Outcomes of surgical repair of Tetralogy of Fallot in an African tertiary care centre with emphasis on post-operative pulmonary regurgitation

BACKGROUND: Despite the advances in the surgical treatment of Tetralogy of Fallot(TOF), pulmonary regurgitation (PR) remains as a possible complication with detrimental impact on right ventricular function (RV) in the long term. If these effects are not reversed timeously by replacing the pulmonary valve, serious morbidity and even mortality may occur. AIM: The aim of the study was to assess the outcomes in children who had complete repair of TOF at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) with or without a RV outflow conduit with emphasis on the development of PR, as well as signs and symptoms that could be linked to PR. METHOD: A retrospective clinical audit on patients with a diagnosis of TOF and who had surgery at the CMJAH between 01/01/1994 and 31/12/2003 was undertaken. Data collected and entered onto a data collection sheet included ethnicity, sex, type of surgery which was either palliation with a Blalock-Taussig shunt (BTS) or corrective surgery, age at surgery, echocardiographic documentation of PR and RV size during follow-up. Other information included electrocardiogram (ECG) changes, abnormalities detected on chest X-ray (CXR), whether or not the patient was subjected to re-operation, as well as the indications of re-operation. RESULTS: Of the 72 patients with TOF and available data, fifty four patients (75%) had surgery, 50 (92.6%) of whom had corrective surgery and 4(7.4%) had palliative surgery in the form of a BTS only. Of the 50 who had corrective surgery, 2 (4%) patients had an initial BTS shunt while the remaining forty eight (96%) underwent initial primary corrective surgery. There were 46 males (63.9%) and 26 (36.1%) females. The median age at first visit was 13 months (range, 0.03 to 177), median age at corrective repair was 39.5 months (range, 3 to 210) and median age at palliation was 18 months (range, 1.5 to 29). Of the 50 patients undergoing corrective surgery, 60% had complex anatomy and 40% simple anatomy. More females compared to males had complex anatomy with a hypoplastic pulmonary valve (p= 0.047). Two patients undergoing a transannular patch (TAP) developed severe PR in the immediate postoperative period (less than 1 year) whilst no patients in the simple repair group developed severe PR (p= 0.110). In the intermediate postoperative period (1 to 5 years), there was 1 patient each in the TAP and simple repair group with severe PR (p = 0.476). Finally in the long term period (more than 5 years), 8 patients with TAP developed severe PR whilst 2 patients with simple repair developed severe PR (p= 0.005). Two patients out of fifteen patients (13.3%) with TAP had a pulmonary valve replacement (PVR). No patients with simple repair had PVR. CONCLUSION: Severe PR is an expected and serious complication accompanying all forms of repair techniques employed for the wide anatomical spectrum of TOF. In this study, comparison of the two most common types of repair, namely simple versus TAP, revealed a statistically significant occurrence of PR in the TAP group. Appropriate timing for PVR is paramount for the symptomatic patients in order to preserve RV function

Tracking Trends in Emissions of Developmental Toxicants and Potential Associations with Congenital Heart Disease in Alberta, Canada

Congenital heart disease (CHD) is a serious anomaly for which the etiology remains elusive. We explored temporal trend associations between industrial developmental toxicant (DT) air emissions and CHD in Alberta. Patients born between 2004–2011 with a diagnosis of CHD and 18 DTs from the National Pollutant Release Inventory (2003–2010) were identified. We applied principal component analysis (PCA) to DT amounts and toxicity risk scores (RS) and defined yearly crude CHD and septal defects rates for urban and rural regions. Correlations between DT groups and CHD rates were examined with Spearman test and Bonferroni correction was conducted for multiple comparisons. PCA identified three DT groups: Group 1 (volatile organic compounds (VOCs) and other gases,) Group 2 (other VOCs), and Group 3 (mainly heavy metals). Province-wide, we found associations between Group 1 DTs and CHD and septal defect rates, when using amounts (r = 0.86, CI 0.39, 0.97 and r = 0.89, CI 0.48, 0.98, respectively) and RS (r = 0.88, CI 0.47, 0.98 and r = 0.85, CI 0.36, 0.97, respectively). Rural Group 2 DTs were positively associated with septal defect rates in both amounts released and RS (r = 0.91, CI 0.55, 0.98 and r = 0.91, CI 0.55, 0.98, respectively). In this exploratory study, we found a temporal decrease in emissions and CHD rates in rural regions and a potential positive association between CHD and septal defect rates and mixtures of organic compounds with or without gases