary regurgitation on right ventricular function. The need for a transannular patch is determined by the hypoplastic pulmonary artery annulus, and it is not eliminated by the shunt procedure. If a transannular approach is unavoidable, excision and patching should be minimal to prevent the long-term adverse sequelae associated with right ventriculotomy, particularly in the presence of pulmonary insufficiency. Depending on the institutional experience and policy, the staged approach remains a reasonable option.

Keywords

Pulmonary Artery Septal Defect Patent Ductus Arteriosus Atrial Septal Defect Ventricular Septal Defect 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Supplementary material

Clip 1: Echocardiogram and external anatomy of the heart.

Clip 2: Dissection of the pulmonary arteries, closure of the ductus arteriosus. The aortic cross clamp was applied, and antegrade cold crystalloid cardioplegia was delivered. The pulmonary trunk was opened to inspect the pulmonary valve. The pulmonary valve was tricuspid, well developed and had no structural alterations.

Clip 3: Release of the right ventricular outflow tract obstruction.

Clip 4: Patch closure of the ventricular septal defect.

Clip 5: Closure of the atrial septal defect and pulmonary artery trunk.

Clip 6: Postoperative findings.

Fullversion

Clip 1: Commissurotomy of the stenotic bicuspid pulmonary valve, and transatrial correction, with patch closure of the ventricular septal defect.

Clip 1: Echocardiogram and external anatomy of the heart.

Clip 2: Opening of the right ventricular outflow tract and transection of the parietal band.

Clip 3: Patch closure of the ventricular septal defect.

Clip 4: Construction of the mini-transannular patch.

Clip 5: Postoperative findings.

Fullversion

Clip 1: Echocardiogram and external anatomy of the heart.

Clip 2: Opening of the right ventricular outflow tract and resection of the obstructing muscles – opening of the imperforated pulmonary artery valve.

Clip 3: Transection of the obstructing muscles.

Clip 4: Patch closure of the ventricular septal defect.

Clip 5: Reconstruction of the right ventricular outflow tract.

Clip 6: Final result.

Fullversion

Clip 1: Preoperative echocardiogram.

Clip 2: Mobilization of the pulmonary arteries, transection of the ductus arteriosus.

Clip 3: Transection and opening of the pulmonary trunk and the left pulmonary artery.

Clip 4: Ventriculotomy and transection of the parietal band.

Clip 5: Patch closure of the ventricular septal defect.

Clip 6: Reconstruction of the right ventricular outflow tract.

Clip 7: Final results of reconstruction.

Fullversion

Clip 1: Preoperative echocardiogram.

Clip 2: The ascending aorta, aortic arch, and brachiocephalic vessels are widely mobilized. The superior vena cava is dissected free, and the azygos vein is transected to improve mobility of the superior vena cava.

Clip 3: The standard technique of cardiopulmonary bypass with full flow and mild hypothermia (32°C) is employed. Myocardial protection is provided by crystalloid antegrade cardioplegia.

Clip 4: Repair of the tetralogy of Fallot is undertaken first.

Clip 5: A short, vertical incision is made in the infundibular portion of the right ventricle. Subsequently, the pulmonary artery trunk is transected above the annulus.

Clip 6: After another dose of cardioplegia, the aorta is transected just above the commissures. At this point, one should consider shortening the aorta by resecting the appropriate tubular segment to facilitate an anteposition of the pulmonary artery.

Clip 7: The pulmonary artery is brought anteriorly.

Clip 8: The end-to-end anastomosis of the ascending aorta is performed.

Clip 9: Direct connection between the obliquely shortened pulmonary trunk and the right ventricular outflow tract is accomplished.

Clip 10: Complementary anterior–posterior downsizing of the pulmonary arteries is performed to decrease wall tension and prevent later development of aneurysmal dilatation of the pulmonary artery.

Clip 11: Final result.

Clip 12: Postoperative echocardiogram.

Fullversion

Recommended Reading

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Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Viktor Hraška
    • 1
  • Peter Murín
    • 1
  1. 1.Department of Cardiac SurgeryGerman Pediatric Heart Centre, Sankt AugustinSankt AugustinGermany

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