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Ann Thorac Surg 2000;70:1507-1510
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Repeated procedure after radical surgery for tetralogy of Fallot

^a Department of Cardiovascular Surgery, Tenri Hospital, Nara, Japan
^b Department of Thoracic Surgery, Nagoya University, Aichi, Japan

Address reprint requests to Dr Sugita, Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima, Tenri, Nara, 632-8552 Japan
e-mail: taandsa{at}maple.ocn.ne.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Although the immediate results of radical operation for tetralogy of Fallot are excellent, long-term follow-up has shown that the number of repeated procedures has increased in many institutions. We describe patients who underwent a second or third procedure after radical operation for tetralogy of Fallot.

Methods. Between April 1981 and August 1996, we operated on 44 patients for the second time and on 4 for the third time after radical operation for tetralogy of Fallot. Indications for a second and third procedure included right ventricular outflow tract obstruction in 38 patients, infective endocarditis in 4, and isolated residual ventricular septal defect in 3.

Results. One patient died after concomitant replacement of the pulmonary and tricuspid valves. Three patients who underwent sternotomy more than twice (before the second or third operation) underwent accidental cardiovascular trauma during this procedure (30%). Moreover, when patients underwent more than two sternotomy procedures before the repeated operation for tetralogy of Fallot, the total bypass time, interval between cessation of the cardiopulmonary pump to completion of the operation, amount of blood transfusion, and length of intensive care unit stay were significantly higher compared with those who underwent less than two sternotomy procedures (p < 0.05). Right ventricular outflow tract obstruction was the main indication for a second operation. After the second operation for right ventricular outflow tract obstruction in 35 patients, the preoperative right ventricle to left ventricle pressure ratio decreased significantly (from 0.75 ± 0.13 to 0.51 ± 0.12; p < 0.0001). However, the right ventricle to left ventricle pressure ratio did not significantly decrease in patients who underwent a third procedure to treat right ventricular outflow tract obstruction.

Conclusions. The surgical results of a second procedure after radical operation for tetralogy of Fallot were acceptable. However, the risk of accidental cardiovascular trauma during dissection was high among patients who underwent sternotomy more than twice before repeat operation.

	Introduction

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The surgical results of radical operation for tetralogy of Fallot (TF) are excellent [1, 2]. However, long-term follow-up revealed that some patients who underwent radical operation for TF required repeated operation to treat right ventricular outflow tract obstruction (RVOTO), ventricular septal defect (VSD) leak, infective endocarditis, pulmonary regurgitation, and other complications. The number of such patients has increased in many institutions, concomitant with an increasing incidence of radical operation for TF. However, few reports address repeated operation [3–7]. We describe patients who underwent a second or third operation after radical operation for TF.

	Material and methods

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Background clinical information was obtained from the patients’ medical records, including cardiac catheterization reports and surgical notes.

Five hundred ninety-eight radical operations have been performed up to August 1996 at our hospital. Before 1976, this type of operation was performed using extracorporeal circulation under normothermia, and under moderate hypothermia thereafter. Intermittent anoxic cross-clamps were applied in 164 patients, and blood or crystalloid cardioplegic solution was administered to 434 patients thereafter. All VSDs were closed through ventriculotomy during the radical operation, details of which have been reported [8].

Patients with symptoms or residual murmurs caused by regurgitation, stenosis, or shunt underwent echocardiography on an outpatient basis. Thereafter, cardiac catheterization was scheduled for further examination to determine the need for repeated operation. A systolic pressure gradient between the right ventricle and the left or right pulmonary artery of 50 mm Hg indicated significant RVOTO. Some patients whose pressure gradient was less than 50 mm Hg were also considered for repeated operation, as the main cause of RVOTO was muscular. A left to right shunt of 30% indicated a need for repeated operation for residual VSDs.

During repeated operation, we measured the total bypass time, the interval between the skin incision and starting the cardiopulmonary pump (dissection time, or time required to dissect the heart), the interval between stopping the cardiopulmonary bypass and the completion of surgery (hemostasis time, or time required to achieve hemostasis), the amount of blood transfused, and the length of the intensive care unit stay.

Data are presented as mean (± SD) or median. Groups were compared using Student’s t test or the Mann-Whitney U test when appropriate. Relationships between variables were assessed using Pearson’s product moment correlation. A value of p less than 0.05 was considered significant.

Patients
Between April 1981 and August 1996, we performed second and third operations on 44 and 4 patients, respectively, after radical operation to treat TF. The radical procedure was performed mainly by one surgeon (31 of 44 patients who underwent reoperation). Those patients who underwent radical operation using valved conduit were excluded from this study.

The median ages at the time of radical operation and of second and third operations were 4.4, 12.5, and 13.1 years (range, 1.6 to 41 years, 1.8 to 49.9 years, and 12.0 to 43.9 years), respectively. The median interval between the radical and repeated operation was 6.6 years, and the median interval between the second and third reoperations was 3.7 years. Indications for second and third reoperations included RVOTO in 38 patients, infective endocarditis in 4, isolated residual VSD in 3, pulmonary valve regurgitation in 2, and jammed in situ pulmonary valve in 1 (Table 1).

	Results

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The interval between the skin incision and starting the cardiopulmonary bypass (dissection time) ranged from 23 to 160 minutes (median, 76 minutes), total bypass time was 40 to 373 minutes (median, 105 minutes), the interval between stopping the cardiopulmonary bypass and the end of the operation (hemostasis time) was 36 to 890 minutes (median, 86.5 minutes), and the intensive care unit stay was 1 to 20 days (median, 1.0 day). During the second and third reoperations, 23 patients did not require blood transfusion.

A 43.9-year-old male patient who underwent a third procedure died after concomitant replacement of pulmonary and tricuspid valves to treat fascia lata valve dysfunction in the pulmonary position. These valves had been implanted in 1970 and the patient had severe tricuspid regurgitation in 1984.

At the time of the second and third operations, 5, 3, and 2 patients had to undergo sternotomy for the third, fourth, and fifth times, respectively, because of such things as a previous open Brock procedure, central shunt, and reoperation Among those patients who underwent sternotomy more than twice, 3 had accidental cardiovascular trauma during this procedure (30%). One patient required an emergency cardiopulmonary pump with femoral arterial return, but the appropriate repair was completed in all patients.

Of those patients who underwent sternotomy more than twice before the second surgery for TF, the total bypass time, hemostasis time, intensive care unit stay, and amount of blood transfused were significantly higher (Table 2). However, dissection time was not significantly different between those who had undergone sternotomy more than twice and those who had undergone it less than twice. Because ventricular fibrillation during dissection of the heart started in 1 patient who had endured a third sternotomy at the time of a third operation to treat TF. Cardiopulmonary bypass was immediately established. Among the patients who had a second sternotomy at reoperation, the dissection time negatively correlated with the interval after the initial radical operation (p < 0.05; Fig 1).

View larger version (19K): [in this window] [in a new window]   Fig 1. Correlation between dissection time and interval after the initial radical operation.

Fourteen patients had 17 residual VSDs. Three had isolated residual VSDs, and 11 had VSDs with other lesions (Table.1). The posteroinferior quadrant was the most common location for VSD leak (n = 6), and the posterosuperior quadrant was the next most frequent site (n = 5). The VSDs were closed with horizontal mattress sutures (n = 13; 1 patient underwent operation for infective endocarditis) or by additional patch repair (n = 4; 1 patient underwent operation for infective endocarditis).

Four patients had infective endocarditis. Two of them underwent VSD leak closure, 1, tricuspid valve replacement, and 1, aortic valve replacement. Two patients were in the active phase and 2 were in the chronic phase. All of them were managed by the repeated operation followed by an antibiotics regimen for more than 6 weeks.

Five patients underwent pulmonary valve replacement during operation for persistent right heart failure after the radical operation, and 2 underwent a second procedure to correct prosthetic valve dysfunction in the pulmonary position.

	Comment

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The recent results of the radical operation for TF are generally excellent even in very young patients [1, 2]. Therefore, concerns have shifted toward long-term outcome [8–13]. Residual complications and sequelae, such as RVOTO, residual VSD, and pulmonary regurgitation, are risk factors that negatively affect long-term results. During reoperation to address these residual defects, the inherent risk of the procedure itself is the main concern. The reported mortality rates for reoperation have historically been quite high at 15.5% to 7.1% [4–6]. One of our patients died after a third pulmonary and tricuspid valve replacement. He was a cachectic, 43-year-old man who had undergone in situ pulmonary valve replacement 14 years previously (1984). None of our patients died after reoperation or after a third procedure during the last 15 years, so we consider reoperation to be associated with a very low risk.

However, perioperative morbidity can be detrimental, and recovery from reoperation may be prolonged. In particular, accidental cardiovascular trauma during dissection is a frequent type of perioperative morbidity. We did not encounter any accidental cardiovascular trauma during the second sternotomy. However, accidental cardiovascular trauma during dissection occurred three times among the 10 patients who had undergone sternotomy more than twice before the second procedure (30%). All patients survived with the appropriate repair. The total bypass time, closing time, amount of blood transfusion, and length of intensive care unit stay were significantly higher (p < 0.05) among patients who underwent sternotomy more than twice before reoperation.

In contrast, the heart could be easily dissected at the second sternotomy as many years had passed since the radical operation. The correlation between the dissection time and the interval after the initial radical operation was significantly negative (Fig 1). The causes of this correlation were not only the feasibility of heart dissection many years after the first sternotomy, but also the stability and growth of the patient, because they did not require repeated operation soon after the radical operation.

Most of our patients (79.2%) underwent second and third operations for RVOTO. The intraoperative RV/LV pressure ratio during the radical operation was more than 0.8 in 23 of these patients. Therefore, insufficient relief of RVOTO at the time of the initial radical operation before 1984 (19 patients underwent radical operation at that time) was the most important cause of reoperation. We used various types of outflow patches (for example, auto pericardium, porcine pericardium, equine pericardium, and polyethylene terephthalate fiber) to relieve RVOTO, so we could not determine whether or not some of these materials were risk factors for reoperation for RVOTO.

Two of the patients had RVOTO gradients of more than 50 mm Hg. However, their preoperative RV/LV pressure ratios (0.42 and 0.48) did not decrease sufficiently during reoperation (0.48 and 0.45, respectively). We therefore recommend reoperation in the presence of a surgically relievable obstruction, a preoperative RV/LV pressure ratio of more than 0.5, and a pressure gradient greater than 50 mm Hg. We also could not electively relieve RVOTO after the third operation, as the surrounding tissue of the right ventricular outflow tract was quite rigid. Therefore, we recommend a third operation for RVOTO at a higher pressure gradient or a higher RV/LV pressure ratio, even when RVOTO is considered surgically relievable.

Residual VSDs constituted the second most frequent cause for reoperation in our series (29.1%). We had 7 patients with residual VSD of the left to right shunt of more than 30%. Only 3 patients underwent reoperation for isolated residual VSDs (Table.1). The residual VSDs consisted of Kirklin type II (n = 12), Kirklin type I (n = 1), and total conus defect type (n = 1). The most common location of residual VSDs was the posteroinferior or the posterosuperior quadrant (64.7%) near the location of the conductive tissue. Reluctance to take deep bites of suture in this area no doubt accounts for this [11]. Castañeda and associates [3] suggested that closing the residual VSD using an additional patch might be preferable to direct suturing. We closed most residual VSDs by direct suturing (76.5%), as they were very small and the peripheral tissue around the VSDs promoted thick scar formation. We had no complete atrioventricular block or a third operation after residual VSDs were closed.

Pulmonary valve replacements were effective for persistent right heart failure after radical operation [13]. However, prosthetic dysfunction was unavoidable, so the indication for this operation was not clear.

We concluded that the surgical results of reoperation after radical operation for TF were acceptable. However, the risk of accidental cardiovascular trauma during dissection was high among patients who had undergone sternotomy more than twice previously. The results of the third operation for RVOTO remained pessimistic, so the indication and the procedure should be considered more carefully with respect to previous operation.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Takaaki Sugita Yuichi Ueda Masahiko Matsumoto Hitoshi Ogino Katsuhiko Matsuyama Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sugita, T. Articles by Matsuyama, K. Search for Related Content PubMed PubMed Citation Articles by Sugita, T. Articles by Matsuyama, K.