CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
180
AFRICA
Patients were evaluated at one, three, six and 12 months, and
then annually after surgery. Postoperative evaluation included a
complete physical examination, an electrocardiogram, and two-
dimensional and Doppler echocardiography in all patients.
Statistical analysis
Statistical analyses were performed using the
χ
2
test and the
Wilcoxon rank sum test for non-parametric variables. A paired
t
-test was used for continuous variables. The results were calcu-
lated as the mean
±
standard deviation. All statistical analyses
were performed using the SPSS 11 program.
Results
Classical ToF was found in 10 patients. Twelve cases had associ-
ated anomalies (two patients with hypoplastic pulmonary artery
branches, two with arterial duct malformations, and eight had
proximal stenosis of the left branch of the pulmonary artery).
NYHA class distribution was as follows: class I: two patients;
class II: five subjects; class III: 10 patients; class IV: five
subjects.
Five patients (25%) were symptomatic, with more than one
episode of hypoxic spells
or persistent hypoxaemia (arterial
oxygen saturation less than80%). Among these was one boy with
hypotony of the lower limbs because of prolonged immobility
due to the hypoxic spells during mild physical exertion.
Early postoperative course
Complete repair was carried out on 22 patients. Closure of the
ventricular septal defect (VSD) with the insertion of a trans-
annular patch was performed in 12 subjects, and closure of the
VSD with the insertion of an infundibular patch was performed
in 10 patients. The acute post-surgical complications were mild
pericardial effusion detected in four cases and pleural effusion
in three cases. The dosage of diuretic was increased in these,
with good results. In one case there was chylothorax, which was
treated with diet. There were no cases of arrhythmia. We did not
observe any differences in follow-up results regarding age of the
children at surgery, nor for surgical technique.
The mean hospital stay was 15
±
7 days and the range was
between 10 and 20 days. In the intensive care unit, the mean stay
was 5
±
3 days. The chest tubes for drainage were removed in the
general children’s ward, mostly on the seventh to eighth postop-
erative day. The mean oxygen saturation of the patients changed
from 67
±
5% before surgery to 90
±
2.5% after the correction.
A five-year-old boy and a girl died in the acute post-surgical
period (9%). The cause of death was profuse bleeding from a
poorly controlled collateral vessel.
Follow-up data
The duration of follow up was from eight months to six years.
Electrocardiographic data:
All patients were
in regular sinus
rhythm. First-degree atrio-ventricular block was observed in two
patients in the acute post-surgical period and thereafter. Right
bundle branch block and right ventricular hypertrophy present
before surgery persisted in 88% of patients. In three patients we
detected isolated monomorphic ventricular extra-systoles.
Echocardiographic data:
There were no significant differences
in RVOT gradients and right ventricular (RV) pressures during
follow up in all patients except one, who developed mild to
moderate RVOT obstruction, with a pressure gradient of 25
to 35 mmHg proximal
to the patch. The mean RVOT pressure
gradient was 29
±
1.5 mmHg in the acute post-surgical period.
Three months later, it was 27.6
±
1.7 mmHg. The RVOT pres-
sure at one year was 26.8
±
1.1 mmHg (
p
≤
0.05) compared to
the acute post-surgical reading. After two years, the mean RVOT
pressure was constant at around 26.2
±
2.9 mmHg (
p
>
0.6).
This was maintained for about two years, until the last follow-up
measurements.
Right ventricular function was defined as normal in 95% of
the patients in the entire study and mildly depressed in 5%. A
mild to moderate degree of pulmonary regurgitation was evident
in three patients, associated with mild triscupid regurgitation and
a mild right ventricular dilatation.
A diagnostic cardiac catheterisation was done prior to surgery
in only three cases, for better visualisation of the coronary arter-
ies, pulmonary arterial trunk and pulmonary branches. Proximal
left pulmonary artery stenosis with a pressure gradient of 20
mmHg was found in one patient a week after surgery. A success-
ful dilatation was done in the catheterisation laboratory.
Discussion
Although the presentation of ToF in adults is becoming a rarity in
Western countries, it is still common in developing countries. In
our study we aimed to analyse the early results and follow up of
older Cameroonian patients operated on for ToF. All our patients
had surgery after 12 months of age, with a good outcome.
In the literature, correction is usually performed before one
year of age and some authors advocate very early repair, before
six months of age. However, Vohra
et al
.
5
found that early
primary repair of ToF was comparable to later repair. Ooi
et
al
.
7
showed that early definitive repair of ToF can be performed
safely on patients under six months old. Both approaches
are
supported by clinical reports of excellent early results.
8
However, in our cases, because of lack of adequate medical
facilities and poverty of patients, the diagnosis and surgery were
performed late.
In our cohort of ToF patients, the most commonly occur-
ring problems before surgery were hypotony of the lower limbs
and stiffness caused by immobility due to hypoxic spells. After
surgery, we observed pulmonary and triscupid regurgitation and
residual obstruction of the RVOT. It is important to mention that
hypoxic spells during mild physical exertion are an incapacitat-
ing factor in our context, leading to stiffness and hypotony of the
lower limb muscles, which will need later physiotherapy.
Late diagnosis and late surgical intervention are probably
the reasons why early mortality in our series was 9%, which is
quite elevated when compared to data by Wu
9
(0.9% death rate
in patients aged between one and 37 years) or Ghavidel
et al
.
10
(1.9% in adult patients with ToF). In our case, the cause of death
was poorly controlled severe bleeding from the collaterals. It is
well known that deeply cyanosed patients have a well-developed
collateral circulation. Furthermore, the presence of combined
chronic latent diseases (tropical infections) on admission could
have influenced the acute post-surgical period.
The length of the chest tube for drainage was notably longer
in our series than in ToF subjects treated between six and 12
