What are the indications for early reoperation for the repair of tetralogy of Fallot (TOF)?

Updated: Nov 13, 2018
  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Yasmine S Ali, MD, FACC, FACP, MSCI  more...
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Answer

The literature suggests that approximately 5% of individuals with tetralogy of Fallot (TOF) who underwent repair in childhood will need a revision/reoperation at some point. Indications for early reoperation include a residual ventricular septal defect (VSD) or a residual RV outflow tract obstruction (RVOTO).

Residual VSDs are poorly tolerated in patients with tetralogy of Fallot because these individuals cannot tolerate an acutely imposed volume overload. Small, residual VSDs are common after surgical repair and are usually clinically insignificant. In a cross-sectional prospective study that evaluated the effect of volume overload on global and regional RV and left ventricular (LV) deformation, and their relationships with conventional diagnostic parameters, Menting et al reported a reduction in RV free strain and strain rate in adults late after repair of tetralogy of Fallot, with the apical segment particularly affected. [32] LV septal strain also decreased, which the investigators suggested was likely due to mechanical coupling of the ventricles in which RV dysfunction negatively impacted LV function. [32]

A residual VSD with a 2:1 shunt or an RVOTO of greater than 60 mm Hg is an urgent indication for reoperation. Surgery can be performed with low risk and can result in dramatic improvements. Occasionally, pulmonary valve insufficiency may increase and may be associated with RV failure.


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