1. Right Ventricular Outflow Obstruction after Tetralogy of Fallot Repair Stephan Ziegeler, MD,* George J. Reul, MD,† Raymond F. Stainback, MD‡ *Department of Cardiovascular Anesthesiology, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, TX †Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, TX ‡Department of Cardiology, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, TX Address for correspondence: Raymond F. Stainback, MD, Department of Cardiology, St. Luke’s Episcopal Hospital, Houston, TX 77030; phone: 832-355-6676; FAX: 932-355- 8374; e-mail: rstainback@sleh.com. © 2001-2002 Texas Heart Institute Cardiac Society

2. A 45-year-old woman with tetralogy of Fallot presented for elective repair of recurrent right ventricular outflow tract (RVOT) obstruction. The original RVOT obstruction and ventricular septal defect (VSD) had been completely repaired in 1961 (at age 6 years). Ever since then, the patient had been in stable condition with minimal cardiac follow-up until a recent diagnosis of significant residual pulmonary valve (PV) stenosis. Right heart catheterization revealed a mean right atrial pressure of 6 mm Hg, peak right ventricular systolic pressure of 98mm Hg, pulmonary artery pressure 30/14 mm Hg, and mild pulmonary insufficiency. Intraoperative transesophageal echocardiography (TEE) confirmed adequate pulmonary trunk size (Figure 1). Residual distal infundibular muscle bands and fibrotic PV tissue revealed by 2-dimensional and color Doppler imaging (Figure 2) were resected. A 25-mm homograft conduit was placed and pulmonary arterioplasty utilizing bovine pericardium was performed. Homograft repair in this case, as in others, 1 produced encouraging results. After residual VSD leakage, persistent or recurrent RVOT obstruction is the second most common reason for reoperation following tetralogy of Fallot repair 2,3 and has a reported incidence as high as 14.1%. 4 The present case indicates that this condition can be effectively managed surgically.

3. Figure 1. Intraoperative transesophageal long axis view of right ventricular outflow tract (RVOT) showing prior infundibular patch repair (double arrow) and ventricular septal defect patch repair (single arrow). Note overriding aortic valve (AV); dilated, hypertrophic right ventricle (RV); moderator band (MB); left atrium (LA); and interventricular septum (IVS). Still image. RV RVOT LA LV AV PV MB IVS

4. Figure 2. Residual valvular and subvalvular pulmonary stenosis, as revealed by color Doppler imaging. Click here for motion image.Click here for motion image

5. References 1.McGrath LB, Gonzalez-Lavin L, Graf D. Pulmonary homograft implantation for ventricular outflow tract reconstruction: early phase results. Ann Thoracic Surg 1988;45:273-7. 2.Abe T, Asai Y, Sugiki K, Komatsu S. Reoperation after initial correction of tetralogy of Fallot. J Cardiovasc Surg (Torino) 1985;26:568-72. 3.Murphy JG, Gersh BJ, Mair DD, et al. Long term outcome in patients undergoing surgical repair of tetralogy of Fallot. N Engl J Med 1993;329:593- 9. 4.Knott-Craig CJ, Elkins RC, Lane MM, et al. A 26-year experience with surgical management of tetralogy of Fallot: risk analysis for mortality or late reintervention. Ann Thoracic Surg 1998;66:506-11.