Tetralogy Repair in an Infant

Tetralogy of Fallot (TOF) is one of the most common cyanotic congenital heart diseases, characterized by a constellation of anatomical abnormalities, including ventricular septal defect, right ventricular outflow tract (RVOT) obstruction, overriding aorta, and right ventricular hypertrophy. Complete surgical repair remains the definitive treatment, and a clear understanding of operative steps is essential for trainees beginning congenital cardiac surgery. 

The aim of this video is to demonstrate the key technical aspects of total correction of TOF, with particular emphasis on operative sequencing, anatomical landmarks, and safe surgical principles, making it suitable for beginners and trainees. 

Surgery was performed through a median sternotomy, providing excellent exposure of the heart and great vessels. A preoperative transesophageal echocardiogram (TEE) confirmed the preoperative diagnosis. delineating the large, non-restrictive malaligned ventricular septal defect (VSD) with aortic override and the RVOT obstruction at the infundibulum and valvar levels. After systemic heparinization, standard cardiopulmonary bypass (CPB) was established using aorto-bicaval venous cannulation, allowing complete decompression of the heart and optimal surgical field. Myocardial protection was achieved using antegrade root cardioplegia, and in this case, del Nido cardioplegia was used for its advantages of prolonged myocardial protection and reduced need for repeated dosing in pediatric patients. 

The principal steps of the operation include: 

• Establishment of safe cardiopulmonary bypass and myocardial protection, ensuring hemodynamic stability and adequate myocardial preservation throughout the procedure. 

• Relief of right ventricular outflow tract obstruction, which is a critical component of TOF repair. This involves careful resection of hypertrophied parietal muscle bands and sparing the septal bands, while avoiding injury to the conduction system and pulmonary valve apparatus. 

• Closure of the ventricular septal defect (VSD), performed through a trans-atrial approach using a patch. Meticulous suturing is essential to achieve a secure closure, preventing residual shunts and protecting the conduction tissue. The authors’ preference is using interrupted pledgetted 5-0 polypropylene sutures. 

• Reconstruction of the right ventricular outflow tract, aimed at establishing an unobstructed pathway from the right ventricle to the pulmonary artery. In this video, a transannular patch was used, which is indicated when the pulmonary valve annulus is hypoplastic.  

• Following the completion of the procedure, careful deairing was done, and the aortic cross-clamp was released followed by safe weaning from CPB. 

• A post-repair TEE was conducted to assess the adequacy of repair. 

This step-by-step demonstration highlighted the fundamental surgical principles of TOF repair, including adequate RVOT relief, precise VSD closure, and RVOT reconstruction, providing a practical learning resource for surgeons in training. 

References

1. Tamesberger MI, Lechner E, Mair R. Early primary repair of tetralogy of Fallot in neonates and infants less than four months of age. Ann Thorac Surg. 2008;86:1928–1936.  
2. Reddy VM, Liddicoat JR, McElhinney DB, Brook MM, Stanger P, Hanley FL. Routine primary repair of tetralogy of Fallot in neonates and infants less than three months of age. Ann Thorac Surg. 1995;60:592–596. 
3. Van Arsdell GS, Maharaj GS, Tom J, Rao VK, Coles JG, Freedom RM, et al. What is the optimal age for repair of tetralogy of Fallot? Circulation. 2000;102(Suppl 3):123–129.  
4. Al Habib HF, Jacobs JP, Mavroudis C, Tchervenkov CI, O’Brien SM, Mohammadi S, et al. Contemporary patterns of management of tetralogy of Fallot: data from the Society of Thoracic Surgeons database. Ann Thorac Surg. 2010;90:813–819.  
5. Barron DJ. Tetralogy of Fallot: controversies in early management. World J Pediatr Congenit Heart Surg. 2013;4:186–191.  
6. Yang S, Wen L, Tao S, Jiangrong G, Jiangang H, Junping Y, et al. Impact of timing on in-patient outcomes of complete repair of tetralogy of Fallot in infancy: an analysis of the United States National Inpatient 2005–2011 database. BMC CardiovascDisord. 2019:19:46-53.

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