Surgical Problems in Total Correction of Tetralogy of Fallot after Primary Palliation

Abstract

Depan ment 01 Tho rac ic and Card iOYilSCu lal Su rgery 01 the $ urg ieel Clinic. UniYersilV o f Tiibinge n Sum maryThe surgical problems in toul eonecuon of lellalog of Fallol following l»llialio n e ncou nte red in 6S pa tient s after co nstruc tio n o f 'W/IIv ston-Coolq (33) a nd Blo.fock.·TflUss;' ( )2) anastomoses are presented. The Wu e rst on-Coo le y sh u nt was severely angu late d in 9 pa tients, causing underp erfu sion o r occlusion of th e Jeft pulmonary a rte ry. Pulmo nary hype rte nsio n was p rese n t in 3 p atien ts with increased vascular resista nce in one. The Blaloc k-Ta ussig a nas to mosis was oblitera ted in 9 pa tient s, cause d co mple te occ lusion o f th e ri&ht pulmonary a rte ry in one and formation o f an aneurysm o f th e subclavilln u tery a t the site o f th e a nastomosis in one. Tran sannular pa tching o f th e right ven tricul u ce trtow trac t was necessary in 95 "; o f the patient s pallial· ed in th e r...st yeu of life. As some degree o f angu latio n o f the Wate rslo n-Cool ey anastom os is W llS seen in alm ost 60 ,.; of the pat jent s, we have aba ndo ned its transacruc ctosure technique. The right pulmonary a rte ry is no w dissected fro m the aorta and bo th th e ao rt a and p ulmonary artery are sutu red separa tely. The ope rat ive m or talit y rate was 16.9 % and is ma rked ly highe r tha n in ou r non-pafliated paucnts unde rgoing co rrec tio n o f te tr alogy of Palle t. Two ea rly and o ne la te dea th must be a ttribu ted to the previous shu n t procedure.With regard to th e high incidence of co mplica tio ns a nd failu res o f th e aortopulmonary shu nt~we co nclude tha i the ir applica tio n shou ld be restrict ed to iy m p to ma tic ba bies with a h ypo plastic pulm onary valve and annulus req uiring ea rly w rgi<:a1 in te....en tio n beca use o f severe h ypox:emia.KfY-Wo rds: Tetralogy of Falle r -Staged repa ir -Com plleeuc ns o f Wat ersto n-Cool ey anasto mos is -Co mplica lion!' of Blalock -Tau ssig anas to mos is group, particularly if severe hypoxemia and coagulation disorders were present. Recently, however, we were confronted with several complications originating from the previous shunt procedure. The purpose of this communication is to report on the surgical problems encounte red in total correction of tetralogy of Fallct following primary palliation. Materials and method sSince 197 1 we have perform ed total co rrec tio n of tetralos y o f Fa llo l in 16 1 pa tie nt s. Am ong th t se the re were 65 patioe nls who h ad been wbjecled to a p reviou s ao rt o-pul monary shu nl p rocedure. These 65 patient s fo rm the basis o f our study.Thirty-tw o pa tie nts had a BT an d 33 a we type o f anastomo sis. ln th e BT grou p 3 patie n ts had receive d the ir shu nt in th e fint year o f life (mean to.6 t 0.9 m onths). The remaining 29 pa tients had been palliated at the age of 4.2 t 3 year s (r ange 2 to 14 yea rs). Seven tee n pa tien ts of th e WC grou p we re un der on e yea r o f age a t th e time o f aorto-pulmcn ary shu nting (mea ns 6.1 ! 3 mo...

The Preoperative and Postoperative Findings in 627 Patients with Tetralogy of Fallot*

“…The percentual frequency of the anastomotic operations performed in our clinic is similar to those of other large studies and lies between 40 % and 62 % (1,9,13,26).…”

“…The operative mortality in our patient population, as in other centers, could be markedly reduced during the-Iast years (14,18,19,26). An exact comparison of our results with those in the literature in terms of overall mortality is difficult as the separate time periods are not given in some reports, patients with additional pulmonary atresia are not included in the numbers and the mortality rates for the relevant operative procedures are not presented (9,20,26).…”

“…Even in cases in which, by means of an early primary corrective operation, a shunt operation and the associated risks of developing pulmonary hypertension or kinking of the right pulmonary artery could be avoided, the application of a Cooley anastomosis, especially in newborn or young infants with hypoplastic pulmonary arte ries, was often a life-saving measure which also served to widen the pulmonary vascular bed (2,13,26). Our observations after shunt operation agree with the results of other authors: that, despite a widening of the pulmonary arte ries in patients with pulmonary valve hypoplasia, the valve ring remains hypoplastic in all cases (13,25,26). The hope, that a later transannular patch could be avoided as a result of palliation was also not realized in these patients.…”