[HSF] Tetralogy of Fallot

Tue Jan 23 01:48:28 EST 2007

most welcome Sir ... 
I just tried to copy my little experience ...
I'm sure you will do the best as you are the one seeing the case
best of luck with your case
please keep us posted as to the progress 

Yours   

NFA
> -----Original Message-----
> From: openheart-l-bounces at lists.hsforum.com [mailto:openheart-l-
> bounces at lists.hsforum.com] On Behalf Of Dr. Daniel Bigalli
> Sent: Monday, January 22, 2007 8:20 PM
> To: OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] Tetralogy of Fallot
> 
> Dear Dr Nasser:
> thank you for your advice.
> I will keep in touch with you as soon as I have any notice.
> Regards
> 
> Daniel
> 
> 
> ----- Original Message -----
> From: "Nasser F. Abou'Seada" <nfaabouseada at gmail.com>
> To: <OpenHeart-L at lists.hsforum.com>
> Sent: Sunday, January 21, 2007 12:15 PM
> Subject: RE: [HSF] Tetralogy of Fallot
> 
> 
> Dear Dr. Daniel
> I would agree more with John about the strategy and technique for
> this case. a case of an old TOF of this age, one should be clear in his
mind
> about the INCIDATIONS for "interference", AIM of any "intervention",
> Strategy adopted and Technique to be utilized.
> 
> I do totally concur with John that the aim should be to reach a
> status of "Pink Tetralogy" rather than a total correction.
> 
> With an occluded RC, I would not think of a total correction for a
> compromised RV, "options for revascularization ???" ..
> Trying to radically correct such case and subject the RV to a volume
> overload whereas it has been for 55 years a victim of pressure overload,
> might just get the operator to cry by her side, not being able to do
> anything. The anatomy and pathophysiology or her hemodynamics should be
> looked at in view of her reaching such an age of 55, with such a diagnosis
> of TOF, a rather totally different pathology.
> 
> Moreover; a severely HYPERTROPHIC LV, 14 mm, with EDD 56mm, in face or a
> severe AR ..!!! ... can be accounted for by the VSD-related haemodynamics,
> but in no way can the EDD be in such severe AR ...!! ..... I'd be very
> careful in evaluating such finding. Let alone thinking about correcting AR
> ...!!
> 
> Closure of the VSD - in HER particular case- might just as well end in a
> ventricular failure, Depriving such an RV from an assisting hypertrophic
LV.
> !!
> 
> I do agree with John and Prasanna that "HER" problem can be
> approached via augmenting her PBF, better through the PV with a protective
> infundibulum than to flood her lungs by a systemic to pulmonary shunt
> "central?" ..... patient would drown in her own blood ..on table !!! .....
> An MBTS, should that be ever feasible in her case, would increase work of
> the heart greatly, a compromised heart already "VSD, AR, RC occlusion,
> Ischaemic hypertrophic LV, ... "
> 
> I totally concur with John that the "trick" is to avoid over-resection of
> the infundibulum, flooding the lung with increased PBF .... pt would drown
> in her own blood ...
> 
> Doming of the valve is a good sign in the eyes of performing a suitable
> intervention - rather than interference- in her particular case. I do
agree
> that using BPV would ravage the valve, in a severely blind way, tearing
the
> valve in a non expected manner, especially in such an age. In a non
> complicated case I would have thought of open trans-PA pulmonary valvotomy
> where the commissures can be split under vision and accurately freed /
> separated from the PA wall. still, I'd be very careful to consider an
> ischaemic arrest in such a case, with prohibited total correction, and AR,
> IWMI.
> 
> I do totally concur with John about utilizing a closed heart method, like
> the Brock's procedure, through the RV ... valve will not be ravaged,
> protective infundibulum -in HER case- is secured, especially that it
appears
> that the obstruction is mainly valvular. a severe infundibular stenosis
> would be incompatible with her age !! ... also a proper gradient -and
blood
> flow- can be worked out while on table.
> 
> Should that fail, there is always an option of an on pump open release of
> PV, and calculated resection of the obstructing infundibulum "should be
> worked out from cath"
> 
> I would think that the main aim - achieving a status of PINK FALLOT,
rather
> than total correction- is to determine the strategy adopted and technique
> used.
> 
> As John Hutter of Bristol Royal Infirmary 1990 once told me, it is not
> courage to jeopardize a man's life, doing a rather text book procedure for
a
> text book indication, as I believe that it takes a surgeon 6 weeks to know
> HOW to do it, 6 years to know WHEN to do it, 60 years to know WHEN NOT to
do
> it.
> 
> Good luck with your case
> 
> please keep us posted.
> 
> Yours
> 
> NFA
> 
>  From: jbflegejr at aol.com
>  This patient sounds like a good candidate for the Brock procedure which
>  probably has not been performed in the U.S. for the past 40 years and
>  maybe no place else either, but that does not negate its value in
>  selected cases, and where the principal obstruction is of the pulmonary
>  valve which you describe, it should be considered. The goal is to
>  reduce the pulmonary outflow obstruction enough to allow the pulmonary
>  flow to approximate the systemic flow and produce what is sometimes
>  termed "acyanotic tetralogy". In London and later in Iowa City we did
>  this with Hegar dilators passed through the wall of the right ventricle
>  and dilated the valve progressively until the pulmonary artery
>  pressures were around 30 to 40 mmHg and the arterial oxygen saturations
>  were above 90%. A left anterior thoracotomy or a median sternotomy
>  provides exposure but the sternotomy would be best as more options
>  would be available to you. It is important not to overdo it and flood
>  the lungs. Infundibular obstruction can be relieved using a Brock punch
>  through the right ventricule but this may be difficult in the older
>  adult and probably should not be done by someone without a lot of
>  experience. From your description, it sounds predominately valvular.
>  One might be tempted to try a PCI with a dilating balloon which might
>  be disastrous since the secret to success is to do just enough and not
>  too much. A systemic pulmonary shunt might be considered but cannot
>  achieve nearly as high arterial oxygen saturation as the Brock
>  operation and increases the cardiac work more. Brock and others wrote
>  about this in 50's and 60's. John Flege
> 
> From: biga at multitel.com.uy
> Dear members:
> I would like to know your opinions and treatment about this case.
> 55 year old woman with an unoperated Tetralogy of Fallot.
> This year she has been Hospitalized because of HF.
> She  refuses the definit surgery but does not a palliative procedure of
> lower risk.
> The following describes her clinical situation and the last echocardiogram
:
> Age : 55. White race.
> Works in an office. She describes excercice disphnea, functional class II.
> She has had hospitalized 3 times this year because HF (not acute lung
> edema).
> She has elements of systemic venous hypertension as low limbs edema,
> yugular and high limbs venous ingurgitation.
> She has universal cyanosis and elements of cronic hypoxemia.
> 
> Last transthoracic echocardiography  showed :
> 50% overriding of the aorta,
> wide ventricular septal defect with few bidireccional flow (probably
because
> of equal pressures),
> left ventricle hypertrophy 14 mm, diastolic diameter of 56 mm,
> right ventricle hipertrophy,
> bi-atrial dilation,
> ejection fraction of 40%,
> pulmonic valve with domo movement, maximum gradient of 100 mmHg at
pulmonary
> valve,
> hypertrophy of infundibular area,
> severe aortic regurgitation,
> dilation of inferior vena cava.
> There is no angiography of pulmonar vessels.
> 
> 
> She also has comorbidities :
> grade I esophagus varices,
> inferior myocardial infarction in 2002 by occlusion of the right coronary.
> 
> Laboratory shows an hemoglobin of 22 g/dl, hematocrit of 64%, 123000
> platelets,
> creatinin of 1.3 g/dl.
> Arterial gasometry PaO2 of 40 mmHg while compensated.
> 
> Best regards
> Dr. Daniel Bigalli
> Montevideo-Uruguay
> 
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