Total Correction of Tetralogy of Fallot in an Infant

Tetralogy of Fallot (TOF) is one of the most common cyanotic congenital heart diseases. The aim of this video is to demonstrate the technical aspects of total correction of TOF in a 5-month-old, 5 kg infant. Median sternotomy was performed. The surgery required standard cardiopulmonary bypass with aortobicaval venous cannulation. The authors’ choice of cardioplegia is del Nido cardioplegia. 

The main steps are:

• Resection and relief of right ventricular outflow tract (RVOT) obstruction
• VSD closure
• Reconstruction of RVOT (transannular patch in this video)
• Postoperative transesophageal echocardiographic assessment

Since it is one of the most common cyanotic congenital heart conditions which requires surgical attention, the optimal timing of surgery has remained a matter of debate (1-3). In spite of ambiguity about timing of surgery for TOF, it is now established and repair in infancy is a safe strategy (3-4).

The two-stage strategy of initial palliation with a systemic to PA shunt followed by complete correction at alter stage has largely been replaced by primary complete repair on younger infants, regardless of presence of symptoms (1-4). The reason for this debate is higher mortality and morbidity at the earlier age of surgery and whether earlier surgery offered any benefit at all for more physiological developments of the heart.

With enough evidence in literature showing the safety of complete repair in TOF in infants, it should be the preferred strategy for treating this important subset of cyanotic congenital heart diseases (2-5).

References

1. Tamesberger MI, Lechner E, Mair R. Early primary repair of tetralogy of Fallot in neonates and infants less than four months of age. Ann Thorac Surg. 2008;86:1928–1936. 
2. Reddy VM, Liddicoat JR, McElhinney DB, Brook MM, Stanger P, Hanley FL. Routine primary repair of tetralogy of Fallot in neonates and infants less than three months of age. Ann Thorac Surg. 1995;60:592–596.
3. Van Arsdell GS, Maharaj GS, Tom J, Rao VK, Coles JG, Freedom RM, et al. What is the optimal age for repair of tetralogy of Fallot? Circulation. 2000;102(Suppl 3):123–129. 
4. Al Habib HF, Jacobs JP, Mavroudis C, Tchervenkov CI, O'Brien SM, Mohammadi S, et al. Contemporary patterns of management of tetralogy of Fallot: data from the Society of Thoracic Surgeons database. Ann Thorac Surg. 2010;90:813–819. 
5. Barron DJ. Tetralogy of Fallot: controversies in early management. World J Pediatr Congenit Heart Surg. 2013;4:186–191. 
6. Yang S, Wen L, Tao S, Jiangrong G, Jiangang H, Junping Y, et al. Impact of timing on in-patient outcomes of complete repair of tetralogy of Fallot in infancy: an analysis of the United States National Inpatient 2005–2011 database. BMC CardiovascDisord. 2019:19:46-53.

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