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The current strategy of repair of tetralogy of Fallot in children and adults*

  • Guo-Wei He (a1) (a2) (a3) (a4), Xiao-Cheng Liu (a1), Xiang-Rong Kong (a1), Li-Xin Liu (a1), Ying-Qun Yan (a1), Bao-Jun Chen (a2), Zong-Xiao Li (a1), Wen-Bin Jing (a1), Zheng-Qing Wang (a1), Kai Wang (a1), Wei Zhang (a1), Tie-Nan Chen (a1), Ping-Shan Wang (a1), Wan-li Lu (a1), Jian-Liang Zhang (a1), Zhi-Peng Guo (a1), Lan-Gang Xue (a1), Yu-Xiang Zhu (a1), Xiu-Li Wang (a1) and Lei Xi (a1)...



The strategies of repair of tetralogy of Fallot change with the age of patients. In children older than 4 years and adults, the optimal strategy may be to use different method of reconstruction of the right ventricular outflow tract from those followed in younger children, so as to avoid, or reduce, the pulmonary insufficiency that is increasingly known to compromise right ventricular function.


From April, 2001, through May, 2008, we undertook complete repair in 312 patients, 180 male and 132 female, with a mean age of 11.3 years ±0.4 years, and a range from 4 to 48 years, with typical clinical and morphological features of tetralogy of Fallot, including 42 patients with the ventriculo-arterial connection of double outlet right ventricle. The operation was performed under moderate hypothermia using blood cardioplegia. The ventricular septal defect was closed with a Dacron patch. When it was considered necessary to resect the musculature within the right ventricular outflow tract, or perform pulmonary valvotomy, we sought to preserve the function of the pulmonary valve by protecting as far as possible the native leaflets, or creating a folded monocusp of autologous pericardium.


The repair was achieved completely through right atrium in 192, through the right ventricular outflow tract in 83, and through the right atrium, the outflow tract, and the pulmonary trunk in 36 patients. A transjunctional patch was inserted in 169 patients, non-valved in all but 9. There were no differences regarding the periods of aortic cross-clamping or cardiopulmonary bypass. Of the patients, 5 died (1.6%), with no influence noted for the transjunctional patch. Of those having a non-valved patch inserted, three-tenths had pulmonary regurgitation of various degree, while those having a valved patch had minimal pulmonary insufficiency and good right ventricular function postoperatively, this being maintained after follow-up of 8 to 24-months.


Based on our experience, we suggest that the current strategy of repair of tetralogy of Fallot in older children and adults should be based on minimizing the insertion of transjunctional patches, this being indicated only in those with very small ventriculo-pulmonary junctions. If such a patch is necessary, then steps should be taken to preserve the function of the pulmonary valve.


Corresponding author

Correspondence to: Professor Guo-Wei He, MD, PhD, DSc., Senior Cardiac Surgeon, Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, 61, Third Avenue, TEDA, Tianjin, China, Post code: 300457. Tel: (Hong Kong ) – (852) 2645 0519; Fax: (852) 2645 1762; E-mail:


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The presentation on which this work is based was given at the Inaugural Meeting of the World Society for Pediatric and Congenital Heart Surgery, held in Washington, District of Columbia, May 3 and 4, 2007.



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1.Bove, EL, Byrum, CJ, Thomas, FD, et al. . The influence of pulmonary insufficiency on ventricular function following repair of tetralogy of Fallot. Evaluation using radionuclide ventriculography. J Thorac Cardiovasc Surg 1983; 85: 691696.
2.Oku, H, Shirontani, H, Sunakawa, A, Yokoyama, T. Postoperative long-term results in total correction of tetralogy of Fallot: hemodynamics and cardiac function. Ann Thorac Surg 1986; 41: 413418.
3.d’Udekem, Y, Rubay, J, Shango-Lody, P, et al. Late homograft valve insertion after transannular patch repair of tetralogy of Fallot. J Heart Valve Dis 1998; 7: 450454.
4.Giannopoulos, NM, Chatzis, AK, Karros, P, et al. Early results after transatrial/transpulmonary repair of tetralogy of Fallot. Eur J Cardiothorac Surg 2002; 22: 582586.
5.Roughneen, PT, DeLeon, SY, Parvathaneni, S, Cetta, F, Eidem, B, Vitullo, DA. The pericardial membrane pulmonary monocusp: surgical technique and early results. J Card Surg 1999; 14: 370374.
6.Borowski, A, Ghodsizad, A, Litmathe, J, Lawrenz, W, Schmidt, KG, Gams, E. Severe pulmonary regurgitation late after total repair of tetralogy of Fallot: surgical considerations. Pediatr Cardiol 2004; 25: 466471; Epub 2004 Mar 4.
7.Conte, S, Jashari, R, Eyskens, B, Gewillig, M, Dumoulin, M, Daenen, W. Homograft valve insertion for pulmonary regurgitation late after valveless repair of right ventricular outflow tract obstruction. Eur J Cardiothorac Surg 1999; 15: 143149.
8.Giannopoulos, NM, Chatzis, AC, Bobos, DP, Kirvassilis, GV, Tsoutsinos, A, Sarris, GE. Tetralogy of Fallot: influence of right ventricular outflow tract reconstruction on late outcome. Int J Cardiol 2004; 97: 8790.
9.Bigras, JL, Boutin, C, McCrindle, BW, Rebeyka, IM. Short-term effect of monocuspid valves on pulmonary insufficiency and clinical outcome after surgical repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 1996; 112: 3337.
10.Rao, V, Kadletz, M, Hornberger, LK, Freedom, RM, Black, MD. Preservation of the pulmonary valve complex in tetralogy of fallot: how small is too small? Ann Thorac Surg 2000; 69: 176179; discussion 179–80.
11.Pozzi, M, Trivedi, DB, Kitchiner, D, Arnold, RA. Tetralogy of Fallot: what operation, at which age. Eur J Cardiothorac Surg 2000; 17: 631636.
12.Brizard, CP, Mas, C, Sohn, YS, Cochrane, AD, Karl, TR. Transatrial-transpulmonary tetralogy of Fallot repair is effective in the presence of anomalous coronary arteries. J Thorac Cardiovasc Surg 1998; 116: 770779.
13.He, GW, Kuo, CC, Mee, RB. Pulmonic regurgitation and reconstruction of right ventricular outflow tract with patch. An experimental study. J Thorac Cardiovasc Surg 1986; 92: 128137.
14.Bogers, AJ, Roofthooft, M, Pisters, H, Spitaels, SE, Bos, E. Long-term results of the gamma-irradiation-preserved homograft monocusp for transannular reconstruction of the right-ventricular outflow tract in tetralogy of Fallot. Thorac Cardiovasc Surg 1994; 42: 337339.
15.Sievers, HH, Lange, PE, Regensburger, D, et al. Short-term hemodynamic results after right ventricular outflow tract reconstruction using a cusp-bearing transannular patch. J Thorac Cardiovasc Surg 1983; 86: 777783.
16.Noera, G, Gatti, M, Massini, C, Medici, SI, Fattori, G. Experimental right ventricular outflow tract reconstruction with a composite mitrathane monocusp patch: preliminary results. Thorac Cardiovasc Surg 1988; 36: 8995.
17.Marchand, P. The use of a cusp-bearing homograft patch to the outflow tract and pulmonary artery in Fallot’s tetralogy and pulmonary valve stenosis. Thorax 1967; 22: 497509.
18.Trusler, GA, Iyengar, SR, Mustard, WT. Reconstruction of the pulmonary valve and outflow tract. J Thorac Cardiovasc Surg 1973; 65: 245251.
19.Revuelta, JM, Ubago, JL, Duran, CM. Composite pericardial monocusp patch for the reconstruction of right ventricular outflow tract. Thorac Cardiovasc Surg 1983; 31: 156159.
20.Abdulali, SA, Silverton, NP, Yakirevich, VS, Ionescu, MI. Right ventricular outflow tract reconstruction with a bovine pericardial monocusp patch. J Thorac Cardiovasc Surg 1985; 89: 764771.
21.Gundry, SR, Razzouk, AJ, Boskind, JF, Bansal, R, Bailey, LL. Fate of the pericardial monocusp pulmonary valve for right ventricular outflow tract reconstruction. J Thorac Cardiovasc Surg 1994; 107: 908913.
22.Ross, D, Somerville, J. Fascia-lata reconstruction of the right ventricular outflow tract. Lancet 1971; 1: 941943.
23.Ionescu, MI, Macartney, FJ, Wooler, GH, Gerbode, F. Reconstruction of the right ventricle outlet with fascia lata composite graft. J Thorac Cardiovasc Surg 1972; 63: 6074.
24.Trusler, GA, Ishizawa, E, Echevarre, E. Use of autogenous pericardium and homograft aortic valves in pulmonary valve reconstruction: an experimental study. Can J Surg 1974; 17: 1619.
25.Egloff, L, Turina, M, Senning, Å. An experimental study on transannular patching of the right ventricular outflow tract with and without a pulmonary valve monocusp mechanism. Thorac Cardiovasc Surg 1981; 29: 246251.
26.Sievers, HH, Storde, U, Rohwedder, EB, et al. Superior function of a bicuspid over a monocuspid patch for reconstruction of a hypoplastic pulmonary root in pigs. J Thorac Cardiovasc Surg 1993; 105: 580590.
27.Shatapathy, P, Aggarwal, BK, Kamath, SG, Sai, S. Pulmonary valve reconstruction in absent pulmonary valve syndrome: a new technique. J Card Surg 1997; 12: 180184.
28.Yamagishi, M, Kurosawa, H. Outflow reconstruction of tetralogy of Fallot using a Gore-Tex valve. Ann Thorac Surg 1993; 56: 14141417.
29.Turrentine, MW, McCarthy, RP, Vijay, P, Fiore, AC, Brown, JW. Polytetrafluoroethylene monocusp valve technique for right ventricular outflow tract reconstruction. Ann Thorac Surg 2002; 74: 22022205.
30.Quintessenza, JA, Jacobs, JP, Chai, PJ, Morell, VO, Giroud, JM, Boucek, RJ. Late replacement of the pulmonary valve: when and what type of valve? Cardiol Young 2005; 15 (Suppl 1): I5863.
31.Quintessenza, JA, Jacobs, JP, Morell, VO, Giroud, JM, Boucek, RJ. The initial experience with a bicuspid polytetrafluoroethylene pulmonary valve in 41 children and adults: a new option for right ventricular outflow tract reconstruction. Ann Thorac Surg 2005; 79: 924931.
32.He, GW. A new technique of transannular monocusp patch-repair of the right ventricular outflow tract in repair of tetralogy of Fallot. Heart Lung Circ 2007; 16: 107112; Epub 2007 Feb 20.
33.He, GW, Mee, RB. Complete atrioventricular canal associated with tetralogy of Fallot or double-outlet right ventricle and right ventricular outflow tract obstruction: a report of successful surgical treatment. Ann Thorac Surg 1986; 41: 612615.
34.Ilbawi, MN, Idriss, FS, DeLeon, SY, et al. Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair. Surgical implications. J Thorac Cardiovasc Surg 1987; 93: 3644.
35.Singh, GK, Greenberg, SB, Yap, YS, Delany, DP, Keeton, BR, Monro, JL. Right ventricular function and exercise performance late after primary repair of tetralogy of Fallot with the transannular patch in infancy. Am J Cardiol 1998; 81: 13781382.
36.Norgard, G, Gatzoulis, MA, Moraes, F, et al. Relationship between type of outflow tract repair and postoperative right ventricular diastolic physiology in tetralogy of Fallot. Implications for long-term outcome. Circulation 1996; 904: 32763280. Ruijter, FT, Weenink, I, Hitchcock, FJ, Meijboom, EJ, Bennink, GB. Right ventricular dysfunction and pulmonary valve replacement after correction of tetralogy of Fallot. Ann Thorac Surg 2002; 73: 17941800; discussion 1800.
38.Faidutti, B, Christenson, JT, Beghetti, M, Friedli, B, Kalangos, A. How to diminish reoperation rates after initial repair of tetralogy of Fallot? Ann Thorac Surg 2002; 73: 96101.
39.d’Udekem, Y, Ovaert, C, Grandjean, F, et al. Tetralogy of Fallot: transannular and right ventricular patching equally affect late functional status. Circulation 2000; 102: III116III122.
40.Yankah, AC, Lange, PE, Sievers, HH, et al. Late results of valve xenograft conduits between the right ventricle and the pulmonary arteries in patients with pulmonary atresia and extreme tetralogy of Fallot. Thorac Cardiovasc Surg 1984; 32: 250252.
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Cardiology in the Young
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