What are the treatment options for tetralogy of Fallot?

There is no medical treatment for tetralogy of Fallot. The structural abnormalities in the heart require surgical correction. In most cases, infants undergo the operation within the first year of life. In children, the first step is usually palliative surgery to improve the blood flow to the lungs without directly repairing the structural defects. Palliative surgery usually involves some type of shunt to increase blood flow to the lungs and possibly a valve repair or a closure of the ventricular septal defect. These techniques can relieve symptoms for a number of years, until more definitive repair surgery can be performed.

What type of ongoing care is necessary for an adult who has had surgical repair of Tetralogy of Fallot?

Specialists in adult congenital heart disease recommend that an adult who has had surgery for tetralogy of Fallot as a child periodically undergo a thorough cardiac evaluation. The shunts used in the palliation are associated with problems such as narrowing (stenosis), high blood pressure in the pulmonary artery or causing excess volume load on the left side of the heart. Definitive surgery often results in significant leaking of the pulmonary valve and the size and function of the right side of the heart needs to be monitored closely. Some patients may also develop large aortopulmonary collateral vessels as a way of getting extra blood flow to the lungs. These need to be closed prior to definitive surgical repair. The presence of any of these problems or worsening of symptoms, such as cyanosis or fatigue, are reasons for an adult to undergo a repeat surgery. Occasionally, an individual reaches adulthood without having had any surgical repair, although this is not common. Specialists recommend that these individuals consider undergoing a complete surgical repair to prevent future complications or sudden death.

How is tetralogy of Fallot surgically repaired in an adult?

Surgical repair for tetralogy of Fallot is complex, delicate and highly technical, and should be performed by a surgeon who specializes in adult congenital heart disease. The operation will involve a combination of techniques to fix all four defects. To perform a complete repair, the surgeon closes the ventricular septal defect with a patch. The passageway out of the right ventricle is opened, and the pulmonary valve is repaired or replaced. The pulmonary arteries to both lungs are enlarged, and sometimes a tube is placed between the right ventricle and the pulmonary artery to improve blood flow.

How successful is the surgery in adults?

When performed by an experienced congenital heart disease surgeon, surgical repair of the defect in adults has a very high success rate. In one long-term study, the 36-year survival rate for adults who underwent surgical repair for tetralogy of Fallot was 86 percent.

Are there any potential problems or complications associated with the surgery?

Although the surgery to correct tetralogy of Fallot is very effective in correcting the structural defects and blood flow through the heart, it can cause some ongoing abnormalities in the heart’s function. If these problems develop, they can be treated with surgery. Many adults who undergo repair for tetralogy of Fallot will eventually require further surgical treatment. The potential complications associated with surgical repair for tetralogy of Fallot include:

• Electrical disturbances: Putting a patch on the ventricular septal defect can block the ability of the atria to transmit electrical signals to the ventricles. This can be corrected by a pacemaker.

• Rhythm disturbances (arrhythmias): Atrial fibrillation – when the heart’s upper chambers contract irregularly and often too quickly - is a common complication following heart surgery. This can be treated with medication or a non-surgical procedure. A rarer but more serious arrhythmia is ventricular tachycardia. This is a life-threatening, overly-rapid heartbeat in the lower heart chambers. The congenital heart disease specialist will determine if an individual is at risk for this postoperatively.

• Leaking valves: Heart valves are designed to allow blood to flow in one direction. When a valve leaks, blood can flow back into the chamber. The most common valve problem after tetralogy of Fallot repair is a leaking pulmonary valve, but the aortic and tricuspid heart valves can leak also. Leaky valves can be surgically repaired.

• Residual ventricular septal defect: Sometimes the ventricular septal defect does not seal completely and there is some leaking around the patch. If the leak is large or causes major symptoms, it can be repaired surgically.

• Aneurysm: The patches placed on the ventricle to repair it can cause weak sections of the ventricle to bulge out, forming an aneurysm. There is also an increased risk for developing aneurysms of the ascending aorta. Aneurysms require surgical repair. 

What follow up care is needed after surgery?

Adults who have had a tetralogy of Fallot repaired need to have regular cardiac checkups with an adult congenital heart disease specialist. Various tests of cardiac function such as an echocardiogram, a Holter monitor, electrocardiogram or an exercise stress test may be required periodically to ensure that the heart is functioning adequately. People with repaired tetralogy of Fallot typically have some restrictions on certain strenuous activities, such as competitive sports.