HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Poul Lauridsen Morten Helvind Gösta Pettersson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nørgaard, M. A. Articles by Pettersson, G. Search for Related Content PubMed PubMed Citation Articles by Nørgaard, M. A. Articles by Pettersson, G.

Eur J Cardiothorac Surg 1999;16:125-130
© 1999 Elsevier Science NL

Twenty-to-thirty-seven-year follow-up after repair for Tetralogy of Fallot

Department of Cardiothoracic Surgery, RT 2152 Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark

Corresponding author. Tel.: +45-3545-2152; fax: +44-3544-2548
e-mail: bar{at}rh.dk

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
Objective: To describe the long-term prognosis after repair of Tetralogy of Fallot with pulmonary stenosis beyond 20 years. Methods: One hundred and eighty five patients underwent corrective repair of Tetralogy of Fallot at Rigshospitalet in Copenhagen between January 1960 and July 1977. Ninety seven patients had undergone a palliative operation prior to Tetralogy of Fallot repair. All the 125 patients who were discharged from the hospital were traced through the population register and the patients alive July 1997 were contacted by mail and/or telephone and questioned about use of medicine, professional status, family status and ability to perform sport activities. Results: Sixty patients died in hospital and 125 patients, 78 males and 47 females, were discharged alive. Among operative survivors, median age at operation was 12.8 years (range 0.4–41 years). Thirteen patients required a reoperation, the main indication was failed VSD closure. There were 16 late cardiac deaths, out of which seven were sudden and unexpected and three were in immediate relation to reoperations. One hundred and nine patients were alive at follow-up. The mean follow-up time was 25.5 years (range 20–38 years). Sixteen percent used cardiac drugs, 89% were, or had been, working normally (all professions from academics to hard manual labors were represented), 53% (64% of women) had given birth after the repair and 51% performed sport activities regularly. No patients were lost to follow-up. Conclusions: The vast majority of the patients seemed to live normal lives 20–37 years after Tetralogy of Fallot repair. Late deaths were cardiac in origin, including sudden death from arrhythmias. The number of late reoperation has been low. Considering the natural history of the disease, Fallot repair has proven to be a beneficial procedure even including the very early experience short after introduction of open heart surgery.

Key Words: Congenital heart disease • Tetralogy of Fallot • Surgery • Long term follow-up • Quality of life

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
Tetralogy of Fallot is a rather common complex cardiac malformation with an incidence of 0.1/1000 live births. Without surgical intervention, patients had a 1 year survival rate of 66%, 49% after 2 years and only 10–15% after more than 20 years [1,2]. Today the awareness and knowledge of this natural history of Tetralogy of Fallot without cardiac surgery is fading. The natural history was dramatically changed with the introduction of palliative procedures by Blalock and Taussig in 1945 [3] and radical repair by Lillehei in 1954 [4] and Kirklin in 1955 [5]. The new ‘natural’ history with cardiac surgery is yet to be written.

Most previous papers have presented long-term follow-up with a mean follow-up of 5–20 years [6–12].

In 1982, the 14–19-year follow-up of our early series was published [13]. The object of the present study was to present the 20–37-year follow-up of our material.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
All patients who underwent and survived corrective repair of Tetralogy of Fallot with pulmonary stenosis at our institution between January 1960 and July 1977, were included in the study. Patients with pulmonary atresia were excluded. Patient data were collected from patient records, including the operation notes and the perfusion records. To ascertain whether patients were alive, all patients were traced through the national population register. The patients who were still alive at the follow-up (1997) could all be located and contacted by mail and/or telephone and questioned about use of medicine, working ability, family status and ability to perform sport activities. The study was approved by the local ethical research committee.

2.1. Surgery
One hundred and eighty five patients underwent corrective repair of Tetralogy of Fallot with pulmonary stenosis at our institution between January 1960 and July 1977.

Prior to Tetralogy of Fallot repair, 97 patients had undergone a palliative surgical procedure. Seventy four had received a Blalock-Taussig shunt, nine had received pulmonary valvulotomy, 11 had received a Waterston-shunt, six had received a Brocks infundibulotomy, three had received a Pott-shunt, and four had received a Barrett pleurodesis. Sixteen patients had received more than one palliative procedure. Three patients had been explored via a thoracotomy, without any attempt of palliation performed.

Repair including relief of the right ventricular outflow obstruction and closure of the VSD was performed with techniques and approaches corresponding to time. The VSDs were closed with a transventricular approach, always by use of patch. Muscle removal was generally more generous than today. A RV/LV of less than 0.75 was accepted.

About one-third of the patients received a transannular right ventricular outflow patch (pericardium or dacron) while three patients received valved conduits (one Polystan® pulmonary valve conduit and two Hancock conduits).

2.2. Statistics
Survival data have been evaluated using Kaplan–Meiers product limit method. Comparisons between groups have been made using a log-rank test or chi square test, where appropriate

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
3.1. Activity and operative mortality
Out of the 185 patients operated with Fallot repair during the period, 60 patients (30 female, 30 male) died in hospital while 125 patients (78 males and 47 females) were discharged alive.

The operative activity during the following periods was: 1960–1964: 53 (27 discharged), 1965–1969: 27 (15 discharged), 1970–1974: 53 (39 discharged) and 1975–1977: 52 (44 discharged) (Fig. 1). Among operative survivors median age at operation was 12.8 years (range 5 months–41 years) (Fig. 2). At the follow-up, 109 patients were alive while another 16 patients had died, six of the reoperated.

View larger version (14K): [in this window] [in a new window]   Fig. 1. The perioperative mortality had decreased with increasing experience and development of the surgical technique.

View larger version (16K): [in this window] [in a new window]   Fig. 2. The patients age at repair of Tetralogy of Fallot.

One patient underwent an aortic valve repair for severe insufficiency. One patient was given a pulmonary stenosis repair by mono-cusp outflow patch implantation at the age of 13 and was operated for tricuspid insufficiency and persistent VSD 1 year later, finally to be heart transplanted at the age of 23, but died 3 weeks postoperatively.

Three patients died in immediate relation to the reoperation, including the heart transplant patient already mentioned. A further three of the reoperated patients died later.

3.3. Survival and causes of late death
Although previous palliative procedures were associated with increased operative mortality (P=0.04 by Chi-square test), there were no differences in survival (from birth and from Fallot repair) between operative survivors who had had a palliative procedure prior to the Fallot repair and those who received the repair as the primary operation (Fig. 3). Sixteen patients had died between discharge and follow-up (1997). The causes of death were all cardiac, seven were sudden deaths probably related to arrhythmias. The time and causes of death are presented in Table 1. Three patients died early following the reoperation and another three died late.

View larger version (23K): [in this window] [in a new window]   Fig. 3. There have been no significant differences in survival (from birth and from repair of Tetralogy of Fallot) between patients who had received a palliative procedure prior to repair of Tetralogy of Fallot and patients who received repair of Tetralogy of Fallot as the primary procedure.

Fifty two patients (28 female and 24 male) out of 97 who answered the question had one or more children. Two of the female patients had each given birth to a child with Tetralogy of Fallot, while all other children were healthy and none had congenital heart disease.

Seventeen patients out of 100 who answered the question were presently using some kind of cardiac medication (10 used anti-arrhythmics, 10 used diuretics, two used digoxin and two used anticoagulative medication).

Fifty patients out of 99 who answered the question performed sport activities, primarily athletics, badminton, swimming and bicycling.

Eighty nine patients out of 105 who answered the question were working in a variety of ordinary professions. All kinds of professions from academics to hard manual labor were represented. Out of the 16 who were not in employment, two were housewives, four were unemployed, one was retired, and eight received disability pension. The impression was that many of these patients did not attend regular medical check-ups.

Medical reexaminations were almost exclusively performed as a consequence of symptoms.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
The present series of patients after repair of Tetralogy of Fallot is one the largest series with a follow-up longer than 20 years. No patient was lost to follow-up although four did not answer the questionnaire. Even with a mortality far beyond what is acceptable today, the overall results are impressive in comparison to the natural history of the disease. Selected by the very high early hospital mortality, it is clear that the majority of the surviving patients live normal lives in ordinary professions, without any severe limitations in their normal daily activities, including sport activities, and without taking any medication. This indicates good intellectual, physical and social performance and is in agreement with other early series with long follow-up periods [6,8–10]. However, the results also confirm that improvements are possible by close clinical monitoring to prevent, diagnose and treat cardiac complications/problems. This is true even though a lot of detailed information is still missing.

In the early era of Tetralogy of Fallot repair, the use of a right ventricular outflow patch was associated with very high risk and there are only 10 patients with outflow patches among our survivors. Additional surgical technical causes of fatal outcome were: insufficient relief of the right ventricular outflow tract obstruction, A-V block, bleeding, injury to the aortic valve and cardiac failure possibly caused by poor myocardial protection. The poor surgical technique was also the main cause of reoperation for ineffective VSD closure. Although the operative mortality was high, the frequency of reoperations was the same as that reported by others for the same indications [12].

Since detailed information about remaining obstruction and/or insufficiency are lacking in this study, our results might be interpreted as if some residual right ventricular stenosis and/or insufficiency is well tolerated by most patients and this is also in agreement with the observation of others [7]. Miyamura et al. [14] presented a 20–29-year follow-up of 50 patients and showed no adverse effects of transannular patching. The negative influence of pulmonary insufficiency on early and late outcome has, however, been stressed by others, both in relation to working capacity and risk of arrhythmias, reoperation and/or late death [15]. Vetter et al. [16] demonstrated the relation between transannular patching and increased right ventricular volume and reduced working capacity following repair of Fallot in an echocardiographic and exercise study. Zhao et al. [12] found that the length of the transannular patch was a predictor of the need for reoperation. Because of the very high operative mortality associated with right ventricular outflow patch, patients without outflow patch are over-represented in our series in comparison with later series.

How these results should be interpreted in relation to the use of valved conduits in the repair of Fallot with a need for transannular patching, is therefore not clear. Monocusp valves might serve to reduce the immediate postoperative problems, while most of them will have no long-term function but probably do little or no harm. Valved conduits (homografts and others) will serve well in the early postoperative period but eventually all will deteriorate and become obstructed and will have to be replaced with regular intervals (10–15 years or less) [17]. The outcome in this series justifies the advice to minimize pulmonary insufficiency, as suggested above with the conservative approach to outflow patching, and reserve valved conduits for patients with an additional indication usually including a suspicion of increased pulmonary vascular resistance. The study by Norgard et al. [18] of the right ventricular diastolic function following Tetralogy of Fallot repair indicates that a restrictive physiology might be beneficial to long-term outcome. In the present material, only one patient was recently given a homograft in the right ventricular outflow tract for severe pulmonary insufficiency and ventricular dilatation.

In this series, there were seven late, sudden deaths indicating an important problem to look for and try to prevent. This incidence is identical to that observed by Jonsson et al. [19] while Waien et al. [11] found a very low risk in adults with previous repair. The cause of sudden death may be heart block or taccyarrhythmia/ventricular fibrillation. A trifascicular block pattern was associated with early sudden death [20]. The risk of symptomatic arrhythmia is high when marked right ventricular enlargement and QRS prolongation develop [21]. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death [21]. Earlier repair seems to reduce the risk of late ventricular arrhythmias [19]. Deanfield et al. [22] have found late Tetralogy of Fallot repair to be associated with more arrhythmias. This might explain our high incidence of late, sudden death. Transatrial VSD closure with short transannular incision, less aggressive muscle resection in right ventricular outflow tract and less generous outflow patching have been found to be associated with reduced ventricular arrhythmias and less right ventricular dilatation/dysfunction and improved working capacity [23,24]. Diagnostic possibilities and treatment options have increased, and today the treatment includes the option of cardioverter-defibrillator implantation. Hopefully, more aggressive medical treatment of ventricular arrhythmias, will reduce the number of sudden deaths. Arrhythmias after repair of Tetralogy of Fallot also include atrial taccyarrhythmias [25].

As a consequence of the present study, the patients will be approached and offered a check-up by a qualified cardiologist. It will take a long time before all patients have been reexamined. It is possible that a few patients in the series will be in need of a reoperation, e.g. those three who primarily received valved conduits. In addition, such a follow-up program can be expected to produce additional interesting information.

	5. Conclusions

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
The majority of survivors following repair of Tetralogy of Fallot live normal lives. Future patients may hope that an earlier, more perfect operation and a more close postoperative medical follow-up and treatment of complications will reduce the risk of sudden death, improve the working capacity and reduce the need for reoperation.

	Footnotes

 
Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998.

	Appendix A

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 
Conference discussion
Dr E. Baudet (Bordeaux, France): Do you consider that current myocardial protection with cardioplegia, if available at that time, could have avoided some of these late deaths?

Dr Norgaard: We expect that if the patients had been followed closer we may have been able to discover some cardiac arrhythmias and intervene. As a consequence of this study, we will offer all the patients that are still alive to be followed closely by cardiologists.

Dr C. Knott-Craig (Oklahoma, OK): With respect to the late deaths, were any of those related to exercise? How do you advise your patients whether they are able to exercise? For example, do you do an exercise Holter monitoring before allowing them to exercise, or do you just give them carte blanche ability to exercise if they feel fit enough?

Dr Norgaard: We have not pointed out any kind of restrictions to these patients. We think if the patients should really benefit from Fallot repair, they should be able to live a normal life, and at controls performed by cardiologists, cardiac arrhythmias should be discovered.

Dr Knott-Craig: Were any of the late deaths related to exercise at all?

Dr Norgaard: We don't know what the patients were doing at the time of death.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A References

 

1. Rygg I.H. Tetralogy of Fallot. A study of all cases diagnosed in Denmark from till 1965. Dan Med Bull 1971;18(2):1-129.[Medline]
2. Bertranou E.G., Blackstone E.H., Hazelrig J.B., Turner M.E., Kirklin J.W. Life expectancy without surgery in tetralogy of Fallot. Am J Cardiol 1978;42(3):458-466.[Medline]
3. Blalock A., Taussig H.B. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. J Am Med Assoc 1945;128:189-202.[Abstract/Free Full Text]
4. Lillehei C.W., Varco R.L., Cohen M., Warden H.E., Patton C., Moller J.H. The first open-heart repairs of ventricular septal defect, atrioventricular communis, and tetralogy of Fallot using extracorporeal circulation by cross-circulation: a 30-year follow-up. Ann Thorac Surg 1986;41(1):4-21.[Abstract]
5. Kirklin J.W., DuShane J.W., Patrick R.T., Donald D.E., Hetzel P.S., Harshbarger H.G., Wood E.H. Intracardiac surgery with the aid of a mechanical pump-oxygenator system (Gibbon type): report of eight cases. Proc Staff Meet Mayo Clin 1955;30:201-206.[Medline]
6. Lillehei C.W., Varco R.L., Cohen M., Warden H.E., Gott V.L., DeWall R.A., Patton C., Moller J.H. The first open heart corrections of tetralogy of Fallot. A 26-31 year follow-up of 106 patients. Ann Surg 1986;204(4):490-502.[Medline]
7. Gersony W.M. Long-term follow-up of operated congenital heart disease. Cardiol Clin 1989;7(4):915-923.[Medline]
8. Horneffer P.J., Zahka K.G., Rowe S.A., Manolio T.A., Gott V.L., Reitz B.A., Gardner T.J. Long-term results of total repair of tetralogy of Fallot in childhood. Ann Thorac Surg 1990;50(2):179-183.[Abstract]
9. Miyamura H., Eguchi S., Asano K. Long-term results of the intracardiac repair of tetralogy of Fallot: a follow-up study conducted over more than 20 years on 100 consecutive operative survivors. Surg Today 1993;23(12):1049-1052.[Medline]
10. Rosenthal A., Behrendt D., Sloan H., Ferguson P., Snedecor S.M., Schork A. Long-term prognosis (15 to 26 years) after repair of tetralogy of Fallot: I. Survival and symptomatic status. Ann Thorac Surg 1984;38(2):151-156.
11. Waien S.A., Liu P.P., Ross B.L., Williams W.G., Webb G.D., McLaughlin P.R. Serial follow-up of adults with repaired tetralogy of Fallot. J Am Coll Cardiol 1992;20(2):295-300.[Abstract]
12. Zhao H.X., Miller D.C., Reitz B.A., Shumway N.E. Surgical repair of tetralogy of Fallot. Long-term follow-up with particular emphasis on late death and reoperation. J Thorac Cardiovasc Surg 1985;89(2):204-220.[Abstract]
13. Wennevold A., Rygg I., Lauridsen P., Efsen F., Jacobsen J.R. Fourteen- to nineteen-year follow-up after corrective repair for tetralogy of Fallot. Scand J Thorac Cardiovasc Surg 1982;16(1):41-45.[Medline]
14. Miyamura H., Takahashi M., Sugawara M., Eguchi S. The long-term influence of pulmonary valve regurgitation following repair of tetralogy of Fallot: does preservation of the pulmonary valve ring affect quality of life?. Surg Today 1996;26(8):603-606.[Medline]
15. Rowe S.A., Zahka K.G., Manolio T.A., Horneffer P.J., Kidd L. Lung function and pulmonary regurgitation limit exercise capacity in postoperative tetralogy of Fallot. J Am Coll Cardiol 1991;17(2):461-466.[Abstract]
16. Vetter H.O., Reichart B., Seidel P., Kleinhans E., Bull U., Klinner W. Non-invasive assessment of right and left ventricular volumes 11 to 24 years after corrective surgery on patients with tetralogy of Fallot. Eur J Cardio-thorac Surg 1990;4(1):24-28.[Abstract]
17. Jonas R.A., Freed M.D., Mayer J.E.J., Castaneda A.R. Long-term follow-up of patients with synthetic right heart conduits. Circulation 1985;72(3 Part 2):II77-II83.
18. Norgard G., Gatzoulis M.A., Moraes F., Lincoln C., Shore D.F., Shinebourne E.A., Redington A.N. Relationship between type of outflow tract repair and postoperative right ventricular diastolic physiology in tetralogy of Fallot. Implications for long-term outcome. Circulation 1996;94(12):3276-3280.[Abstract/Free Full Text]
19. Jonsson H., Ivert T., Brodin L.A., Jonasson R. Late sudden deaths after repair of tetralogy of Fallot. Electrocardiographic findings associated with survival. Scand J Thorac Cardiovasc Surg 1995;29(3):131-139.[Medline]
20. Cairns J.A., Dobell A.R., Gibbons J.E., Tessler I. Prognosis of right bundle branch block and left anterior hemiblock after intracardiac repair of tetralogy of Fallot. Am Heart J 1975;90(5):549-554.[Medline]
21. Gatzoulis M.A., Till J.A., Somerville J., Redington A.N. Mechanoelectrical interaction in tetralogy of Fallot. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death [see comments]. Circulation 1995;92(2):231-237.[Abstract/Free Full Text]
22. Deanfield J.E., McKenna W.J., Presbitero P., England D., Graham G.R., Hallidie S.K. Ventricular arrhythmia in unrepaired and repaired tetralogy of Fallot. Relation to age, timing of repair, and haemodynamic status. Br Heart J 1984;52(1):77-81.[Abstract/Free Full Text]
23. Dietl C.A., Cazzaniga M.E., Dubner S.J., Perez B.N., Torres A.R., Favaloro R.G. Life-threatening arrhythmias and RV dysfunction after surgical repair of tetralogy of Fallot. Comparison between transventricular and transatrial approaches. Circulation 1994;90(5 Part 2):II7-II12.
24. Atallah Y.N., Kavey R.E., Bove E.L., Smith F.C., Kveselis D.A., Byrum C.J., Gaum W.E. Postoperative assessment of a modified surgical approach to repair of tetralogy of Fallot. Long-term follow-up. Circulation 1996;94(9):II22-II26.
25. Roos H.J., Perlroth M.G., McGhie J., Spitaels S. Atrial arrhythmias in adults after repair of tetralogy of Fallot. Correlations with clinical, exercise, and echocardiographic findings [see comments]. Circulation 1995;91(8):2214-2219.[Abstract/Free Full Text]

This article has been cited by other articles:

				S. Rosianu, D. Paprika, I. Osztheimer, A. Temesvari, and T. Szili-Torok Echocardiographic evaluation of patients with undocumented arrhythmias occurring in adults late after repair of tetralogy of Fallot Eur J Echocardiogr, January 1, 2009; 10(1): 139 - 143. [Abstract] [Full Text] [PDF]

				C. A. Warnes, R. G. Williams, T. M. Bashore, J. S. Child, H. M. Connolly, J. A. Dearani, P. del Nido, J. W. Fasules, T. P. Graham Jr, Z. M. Hijazi, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease) Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., December 2, 2008; 52(23): e143 - e263. [Full Text] [PDF]

				C. A. Warnes, R. G. Williams, T. M. Bashore, J. S. Child, H. M. Connolly, J. A. Dearani, P. del Nido, J. W. Fasules, T. P. Graham Jr, Z. M. Hijazi, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Adults With Congenital Heart Disease) Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., December 2, 2008; 52(23): 1890 - 1947. [Full Text] [PDF]

				C. A. Warnes, R. G. Williams, T. M. Bashore, J. S. Child, H. M. Connolly, J. A. Dearani, P. del Nido, J. W. Fasules, T. P. Graham Jr, Z. M. Hijazi, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease): Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, December 2, 2008; 118(23): e714 - e833. [Full Text] [PDF]

				C. A. Warnes, R. G. Williams, T. M. Bashore, J. S. Child, H. M. Connolly, J. A. Dearani, P. del Nido, J. W. Fasules, T. P. Graham Jr, Z. M. Hijazi, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Adults With Congenital Heart Disease): Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, December 2, 2008; 118(23): 2395 - 2451. [Full Text] [PDF]

				J. K. Triedman Should patients with congenital heart disease and a systemic ventricular ejection fraction less than 30% undergo prophylactic implantation of an ICD?: Implantable Cardioverter Defibrillator Implantation Guidelines Based Solely on Left Ventricular Ejection Fraction Do Not Apply to Adults With Congenital Heart Disease Circ Arrhythm Electrophysiol, October 1, 2008; 1(4): 307 - 316. [Full Text] [PDF]

				K. Zeppenfeld, M. J. Schalij, M. M. Bartelings, U. B. Tedrow, B. A. Koplan, K. Soejima, and W. G. Stevenson Catheter Ablation of Ventricular Tachycardia After Repair of Congenital Heart Disease: Electroanatomic Identification of the Critical Right Ventricular Isthmus Circulation, November 13, 2007; 116(20): 2241 - 2252. [Abstract] [Full Text] [PDF]

				E. P. Walsh Interventional Electrophysiology in Patients With Congenital Heart Disease Circulation, June 26, 2007; 115(25): 3224 - 3234. [Full Text] [PDF]

				T. M. Bashore Adult Congenital Heart Disease: Right Ventricular Outflow Tract Lesions Circulation, April 10, 2007; 115(14): 1933 - 1947. [Full Text] [PDF]

				E. P. Walsh and F. Cecchin Arrhythmias in Adult Patients With Congenital Heart Disease Circulation, January 30, 2007; 115(4): 534 - 545. [Full Text] [PDF]

				T. Karamlou, I. Silber, R. Lao, B. W. McCrindle, L. Harris, E. Downar, G. D. Webb, J. M. Colman, G. S. Van Arsdell, and W. G. Williams Outcomes after late reoperation in patients with repaired tetralogy of fallot: the impact of arrhythmia and arrhythmia surgery. Ann. Thorac. Surg., May 1, 2006; 81(5): 1786 - 1793. [Abstract] [Full Text] [PDF]

				K. Norozi, R. Buchhorn, C. Kaiser, G. Hess, R. W. Grunewald, L. Binder, and A. Wessel Plasma N-Terminal Pro-Brain Natriuretic Peptide as a Marker of Right Ventricular Dysfunction in Patients With Tetralogy of Fallot After Surgical Repair Chest, October 1, 2005; 128(4): 2563 - 2570. [Abstract] [Full Text] [PDF]

				P. A. Davlouros, P. J. Kilner, T. S. Hornung, W. Li, J. M. Francis, J. C. C. Moon, G. C. Smith, T. Tat, D. J. Pennell, and M. A. Gatzoulis Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction J. Am. Coll. Cardiol., December 4, 2002; 40(11): 2044 - 2052. [Abstract] [Full Text] [PDF]

				B. Faidutti, J. T. Christenson, M. Beghetti, B. Friedli, and A. Kalangos How to diminish reoperation rates after initial repair of tetralogy of Fallot? Ann. Thorac. Surg., January 1, 2002; 73(1): 96 - 101. [Abstract] [Full Text] [PDF]

				H. P. Nieminen, E. V. Jokinen, and H. I. Sairanen Late Results of Pediatric Cardiac Surgery in Finland: A Population-Based Study With 96% Follow-Up Circulation, July 31, 2001; 104(5): 570 - 575. [Abstract] [Full Text] [PDF]

				R. Pretre, G. Gendron, D. Tamisier, F. Vernant, D. Sidi, and P. Vouhe Results of the Lecompte procedure in malposition of the great arteries and pulmonary obstruction Eur. J. Cardiothorac. Surg., March 1, 2001; 19(3): 283 - 289. [Abstract] [Full Text] [PDF]

				C. Alexiou, H. Mahmoud, A. Al-Khaddour, J. Gnanapragasam, A. P. Salmon, B. R. Keeton, and J. L. Monro Outcome after repair of tetralogy of Fallot in the first year of life Ann. Thorac. Surg., February 1, 2001; 71(2): 494 - 500. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Poul Lauridsen Morten Helvind Gösta Pettersson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nørgaard, M. A. Articles by Pettersson, G. Search for Related Content PubMed PubMed Citation Articles by Nørgaard, M. A. Articles by Pettersson, G.