Haemodynamic and cine-angiocardiographic findings after one-stage repair of Fallot's tetralogy.

Abstract

One-stage repair of Fallot's tetralogy is a satisfactory operative procedure with an acceptable mortality, provided the operation is undertaken by a team who are skilled in managing this heart lesion (Kirklin et al., 1959;Barnard and Schrire, 1961;Malm et al., 1963). The clinical results in the survivors are rewarding because the change in status is remarkable. Several recent reports on the haemodynamics have emphasized the clinical well-being of the patients. The present study set out to confirm this clinical impression, to assess the long-term improvement in the anatomy of the outflow tract, and to study the response of the heart and pulmonary circulation to exercise. PATIENTS AND METHODSEleven patients with the most severe pre-operative disability who had undergone a one-stage repair operation of Fallot's tetralogy were selected from a group of 34 long-term survivors. They were cyanosed before operation with clubbing of the fingers. Three were having recurrent episodes of extreme cyanosis. They were small (below the 25th percentile of height and weight for age). The right ventricle was dominant with a short systolic ejection murmur in the pulmonary area and a loud, apparently single second sound in the aortic area. Electrocardiography, chest radiograph, cardiac catheterization, and selective angiocardiography confirmed the presence of severe cyanotic Fallot's tetralogy, with marked obstruction to the outflow tract of the right ventricle and a large right-to-left shunt through the ventricular septal defect.Pulmonary valvotomy and infundibular resection was performed in all the patients: in 10 an outflow tract prosthesis was inserted, and in 7 it was carried across the pulmonary valve ring into the pulmonary artery. Two patients had such severe outflow tract obstruction that there was only a probe patent communication between the body of the right ventricle and the pulmonary artery. The ventricular septal defect was closed by Received April 26, 1965. * Present address: The Cardiac Clinic, Groote Schuur Hospital Observatory, Cape, South Africa. 448 direct suture in 6 and with a teflon patch in 5. Six patients in whom the prosthesis was extended into the pulmonary artery had severe residual pulmonary incompetence.The patients were all well, living a normal life, and with a near normal exercise tolerance. They were able to run up four flights of stairs, a vertical height of 60 ft. (18-3 m.), without becoming short of breath. The finger clubbing disappeared.In the presence of pulmonary incompetence, the right ventricle was hyperdynamic with a long systolic ejection murmur heard best in the pulmonary area, a single second sound of aortic valve closure, and a diamondshaped early diastolic murmur which was delayed 0 04 sec. after aortic valve closure. Complete right bundle-branch block was present in all the patients (Fig. 1). The pulmonary vascularity had become normal but the heart size had increased since operation. A convex left middle segment was present in patients with an outflow tract prosthesis (Fig. 2). Pul...

Ventricular structure and function after radical correction of the tetralogy of Fallot.

“…The remaning 10 patients may be regarded as very satisfactory and unlikely to give rise to anxiety in the future. These results are in general agreement with those of Gotsman (1966) who studied 11 patients after radical correction and found pulmonary incompetence in 6 and residual obstruction in 2. The angiographic appearances indicate that excellent anatomical results are achieved in the majority of patients (Gotsman, 1966).…”

“…These results are in general agreement with those of Gotsman (1966) who studied 11 patients after radical correction and found pulmonary incompetence in 6 and residual obstruction in 2. The angiographic appearances indicate that excellent anatomical results are achieved in the majority of patients (Gotsman, 1966). The appearances of residual obstruction and patency of the ventricular septum in the relevant patients were predictable from the heemodynamics or physical signs, but the diverticulum-like lesions near the ventriculotomy cannot be diagnosed without angiography, and may be present in a number of patients after an operation of this type.…”

Results of total correction of the tetralogy of Fallot. Long-term haemodynamic evaluation at rest and during exercise.

“…In addition, the majority of follow-up catheterizations did not examine the effects of exercise on the right ventricular outflow tract gradient and the cardiac output. The haemodynamic response to submaximal exercise in the supine position has been reported (Malm et al, 1966;Gotsman, 1966;Bristow et al, 1970;Joransen and Moller, 1972;Shah and Kidd, 1966) and intense exercise in the upright position has been the subject of one report (Epstein et al, 1973).…”

“…It was also possible to make an assessment of the serial haemodynamic changes in 6 patients who had been studied 1 to 4 years after operation (Gotsman, 1966).…”

Maximal supine exercise haemodynamics after open heart surgery for Fallot's tetralogy.

“…There are several published reports of haemodynamic studies after open heart surgery in patients with Fallot's tetralogy, and some of these include exercise data (Gotsman, 1966;Shah and Kidd, 1966;Bristow et al, 1970;Epstein et al, 1973;Bjarke, 1975;Mocellin et al, 1975Mocellin et al, , 1976. The following report differs from these others in one or more ways: studies were made during exercise on a large number of subjects including those with and without various residual defects; measurements were made during maximal exercise; haemodynamic measurements included intracardiac pressures, arterial and mixed venous blood gas tensions, and cardiac output (by indicator dilution method), during submaximal and maximal exercise in the supine position.…”