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Department of Pediatrics
Prof. Mona El-Samahy unit
TETRALOGY OF FALLOT
In The name of The Holy GOD
Presentation
The teamwork,
Index
Introduction ………………………………………………………………………….... 2
References …………………………………………………………………………….. 17
Fallot Tetralogy
Introduction :
*Congenital cardiac defects can be divided into two major groups based on the
presence or absence of cyanosis into:
Classification:
**the fallot tetralogy is one of cyanotic congenital heart lesions with decreased
pulmonary blood flow.
3) Overriding aorta , the aorta lies directly over the ventricular septal
defect .
Figure 1 : ventricular septal defect
4) Right ventricle develops hypertrophy .
*In addition, tetralogy of Fallot may present with other anatomical anomalies, including:
- stenosis of the left pulmonary artery, in 40% of patients
- a bicuspid pulmonary valve, in 40% of patients
- right-sided aortic arch, in 25% of patients
- coronary artery anomalies, in 10% of patients
- a foramen ovale or atrial septal defect, in which case the syndrome is sometimes called
a pentalogy of Fallot,
- an atrioventricular septal defect
partially or totally anomalous pulmonary venous return
forked ribs and scoliosis
- triology of fallot
Epidemiology:(6)
Etiology:(6)(7)
*Its cause is thought to be due to environmental as carbon monoxide or genetic factors
or a combination.
*It is associated with chromosome 22 deletions.
*mothers who experience rubella or other viral illnesses during pregnancy have a higher
risk of having a baby with tetralogy of fallot, in addition maternal alcoholism
and diabetes.
*There is higher risk for tetralogy of fallot among white babies than babies of other races
*it may be seen more commonly in patients with Down syndrome (in association with AV
canal defects) , DiGeorge syndrome , Alagille syndrome , charge syndrome ,vacteral
syndrome , fetal alcohol syndrome .
Pathophysiology:
The combination of congenital defects in TOF results
in right to left shunt across the large VSD from the
hypertrophied right ventricle to the overriding aorta
due to obstructed right ventricle outflow tract mixing
of oxygenated and deoxygenated blood in left
ventricle causing persistent arterial desaturation and
cyanosis(5)(figure 4) . The degree of right ventricular
outflow obstruction determines the timing of the
onset of symptoms, the severity of cyanosis, and the
degree of right ventricular hypertrophy(2). So Fallot is
described in three types depending on the severity or
extent of the anatomical defects(5):
Clinical picture:
A. Symptoms:
1. Cyanosis:(5)
Onset of cyanosis usually observed weeks after delivery when the ductus
begins to close as PDA in the early postnatal life redirect a large portion of
partially oxygenated blood leaving the heart for the body to the lungs
increasing flow through the pulmonary circulation with relatively better
oxygenation.
Or sever cyanosis at birth in infant with TOF associated with pulmonary
atresia.
B. Signs:
Infants with acyanotic Tetralogy of Fallot may be asymptomatic or may show signs of
CHF from a large right-to-left ventricular shunt.(3)
-Children assume a squatting position for the relief of dyspnea caused by physical effort;
the child is usually able to resume physical activity within a few minutes.(2)
Squatting increases the pressure transiently in the aorta and left ventricle, causing less
blood to move into the left ventricle, more out the pulmonary artery to the lungs.(9)
-By inspection:
The apex is shifted outwards and diffuse in extent.
The left anterior hemithorax may bulge anteriorly because of right
ventricular hypertrophy.
There are parasternal pulsations.
- Palpation reveals:
Right ventricular predominance.
In about half the cases, a systolic thrill is felt along the left sternal border in
the 3rd and 4th parasternal spaces.
A left parasternal heave can be detected.
A thrill may be felt in the pulmonary area.
No special character and no thrills are felt on the apex.
-On percussion: Increased area of cardiac dullness on both sides of the chest.
-On auscultation:
The first heart sound (S1) is normal.
The second heart sound (S2) is single.
The more severe the obstruction of the right ventricular outflow tract, the
shorter and softer the systolic murmur. In a deeply cyanotic neonate with
Tetralogy of fallot with pulmonary atresia, heart murmur is either absent or
very soft, although a continuous murmur representing PDA may be
occasionally audible.(3)
Investigations:
There is a normal-sized boot-shaped heart (coeur en sabot) with prominence of the right
ventricle, elevation of the apex and a concavity in the region of the underdeveloped
right ventricular outflow tract and main pulmonary artery. The pulmonary vascular
markings are typically diminished.(4)
Electrocardiogram (ECG):
Figure 10 : tall-peaked-bifid
P wave
peaked
bifid
ECG demonstrates right axis deviation and evidence of right ventricular hypertrophy.
Note the tall R waves in the right precordium and deep S waves in V6.The positive T
waves in V4R and V1are also characteristic of right ventricular hypertrophy. (figure 9)
P wave is tall and peaked or sometimes bifid .(figure 10)
a catheter is inserted through the skin into a blood vessel (usually in the groin)
and advanced up the inferior vena cava into the heart. An x-ray image is taken while a
small amount of dye is infused. The dye helps highlight the ventricular septal defect,
pulmonary stenosis, overriding aorta, and the size of the pulmonary arteries.(9)
Lab tests:
Polycythemia as the body attempts to compensate for the lack of oxygen to the
tissues.
MRI:
The goals of MRI after tetralogy of Fallot repair include the quantitative assessment of left
and particularly right ventricular volumes, stroke volumes and ejection fraction; imaging
of the anatomy of the right ventricular outflow tract, the pulmonary arteries, the aorta
and aortopulmonary collaterals; and quantifying pulmonary, aortic, and tricuspid
regurgitation. (4)
Complications:(2)(9)
Bacterial endocarditis may occur in the right ventricular infundibulum or on
the pulmonic, aortic, or, rarely, tricuspid valves. Endocarditis may complicate
palliative shunts or, in patients with corrective surgery, any residual pulmonic
stenosis or VSD.
Arrythmia: junctional tachycardia
Heart block:postoperative due to right bundle branch block after right
venriculotomy Pulmonary valve regurge with right ventricular
enlargement[postoperative]
Brain abscess is less common than cerebral vascular events and extremely
rare when most patients are repaired at young ages. Patients with a brain
abscess are usually older than 2 yr. The onset of the illness is often insidious
and consists of low-grade fever or a gradual change in behavior, or both.
Some patients have an acute onset of symptoms that may develop after a
recent history of headache, nausea, and vomiting. Seizures may occur;
localized neurologic signs depend on the site and size of the abscess and the
presence of increased intracranial pressure.
Heart failure is not a usual feature in patients with the tetralogy of Fallot. It
may occur in a young infant with “pink” or acyanotic tetralogy of Fallot. As
the degree of pulmonary obstruction worsens with age, the symptoms of
heart failure resolve and eventually the patient experiences cyanosis, often
by 6–12 mo of age.
Shunt procedures are performed to increase PBF. Indications for shunt procedures vary
from institution to institution. Many institutions, however, prefer primary repair without a
shunt operation regardless of the patient's age. However, when the following situations
are present, a shunt operation may usually be chosen rather than primary repair.
Technique:
Although several other procedures were performed in the past (see Fig. 14-22 ), a
modified Blalock-Taussig (Gore-Tex interposition) shunt is the only popular procedure
performed at this time. Occasionally, a classic Blalock-Taussig shunt is performed.
1. Classic Blalock-Taussig shunt, anastomosed between the subclavian artery and
the ipsilateral PA, is usually performed for infants older than 3 months (see Fig. 14-
22 ) because the shunt is often thrombosed in younger infants with smaller
arteries. A right-sided shunt is performed in patients with left aortic arch; a left-
sided shunt is performed for right aortic arch.
2. Modified Blalock-Taussig (BT) shunt. A Gore-Tex interposition shunt is placed
between the subclavian artery and the ipsilateral PA. This is the most popular
procedure for any age, especially for small infants younger than 3 months of age
(see Fig. 14-22 ). A left-sided shunt is preferred for patients with a left aortic arch,
whereas a right-sided shunt is preferred for patients with a right aortic arch. The
surgical mortality rate is 1% or less.
3. The Waterston shunt, anastomosed between the ascending aorta and the right
PA, is no longer performed because of a high incidence of surgical complications
(see Fig. 14-22 ). Complications resulting from this procedure included too large a
shunt leading to CHF or pulmonary hypertension, of both, and narrowing and
kinking of the right PA at the site of the anastomosis. This created difficult
problems in closing the shunt and reconstructing the right PA at the time of
corrective surgery.
4. The Potts operation, anastomosed between the descending aorta and the left
PA, is no longer performed either (see Fig. 14-22 ). It may result in heart failure or
pulmonary hypertension, as in the Waterston operation. A separate incision (i.e.,
left thoracotomy) is required to close the shunt during corrective surgery, which is
performed through a midsternal incision.
Complications:
1) Chylothorax: treated by repeated thoracocentesis or reoperation the ligate the
thoracic duct.
2) Diaphragmatic paralysis: requires prolonged ventilator support and vigorous
physical therapy, until the function of the phrenic nerve returns in 1 to 2 months(
unless it's completely devided )
3) Horner syndrome: usually temporary and doesn't require treatment.
Figure 12
Prognosis:
After successful total correction, patients are generally asymptomatic and are able to
lead unrestricted lives.
References
Textbook:
th
1) Medical Embryology 9 edition page 250
2) Nelson Textbook of Pediatrics,18 ed, chapter 430 ( Cyanotic congenital heart lesions:
Lesions Associated with decreased pulmonary blood flow, tetralogy of fallot)
3) Tetralogy of Fallot.Park textbook: Pediatric Cardiology for Practitioners, Elsevier ,5th ed.
6) www.wikipedia.com
7) www.nlm.nih.gov/medlineplus/ency/article/001567.htm
8) www.whonamedit.com/synd.cfm/2280.html
9) www.emedicine.com
10) www.pubmed.gov.com
11) www.mayoclinic.com
12) www.medlineplus.com
14) www.ajronline.org/cgi/content-nw/full/189/6/1353/FIG24
15) www.pediatriconcall.com/FORDOCTOR/Diseasesand
Teamwork