Objectives: Restrictive right ventricular (RV) physiology is a major cause of low output syndrome following surgical repair of Tetralogy of Fallot (TOF). Treatment includes preload volume optimization, inotropes, inhaled nitric oxide and respiratory manipulation to enhance forward pulmonary flow. We investigated the role of atrial septostomy as salvage treatment in patients who failed these measures.
Methods: Retrospective review of all TOF operated between years 2005 – 2008 in our institution. Cases requiring atrial septostomy were identified and their postoperative notes and ICU charts were reviewed.
Results: 5 patients (mean age 3.2 ± 0.6 years) had severe low output syndrome and underwent atrial septostomy at median time 20 hours (ranged 17 to 50 hours) after surgery. All had restrictive RV physiology by echocardiography criteria and did not respond to medical treatment. 4 were performed transcatheterly and 1 surgically under cardiopulmonary bypass. Haemodynamic parameters improved following the procedure: mean systolic BP (from 57 ± 3 mmHg to 68 ± 8 mmHg), urine output (from 0.8 ± 0.3 ml/kg/h to 2.4 ± 2.1 m/kg/h), base excess (from – 9.5 ± 2.3 mmol/L to – 5.7 ± 2.1 mmol/L). It resulted in slight drop of oxygen saturation from 96 ± 3 % to 92 ± 2 %. All patients survived without neurological sequelae although they required prolonged ventilation (8.0 ± 2.1 days) and ICU stay (11.4 ± 1.1 days).
Conclusions: Atrial septostomy improves haemodynamics and is effective as salvage treatment for patients with severe low output syndrome and restrictive RV following TOF repair.