Early Primary Repair of Tetralogy of Fallot

Richard A. Jonas

Outcomes for surgical repair of tetralogy of Fallot with pulmonary stenosis are often
considered to be a useful benchmark for the assessment of congenital surgical programs.
This procedure, including preoperative assessment and postoperative management, falls in
the middle of the spectrum of difficulty of all the congenital cardiac procedures. Within this
anomaly itself, there is a wide spectrum of severity and difficulty. However, it is important
to distinguish tetralogy with pulmonary stenosis or “simple tetralogy” from the much more
complex anomaly tetralogy of Fallot with pulmonary atresia. Tetralogy of Fallot with pul-
monary stenosis is virtually always operable. It is also a progressive condition that is
therefore best repaired in early infancy following echocardiographic diagnosis alone.
Semin Thorac Cardiovasc Surg Pediatr Card Surg Ann 12:39-47 © 2009 Published by
Elsevier Inc.

KEYWORDS Tetralogy of Fallot, Surgical repair

Anatomy of Tetralogy of pulmonary stenosis inoperable. It must be remembered that

the pulmonary arteries are underfilled and underpressurized
Fallot With Pulmonary Stenosis preoperatively, so whatever imaging technique is used, the

T he precise anatomy of the child with tetralogy of Fallot

must be accurately defined preoperatively to allow safe
and complete repair. This can usually be accomplished with
echocardiography alone. There are two common misconcep-
tions about the anatomy of tetralogy of Fallot with pulmonary
stenosis. The first relates to the size of the pulmonary arteries.
Size of Pulmonary
Arteries in Simple Tetralogy
If there are no important aortopulmonary collaterals present
there is no difficulty in deciding whether the size of the pul-
monary arteries is adequate for complete repair. Because the
child is receiving essentially all pulmonary blood flow preop-
eratively through the true pulmonary arteries, and assuming
that the arterial oxygen saturation is greater than 70% to
80%, then it can be assumed that the pulmonary arteries can
readily accommodate a full cardiac output, which is all that is
required of them postoperatively. Despite this simple physi-
ological fact, there are still many centers that debate the ques-
tion as to the adequacy of the size of the true pulmonary
arteries for complete repair. This should rarely if ever be a
consideration in declaring a child with tetralogy of Fallot and
Children’s National Heart Institute, Children’s National Medical Center,
Washington, DC.
Address correspondence to Richard A. Jonas, MD, Department of Cardiac
Surgery, Children’s National Heart Institute, 111 Michigan Ave NW,
Washington, DC 20010; E-mail: rjonas@cnmc.org
potential size of the pulmonary arteries is unknown. The
anatomy of the mediastinal branch pulmonary arteries in
tetralogy with pulmonary stenosis was well defined in an
angiographic study by Shimazaki et al (Fig. 1).1
Size of the Left Ventricle
Just as with the size of the pulmonary arteries, it is exceed-
ingly rare in a practice predominantly involving neonatal and
infant surgery to find a child with tetralogy whose left ven-
tricle is inadequate for biventricular repair. In centers that
manage children at an older age (including during the teen-
age years), it is common to hear low postoperative cardiac
output being attributed to inadequacy of the left ventricle.
Ventricular Septal Defect
The size and location of the anterior malalignment ventricu-
lar septal defect (VSD) in simple tetralogy is remarkably uni-
form across the spectrum of this anomaly. Additional mus-
cular VSDs are present in 3% to 15% of patients and must be
defined preoperatively.2
Right Ventricular Outflow Tract Obstruction
There is a wide spectrum of severity of right ventricular out-
flow tract. Obstruction can be supravalvar (including hyp-
oplasia of the main pulmonary artery), valvar at the level of
the pulmonary valve, and muscular infundibular. The anat-
omy of right ventricular outflow tract obstruction, including

1092-9126/09/$-see front matter © 2009 Published by Elsevier Inc. 39

doi:10.1053/j.pcsu.2009.01.021
40 R.A. Jonas

Figure 1 This figure from the study by Shimazaki et al illustrates that the right (A) and left (B) mediastinal pulmonary
arteries are usually close to normal size in tetralogy of Fallot with pulmonary stenosis. As one moves more proximally
the pulmonary trunk (PT), pulmonary valve annulus and RV infundibulum become increasingly small relative to
normal (ie, z score is less). (Reprinted with permission.1)

the underdevelopment of the main pulmonary artery and
pulmonary annulus, were well defined in a comprehensive
radiographic study by Shimizaki et al (Fig. 1).1
One of the important variables in the infundibular ob-
struction of tetralogy is the length of the conal septum. In
some forms of tetralogy the conal septum is completely ab-
sent and there is a small fibrous band only below the pulmo-
nary valve. This allows excellent exposure of the VSD
through a very short ventricular incision. On the other hand,
if there is a long conal septum, then generally a longer infun-
dibular incision is required both to expose the anterior mal-
alignment VSD as well as to allow patch enlargement of the
full length of the underdeveloped infundibulum.
Coronary Artery Distribution
Moving through the spectrum of tetralogy from normality,
the aorta moves forward relative to the pulmonary artery and
the distance that the left main coronary artery must traverse
in order to pass posteriorly behind the pulmonary artery
before bifurcating into the anterior descending and circum-
flex coronary artery increases. Not surprisingly, therefore, a
Early primary repair of tetralogy of Fallot
small number of patients (about 5%) have anomalous coro-
nary distribution where the anterior descending coronary
artery takes a shorter course.3,4 It arises from the right coro-
nary artery and passes leftward across the infundibulum of
the right ventricle before turning inferiorly in the anterior
interventricular groove. It is also common to see a very large
branch of the right coronary artery passing obliquely across
the anterior wall of the right ventricle toward the apex of the
heart. Branches of this coronary artery run leftward, usually
overlying the hypertrophied muscle bundles that lie within
the infundibulum of the right ventricle. This coronary artery
distribution is so common that it should be considered a
standard feature of tetralogy of Fallot.
Patent Foramen Ovale
There is almost always a patent foramen ovale associated with
tetralogy of Fallot. Occasionally, this can enlarge to become a
secundum atrial septal defect and allow a left to right shunt
posteriorly if it is not partially closed at the time of surgery.
Right Aortic Arch
About 25% of patients with tetralogy of Fallot have a right
aortic arch.
Discontinuous Pulmonary Arteries
It is common for ductal tissue to extend into the origin of the
left pulmonary artery and to cause an origin stenosis. At the
severe end of the spectrum, the pulmonary arteries become
discontinuous (usually between the main pulmonary artery
and left pulmonary artery).
Indications for
and Timing of Surgery
Considerable controversy persists regarding the optimal tim-
ing for repair of tetralogy of Fallot. Although primary repair
was attempted in the early years of open heart surgery,5 the
morbidity of early heart-lung machines led to a high mortal-
ity and acceptance of a routine two-stage approach with an
initial palliative shunt. However, it subsequently became ap-
parent that shunts also carried significant mortality and mor-
bidity. In particular, early shunts (such as the Potts shunt and
Waterston shunt) were very damaging to patients with tetral-
ogy because they resulted in severe distortion of the left or
right branch pulmonary artery and often an elevation in pul-
monary resistance. The classical Blalock shunt often throm-
bosed when performed in the neonatal period or early in-
fancy. It was not until the introduction of the modified
Blalock shunt with a PTFE interposition graft by de Leval6 in
the early 1980s that the neonatal Blalock shunt became more
consistently successful.
However, even the modified Blalock shunt usually results
in scarring and distortion at the level of the distal anastomo-
sis, which is an important consideration in the child who
requires a highly compliant pulmonary artery tree to amelio-
41
Figure 2 Typical distortion of the right pulmonary artery caused by
a modified right Blalock shunt.
rate the deleterious effects of the pulmonary regurgitation
that accompanies a transannular patch (Fig. 2).
Advantages of Early Primary Repair
There are multiple advantages for all developing organ sys-
tems in the body to have a normal circulation as early in life
as possible.7 In children with tetralogy of Fallot, the develop-
ing pulmonary vasculature is exposed to abnormally low
pressure as well as reduced flow. There is evidence to indicate
that this results in a reduced ratio of gas-exchanging capillar-
ies relative to alveoli.
Lung development continues for the first several years of
life, but deferring surgery beyond this time may result in a
reduced cross sectional area for gas exchange.8
Development of the heart is also abnormal in the child with
unrepaired tetralogy. The right ventricle is exposed to sys-
temic pressure in the child with usual unrestrictive anterior
malalignment VSD (Fig. 3). Persistence of systemic pressure
in the right ventricle results in abnormal right ventricular
hypertrophy with subsequent fibrosis and decreased compli-
ance. In the normal heart, the right ventricle is highly com-
pliant, allowing an enormous increase in pulmonary blood
flow with little or no change in systemic venous pressure.
Failure to repair tetralogy early in life is likely to lead to a
lifetime decrease in right ventricular compliance. There is
also evidence that left ventricular function is less good when
repair of tetralogy is delayed.9 Arrhythmias are also more
common late after repair if repair is performed beyond
infancy.10
The organ that undergoes the most rapid development in
the first year of life is the brain. It seems highly probably that
chronic cyanosis in the first year of life will be accompanied
by reduced developmental outcome relative to what might
otherwise have been achieved.
42
Figure 3 Van Praagh has emphasized that the two principal features of tetralogy of Fallot, namely a VSD and infundib-
ular obstruction, result from underdevelopment of the subpulmonary conus. The infundibular septum no longer sits
between the two divisions of the septal band because it is anteriorly displaced. There is an anterior malalignment VSD
and muscular subpulmonary stenosis. (a) Normal anatomy. (b) Tetralogy of Fallot.
In addition to the multiple developmental advantages for
the child, there are additional important economic and psy-
chosocial advantages for the young family with a child born
with tetralogy of Fallot. It is not difficult to empathize with
young inexperienced parents who are told by their physician
that their child has a potentially fatal cardiac condition that
can result in sudden cyanotic spells and death if the child is
allowed to become agitated. One can only imagine the fear
that a single cry at night from this child will cause. One
option adopted by many centers is to defer reparative surgery
beyond 6 to 12 months and to undertake a preliminary shunt
if the child becomes symptomatic within that timeframe.11,12
The family must then endure a second hospitalization with its
attendant stresses and costs. It seems infinitely preferable
from the perspective of the family, as well as the cost to
society, to undertake single-stage elective repair early in in-
fancy before the development of symptoms.
Specific Indications for Surgery
Symptoms
Prostaglandin-dependent neonate. Occasionally a child will
be born with a sufficiently severe degree of fixed right ven-
tricular outflow tract obstruction that the child is prostag-
landin-dependent from birth. In this setting, it is particularly
important to exclude the presence of important aortopulmo-
nary collateral vessels as the child is likely to be close to
having tetralogy of Fallot with pulmonary atresia. Mediasti-
nal continuity of the true pulmonary arteries should also be
carefully confirmed.
Worsening cyanosis. Right ventricular outflow tract ob-
struction almost always progressively worsens in the first
weeks and months of life, usually due to increasing muscular
outflow tract obstruction, but on occasion because of wors-
ening valvar stenosis. This may result in the resting oxygen
saturation gradually decreasing from a level of greater than
R.A. Jonas
90% at birth to less than 75% to 80%. This should be an
indication to move ahead relatively urgently with surgery.
Cyanotic spells. Cyanotic spells are usually observed in a
child who is initially agitated. This is followed by a period of
cyanosis with an arterial oxygen saturation of less than 20%
to 30%. In a classic cyanotic spell, the child subsequently
becomes gray, pale, and comatose, presumably related to a
fall in cardiac output secondary to hypoxia. Cyanotic spells
can result in brain injury and death and should be an indica-
tion for immediate hospitalization and surgical repair. In the
past, both parents and hospital staff were taught maneuvers
to reverse cyanotic spells; although today it should be rare
that a child progresses to the point of having recurrent cya-
notic spells. The child’s agitation should be treated with mor-
phine. Systemic vascular resistance can be increased by plac-
ing the child in a knee-to-chest position. (This is equivalent
to the “squatting” position often adopted by the older, un-
treated child.) Oxygen should also be given. If necessary, the
child should be anesthetized, intubated, paralyzed, and ven-
tilated. Systemic resistance can be further increased pharmaco-
logically with alpha-adrenergic agents such as phenylepheph-
rine (Neo-Synephrine; Bayer Healthcare, Pittsburgh, PA) and
the catecholamine drive exacerbating the spell can be dimin-
ished by administration of a beta-blocking agent such as pro-
pranolol.
Elective Repair
At present, it is our practice to schedule elective repair fol-
lowing diagnosis, which is usually made within a few days of
birth. This allows the parents and caregivers the time to plan
necessary logistics and for the financial aspects of the proce-
dure to be put in place, usually over a 4- to 6-week period.
Over this time frame, ductal tissue that may extend into the
origin of the left pulmonary artery may declare itself as a
possible stenosis at the origin of the left pulmonary artery.
Although there was concern that repair in early infancy re-
Early primary repair of tetralogy of Fallot 43

Figure 4 (a) A ventriculotomy approach is preferred for repair of tetralogy of Fallot when there is moderate or severe
infundibular obstruction. The incision should be extended across the annulus (transannular incision) when the z score
of the pulmonary annulus is smaller than two to three standard deviations below normal. (b) Autologous pericardium
lightly tanned with glutaraldehyde is ideal for use as a right ventricular outflow tract patch. The patch should usually
be pear shaped as indicated. (c) Placement of a transannular pericardial right ventricular outflow tract patch. (d) On
occasion there may be an adequate pulmonary annulus but moderate or severe hypoplasia of the supravalvar main
pulmonary artery. (e) Two separate patches are placed, one in the main pulmonary artery for management of supra-
valvar pulmonary stenosis and one in the infundibulum of the right ventricle for infundibular obstruction.
44 R.A. Jonas

Figure 5 (a) Division of the parietal (free wall) and septal extensions of the conal septum will allow the conal septum to
move posteriorly when the VSD patch is anchored to it. (b) Placement of multiple interrupted pledgetted 5/0 sutures
for closure of the anterior malalignment VSD. In this patient there is considerable muscular separation between the
tricuspid and aortic valves so that sutures can be placed into the muscle ridge in this area. Sutures would usually not
be separated from each other as depicted here. The inset (c) demonstrates that sutures are placed on the right
ventricular aspect of the septum. The muscle bar separates the edge of the VSD from the conduction bundle.

sulted in a higher probability of transannular patch place-
ment this appears in fact not be borne out by experience with
elective repair.13
Contraindications to
Early Primary Repair
There are essentially no contradictions to early primary re-
pair, including anomalous anterior descending coronary ar-
tery, multiple VSDs, and discontinuous pulmonary arteries.
In the newborn period, the child with an anomalous coro-
nary artery can usually be managed with a transatrial ap-
proach and placement of outflow patches above or below or
both relative to the coronary artery to avoid conduit place-
ment. Multiple muscular VSDs can frequently be closed by
direct suture, often using adjacent muscle bundles, particu-
larly the moderator band, which can be folded into the mus-
cular defect using multiple interrupted doubly pledgetted
sutures.14
Technique of Repair
Cardiopulmonary Bypass Setup
The development of small, thin-walled, right angle venous
cannulas down to 10 Fr caliber (eg, Terumo, Tokyo, Japan)
has facilitated the performance of repair of tetralogy using
bicaval cannulation and continuous cardiopulmonary bypass
in babies weighing as little as 2 to 2.5 kg. Moderate hypo-
thermia (eg, 25 to 28°C) can be used, although many groups
today employ a mild degree of hypothermia or even normo-
thermia. For the very premature and small child (eg, less than
1.5 to 2 kg), we continue to use a single venous cannula and
usually a period of deep hypothermic circulatory arrest for
VSD closure.
Ventricular or Transatrial Approach
Although either approach is reasonable, the ventricular ap-
proach offers several advantages. The hypoplastic infundib-
ulum can be enlarged without unduly aggressive resection of
muscle, which can lead to extensive endocardial scar forma-
tion. The VSD is closed without undue traction on the tricus-
pid annulus, which can cause injury to the tricuspid valve
and conduction bundle. However, a number of important
technical considerations must be observed if the ventricular
approach is to be used correctly:
1. Decision regarding transannular patch: If the pulmonary
annulus and the pulmonary artery are more than two to
three standard deviations below normal, a transannular
patch is indicated (Fig. 4).
Early primary repair of tetralogy of Fallot 45

Figure 6 (a) It is not uncommon in the patient with tetralogy of Fallot to have virtual fibrous continuity between the
aortic and tricuspid valves. There may be a fibrous rim in this area that may represent a remnant of the membranous
septum. (b) The sutures may be safely placed in the fibrous rim or, alternatively, must be placed some distance below
the VSD edge to avoid injury to the bundle of His. (c) Placement of interrupted pledgetted sutures using the remnant
of the membranous septum. (d) Completed VSD closure using a patch of double velour knitted Dacron.

2. Location of the ventriculotomy: No right ventricular cor-
onary arteries should be divided, other than the conal
coronary branch of the anterior right ventricular branch of
the right coronary artery.
3. Length of the ventriculotomy should be limited.
4. Division of infundibular muscle bundles should not in-
clude division of the moderator band (Fig. 5).
5. VSD closure: Tricuspid chordae must be carefully pre-
served (Figs. 5, 6).
6. Dimensions of the outflow patch: An autologous pericar-
dial patch treated with 0.6% glutaraldehyde for 20 to
30 minutes should be used. The patch should enlarge
the infundibulum and pulmonary annulus to a normal
size for the child’s surface area.
7. Avoidance of coronary artery injury caused by suturing: It
is important that suture lines not cause undue tension
on the epicardium, which may compress coronary ar-
teries.
8. Management of the foramen ovale: It is very important in
the young infant that the foramen ovale should be left
patent in order to allow right to left decompression so
as to maintain cardiac output in the postoperative pe-
riod. The mild degree of cyanosis that results is well
tolerated in early infancy.
Results of Surgery
In an important study described by Kirklin et al,13 the results
of an approach of early primary repair were compared with a
two-stage approach. One hundred consecutive patients from
the University of Alabama were compared with 100 consec-
utive patients from Children’s Hospital Boston undergoing
correction of tetralogy of Fallot between 1984 and 1989. The
authors concluded that there was a possible disadvantage of
the two-stage approach using preliminary shunting and later
repair. Other excellent results have been described by Karl et
46
al,11 who described a review of 366 patients with a median
age of 15.3 months. There were two hospital deaths for a
hospital mortality of 0.5%. Hennein et al15 described no hos-
pital deaths among 30 neonates with symptomatic tetralogy
of Fallot.
Long-Term Results
After Early Primary Repair
A recent review of 49 long-term survivors of early repair of
tetralogy of Fallot with a median follow-up of 23.5 years
described an actuarial survival of 85% at 20 years.16 Freedom
from reintervention was 93% at 5 years and 79% at 20 years.
No significant differences were found between patients with
and without a transannular patch. Right ventricular outflow
tract obstruction was the most common indication for late
reoperation; 41 of 45 long-term survivors for whom recent
follow-up was available were in NYHA Class 1.
Primary Versus Two-Stage Repair
A small number of centers continue to support an approach
of initial palliation with a modified Blalock shunt in the first
6 to 12 months of life, followed by subsequent repair.11,12
Although some centers have described a low mortality for
shunt procedures, a number of excellent centers have de-
scribed significant risks. For example, in a 1997 report by
Gladman et al,17 overall survival for patients who had a two-
stage approach at the Hospital for Sick Children in Toronto
was 90%, while in patients who had primary repair the sur-
vival was 97%.
Transatrial Versus Transventricular Repair
A number of studies have presented excellent results using a
primarily transatrial approach.12,18 Nevertheless, it is ac-
cepted that the truly hypoplastic pulmonary annulus must be
enlarged with a transannular patch when the degree of hyp-
oplasia is severe. There are important technical factors that
determine how much right ventricular function is likely to be
affected by a ventricular approach, as listed above. Funda-
mentally, the transventricular approach allows enlargement
of the infundibulum through a patch plasty approach, while
the transatrial approach requires more extensive muscular
excision to “bore out” the infundibulum from within, poten-
tially leading to a greater degree of endocardial fibrosis and
scarring.
Late Pulmonary Valve Replacement
The indications for late pulmonary valve replacement are
continuing to be refined. The ability of magnetic resonance
imaging to accurately define right ventricular volume as well
as regurgitant fraction has been an important advance. Geva
et al19 suggest that a right ventricular end diastolic volume
index of greater than 160 to 165 mL/m2 in the setting of a
regurgitant fraction of greater than 25% should be consid-
ered an indication for valve replacement. The continuing
refinement of percutaneous pulmonary valve replacement
where clinical trials are currently underway of commercially
produced stent-mounted valves may lower the threshold for
R.A. Jonas
pulmonary valve replacement in the native right ventricular
outflow tract. Currently, such valves are limited to placement
in regurgitant conduits.
The Role of the Monocusp Valve
Although some centers have expressed enthusiasm for place-
ment of a monocusp valve at the time of initial tetralogy
repair follow-up, studies have suggested that the function of
such “valves” is transient at best. For example, Gundry et al20
described 19 patients who had monocusp valves placed and
were assessed up to 24 months postoperatively. Although 16
of 19 patients had component monocusp valves immediately
postoperatively, by 24 months only one of seven patients had
a competent valve. Similar findings were described by Bigras
et al.21
Conclusion
Repair of tetralogy of Fallot with pulmonary stenosis is an
important benchmark for the congenital cardiac team. Accu-
racy of diagnosis, surgical decision making, and technical
skills, as well as postoperative management team work, all
play a role in achieving excellent outcomes. Fortunately, the
long-term outlook for the majority of patients with tetralogy
of Fallot and pulmonary stenosis today is excellent.
References
1. Shimazaki Y, Blackstone EH, Kirklin JW, et al: The dimensions of the
right ventricular outflow tract and pulmonary arteries in tetralogy of
Fallot and pulmonary stenosis. J Thorac Cardiovasc Surg 103:692-705,
1992
2. Fellows KE, Smith J, Keane JF: Preoperative angiocardiography in in-
fants with tetrad of Fallot. Review of 36 cases. Am J Cardiol 47:1279-
1285, 1981
3. Dabizzi RP, Caprioli G, Aiazzi L, et al: Distribution and anomalies of
coronary arteries in tetralogy of Fallot. Circulation 61:95-102, 1980
4. Fellows KE, Freed MD, Keane JF, et al: Results of routine preoperative
coronary angiography in tetralogy of Fallot. Circulation 51:561-566,
1975
5. Lillehei CW, Varco RL, Cohen M, et al: 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 41:4-21, 1986
6. de Leval MR, McKay R, Jones M, et al: Modified Blalock-Taussig shunt.
Use of subclavian artery orifice as flow regulator in prosthetic systemic-
pulmonary artery shunts. J Thorac Cardiovasc Surg 81:112-119, 1981
7. Jonas RA: Comprehensive Surgical Management of Congenital Heart
Disease. London; Arnold; 2004, pp 1-12
8. Rabinovitch M, Herrera-deLeon V, Castaneda AR, et al: Growth and
development of the pulmonary vascular bed in patients with tetralogy
of Fallot with or without pulmonary atresia. Circulation 64:1234-1249,
1981
9. Borow KM, Green LH, Castaneda AR, et al: Left ventricular function
after repair of tetralogy of Fallot and its relationship to age at surgery.
Circulation 61:1150-1158, 1980
10. Walsh EP, Rockenmacher S, Keane JF, et al: Late results in patients with
tetralogy of Fallot repaired during infancy. Circulation 77:1062-1067,
1988
11. Karl TR, Sano S, Pornviliwan S, et al: Tetralogy of Fallot: Favorable
outcome of nonneonatal transatrial, transpulmonary repair. Ann Tho-
rac Surg 54:903-907, 1992
Early primary repair of tetralogy of Fallot
12. Fraser CD, McKenzie ED, Cooley DA: Tetralogy of Fallot: Surgical man-
agement individualized to the patient. Ann Thorac Surg 71:1556-1561,
2001
13. Kirklin JK, Blackstone EH, Jonas RA, et al: Morphologic and surgical
determinants of outcome events after repair of tetralogy of Fallot with
pulmonary stenosis: A two institution study. J Thorac Cardiovasc Surg
103:706-723, 1992
14. Jonas RA: Comprehensive Surgical Management of Congenital Heart
Disease. London; Arnold; 2004, p 251
15. Hennein HA, Mosca RS, Urcelay G, et al: Intermediate results after
complete repair of tetralogy of Fallot in neonates. J Thorac Cardiovasc
Surg 109:332-344, 1995
16. Bacha EA, Scheule AM, Zurakowski D, et al: Long-term results after
early primary repair of tetralogy of Fallot. J Thorac Cardiovasc Surg
122:154-161, 2001
47
17. Gladman G, McCrindle BW, Williams WG, et al: The modified Blalock-
Taussig shunt: Clinical impact and morbidity in Fallot’s tetralogy in the
current era. J Thorac Cardiovasc Surg 115:25-30, 1997
18. Hirsch JC, Mosca RS, Bove EL: Complete repair of tetralogy of Fallot in
the neonate: Results in the modern era. Ann Surg 232:508-514, 2000
19. Geva T: Indications and timing of pulmonary valve replacement after
tetralogy of Fallot repair. Semin Thorac Cardiovasc Surg Pediatr Card
Surg Ann 9:11-22, 2006
20. Gundry SR, Razzouk AJ, Boskind JF, et al: Fate of the pericardial mo-
nocusp pulmonary valve for right ventricular outflow tract reconstruc-
tion. J Thorac Cardiovasc Surg 107:908-912, 1994
21. Bigras JL, Boutin C, McCrindle BW, et al: Short-term effect of mono-
cuspid valves of pulmonary insufficiency and clinical outcome after
surgical repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 112:33-
37, 1996