CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
AFRICA
179
Late surgical treatment of tetralogy of Fallot
JCT TCHOUMI, JC AMBASSA, A GIAMBERTI, S CIRRI, A FRIGIOLA, G BUTERA
Abstract
Aim:
To study early post-operative results and follow up of
patients over a year old, operated on for tetralogy of Fallot
(ToF).
Methods:
This retrospective analysis included 22 patients (14
male and eight female) with a mean age of 9.18
±
6.5 years
(range 13.5 months to 26 years), who underwent complete
repair of ToF between April 2003 and June 2009. Data
from patients’ records, pre-operative cardiac catheterisation
studies, operative intervention, and pre-operative and post-
operative two-dimensional echocardiographic studies were
reviewed. All patients underwent complete repair including
closure of ventricular septal defect (VSD). A trans-annular
patch was used in 12 patients while an infundibular patch
was used in 10 others. Patients were evaluated one, three, six
and 12 months after surgery, and annually thereafter. The
duration of follow up was from eight months to six years post
surgery.
Results:
Classical ToF was found in 10 patients. Twelve cases
had associated anomalies: two patients with hypoplastic
pulmonary artery branches, two with arterial duct malfor-
mations, and eight had proximal stenosis of the left branch
of the pulmonary artery. NHYA class distribution was as
follows: class I: two patients; class II: five subjects; class III:
10 patients; class IV: five subjects. The mean stay in hospital
was 15
±
7 days. Two patients (9%) died during the early
post-surgical period. At a mean follow-up interval of 32
±
9
months, all patients were asymptomatic and in NYHA class
I. No late deaths occurred. In three patients, we registered
isolated monomorphic ventricular extrasystoles. The right
ventricle outflow tract (RVOT) pressure gradient was 29
±
1.5 mmHg in the acute post-surgical period and it did not
change significantly during follow up. The right ventricular
function was defined as normal in 95% of the patients in the
study and was mildly depressed in 5%.
Conclusion:
Even if treated later in life, our study showed
very good surgical results of patients with ToF.
Keywords:
tetralogy of Fallot, older patients, follow up
Submitted 17/2/10, accepted 12/7/10
Cardiovasc J Afr
2011;
22
: 179–181
DOI: 10.5830/CVJA–2010–057
Tetralogy of Fallot (ToF) is the most common cause of cyanotic
congenital heart disease.
1
The best age for ToF repair remains
controversial and the strategy employed may influence the tech-
nique of operation.
2
Early repair of ToF has many advantages. It
abolishes the secondary effects of increasing cyanosis on vital
organs and its adverse effects on cognitive and psychomo-
tor development of the patient. The relief of right ventricular
outflow obstruction eliminates the secondary right ventricular
hypertrophy and maintains the systolic and diastolic properties
of the ventricle when compared with either two-stage repair or
repair later in life.
3
Supporters of primary neonatal repair cite
factors such as prevention of time-related end-organ damage
from cyanosis, removal of stimulus for right ventricular hyper-
trophy and fibrosis, improved lung development (vascular and
alveolar), avoidance of deleterious effects and risks of palliative
shunts, and psychosocial-economic issues (for the family and
care givers).
4
In large centres worldwide, correction is performed between
six and nine months of age.
5
However, in developing countries,
early repair may be difficult due to many factors, including
facilities for diagnosis, cultural background of patients, and
availability of surgical centres. The purpose of this retrospec-
tive
investigation was to study the early results and follow up
in patients with ToF operated on when older than a year and
coming from a developing country.
Methods
This retrospective analysis included 22 patients (14 males and
eight females) with a mean age of 9.18
±
6.5 years (range 13.5
months to 26 years) who underwent complete repair of ToF
between April 2003 and June 2009. All subjects came from
Cameroon and were evaluated in the Cardiac Centre of the Saint
Elizabeth Hospital in Shisong. Data from patients’ records, pre-
operative cardiac catheterisation studies, operative intervention,
and pre- and postoperative two-dimensional echocardiographic
studies were reviewed.
All patients were operated on in the paediatric surgical unit
of San Donato teaching hospital in Shisong, and the project was
supported by the Tertiary Sisters of St Francis and two non-
governmental, non-profit organisations, Cuore Fratello (www.
cuorefratello.org) and Associazione Bambini Cardiopatici nel
Mondo
).
The ethics committee of the hospital approved the study.
A consent form was signed by patients, or their parents when
patients were unable to sign. It is significant that during the peri-
od of the study while awaiting surgery, 25 patients aged between
seven months and 15 years (nine males) died due to ToF-related
complications.
The operative technique to repair ToF has been described
previously.
6
RVOT reconstruction included a trans-annular patch
in the pericardium with a monocusp made of goretex. Some
subjects needed a trans-infundibular patch without any surgical
treatment of the pulmonary valve.
6
St Elizabeth Catholic General Hospital, Cardiac Centre,
Shisong, Cameroon
JCT TCHOUMI, MD, PhD,
JC AMBASSA, MD
Policlinico San Donato IRCCS, Pediatric Cardiology, Cardiac
Surgery and GUCH Unit, Milan, Italy
A GIAMBERTI, MD
S CIRRI, MD
A FRIGIOLA, MD
G BUTERA, MD, PhD
