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(TOF)
Dr. Sayeedur Rahman Khan Rumi
dr.rumibd@gmail.com
MD Final Part Student
NHFH&RI
Introduction
• It is the most common form of cyanotic heart
disease .
• It occurs in approximately 1 in 3000 live births and
accounts for 10% of CHD.
• It is also the most common CHD requiring surgical
correction in the first year of life without which
only 10% of patient survive beyond the age of 20
yrs.
Arthur Fallot
• RAD
• There is right ventricular hypertrophy, with a tall R wave in the
right precordial leads and a deep S wave in the left leads.
• A QRS duration of >180 ms is a predictor of sustained VT and
sudden cardiac death.
• Some of these patients have right atrial hypertrophy.
Chest X-ray
• The total heart size is usually normal on chest xray,
but right ventricular enlargement is present in the
lateral view.
• The pulmonary segment is concave and the apex is
elevated, giving the coeur en sabot (boot-shaped)
contour.
• The aorta arches to the right in many cases.
• Pulmonary flow is diminished.
Echocardiography
• Two-dimensional echocardiography and Doppler
studies usually make the diagnosis and quantitate the
severity of TOF.
• A large, perimembranous infundibular VSD and
overriding of the aorta are readily imaged in the
parasternal long-axis view.
• Anatomy of the RVOT, the pulmonary valve, the
pulmonary annulus, and the main PA and its branches
is imaged in the parasternal short-axis and subcostal
short-axis views.
• Doppler studies estimate the pressure gradient across
the RVOT obstruction.
• Anomalous coronary artery distribution can be
imaged accurately by echocardiographic studies.
• The major concern is to rule out any branch of the
coronary artery crossing the RVOT.
• Associated anomalies such as ASD and persistence of
the left superior vena cava (LSVC) can be imaged.
• PLAX view showing the overriding aorta and a large
subaortic VSD (star).
• RVH is also present
Color flow imageing showing VSD jet
PLAX view of repaired TOF showing RV is dilated and the
echogenic region at the superior portion of the IVS
represents synthetic patch (arrow)
Cardiac Catheterization
• To assess the anatomy of RVOT and main PA
branches, RV and LV function, site and size of VSD
and competence of aortic valve.
• Arterial O2 saturation is <85%
• Identical systolic pressure in RV and LV and low
systolic pressure in PA (diagnostic of TOF)
RV graphy
• Percentage of
overriding aorta
• Size of the VSD
• RVOT obstruction
• To differentiate
TOF from DORV
LV graphy
Root & Arch aortography
Hypoxic Spell
Hypoxic Spell
• Also called cyanotic spells, hypercyanotic spells, “tet”
spells
• Hypoxic spells are characterized by:
Paroxysm of hyperpnea (i.e., rapid and deep respiration),
Irritability and prolonged crying,
Increasing cyanosis, and
Decreasing intensity of the heart murmur.
• Hypoxic spells occur in infants, with a peak incidence
between 2 and 4 months of age.
• These spells usually occur in the morning after crying,
feeding, or defecation.
• A severe spell may lead to limpness, convulsion,
cerebrovascular accident, or even death.
Mechanism of hypoxic spell
• Hypercyanotic episodes (spells) in patients with
tetralogy are of uncertain origin.
Indication:
1. Neonates with TOF and pulmonary atresia
2. Infants with hypoplastic pulmonary annulus
3. Children with hypoplastic PAs
4. Unfavorable coronary artery anatomy
5. Infants younger than 3 to 4 months old who have
medically unmanageable hypoxic spells
6. Infants weighing less than 2.5 kg
Palliative Shunt Procedures
• Classic BT shunt, anastomosed between the subclavian
artery and the ipsilateral PA, is usually performed for
infants older than 3 months because the shunt is often
thrombosed in young infants.
Mortality:
• For patients with uncomplicated TOF, the mortality rate
is 2% to 3% during the first 2 years.
• Patients at risk are those younger than 3 months and
older than 4 years, as well as those with severe
hypoplasia of the pulmonary annulus and trunk.
Diagrammatic representation of surgical repair of tetralogy of Fallot.
1. Patch closure of a VSD
2. Right ventricular outflow/main pulmonary artery outflow patch
(transannular patch)
Complications
• Bleeding problems may occur during the postoperative
period, especially in older polycythemic patients.
• Pulmonary valve regurgitation may occur, but mild
regurgitation is well tolerated.
• Right bundle branch block (RBBB) on the ECG caused
by right ventriculotomy, which occurs in more than
90% of patients, is well tolerated.
• Complete heart block (i.e., <1%) and ventricular
arrhythmia are both rare
Thank you