COLLECTIVE REVIEW
The Surgical Treatment of Tetralogy of Fallot
H. E. Sinchez, M.D., D.Sc., E. M. Cornish, B.Sc.(Hons), M.B., Ch.B.,
Feng Chu Shih, M.D., J. de Nobrega, F.R.C.S., J. Hassoulas, M.Med.(Cape Town),
J. Netto, M.D., R. E. Thornington, F.F.A.(S.A.),
and C. N. Barnard, M.D., Ph.D., D.Sc.(Hon Causa)
ABSTRACT This is a review of the last 307 patients with
tetralogy of Fallot who were operated on in our unit at
Groote Schuur Hospital and Red Cross War Memorial
Children's Hospital. Complete repair was undertaken in
301 patients, and shunts were performed in 6 children.
There were 17 hospital deaths and 1 late death. The mortal-
ity was 5.5% for children less than 12 years old and 6.6% in
patients between 12 and 20 years old.
During this study period, there was a change in our pol-
icy as to when complete repair should be attempted. At
present, we perform systemic-pulmonary shunts in pa-
tients less than 6 months old and delay complete repair
until the child is 2 years old. In deciding whether a shunt
should precede complete repair, our experience has shown
that age is not as important a consideration as the anatomy
of the outflow tract of the right ventricle and pulmonary
arteries.
Tetralogy of Fallot is a common cardiac malformation,
accounting for about 20% of all congenital operations
performed in our unit [l-41. Disregarding minor varia-
tions in the definition of this defect, it is agreed, in gen-
eral, that two fundamental malformations are present: a
large, unrestrictive ventricular septa1 defect (VSD) and
severe obstruction to the outflow of the right ventricle.
The position of the VSD in tetralogy of Fallot is nearly
always constant; it involves the membranous area of the
septum, just below the aortic valve, and is slightly more
ventral in its location than the isolated VSD. Occasion-
ally the defect may extend into the supracristal area of
the septum, and very rarely it may be supracristal only.
The obstruction to the outflow tract of the right ven-
tricle is due to pulmonary stenosis, which is partly or
wholly infundibular, with or without underdevelop-
ment of the outflow tract. This underdevelopment may
involve the whole or a portion of the outflow from the
infundibular ostium to the branches of the pulmonary
arteries.
Hemodynamics
A large, unrestrictive VSD and severe obstruction to the
outflow of the right ventricle produce equal pressures in
From the Cardiac Unit and the Department of Anaesthetics (RET), G m t e
Schuur Hospital and Red Cross War Memorial Children's Hospital, Uni-
versity of Cape Town, Cape Town, Republic of South Africa.
Address correspondence to Dr. Sdnchez, Department of Cardiac
Surgery, Groote Schuur Hospital, Observatory, Cape Town, Republic of
South Africa.
431
the right and left ventricles. Hemodynamically, this re-
sults in a single pumping chamber with two resistances:
the systemic resistance and the resistance posed by
the right ventricular obstruction. The more severe the
right ventricular obstruction, the greater the right-to-left
shunt, the greater the cyanosis, and the smaller the
blood flow into the lungs.
Thus, the large, unrestrictive VSD functions as an es-
cape mechanism, and the structural changes that result
are of great importance in planning the surgical repair.
One of these changes is hypertrophy of the right ventri-
cle. Right ventricular hypertrophy develops only until it
can overcome the systemic resistance. This contrasts
with pulmonary artery stenosis in which, with an intact
ventricular septum, the hypertrophy of the right ventri-
cle is progressive in an attempt to overcome the resis-
tance caused by the pulmonary valve obstruction.
Another structural change is failure of the outflow
tract of the right ventricle to develop adequately. Be-
cause of the poor flow through these anatomical areas
and in an attempt to improve the pulmonary blood flow,
a bronchial collateral system develops [l-51. The more
severe the obstruction, the richer this collateral system.
Indications
More than 25 years have elapsed since total repair of
tetralogy of Fallot was reported by Lillehei and col-
leagues [6] and demonstrated to be a feasible, low-risk
operation by Kirklin and associates (71. Whatever ap-
proach is taken, surgical intervention plays an extremely
important role in tetralogy of Fallot. The life expectancy
without operation is very poor: 25 to 30% of patients will
die within a year, 40% within 3 years, and only 30 to 35%
will live longer.
The proper timing of the surgical intervention and the
choice of surgical procedure are based on an under-
standing of the spectrum of anatomical and physiologi-
cal conditions that can occur. Although small size,
young age, and severity of hypoxemia may correlate
with increased risk of primary total repair, the most cru-
cial variable appears to be the degree of hypoplasia of
the main and branch pulmonary arteries and therefore
the capacity of the pulmonary arteries. A poorly devel-
oped pulmonary arterial system will not accommodate
the total cardiac output resulting from closure of the
VSD. This causes right ventricular failure and death
from low cardiac output.
A number of methods have been developed to desig-
nate patients with a hypoplastic pulmonary arterial sys-
tem. One involves the ratio of the main pulmonary ar-
432 The Annals of Thoracic Surgery Vol 37 No 5 May 1984

tery to the ascending aorta. This ratio should be equal to 105-

or more than 0.3. If it is less than 0.3, palliative operation 100-

is performed. Another method uses the ratio of the right 95-

pulmonary artery to the ascending aorta. If the ratio is 90-

less than 0.3, initial palliation is undertaken. Finally, 85.
Pacific0 and colleagues [8] have described a formula 80.
using the ratio of the right and left pulmonary arteries to 75-
the descending thoracic aorta. v) 70-
In the presence of an adequate pulmonary artery, our I-
65.
contraindications to total repair in infants are as follows: 60.
(1) an abnormal coronary artery; (2) a single pulmonary L 55.
LL
artery; and (3) a patient less than 6 months of age in 50.
a
whom a patch is needed across the pulmonary valve W
m 45.
ring. In the experience of our cardiac clinic, pulmonary 3z 40-
incompetence is not well tolerated in small babies. The 35.
abnormal origin of the coronary arteries is a contraindi- 30.
cation for total repair only in very small infants, not for 25-
older patients. Other authors [9-121, however, do not 20.
consider this a contraindication. 1s.
10.
Material and Methods
5‘
Between January, 1974, and December, 1981, 307 pa-
tients underwent consecutive procedures for repair of 0-6m. 7-12m. 13-23m. 24-59m. 5 10-13y. r14y.

tetralogy of Fallot at Groote Schuur Hospital and Red a TRANSANNULAR GUSSET

RIGHT VENTRICULAR GUSSET
Cross War Memorial Children’s Hospital in Cape Town.
There were 184 male and 123 female patients. Nine pa- Number of patients requiring outpow tract gussets compared with age
tients were less than 6 months old; 18 were less than l at operation.
year old; 22 were less than 2 years of age; and the rest
were older than 2 years. Cyanosis was present in 285
patients; 22 were acyanotic. Surgical Procedure
The VSD was in the membranous area in 294 patients CHOICE OF PALLIATIVE PROCEDURE. We have detailed the
and in the supracristal region in 7. Associated defects are reasoning underlying our choice of systemic-pulmonary
listed in Table 1. shunts. In the last 3 years, it has been our policy to
Complete repair was performed in 301 patients. In the perform only Blalock-Taussig shunts or a modified
other 6, systemic-pulmonary shunts were done. Previ- shunt with a 5 mm Gore-Tex graft. For multiple reasons,
ous operations had been performed in 20 patients: 11 use of the Waterston shunt has been abandoned. Since
had Blalock-Taussig shunts and 9, Waterston shunts. we adopted this policy, we have performed the Blalock-
Valvular obstruction was found in 3 patients, isolated Taussig shunt with no deaths [5, 12, 13-17].
infundibular obstruction in 104, infundibular and valvu- All patients receive systemic heparinization (heparin, 1
lar obstruction in 155, and hypoplasia of the main pul- mg per kilogram of body weight) before the shunt is
monary artery with different degrees of narrowing of its performed. The heparin is never reversed. A small pul-
two branches in 45 (Figure). monary artery is not a contraindication; we have made
shunts in pulmonary arteries about 3 mm in diameter.
The Blalock-Taussig shunt is performed using the sub-
Table 1 . Associated Defects among clavian artery on the side opposite to the aortic arch. The
307 Patients with Tetralogy of Fallot incision in the pulmonary artery is always made longitu-
~ ~
dinally.
No. of In patients with tetralogy of Fallot, there is an addi-
Defect Patients tional way to increase pulmonary blood flow, that is, to
place a patch across the pulmonary annulus, either leav-
Atrial septal defect 15 ing the VSD open or partially closing it with a perforated
Patent foramen ovale 27 patch. This approach can result in symmetrical growth
Patent ductus arteriosus 6 of the pulmonary arteries. More time will be necessary
Ostium primum defect 4 to determine how this method of palliation compares
Complete atrioventricularcanal 1 with the classic Blalock-Taussig shunt.
Hemitruncus 1 CLOSURE OF SYSTEMIC PULMONARY SHUNTS. The pa-
Hypertrophic obstructive cardiomyopathy 1 tency of shunts should be confirmed at catheterization,
Multiple ventricular septal defects 5 because the presence of a continuing murmur, especially
Absent left pulmonary artery 2 in older patients, may be due to bronchial collaterals and
does not indicate a patent shunt.
433 Collective Review: Sanchez et al: Tetralogy of Fallot
The approach to the Blalock shunt on the left side is
extrapericardial, following the left pulmonary artery or
the aortic arch or both. The dissection is guided by the
palpable thrill. The right-sided Blalock shunt is usually
easier to find. The approach is intrapericardial, between
the superior vena cava and the ascending aorta. In both
approaches, the subclavian artery is dissected and en-
circled with a ligature. It is tied after cardiopulmonary
bypass is begun.
The approach for a Waterston shunt can usually be
accomplished through the ascending aorta. If the right
pulmonary artery is kinked or narrowed, it should be
detached from the aorta and patched with pericardium if
necessary [13-171.
COMPLETE REPAIR OF TETRALOGY OF FALLOT. The suc-
cess of this operation depends on four factors. These are
(1) adequate selection of the patient; (2) adequate repair
of the defects present; (3) maximal protection of the
myocardium; and (4) maintenance of a normal internal
environment before, during, and after operation.
In children weighing less than 10 kg, the operation is
performed using surface cooling, circulatory arrest, and
limited cardiopulmonary bypass. In patients weighing
more than 10 kg, conventional total cardiopulmonary
bypass with moderate or deep hypothermia is used.
Cold crystalloid cardioplegic arrest plus local hypother-
mia at 10°C is our method of myocardial preservation.
Relieving the resistance to right ventricular emptying
is an essential component of a successful repair. If possi-
ble, it is desirable to achieve this without producing pul-
monary incompetence. However, relief of the outflow
obstruction is more important than avoidance of pulmo-
nary incompetence. In our experience, the creation of
pulmonary incompetence has not proven a serious dis-
advantage, except in patients with an absent left or right
pulmonary artery. These patients are left with a compe-
tent pulmonary valve. Our methods undergo continual
evaluation in order to predict the necessity of a transan-
nular patch.
Enlargement of the outflow tract is performed with
a pericardial patch. In patients in whom an abnormal
coronary artery, usually the left anterior descending
coronary artery originating in the right coronary artery,
crosses the infundibulum and enlargement of this area
is required, we relieve the infundibular and valvular ob-
struction and then put a graft between the right ventricle
and main pulmonary artery to relieve the residual ob-
struction. The size of the graft is chosen according to the
internal infundibular and valvular obstruction, so that
the final outflow will be a combination of both. In this
way we bypass the abnormal coronary artery. We prefer
this method to that of cutting the coronary artery and
doing a coronary artery bypass graft.
The VSD is large, usually the diameter of the ascend-
ing aorta, and closure is always done with a prosthetic
patch using interrupted sutures. The bundle lies on the
left side of the septum as it reaches the level of the VSD.
The incision in the infundibulum is transverse or
oblique; a vertical incision is made when it is necessary
to enlarge the outflow tract.
Prior to decannulation, pressures are measured in the
right ventricle and other chambers. An acceptable ratio
of right ventricular to left ventricular pressure should be
less than 0.75. In our experience, patients with a ratio of
greater than 0.65 but less than 1.00 immediately after
repair, without patch-graft enlargement, survive the
early postoperative period. In the late postoperative pe-
riod, we are concerned if the right VentricularAeft ven-
tricular pressure ratio is high (greater than 0.60), for that
will result in diminished exercise tolerance (1, 2, 8-11,
18-21].
Results
Hospital Mortality
The overall hospital mortality was 5.5% (17 patients) and
was highest in patients between 7 and 12 months of age
(5 deaths among 18 patients, or 28%) (Table 2). There
was 1 late death, which occurred 4 months postopera-
tively. Causes of death are listed in Table 3. There was
no relationship between previous systemic pulmonary
shunts and hospital mortality.
An 8-year-old patient died of undiagnosed total anom-
alous pulmonary venous drainage of the supracardiac
type. The condition was not noted at catheterization or
at operation. Two patients, 10 months and 2 years old,
died of "pump lung" or respiratory distress syndrome.
Five patients died of low cardiac output due to resid-
ual obstruction at the level of the outflow tract. They also
had small pulmonary arteries. These patients were 18
months, 4 years (2 patients), 5 years, and 16 years old.
A 4-year-old child died of low cardiac output due to a
residual VSD (disruption of the patch). Another patient,
9 months old, died of an acute residual VSD and low
cardiac output. One 8-month-old infant died of low car-
diac output and pulmonary edema, both due to multiple
VSDs that were not diagnosed. Two patients, 10 months
and 5 years old, died of low cardiac output due to
peripheral pulmonary artery obstruction caused by
thrombosis of the small branches of the pulmonary
arteries.
Two patients died of iatrogenic causes. A 14-year-old
teenager experienced hyperpotassemia. In the other, a
9-month-old infant, an acute pneumothorax developed
Table 2. Correlation between Age and Number
of Deaths among 307 Patients with Tetralogy of Fallot
Deaths
No. of
Age Patients Early Late
0-6 mo 9 0
7-12 mo 18 5
13-24 mo 22 1
25-60 mo 99 5
5-10 yr 102 4
10-13 yr 27 0
314 yr 30 2
Total 307 17 (5.5%)
434 The Annals of Thoracic Surgery Vol 37 No 5 May 1984
Table 3 . Causes of Early and Late Deaths
Patient
No. Age Cause of Death
EARLY DEATHS
1 8 'Y Undiagnosed TAPVD
2 10 mo "Pump lung"
3 16 yr Low cardiac output
4 2 Y' "Pump lung"
5 5 Yr Low cardiac output
6 9 mo Pneumothorax; cardiac arrest; brain damage
7 10 mo Thrombosis in peripheral pulmonary
arteries
8 3 'Y Lung infection
9 18 mo Low cardiac output
10 9 mo Acute residual VSD; low cardiac output
11 4 'Y Low cardiac output
12 8 mo Multiple VSDs; low cardiac output
13 5 'Y Thrombosis in peripheral pulmonary
arteries
14 6 'Y Emergency operation; patient unconscious;
no recovery after operation
15 4 Y' Residual VSD; low cardiac output
16 14 yr Iatrogenic hyperpotassemia
17 4 Y' Low cardiac output; small pulmonary
arteries
LATE DEATH
1 13 yr Subacute bacterial endocarditis
TAPVD = total anomalous pulmonary venous drainage; VSD = ven-
tricular septa1 defect.
while he was on the ventilator. Subsequently, brain
damage and cardiac arrest occurred.
A 3-year-old child died of lung infection. Another pa-
tient, 6 years old, underwent emergency operation in a
comatose state caused by severe cyanotic spells. There
already was some brain damage before operation. Total
repair was performed, but the child died postoperatively
with irreversible brain damage.
The single late death occurred 4 months after a 13-
year-old patient had been discharged from the hospital
and was due to subacute bacterial endocarditis. The VSD
patch became detached, and the teenager died suddenly
with pulmonary edema.
Long-term Follow-up
Long-term survivors were reviewed regularly in the out-
patient clinic at Groote Schuur Hospital and Red Cross
Hospital between January, 1974, and June, 1982. The
minimum follow-up was 6 months and the longest, 8
years (mean duration, 4.25 years).
Fifteen percent or 46 of the patients were from over-
seas. Long-term follow-up is available for only 5% of
them. Patients from throughout South Africa who can-
not attend the outpatient clinic in Cape Town are fol-
lowed up in their respective regional hospitals.
One hundred ninety-eight patients were asymptom-
atic and required no medication. They were regarded by
their parents, doctors, or both as having an exercise tol-
erance appropriate to their age. Twenty-five patients
had residual symptoms. The other 20 patients were lost
to follow-up.
Twenty-five patients underwent reexamination be-
cause of a suspected residual defect. In 17 of them, the
outflow gradient was less than 35 mm Hg or the residual
VSD was insignificant. The remaining 8 patients were
the only ones in this series to undergo reoperation. Five
with residual VSDs had another operation because of
congestive cardiac failure or severe hemolysis. Three
underwent reoperation for relief of major obstruction of
the right ventricular outflow tract.
Since routine postoperative catheterization has not
been considered necessary, a few asymptomatic patients
may have residual shunts or right ventricular hyperten-
sion and may require reoperation in the future. Never-
theless, since all reoperations were done within a few
months of the first operation, it is unlikely that longer
follow-up will increase the incidence of this event, ex-
cept possibly in patients with a transannular patch. In
such patients, the finding of increasing right ventricular
enlargement suggests that some may ultimately require
the insertion of a valve beneath the patch.
Right bundle-branch block was present in 80% of the
patients (241 patients) and left anterior hemiblock plus
right bundle-branch block, in 9% (27patients). Complete
heart block was present in 2 patients who both required
permanent pacemakers [ll, 18, 19, 21-24].
Comment
In deciding whether a shunt should precede complete
repair, we believe that age is not as important a consid-
eration as the anatomy of the outflow tract of the right
ventricle and pulmonary arteries, or the presence of ab-
normal coronary arteries. A poorly developed pulmo-
nary artery system will not accommodate the total car-
diac output resulting from closure of the VSD.
In infants, our first choice is a Blalock-Taussigshunt or
the modified shunt with a graft, usually Gore-Tex. We
have abandoned the Waterston shunt in our practice. In
older children, it is still unknown whether the shunt
procedure or roofing the outflow tract (leaving the VSD
open) is preferable to enlarge the pulmonary arteries.
In total correction, the frequency with which a trans-
annular patch is used to repair the right ventricular out-
flow tract varies considerably in different series. Our
approach has been slightly aggressive to minimize the
residual obstruction postoperatively and the number of
early deaths due to low cardiac output. This inevitably
results in a greater incidence of pulmonary regurgita-
tion. However, the incidence of pulmonary regurgita-
tion in early mortality is n$nimal compared with that
caused by incomplete relief of the right ventricular ob-
struction. In the long run, there is evidence to suggest
435 Collective Review: Sdnchez et al: Tetralogy of Fallot
Table 4 . Early Deaths among 820 Patients with Tetralogy
of Fallot Seen at Groote Schuur Hospital and Red Cross War
Memorial Children’s Hospital during a 23-Year Period
No. of No. of
Period Patients Deaths Percentage
1958-1967 146 15 10.3
1968-1970 153 8 5.2
1971-1973 142 5 3.5
1974-1981 307 17 5.5
Adults (>20 years old) 72 5 6.9
Total 820 50 6.1
that postoperative pulmonary regurgitation in these pa-
tients is well tolerated except in the presence of other
severe defects. Nevertheless, with the volume loading of
the right ventricle in patients in whom a transannular
patch is used, the right ventricular function remains a
cause for concern.
Aneurysms of the outflow tract are rare. They can be
divided into either true or false aneurysms. The true
aneurysms usually appear in the first 6 months after
operation. The false aneurysms increase in size more
quickly and have a higher incidence of rupture.
In patients with cyanotic heart disease and low flows,
for example, patients with tetralogy of Fallot, the typical
focal thrombotic lesions of the pulmonary arteries, with
possible fatal outcome, may be seen. These lesions could
be related to the polycythemia and lowered velocities of
flow, although involvement of a variety of coagulation
factors cannot be excluded. Even with early repair at the
age of 10 months and 5 years, 2 of our patients died of
this pathological condition [l-4,231.
Hospital mortality was not higher in those patients
having patch-graft enlargement across the pulmonary
valve ring than in those undergoing other types of re-
pair.
After repair, hemodynamic abnormalities are mini-
mal. The most common are mild right ventricular hyper-
tension (30 to 45 mm Hg), a small gradient between the
right ventricle and pulmonary artery (10 to 25 mm Hg),
and pulmonary regurgitation. Minor electrophysiolog-
ical changes are the rule after repair of tetralogy.
Right bundle-branch block is found in 80 to 90% of
patients after repair. Combined with left anterior hemi-
block, it occurs much less frequently (7 to 10%).Sudden
deaths may occasionally occur in patients with right
bundle-branch block. Therefore, it is an indication of the
need for a permanent pacemaker. In other series, no
deaths were reported [22].
Intracardiac repair of tetralogy of Fallot can be per-
formed in symptomatic children and adults-except for
children with underdeveloped pulmonary arteries-
with low operative risks and excellent late results in
terms of hemodynamics. We believe that some compli-
cations encountered in the present series can be pre-
vented by using proper preoperative and intraoperative
measurements as well as refined techniques of repair.
We wish to thank the Chief Medical Superintendent of Groote
Schuur Hospital, Dr. H. Reeve Sanders, and the Senior Medical
Superintendent of Red Cross Memorial Children’s Hospital,
Dr.J. G. L. Strauss, for permission to publish.
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