Tetralogy of fallot surgical techniques: Difference between revisions
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A transannular patch of the RVOT renders the pulmonary valve incompetent, which may have significant long-term hemodynamic and electrophysiologic consequences, especially if severe. Currently, surgical approaches emphasize maintaining pulmonary valve competence where possible. A "valve sparing approach" is easily applied to individuals with adequate pulmonary annulus size. However, in patients with borderline pulmonary valve annulus sizes, this approach necessitates balancing some degree of residual right ventricular outflow tract obstruction against the obligate insufficiency associated with a transannular patch. | A transannular patch of the RVOT renders the pulmonary valve incompetent, which may have significant long-term hemodynamic and electrophysiologic consequences, especially if severe. Currently, surgical approaches emphasize maintaining pulmonary valve competence where possible. A "valve sparing approach" is easily applied to individuals with adequate pulmonary annulus size. However, in patients with borderline pulmonary valve annulus sizes, this approach necessitates balancing some degree of residual right ventricular outflow tract obstruction against the obligate insufficiency associated with a transannular patch. | ||
At the present time, there is not general consensus upon the size of the pulmonary annulus and the acceptable degree of residual outflow tract obstruction that is amenable to a valve sparing approach | At the present time, there is not general consensus upon the size of the pulmonary annulus and the acceptable degree of residual outflow tract obstruction that is amenable to a valve sparing approach. The most common current surgical strategy consists of ventriculotomy and transannular patch repair for primary repair, as well as repair of TOF after palliation [10]. | ||
An alternate procedure is insertion of a valved conduit from the RV to the distal main pulmonary artery (figure 2). However, stenosis and/or regurgitation of the conduit prosthetic valve, as well as stenosis of the conduit, can occur [11]. (See 'Chronic pulmonary regurgitation' below.) | An alternate procedure is insertion of a valved conduit from the RV to the distal main pulmonary artery (figure 2). However, stenosis and/or regurgitation of the conduit prosthetic valve, as well as stenosis of the conduit, can occur [11]. (See 'Chronic pulmonary regurgitation' below.) | ||
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**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. | ||
*Currently, for primary repair ventriculotomy and transannular patch are preferred | |||
==See also== | ==See also== | ||
* [[Trilogy of Fallot]] | * [[Trilogy of Fallot]] | ||
Revision as of 21:50, 9 August 2011
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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]
<youtube v=Sl6RoaLyIgw/>
A transannular patch of the RVOT renders the pulmonary valve incompetent, which may have significant long-term hemodynamic and electrophysiologic consequences, especially if severe. Currently, surgical approaches emphasize maintaining pulmonary valve competence where possible. A "valve sparing approach" is easily applied to individuals with adequate pulmonary annulus size. However, in patients with borderline pulmonary valve annulus sizes, this approach necessitates balancing some degree of residual right ventricular outflow tract obstruction against the obligate insufficiency associated with a transannular patch.
At the present time, there is not general consensus upon the size of the pulmonary annulus and the acceptable degree of residual outflow tract obstruction that is amenable to a valve sparing approach. The most common current surgical strategy consists of ventriculotomy and transannular patch repair for primary repair, as well as repair of TOF after palliation [10].
An alternate procedure is insertion of a valved conduit from the RV to the distal main pulmonary artery (figure 2). However, stenosis and/or regurgitation of the conduit prosthetic valve, as well as stenosis of the conduit, can occur [11]. (See 'Chronic pulmonary regurgitation' below.)
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.
- 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 TOF with pulmonary atresia.
- Premature babies
- Coronary artery anatomy.
- The Blalock-Taussig procedure was the only surgical treatment until the first total repair was performed in 1954.
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.
- Currently, for primary repair ventriculotomy and transannular patch are preferred
See also
- Trilogy of Fallot
- Pentalogy of Fallot
References
External links
- Tetralogy of Fallot information from Seattle Children's Hospital Heart Center
- Information by University of Michigan Health System
- Diagram of the condition
- Information for adults with ToF from the Adult Congenital Heart Association
- Michael Warman's Website on ToF
de:Fallot-Tetralogie it:Tetralogia di Fallot nl:Tetralogie van Fallot nn:Fallots tetrade uk:Тетрада Фалло