Minimally Invasive ToF Repair in Adult Patient

This video demonstrates a case report of a 33-year-old man diagnosed with Tetralogy of Fallot (ToF). He had progressive exertional dyspnea with oxygen saturation 91% and NYHA class II-III. The preoperative echocardiogram showed large ventricular septal defect (VSD) with aortic overriding and right ventricular outflow tract (RVOT) obstruction.

The operation plan was to perform total repair of ToF through the left anterior minithoracotomy. The patient was positioned with an inflatable pillow under the left chest. The anesthesiologist inserted venous cannula in the right internal jugular vein. The right femoral artery and vein preparation was made for cardiopulmonary bypass (CPB). After heparin was given, femoral arterial and venous cannulations were carried out.

A 6 cm skin incision was performed over the 4th intercostal space (ICS) from the left sternal border to the left midclavicular line, and the left pleural space was entered through the same ICS.

Before CPB was started, peak between right ventricle (RV) and left ventricle (LV) pressure ratio was measured. For better exposure, the authors encircled the ascending aorta with the tape. The cardioplegia catheter was inserted under direct vision in the aortic root. The Chitwood cross-clamp was inserted in the second ICS at the left anterior axillary line. After the aortic cross-clamp was applied, the cold blood cardioplegic solution with added potassium was administered with repeat doses at 20–30 minute intervals. At the same time, a pericardial patch was prepared.

Inferior vena cava and superior vena cava were encircled with suture loops for temporary occlusion. The right atrium was incised and the interatrial septum was inspected. Right ventriculotomy was made in the RVOT to the pulmonary valve annulus. The probe with 25 Hegar passed through the pulmonary artery from the valve. Infundibular stenosis was resected. Muscle bundles were divided. VSD was exposed and closed through the transventricular approach using the patch from glutaraldehyde treated pericardium. The patch was sutured with a continuous 4/0 polypropylene suture.

The aorta was declamped. The RVOT was closed with a pericardial patch. Cardiopulmonary bypass was discontinued without inotropic support, and the direct pressure measurements were performed. The peak RV/LV pressure ratio was measured and revealed no residual RV outflow tract obstruction. The postoperative transesophageal echocardiogram showed good results.

The duration of the operation time was 280 minutes, and CPB time was 155 minutes. The aorta was cross-clamped for 102 min. After the operation, the patient was extubated after four hours. His exudation was 145 ml per the first 12 hours. The patient was discharged from the hospital on the fourth postoperative day with no symptoms and NYHA class I.