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احمد.د.م. أ) اختصاصي جراحة الصدر و القلب و االوعية الدموية ( عبداالمير دفار
1
T ETRALOGY OF FALLOT
Objective : To show the d efinition, criteria and management of TOF ( Tetralogy
of Fallot )

It’s the most common cyanotic con genital heart disease &0 consists of four major

defects:
- Pulmonary stenosis
- Ventricular septal defect
- Aortic overriding
- Right ventricular Hypertrophy

Clinical ….features
- The severity of obstruction of the right ventricular outflow tract determines the
degree of right -to -left shunting, which usually determines the degree of cyanosis and
the age of presentation.
- Complications of TOF include polycythemia leading to cerebrovascular thrombosis,
hemoptysis secondary to enlarged bronchial arteries, paradoxical embolism ( leading
to stroke or end organ failure ), subacute bacterial endocarditis , or brain abscess .
- Squatting is a classical behavioral adaptation of older children with TOF whereby
systemic vascular resistance is increased, producin g more pulmonary blood flow.
- Hypercyanotic episodes (“tet spells”) are characterized by intense cyanosis that may
last minutes to hours, during which time oxygen delivery may be so compromised as
to cause loss of consciousness or impairment of myocardial function. Dehydration,
viral respiratory infection, and the injudici ous administration of medications that lead
to peripheral vasodilation all may cause a hypercyanotic episode in a patient who has
been previously stable.
Physical Examination
- Cyanosis
- Ejection systolic murmur heard loudest in the second left intercostal space .
- Digital clubbing.
Investigations
Chest X -Ray
- Boot -shaped heart due to RVH + small pulmonary artery .
- The lung fields usually appear oligemic
- A right aortic arch occurs in approximately 25% of cases.

Chest film of TOF

احمد.د.م. أ) اختصاصي جراحة الصدر و القلب و االوعية الدموية ( عبداالمير دفار
2

Electrocardiogram

It d emonstrates right ventricular hypertrophy .

Laboratory Studies

Polycythemia
Echocardiography
It's diagnostic

Cardiac Catheterization

For further evaluation

MEDICAL MANAGEMENT

Outpatient Management
The goals of medical management are to allow growth and development of the
child until surgical repair is undertaken while hypercyanotic episodes or
complications arising from the condition are prevented.
The preoperative management includes:
- Maintaini ng these infants in a well -hydrated state.
- Adequate feeding regimen .
- Every effort should be made to protect these infants from respiratory viruses and
dehydration accompanying diarrheal illnesses
- Β-Blockers such as propranolol (Inderal) due to their negative chronotropic effects
with increased ventricula r filling at slower heart rates & relief of RVOT spasm.
- Diuretics are contraindicated in cyanotic tetralogy .

Management of Hypercyanotic Episodes

Basic treatment principles include :
 Administration of intravenous fluids, morphine or other intravenous sedatives,
and oxygen.
 Placing the infant in a knee -chest position can elevate systemic vascular
resistance with a resultant increase in pulmonary blood flow.
 Intravenous β -blockers such as esmolol and α -agonists such as phenylephrine
may also be use d to temporize.
 Intubation and positive pressure ventilation may also be used to attempt to
increase oxygenation .

احمد.د.م. أ) اختصاصي جراحة الصدر و القلب و االوعية الدموية ( عبداالمير دفار
3

SURGICAL TECHNIQUES

Palliative Procedures
- Blalock -Taussig shunt
In performance of a subcla vian -pulmonary anastomosis, the incision is generally
made on the side opposite that on which the aorta descends. Ide ally, the
subclavian branch of the innominate art ery is used for the anastomosis.

- Modified Blalock -Taussig Shunt

It requires interposition of a seg ment graft material between the subclavian
artery and the pulmonary artery.

- Central Aortopulmonary Shunt

This includes interposition of a graft material between the ascending aorta and
main (or right) pulmonary artery.

- Waterston shunt

It’s between the ascending aorta to right pulmonary artery.

- Potts shunt

It’s between the descending aorta to left pul monary artery .

- RV Outflow Tract Patch .

Is to relieve the pulmonary stenosis but leave the ven tricular septal defect
open.

- Balloon Angioplasty of RV Outflow Tract .

Total Correction
The goals of Correction
1-To close the ventricular septal defect
2-To relieve right ventricular outflow obstruction
3-To repair any stenoses in the pulmonary arteries .

احمد.د.م. أ) اختصاصي جراحة الصدر و القلب و االوعية الدموية (عبداالمير دفار

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