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Coronary echocardiography in tetralogy of fallot: diagnostic accuracy, resource utilization and surgical implications
L R Need1, A J Powell, P del Nido
1Department of Cardiology, Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Insights
Coronary echocardiography accurately identifies coronary anatomy in infants with tetralogy of Fallot (TOF), making routine cardiac catheterization unnecessary. This noninvasive tool helps avoid extracardiac conduits in many TOF patients with abnormal coronary arteries.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Diagnostic Imaging
Background:
- Accurate preoperative identification of anomalous coronary arteries is crucial in tetralogy of Fallot (TOF) patients to prevent injury during surgical repair.
- Coronary artery anomalies crossing the right ventricular outflow tract (RVOT) pose a significant risk in TOF surgical candidates.
Purpose of the Study:
- To evaluate the diagnostic accuracy of systematic coronary echocardiography in preoperative tetralogy of Fallot (TOF) patients.
- To assess the impact of routine coronary echocardiography on surgical planning and outcomes in TOF.
Main Methods:
- Retrospective review of 598 patients with TOF who underwent echocardiography before age 2 and surgical repair.
- Analysis of diagnostic performance of coronary echocardiography, including sensitivity, specificity, and accuracy, over time.
- Comparison with intraoperative findings and cardiac catheterization data.
Main Results:
- Coronary echocardiography demonstrated high diagnostic accuracy (98.5%) with 82% sensitivity and 99% specificity in recent years (1991-1995).
- The use of coronary echocardiography increased, while preoperative cardiac catheterization decreased significantly.
- In TOF patients with pulmonary stenosis and abnormal coronary arteries, extracardiac conduit use was avoided in 67% of cases.
Conclusions:
- Coronary echocardiography is a precise, noninvasive method for delineating coronary anatomy in infants with TOF prior to surgical repair.
- Routine preoperative cardiac catheterization solely for coronary anatomy diagnosis is not essential.
- The majority of TOF patients with pulmonary stenosis and major coronary arteries crossing the RVOT can avoid extracardiac conduits.
Objectives:
This study sought to determine the diagnostic accuracy and impact of the systematic use of coronary echocardiography in a large group of preoperative patients with tetralogy of Fallot (TOF).
Background:
Accurate preoperative identification of an anomalous coronary artery crossing the right ventricular outflow tract (RVOT) in patients with TOF is important to prevent coronary injury during surgical repair.
Methods:
A retrospective review identified 598 patients with TOF between 1983 to 1995 who underwent an echocardiogram at <2 years old before complete surgical repair. Associated diagnoses included pulmonary stenosis (n = 433), pulmonary atresia (n = 121), common atrioventricular canal (n = 17), absent pulmonary valve syndrome (n = 24) and aortopulmonary window (n = 3).
Results:
Based on intraoperative findings, 32 patients (5.4%) were found to have a major coronary artery crossing the RVOT. The use and diagnostic performance of coronary echocardiography increased over time, while the number of patients undergoing preoperative cardiac catheterization declined. During the most recent study period (1991 to 1995, n = 274), 97% of patients underwent coronary echocardiography yielding a sensitivity of 82%, specificity of 99% and accuracy of 98.5%. Of the 18 patients with TOF and pulmonary stenosis who had abnormal coronary arteries during this period, only 6 (33%) required an extracardiac conduit as part of their complete repair.
Conclusions:
Coronary echocardiography is an accurate noninvasive tool to delineate coronary anatomy in infants with TOF before complete repair. Routine preoperative cardiac catheterization solely for diagnosis of coronary anatomy is not necessary. The use of an extracardiac conduit can be avoided in the majority of patients with TOF and pulmonary stenosis who have a major coronary artery crossing the RVOT.