Right atrial approach for surgical correction of tetralogy of Fallot

Total correction of tetralogy of Fallot was performed without a ventriculotomy in 39 patients aged 8 months to 39 years (mean age, 9.1 years) between May 1984 and July 1988. A transatrial approach was used to resect the obstructed infundibulum and to close the ventricular septal defect. In 14 patients, the pulmonary annulus was not enlarged (group 1). Twenty-five patients required a transannular patch (group 2), placed by extending the pulmonary artery incision 1 cm into the right ventricular infundibulum. Eleven patients had repair of pulmonary artery branch stenosis, and associated intracardiac anomalies were simultaneously corrected in 10 patients. After repair, the right ventricular to left ventricular systolic pressure ratios ranged from 0.36 to 0.59 (mean ratio, 0.45) in group 1 and 0.33 to 0.70 (mean ratio, 0.51) in group 2. There were no hospital or late deaths in group 1. Two patients in group 2 with a small left ventricle died shortly after operation. The 37 survivors were followed for 2 to 51 months. Postoperative catheterization in 7 patients detected no residual ventricular septal defects, mild pulmonary regurgitation in 2 patients (group 2), and right ventricular to left ventricular pressure ratios ranging from 0.25 to 0.42 (mean ratio, 0.34). Only 1 patient with a previous total repair by ventriculotomy is symptomatic and requires antiarrhythmic agents and diuretics. The other 36 patients are asymptomatic. In conclusion, tetralogy of Fallot can be safely repaired at any age without a ventriculotomy. The results indicate a minimal incidence of postoperative arrhythmias and pulmonary regurgitation, as well as improved right ventricular function.