Tetralogy of fallot surgical techniques

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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]

Overview

Repair of Tetralogy of Fallot reduces mortality. With the development of modern surgical techniques, there was a 40% reduction in mortality attributed to Tetralogy of Fallot between 1979 to 2005.

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 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.

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.

Video

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ACC / AHA Guidelines - Recommendations for Evaluation and Follow-Up of the Repaired Patient in Tetralogy of fallot

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Class I 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) 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) 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) 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) 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)

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Related Chapters

• Trilogy of Fallot
• Pentalogy of Fallot

External links

• Information for adults with ToF from the Adult Congenital Heart Association