Transcript TETRALOGY OF FALLOT: a Philippine Heart Center Review

TETRALOGY OF FALLOT
A PHILIPPINE HEART CENTER
REVIEW
RAUL D. JARA, M.D. MIKAELA NIKKOLA A. JARA, M.D.
Philippine Heart Center
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
GENERAL OBJECTIVE
This
study aims to provide a
comprehensive review of the literature
regarding the postoperative outcome of TOF
in the Philippines
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
SPECIFIC OBJECTIVES
a. To be able to determine the surgical outcome
of patients with TOF in the Philippines.
b. To be able to determine the appropriate
diagnostic examinations for postoperative TOF
patients.
c. To be able to determine the common
complications of TOF in postoperative patients.
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
METHODOLOGY
 study design – A Review
 electronic search using Health Research
Development Information (Herdin)
of the Philippine Council for Health
Research & Development (PCHRD)
 unpublished research initiatives by
fellows of Adult & Pediatric
Cardiology at PHC
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
METHODOLOGY
All retrieved researches were reviewed
by two investigators independently and
articles that contained 20 patients with TOF
were included in the review.
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 1. Recommendation strength and quality of evidence.
Quality of
Evidence
Definition
Example
A
Recommendation based on consistent and
good-quality evidence.
Good quality randomized
controlled trial (RCT) or
meta-analysis.
B
Recommendation based on inconsistent or
limited-quality evidence.
Lower quality RCTs, clinical
cohort studies, and casecontrolled studies.
C
Recommendation based on consensus, expert
opinion, or case series.
Strength of Recommendation
1
Strong recommendation.
2
Weak recommendation.
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 2. Summary of the studies reviewed.
PUBLISHED STUDIES
Principal
Author
Time Interval
of the Study
1
2
Delfin, D.P.
1975-1989
(9)
Bensurto,E.S.
1990-2000
(17)
Patients
n
Interventions
Comparisons
Adult patients with
total correction
None
Mortality
Morbidity
Technique used for
VSD and RVOT
obstruction
Clinical status
Functional class
Oxygen saturation
2D Echo findings
Crosssectional
Preoperative
Left ventricular
indices
Mortality
Morbidity
Technique used for
RVOT obstruction
Crosssectional
25
Pediatric patients with
total correction
42
Outcomes
Study
Design
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 2. Summary of the studies reviewed.
PUBLISHED STUDIES
Principal
Author
Time
Interval of
the Study
3
Daen, C.P.
1994-1996
(15)
Patients
n
Interventions
Comparisons
Patients with TOF
correction with pericardial
monocusp valve
Pericardial
monocusp valve
usage in TOF
correction
Late result of right
ventricular outflow
tract reconstruction:
ECG, Chest
radiograph, 2D Echo
with Doppler
Crosssectional
RVOT repair
technique:
Goretex
monocusp
versus nonvalve
transannular
repair
Two-dimensional
echocardiography
parameters
Functional class
Cohort
21
4
Lazaro,
M.E.R.
2000-2001
(13)
Pediatric patients with total
correction
30
Outcomes
Study
Design
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 2. Summary of the studies reviewed.
UNPUBLISHED STUDIES
5
Principal
Author
Time
Interval of
the Study
Patients
n
Interventions
Comparisons
Bote-Nuñez,
J.R.
1980-1995
Pediatric patients with
total correction able to
follow-up
None
Mortality
Presence of palliative
Procedure
Surgical approach
Technique used for VSD
and RVOT obstruction
Post-operative functional
class
Crosssectional
None
Mortality
Presence of palliative
procedure
Technique used for VSD
and RVOT obstruction
Crosssectional
49
6
Villanueva,
N.J.
1984-1987
(10)
Pediatric patients with
total correction
57
Outcomes
Study
Design
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 2. Summary of the studies reviewed.
UNPUBLISHED STUDIES
Principal
Author
Time
Interval of
the Study
7
8
Patients
n
Interventions
Comparisons
Del Campo,
J.F.M.
1992-1997
(16)
Pediatric patients with
total correction
Surgical
Approach:
Ventriculotomy
or Atriotomy
Mortality
(Arrhythmias)
Presence of palliative
procedure
Technique used for
RVOT obstruction
Bypass time and
ischemic time
Crosssectional
Perfecto,
S.M.
1996-2005
(6)
Total Correction of TOF
None
Morbidity
ECG
2D Echo with Doppler
Symptomatology
Crosssectional
165
157
Outcomes
Study
Design
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 2. Summary of the studies reviewed.
UNPUBLISHED STUDIES
Principal
Author
Time
Interval of
the Study
9
10
Patients
n
Interventions
Comparisons
Claudio,
M.T.E.
1995-2004
(5)
Pediatric patients with
total correction
Good and bad
surgical
outcome group
Claudio,
M.T.E.
1997-2002
(11)
Pediatric patients with
elective total correction
of TOF and
uncomplicated
intraoperative course
150
63
Presence or
absence of
complication
Outcomes
Study
Design
Preoperative
Echocardiographic
predictors
Cohort
Immediate
postoperative
physiologic
parameters (heart
rate, blood pressure,
temperature, etc.)
Bypass time and
Ischemic time
Cohort
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 2. Summary of the studies reviewed.
UNPUBLISHED STUDIES
Principal
Author
Time
Interval of
the Study
11
12
Patients
n
Interventions
Comparisons
Del Campo,
J.F.M..
1999-2000
(16)
Infants or children with
TOF who had hypoxic
spells
Therapeutic response
in terms of heart rate,
detection of murmur,
and saturation
RCT
20
Treatment of
tet spell with or
without
esmolol
Yap, M.C.,
2010
(18)
Patients > 15 years old
who underwent TOF
total correction
TOF correction
before or after
5 years old
Immediate
postoperative
physiologic
parameters (heart
rate, blood pressure,
temperature, etc.)
Bypass time and
Ischemic time
Cohort
29
Outcomes
Study
Design
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
30%
28%
Mortality Rate
25%
20%
15%
10%
5%
6.12%
4%
5%
3.17%
5.50%
0%
1975-1989
Delfin
1984-1987
Villanueva
1980-1995
Bote-Nuñez
1990-1997
Bensurto
1997-2002
Claudio
Figure I. Mortality rate of various studies on TOF done at PHC.
2000-2011
PHC Census
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
ONE-STAGE
APPROACH
TWO-STAGE
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
The Common Palliative Procedures in TOF
Modified BlalockTaussig
Waterston Shunt
Classic Blalock
Taussig
Potts Shunt
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
SURGICAL INTERVENTION
A. PALLIATIVE
1. Progressive cyanosis may still be noted due to:
a. worsening RVOT obstruction
b. gradual stenosis of palliative aorto
pulmonary shunts.
c. development of pulmonary hypertension
d. progressive aortic dilatation and aortic
regurgitation
Bote-Nuñez, J.R., PHC.R.053.01, Unpublished paper
Villanueva, N.J., PHC.R.039.88, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
With a range of 3 to 6 years between
palliative shunt to INTRACARDIAC REPAIR,
no significant difference has been found in
terms of morbidity and mortalities with a
two-stage compared with one-stage
approach
Villanueva, N.J., PHC.039.88. Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
GOALS OF OPERATION
WITH ONE-STAGE APPROACH
1. Close the VSD
2. Relieve the RV outflow obstruction
3. Repair any stenosis in the pulmonary
arteries
Claudio, M.T.E, (2004), crf.006.04, Unpublished paper
Nichols, David G. et al: Critical Heart Diseases in Infants & Children, Missouri,
1995, Mosby Year-Book, Inc.
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
SURGICAL INTERVENTION
A. DEFINITIVE (one stage)
1. Majority of the patients are asymptomatic
although there are long-term complications:
a. atrial tachyarrhythmias
b. ventricular tachyarrhythmias
c. progressive RV dilatation
d. progressive aortic root dilatation
Perfecto, S.M., PHC.R.060.08, Unpublished paper
Bote-Nuñez, J.R., PHC.R.053.01, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
180
atriotomy
160
ventriculotomy
Number of cases
140
120
96
100
80
60
40
20
69
43
25
0
1975-1989
Delfin
6
1980-1995
Bote-Nunez
21
1990-1997
Bensurto
Figure II. Surgical Approach in TOF Correction
12
1992-1997
Del Campo
1994-1996
Daen
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
30
25
25
Mean Age
20
15
10
7.4
5
7.72
5.37
6.12
5.6
0
1975-1989
Delfin
1984-1987 1980-1995 1990-1997 1992-1997 1996-2005
Villanueva Bote-Nuñez Bensurto Del Campo Perfecto
Figure III. Mean age and range at which TOF patients are operated
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 3. Various techniques used in relieving right outflow tract obstruction.
Bote-Nuñez
1980-1995
Villanueva
1990-1997
Infundibulectomy
17
52
Valvotomy
7
Monocusp
2
Interventions
Delfin
1975-1989
Del Campo
1992-1997
Perfecto
1996-2005
TOTAL
38
107
7
26
TAP
4
19
27
RVOT Patch
7
22
24
RVOT
Reconstruction
Rastelli external
conduit with
porcine valve
Bensurto
1990-1997
28
52
52
105
67
1
TAP: transannular patching; RVOT: right ventricular outflow tract.
102
67
1
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Table 4. Post-operative electrocardiographic findings in Filipino TOF patients .
Bote-Nuñez
1980-1995
Villanueva
1984-1987
Del Campo
1992-1997
Daen
1994-1996
Perfecto
1996-2005
TOTAL
CRBBB
20
32
67
12
53
184
Normal
22
ECG Findings
14
36
1st AV Block
24
24
LAD + CRBBB
22
22
IRBBB
7
4
11
RAD
9
9
CHB
3
3
Atrial Tachycardia
1
1
CRBBB: Complete right bundle branch block; AV Block: Atrioventricular block; IRBBB: Incomplete right bundle branch block;
RAD; Right-axis deviation; CHB: Complete Heart Block
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
RECOMMENDATION
In patients who show clinical symptoms, several
examinations may be performed:




Chest X-Ray
ECG
2-D Ech0 Doppler
Magnetic Resonance Imaging
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
RECOMMENDATION
After the first year of intervention, if the
patient is clinically asymptomatic, Doppler
studies may be performed every three years
(Grade C1)
Daen, C.P., (1997), Phil. Heart Center Journal 1996
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
POIRIER’S MODIFIED CLASSIFICATION
 patient has NO symptoms
 NO restriction in activity
 NO known residual VSD
 NO significant residual pulmonary
outflow obstruction
 NO reoperation
 NO related medications
administered at the time of follow-up
Poirier R. etal , J. Thorac Cardiovascular Surgery , 1977
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
POIRIER’S MODIFIED CLASSIFICATION
 mild symptoms with activity
 mild restriction with activity
 minimal residual VSD
residual
outflow
gradient
of
30-50
mmHg.

 a need for Digoxin or diuretics
Poirier R. etal , J. Thorac Cardiovascular Surgery, 1977
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
POIRIER’S MODIFIED CLASSIFICATION
 moderate-to-severe symptoms and
restrictions
 residual VSD with shunt greater than
1.5:1
 outflow gradient greater than 50 mmHg.
 reoperation secondary to any cause other
than bleeding in the early postoperative
period
Poirier R. etal , J. Thorac Cardiovascular Surgery, 1977
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
RECORDED PHILIPPINE STUDIES
GROUP I
-
25 patients
GROUP II -
21 patients
GROUP III -
3 patients
Daen, C.P., Phil Heart Center Journal 1996
Delfin, D.P., Phil Journal of Cardiology, 1991; 2:675-680
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
In unoperated TOF patients, a
threatening complication is the TET SPELL.
life-
These severe hypoxic episodes can be
brought about by STRESS, ANXIETY, and EXERCISE
and is a particular problem during the first two
years of life.
Del Campo, J.F..M., PHC.R.022.99 Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
Emphasis on the education of these
children and possible speech therapy should
be brought up with the parents early in life
(Grade C 1)
Yap, M.C., (2010), Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
A resting ECG with a QRS duration of 180
milliseconds or more has been considered as a
sensitive predictor of life-threatening ventricular
arrhythmias.
1 Fox, D., Cleveland Clinic Journal of Medicine, 2010; 77 (1):821-828
2 Delfin, D.P., Phil. Journal of Cardiology, 1991; 2:675-680
3 Bonow, R.O., A Textbook of Cardiovascular Med, 9th ed. Philadelphia: Elsevier, 2012
4 Gatzoulis MA, et al., Lancet 2000; 356:975-981
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
ECG and 2-D echo monitoring of right
ventricular function in all post-operative TOF
patients is recommended (Grade C 1). It has been
found
that the overall prevalence rate of
ventricular arrhythmias in post-operative Filipino
TOF patients was higher (58%) than those
reported in literature (18%).
Del Campo, J.F.M., PHC.R. 151..98, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CONCLUSION
Because of the growing number of TOF
patients who have undergone repair, it is
important to have a consistent follow-up.
It is recommended to have an annual
check-up with an EXPERT CARDIOLOGIST
whose interest is in congenital heart disease
(Grade C 1).
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CONCLUSION
RE-INTERVENTION has been recommended in
patients with:
 residual VSD with a shunt > 1.5:1
 residual pulmonary stenosis with RV systolic
pressure > 2/3 of systemic pressure
 severe pulmonary regurgitation with RV
dilatation or dysfunction
 exercise intolerance
Sommer, R.J., Circulation 2008; 117:1340-1350
Bonow, R.O, A Textbook of Cardiovascular Medicine, 9th ed.
Philadelphia: Elsevier, 2012
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CONCLUSION
As this review has aimed to discuss TOF and
its context in the Philippines, it is limited by the
fact that some of the data have overlapping
time frames and this might have affected the
results. The data regarding the topic has mostly
been descriptive thus, the recommendations
offered by the authors are also limited by the
lower level of evidence of the data gathered.
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CONCLUSION
This endeavor pioneers in guiding the Filipino
clinician regarding the management of cases of
patients with TOF and highlights possible future
directions of research studies regarding TOF.
Merci beaucoup !
(Thank you very much!!)
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
If a palliative shunt is present, once
nutritional buildup or the original reason for
deferral of extensive surgery is met,
definitive
corrective
surgery
is
recommended (Grade C1)
Bote-Nuñez, J.R., 2001, PHC.R.053.01, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMMON PALLIATIVE PROCEDURES IN TETRALOGY OF FALLOT
PROCEDURE
DESCRIPTION
Classic Blalock-Taussig Shunt
Subclavian artery-to-pulmonary artery
anastomosis (end-to-side)
Modified Blalock-Taussig Shunt
Interposition graft between subclavian artery
and ipsilateral pulmonary artery
Waterston Shunt
Ascending aorta-to-main or right pulmonary
artery (side-by-side)
No artificial material used; shunt grows with the
patient
Pott’s Shunt
Descending aorta-to-left pulmonary artery (sideby-side)
Necessitates reconstructive surgery during repair
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
POST-PERICARDIOTOMY SYNDROME was found
to be a problem in the early post-operative period.
 patient may present with a low-grade fever
and chest discomfort
 Mild leukocytosis and pleural effusion on
chest radiograph
First line of treatment - use of NSAIDs for 2-3
weeks with response within 48 hrs. (Grade B 1).
1 Bote-Nuñez, J.R., PHC.R.053.01, Unpublished paper
2 Bonow, R.O., 2012
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
The QRS prolongation reflects right
ventricular dilatation rather than an increase in
mass as seen in hypertrophy.
Perfecto, S.M., PHC.R.060.08, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
To alleviate these episodes the following
should be done:
 Positioning
 Calming the patient
 Pharmacologic treatment
Del Campo, J.F.M., (2000), PHC.R.022.99, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
Pharmacologic Treatment includes:
 Sodium Bicarbonate
 Morphine sulfate
 Oxygen inhalation (Grade B 1)
Del Campo, J.F.M., (2000), PHC.R.022.99, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CONCLUSION
RE-INTERVENTION has been recommended in
patients with:
 sustained arrhythmias
 substantial LV dysfunction or QRS > 180 ms.
 significant AR with symptoms or progressive LV
dilatation
 aortic root enlargement > 55 mm
 rapidly enlarging RVOT aneurysm
Sommer, R.J., Circulation 2008; 117:1340-1350
Bonow, R.O, A Textbook of Cardiovascular Medicine, 9th ed.
Philadelphia: Elsevier, 2012
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CAUSES OF EARLY DEATH
1. Myocardial Failure
2. Massive bleeding
(14%)
( 7%)
(3.5%)
3. Multiple embolism
4. Intra cranial Bleed
5. Intractable ventricular tachycardia
1 Villanueva N.J.
Results of Repair of TOF at the PHC, PHC.R.039.88
Unpublished Paper
2 Claudio, M.T.E.
Preoperative Echocardiographic Predictors of Outcome of
Pediatric Patients Undergoing Total Correction of TOF
CRF.006-04
3 Griffin, B.P., 2009
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CAUSES OF LATE DEATH
1. Infective Endocarditis
Bote-Nuñez, J.R.
Long Term Results after Total Repair of TOF
PHC.R:053.01
Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Previous shunt has not been noted
to have a significant independent
influence on operative mortality or
morbidity rate.
1 Bote-Nuñez 2001
PHC.R:053.01, unpublished
2 Villanueva, N.J. (1988)
PHC.R:039.88, unpublished
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Primary total correction in infants and
young children is now being advocated
(Grade B1)
1 Gamponia, R.T., January 2012
2 Claudio, M.T.E., PHC.R:049.02 (2002)
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
The fundamental abnormality with TOF is
the anterior and cephalad deviation of the
outlet septum and its misalignment with the
trabecular septum which involves the terminal
spiral portion narrowing the pathway from the
RV to the PA and enlarges the aortic root.
Sommer, R.J., Circ 2008
Bonow, R.D., 2012
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
RECOMMENDATION
Those who have lower LV end diastolic
diameter, LV end diastolic volume, and LV
mass have been shown to have significantly
more postoperative events. Patients thus who
have lower left ventricular indices should be
followed up more frequently.
Bensurto, E.S., Philip Journal of Pediatriics, 2000 Apr-Jun 49(2):117-121
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
Only one parameter had a good predictive
value with a p value of 0.010. Mcgoon’s index is
the sum of the diameters of the left and right
pulmonary arteries divided by the diameter of the
descending aorta. A Mcgoon’s ratio of 1.7 is
defined to have the best predictive value for good
outcome and a value of 0.7 or greater is
recommended at the PHC (Grade B 1)
Claudio, M.T.E.,(2002), PHC.R.049.02, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
In Filipino TOF patients who have the
financial capability to undergo cardiac MRI, it is
recommended to have at least one postoperatively to assess RV systolic function (Grade
B 2)
Claudio, M.T.E.,(2002), PHC.R.049.02, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
Patients who had their operations delayed
after the eighth year of age were found to be more
susceptible to these arrhythmias when
ventriculotomy was performed but there was no
difference found with the transatrial approach.
Del Campo, J.F.M., PHC.R. 151..98, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
In older patients, it is thus important to
emphasize the need to use atriotomy to lessen the
risk of development of ventricular arrhythmias and
SCD (Grade B 1)
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
Finding of prolonged QRS duration > 180 ms
requires re-intervention in the form of an
implanted defibrillator (Grade B 2).
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CONCLUSION
Annual examinations with a Cardiologist
trained in congenital heart disease should be
emphasized to prevent the development of
irreversible complications.
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
CONCLUSION
This endeavor pioneers in guiding the Filipino
clinician regarding the management of cases of
patients with TOF and highlights possible future
directions of research studies regarding TOF.
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
SURGICAL INTERVENTION
After definitive surgery several murmurs may be
auscultated:
a. low-pitched diastolic murmur of PR
b. Systolic ejection murmur from residual
RVOT obstruction
c. high-pitched diastolic murmur of AR
d. pansystolic murmur from a VSD leak
Delfin et al
Phil Journal of Cardiology, 1991: 2:675-680
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
RESULTS
27 Researches
5 Published
22 Unpublished
13/27 is the subject of this report,
one unpublished study was excluded because of
lack of internal validity.
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
RECOMMENDATION
PULMONARY VALVE REPLACEMENT (Grade B 1)




serial prolongation of the QRS duration
severe PR with a PR index < 0.77
pulmonary regurgitant fraction of > 40%
significant RV dilatation as suggested by index
right ventricular end diastolic volume > 150 ml/m2
 right ventricular systolic dysfunction with
ejection fraction less than 40%
Perfecto , S.M., 2008, PHC.R.060.08, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
Of the studies that recorded complications,
the percentage of TOF patients who experienced
complications was 65% of 296 patients.
1 Bote-Nuñez, J.R., PHC.R.053.01, Unpublished paper
2 Villanueva, N.J., PHC.R.039.88, Unpublished paper
3 Del Campo, J.F.M., PHC.R.151.98, Unpublished paper
TETRALOGY OF FALLOT:
A Philippine Heart Center Review
COMPLICATIONS
Postoperative TOF patient
 development of arrhythmias
 sudden cardiac death (SCD)
Perfecto, S.M., PHC.R.060.08, Unpublished paper