CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 2, March 2012
e8
AFRICA
Case Report
Total correction in tetralogy of Fallot with anomalous
major coronary artery: an alternative method to conduit
use
B SARITAS, E OZKER, C VURAN, U YORUKER, C AYABAKAN, R TURKOZ
Abstract
Introduction:
A coronary artery anomaly precludes the use
of a trans-annular patch in right ventricular outflow tract
(RVOT) reconstruction. Herein we present three patients
with coronary artery anomalies who underwent total correc-
tive operations without using a conduit.
Methods:
Between 2007 and 2010, 84 patients with tetralogy
of Fallot (TOF) were operated on. Nine (9.4%) of them had a
coronary artery anomaly. Three (3.1%) of the patients were
operated on using the double-outflow technique and two had
a Blalock-Taussig shunt before the total corrective operation.
In two patients, the left anterior descending artery (LAD)
and in one, the right coronary artery (RCA) crossed the
RVOT.
Results:
Postoperatively, the right-to-left ventricular pressure
ratios were 0.45, 0.59 and 0.60 after cardiopulmonary bypass.
No gradient was detected in the RVOT in postoperative echo-
cardiographical measurements (
<
15 mmHg gradient). In all
three patients, there were moderate pulmonary insufficien-
cies. All were discharged home on the sixth day postopera-
tively. Mean follow-up duration was 9.8
±
8 months. In the
follow up of all three patients, there were moderate pulmo-
nary insufficienciencies but no right ventricular dysfunction.
Conclusion:
The ‘double-outflow’ technique is appropriate
for TOF patients with a major coronary artery anomaly
since it can easily be performed without the need of a conduit.
Keywords:
coronary artery anomaly, tetralogy of Fallot, total
correction
Submitted 29/11/10, accepted 16/2/11
Cardiovasc J Afr
2012;
23
: e8–e10
DOI: 10.5830/CVJA-2011-004
In the total corrective procedures for tetrology of Fallot, the main
goal is closure of the interventricular connection and relieving
the right ventricular outflow obstruction. However, in 2 to 9%
of these patients, there is also a coronary artery anomaly which
crosses the right ventricular outflow and hampers the use of a
trans-annular patch.
1,2
In some symptomatic patients, systemic-
to-pulmonary shunts are performed in the early phase of treat-
ment and later, the right ventricle–pulmonary artery continuity is
achieved through a conduit.
However, conduit use in childhood means reoperation in
the long term due to relative stenosis and degeneration of the
conduit, which occurs as the child grows.
1
Therefore, in most
cases, operation is delayed until the child grows up. This leads
to a hypoxic state and impedes organ development. On the other
hand, the pressure applied by the conduit on the coronary arter-
ies supplying the myocardium can sometimes lead to myocardial
ischaemia.
3
In this report, we present three patients who were
operated on using the ‘double-outflow’ technique, which was
introduced in 1995
4
and modified in the following years.
5,6
Methods
Eighty-four TOF patients were operated on in the Baskent
University Research Hospital, Istanbul between February 2007
and June 2010. Nine patients had concomitant coronary artery
anomalies. Among these, in seven patients the left anterior
descending (LAD) and in two, the right coronary arteries (RCA)
crossed the right ventricular outflow tract (RVOT). In six of these
nine patients, conduits were used in reconstruction of the RVOT.
In the remaining three, the ‘double-outflow’ technique was used.
All procedures were performed on cardiopulmonary bypass
and under cardioplegic arrest. Intermittent normothermic blood
cardioplegia were used.
Following myocardial arrest, the right atrium was opened. The
tricuspid valve was retracted and the interventricular relationship
and RVOT morphology were investigated. Right ventriculotomy
was performed 3–4 mm underneath the coronary artery, which
crossed the right ventricular outflow. Through this right ventricu-
lotomy, the muscle bands were resected. The interventricular
connection was closed with a dacron patch.
Two parallel incisions on the anterior wall of the main
pulmonary artery were performed. Using these incisions, a
rectangular flap was cut out without interfering with the left
and the right pulmonary artery orifices. Pulmonary valvotomy
was performed. The distal end of the flap was sewn to the right
ventriculotomy on the side of the pulmonary artery (Fig. 1). The
Department of Cardiovascular Surgery, Baskent University
Hospital, Istanbul, Turkey
B SARITAS, MD,
E OZKER, MD
C VURAN, MD
U YORUKER, MD
R TURKOZ, MD
Department of Pediatric Cardiology, Baskent University
Hospital, Istanbul, Turkey
CANAN AYABAKAN, MD
