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Ann Thorac Surg 1995;59:1363
© 1995 The Society of Thoracic Surgeons

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Editorial

Transatrial Repair of Tetralogy of Fallot

The Hospital for Sick Children, Toronto, Ontario, Canada

The actuarial survival after repair of tetralogy of Fallot approaches 90% at 10 years postoperatively, and the current therapeutic focus concerns early and late preservation of right ventricular function. The evidence regarding late right ventricular dysfunction, the necessity for pulmonary valve replacement, and late ventricular arrhythmias after repair of classic tetralogy of Fallot appears increasingly to favor the use of the transatrial/transpulmonary surgical approach [1, 2]. It should be recognized that the so-called transatrial/transpulmonary approach often involves, if the annulus is restrictive (z value < 0), the use of an incision 5 to 15 mm in length extending onto the right ventricular infundibulum.

The important technical feature of the transatrial/transpulmonary approach is limitation of the size of the right ventricular incision to that just sufficient to adequately divide or resect septal and parietal bands that contribute to the infundibular obstruction. Ventricular septal defect closure almost always can be accomplished from the right atrial approach so that extension of the right ventricular incision for the express purpose of ventricular septal defect exposure is not warranted and generally not necessary. Detachment of the anterior leaflet of the tricuspid valve can be a useful maneuver to expose the outlet portion of the ventricular infundibular fold and facilitate accurate ventricular septal defect closure.

With this objective in mind, it is useful for the surgeon to recognize the marked tendency for the right ventricular to left ventricular pressure ratio to decline after repair, as demonstrated with both the right atrial and right ventricular approach in our original article published in 1988 [3]. The decline in measured right ventricular to left ventricular pressure ratio appears to be especially evident in the first 30 minutes after transatrial/transpulmonary repair. It therefore is recommended that, provided that the cardiac function is good, the surgeon accept relatively high right ventricular to left ventricular pressure ratios before resorting to a conventional transannular approach with extension of the ventricular incision. Previous studies from the University of Birmingham in Alabama define a right ventricular to left ventricular pressure ratio of 0.80 as the threshold for resorting to this course of action, and this guideline would appear to remain valid even with contemporary experience. This implies that a modest degree of residual infundibular narrowing is preferable to an extension of the right ventricular incision and the attendant pulmonary incompetence.

Much controversy exists concerning the most appropriate therapeutic approach for infants less than 6 months of age with classic tetralogy of Fallot. However, our experience at The Hospital for Sick Children, Toronto, indicates that the development of severe symptoms in the first few months of life necessitating surgical intervention is unusual and probably constitutes less than 10% of the entire spectrum of patients with tetralogy of Fallot. Although there are fewer data relevant to this subset of patients, the principles of minimizing the magnitude of the right ventricular incision would appear to be just as compelling as in the older patients. Balloon dilation of the right ventricular outflow tract using transcatheter approaches in symptomatic neonates with tetralogy of Fallot is a conceptually attractive approach [4, 5]. This is especially true if this approach can be shown to increase the size of the pulmonary annulus relative to somatic growth (ie, positive z value increase) and thus carry the prospect for reduced incidence of pulmonary annular transgression at the time of eventual repair.

Footnotes

Address reprint requests to Dr Coles, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8.

References

1. Karl TR, Sano S, Pornviliwan S, et al. Tetralogy of Fallot: favorable outcome of neonatal transatrial, transpulmonary repair. Ann Thorac Surg 1992;54:903–7.[Abstract]
2. Dietl CA, Cazzaniga ME, Torres AR, Favaloro RG. Life threatening arrhythmia and right ventricular dysfunction after surgical repair of tetralogy of Fallot: comparison between transventricular & transatrial approaches. Circulation 1993;88(Suppl 1):96.
3. Coles JG, Kirklin JW, Pacifico AD, Kirklin JK, Blackstone EH. The relief of pulmonary stenosis by a transatrial versus a transventricular approach to the repair of tetralogy of Fallot. Ann Thorac Surg 1988;45:7–10.[Abstract]
4. Giroud JM, Boucek RJ, Henry JG, et al. Growth of hypoplastic pulmonary arteries after palliative balloon dilatation of the pulmonary valve in infants with tetralogy of Fallot. Circulation 1994;90(Suppl 1):642.
5. Sluysmans T, Ovaert C, Neven B, et al. Early balloon dilatation of the pulmonary valve in infants with tetralogy of Fallot. Circulation 1994;90(Suppl 1):643.

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John G. Coles Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Coles, J. G. Search for Related Content PubMed PubMed Citation Articles by Coles, J. G.