The ventricular function, atrioventricular valve regurgitation, and need for tricuspid intervention were the primary risk factors for survival after the cavopulmonary shunt operation. Although unplanned surgery is associated with poor outcomes, this is related to the primary risk factors and not the timing or age of the patient. Somatic growth also has a significant influence on survival. Thus, an earlier cavopulmonary shunt operation is safe in infants who are thriving, but those with poor weight gain are at higher risk.

Background:Residual right ventricular outflow obstruction during Tetralogy of Fallot repair necessitates peri-operative revision often requiring trans-annular patch with its negative sequels. Bidirectional Glenn shunt in this setting reduces trans-pulmonary gradient to avoid revision.Methods:Bidirectional Glenn shunt was added during Tetralogy repair in patients with significant residual obstruction. A total of 53 patients between January, 2011 and June, 2018 were included. Final follow-up was conducted in July, 2018.Results:Mean age at operation was 5.63±3.1 years. Right to left ventricular pressure ratio reduced significantly (0.91±0.09 versus 0.68±0.05; p<0.001) after bidirectional Glenn, avoiding revision in all cases. Glenn pressures at ICU admission decreased significantly by the time of ICU discharge (16.7±3.02 versus 13.5±2.19; p<0.001). Pleural drainage ≥ 7 days was seen in 14 (26.4%) patients. No side effects related to bidirectional Glenn-like facial swelling or veno-venous collaterals were noted. Mortality was 3.7%. Discharge echocardiography showed a mean trans-pulmonary gradient of 32.11±5.62 mmHg that decreased significantly to 25.64±5 (p<0.001) at the time of follow-up. Pulmonary insufficiency was none to mild in 45 (88.2%) and moderate in 6 (11.8%). Mean follow-up was 36.12±25.15 months (range 0.5–90). There was no interim intervention or death. At follow-up, all the patients were in NYHA functional class 1 with no increase in severity of pulmonary insufficiency.Conclusion:Supplementary bidirectional Glenn shunt significantly reduced residual right ventricular outflow obstruction during Tetralogy of Fallot repair avoiding revision with satisfactory early and mid-term results.

Objective: To compare trans-atrial/Trans-pulmonary and trans-annular/trans-ventricular techniques of surgical correction of tetralogy of fallot. Study Design: Descriptive cross sectional study. Place and Duration of Study: AFIC-NIHD Rawalpindi, from Jan 2005 to Jan 2020. Methodology: Pre-op variables included age, gender, weight, SaO2 and any previous operation (like Modified Blalock Taussig Shunt.) Operative variables were any previous Blalock Taussig Shunts and if present, then their takedown, Cardiopulmonary Bypass Time, Aortic Clamp Time, any Right Ventricle - Pulmonary Artery conduit, Main Pulmonary Artery patch-plasty, Left Pulmonary Artery/ Right Pulmonary Artery patch-plasty, dosage of inotropes and pacing started during weaning off CPB. Post-op variables were mechanical ventilation time (hrs), ventilation time >72 hrs, dosage and duration of inotropes, pacing >24 hrs, renal complications, neurological complications, sepsis, low cardiac output, re-ventilation, tachyarrythmias, any re-opening surgery, mean intensive care unit stay (hrs), overall hospital stay (days) and overall all-cause mortality. Results: A total of 1271 TOF patients were operated. In (38.6%) cases Trans-atrial / Trans-pulmonary approach was used while in 780 (61.3%) correction was done by TAP/TV technique. In both techniques, male patients were 365 (66.4%) vs. 73 (64.1%) females. Mean age was 5 ± 2.3 vs. 4 ± 2.5 years, MPA patch-plasty was 190 ± 5 (38.6%) vs. 780 ± 8 (100%) (p-0.058), RPA/LPA Patch Plasty was 25 ± 6 (5%) vs. 180 ± 10 (23%) (p- 0.025), In ICU, Ventilation hours was 25 ± 8 and 30 ± 12, Ventilation >72 Hrs was 15 (3%) vs. 65 (8.3%) (p-0.015), Inotrope duration >72 Hours was 90 (18.3%) vs. 400 (51.2%) (p-0.338), pacing >24 hours was 30 (6.1%) vs. 150 (19.2%) (p-0.0001), renal complications were 10 (2.3%) vs. 35 (4.4%) (p- 0.285), Neurological complications were 7 (1.4%) vs. 15 (1.9%) (p0.553), Sepsis was 11 (2.2%) vs. 47 (6%) (p-0.33), Low cardiac output was 15 (3%) vs. 66 (8.4%) (p- 1.000), re-ventilation was 10 (2%) vs. 110 (14%) (p- 0.41), Tachy-arrhythmia was 25 (5%) vs. 150 (19.2%) (p- 0.11), re-openings were 19 (3.8%) vs. 65 (8.3%) (p- 0.0003), ICU stay (Hours) was 87 ± 8 vs. 108 ± 10, Mortality was 35 (7.1%) vs. 75 (9.6%) (p-0.094), Mean hospital stay (Days) was 12.2 ± 2.5 vs. 15.8 ± 4.9. Conclusion: Fifteen years’ experience of Tetralogy of fallot corrections at AFIC-NIHD indicates that Trans-atrial / Trans-pulmonary approach is more beneficial to patients due to high survival rate, less morbidity, less hospital stay and an early discharge. This ultimately translates into less financial burden on the patients, hospital, society and the country at large.