Anaesthetic Considerations for Patients with Repaired Tetralogy of Fallot

Preoperative Assessment

The American Heart Association recommends obtaining comprehensive echocardiography to assess RV size and function, severity of pulmonary regurgitation, residual RVOT obstruction, tricuspid regurgitation, and aortic root dilation 1, 2
The American College of Cardiology suggests reviewing recent cardiac MRI for RV volume, systolic function, and pulmonary regurgitation severity 1, 3
The European Society of Cardiology recommends analyzing 12-lead ECG for QRS duration >180 ms, which indicates increased risk of ventricular tachycardia and sudden cardiac death 4
Assess exercise tolerance objectively through formal exercise testing to evaluate functional capacity and detect exertional arrhythmias, as recommended by the American Heart Association 5

Pulmonary regurgitation is the most common problem leading to RV dilation and dysfunction, according to the American College of Cardiology 6
Residual RVOT obstruction with RV systolic pressure >50 mmHg or RV/LV pressure ratio >0.7 is a significant concern, as noted by the European Society of Cardiology 6
RV dysfunction from chronic volume overload is a common issue, as reported by the European Heart Journal 4
Tricuspid regurgitation secondary to RV dilation is a potential complication, according to the American Heart Association 1
Arrhythmias, including atrial flutter, atrial fibrillation, and ventricular tachycardia, are a significant risk, as noted by the American College of Cardiology 1

Maintain RV function by optimizing preload, reducing afterload, and supporting contractility, as recommended by the American Society of Anesthesiologists 7
Minimize increases in pulmonary vascular resistance by avoiding hypoxia, hypercarbia, acidosis, hypothermia, and excessive positive pressure ventilation, according to the European Society of Anesthesiology 7
Prevent tachycardia, which reduces diastolic filling time and coronary perfusion, as noted by the American Heart Association 1
Maintain systemic vascular resistance to prevent right-to-left shunting if residual ASD/VSD is present, as recommended by the American College of Cardiology 6

Ventricular tachycardia related to surgical scarring and haemodynamic abnormalities is a significant risk, as reported by the European Heart Journal 7, 4
Atrial arrhythmias, including atrial flutter and fibrillation, can occur due to atrial dilation, according to the American College of Cardiology 1
Have defibrillator immediately available and antiarrhythmic medications prepared, as recommended by the American Heart Association 7
Treat underlying haemodynamic causes, such as hypovolemia, hypoxia, acidosis, and electrolyte abnormalities, as noted by the European Society of Cardiology 4

Maintain normothermia to prevent increased pulmonary vascular resistance, as recommended by the American Society of Anesthesiologists 7
Ensure adequate pain control to prevent tachycardia and increased oxygen consumption, according to the European Society of Anesthesiology 7

Underestimating RV dysfunction, even in asymptomatic patients, can lead to decompensation under anaesthesia, as noted by the American College of Cardiology 1
Inadequate preoperative assessment, including recent echocardiography and knowledge of residual lesions, increases risk, according to the American Heart Association 1
Excessive positive pressure ventilation can increase RV afterload and impair venous return, as reported by the European Society of Anesthesiology 5
Ignoring QRS duration >180 ms can significantly increase arrhythmia risk and should prompt enhanced monitoring, as recommended by the European Society of Cardiology 4