ACC AHA recommendations for surgery in adults with previous repair of tetralogy of fallot


 * Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [mailto:psingh@perfuse.org], Keri Shafer, M.D. [mailto:kshafer@bidmc.harvard.edu]; Atif Mohammad, M.D.; Assistant Editor-In-Chief: Kristin Feeney, B.S. [mailto:kfeeney@perfuse.org]

Overview
The ACC/AHA has provided the following recommendations regarding repeat surgery in a patient with a previous repair of Tetralogy of Fallot.

==The(ACC/AHA) recommendations for surgery for adults with previous repair of Tetralogy of Fallot (DONOT EDIT)==

Class I

1. Surgeons with training and expertise in congenital heart disease (CHD) should perform operations in adults with previous repair of tetralogy of Fallot. (Level of Evidence: C)

2. Pulmonary valve replacement is indicated for severe pulmonary regurgitation and symptoms or decreased exercise tolerance. (Level of Evidence: B)

3. Coronary artery anatomy, specifically the possibility of an anomalous anterior descending coronary artery across the RVOT, should be ascertained before operative intervention. (Level of Evidence: C)

Class IIa

1. Pulmonary valve replacement is reasonable in adults with previous tetralogy of Fallot, severe pulmonary regurgitation, and any of the following:
 * 1. Moderate to severe right ventricular (RV) dysfunction. (Level of Evidence: B)
 * 2. Moderate to severe RV enlargement. (Level of Evidence: B)
 * 3. Development of symptomatic or sustained atrial and/or ventricular arrhythmias. (Level of Evidence: C)
 * 4. Moderate to severe tricuspid regurgitation (TR). (Level of Evidence: C)

2. Collaboration between ACHD surgeons and ACHD interventional cardiologists, which may include preoperative stenting, intraoperative stenting, or intraoperative patch angioplasty, is reasonable to determine the most feasible treatment for pulmonary artery stenosis. (Level of Evidence: C)

3. Surgery is reasonable in adults with prior repair of tetralogy of Fallot and residual RVOT obstruction (valvular or subvalvular) and any of the following indications:
 * 1. Residual RVOT obstruction (valvular or subvalvular) with peak instantaneous echocardiography gradient greater than 50 mm Hg. (Level of Evidence: C)
 * 2. Residual RVOT obstruction (valvular or subvalvular) with RV/LV pressure ratio greater than 0.7. (Level of Evidence: C)
 * 3. Residual RVOT obstruction (valvular or subvalvular) with progressive and/or severe dilatation of the right ventricle with dysfunction. (Level of Evidence: C)
 * 4. Residual ventricular septal defect (VSD) with a left-to-right shunt greater than 1.5:1. (Level of Evidence: B)
 * 5. Severe aortic regurgitation (AR) with associated symptoms or more than mild LV dysfunction. (Level of Evidence: C)
 * 6. A combination of multiple residual lesions (e.g., VSD and RVOT obstruction) leading to RV enlargement or reduced RV function. (Level of Evidence: C)

Recommendations for Interventional Catheterization

Class I

1.Interventional catheterization in an ACHD center is indicated for patients with previously repaired tetralogy of Fallot with the following indications:
 * 1. To eliminate residual native or palliative systemic–pulmonary artery shunts. (Level of Evidence: B)
 * 2. To manage coronary artery disease. (Level of Evidence: B)

Class IIa

1. Interventional catheterization in an ACHD center is reasonable in patients with repaired tetralogy of Fallot to eliminate a residual ASD or VSD with a left-to-right shunt greater than 1.5:1 if it is in an appropriate anatomic location. (Level of Evidence: C) For ACC/AHA Level of evidence and classes click:ACC AHA Guidelines Classification Scheme