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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Repair of tetralogy of Fallot &#40;TOF&#41; is one of the greatest achievements of congenital cardiac surgery&#46; The first surgical palliation was in 1944 and repair was introduced 10 years later&#44; more than 60 years ago&#44; before the first coronary artery bypass surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;3</span></a> This was followed by remarkable advances in the many areas that contribute to good surgical results&#44; which have enabled many patients not only to survive&#44; but to live largely normal family and working lives&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In an internal review at our institution 10 years ago&#44; 85&#37; of TOF patients with ages ranging from 18 to 63 years&#44; most of them operated long before&#44; had good functional capacity&#46; This is corroborated by the paper by Cruz et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> in which 90&#37; of patients are reported as asymptomatic&#46; Our review included several women who became mothers&#46; One of them is now a physician working as a general practitioner in the Portuguese hinterland&#46; I myself worked as a fellow in Chicago with a resident pediatric cardiologist who had undergone TOF repair&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Even so&#44; not all patients do well&#46; The paper by Cruz et al&#46; draws our attention again to the problems that may arise in relation with a dilated ascending aorta &#40;AAo&#41;&#46; Cardiologists in charge of patients after TOF repair should be aware of this possibility&#59; they actually need to be aware of quite a significant number of possible negative developments&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Indeed&#44; personal attention to each individual person remains a major aspect of clinical medicine&#46; Regardless of how important averages&#44; standard deviations and percentiles may be&#44; the subject of medical practice is still that person sitting in front me with his&#47;her own and unique condition&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">He needs that I understand what he suffers from&#44; even if he is not able to provide me with a full medical history&#46; I will recall some of the problems he may have&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Did he start by having palliative surgery&#44; or did he have a primary repair&#63; &#40;You may get help by looking at his chest&#46; Does he have a lateral thoracotomy scar&#63; Or a sternotomy scar&#44; or both&#63; This might be indicative&#44; although current central palliative shunts are often done via a sternotomy&#41;&#46; If he had a Blalock-Taussig anastomosis&#44; was this a modified or a classic anastomosis&#63; Was the subclavian artery sacrificed&#63; Can blood pressure be measured reliably in the ipsilateral arm&#63; Did he suffer from complications of palliation&#63; Could he have diaphragmatic palsy due to phrenic nerve injury&#63; Could he have pulmonary artery branch stenosis&#63; Did he have&#44; or does he need a ventilation&#47;perfusion scan&#63; What type of corrective surgery was performed&#63; Did he have a transannular patch&#63; or a conduit&#63; or an infundibular resection with pulmonary valvotomy&#63; Does he have a right ventricular outflow aneurysm&#63; Did he have surgical atrioventricular block&#63; Does he have&#44; or need&#44; a pacemaker&#63; Did he have major collaterals&#63; Were they ligated&#63; embolized&#63; Does he have a residual left-to-right shunt&#63; a residual collateral&#63; a residual surgical anastomosis&#63; a residual ventricular septal defect &#40;VSD&#41;&#63; Is there pulmonary valve regurgitation&#63; Is the right ventricle dilated&#63; How severely&#63; Is he in danger of ventricular arrhythmias&#63; Does he need a pulmonary valve replacement&#63; Should this be done surgically or percutaneously&#63; Has he had regular echocardiographic studies&#63; Holter recordings&#63; exercise tolerance tests&#63; Should he undergo cardiovascular magnetic resonance imaging &#40;MRI&#41;&#63; or computed tomography&#63; To look at what&#63;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The purpose of these comments is not to address each and all of these questions&#46; But both the pediatric cardiologist in charge of operated congenital patients and the adult cardiologist with expertise in congenital heart disease need to be familiar with all these issues&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the paper by Cruz et al&#46; the authors address again the possibility of dilatation of the AAo becoming problematic with time&#46; AAo dilatation in TOF is a well-known occurrence&#46; As Cruz et al&#46; point out&#44; it has been postulated that longstanding volume overload of the aorta before TOF repair may be responsible for aortic dilatation&#46; They also mention that a wide range of prevalence of aortic dilatation in TOF has been published&#46; The morphologic features of TOF&#44; which are present since intrauterine life&#44; stimulate aortic development beyond normal&#44; as all right-to-left blood shunting at the ventricular level increases aortic blood flow and promotes aortic growth&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">According to the findings of Cruz et al&#46;&#44; this appears to be more likely to happen in men who underwent repair later in life&#44; and may eventually lead to aortic valve regurgitation&#46; Left ventricular mass index is the only factor independently associated with AAo dilatation in this study&#46; Aortic valve regurgitation is more common in patients with pulmonary valve atresia with VSD&#44; a patient group the authors decided not to include&#46; This decision could be viewed as arguable&#44; since pulmonary valve atresia with VSD and TOF may be no more than different degrees of the same basic disease&#46; The condition is in fact also often called &#8216;TOF with pulmonary atresia&#8217;&#46; In addition&#44; it is not certain that groups 1 and 2 &#40;without and with AAo dilatation&#44; respectively&#41; in Cruz et al&#46;&#8217;s study represent anything more than variations in severity&#44; or time-related differences between patients belonging to the same group&#46; Nevertheless&#44; the study has the merit of stressing the importance of progressive AAo dilatation and the risk of Ao valve incompetence&#46; It is reassuring to note that aortic dissection is rare&#46; It is difficult to ascertain whether the possible intrinsic histological abnormalities of the aortic wall&#44; to which the authors refer&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> are a cause or a consequence of the disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">As the authors point out&#44; there could be some institutional bias in their study resulting from its single-center nature&#46; Still&#44; this large prospective cardiovascular MRI study is relevant and suggests that the new imaging techniques are becoming widespread and an ever more useful tool&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Cruz et al&#46; consider that AAo dilatation following TOF repair is best assessed by cardiovascular MRI&#44; due to its accuracy and lack of ionizing radiation&#44; and they suggest that this should be done at three-year intervals&#46; This is perhaps one of the most interesting take-home messages of this paper&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In dealing with the most common form of cyanotic congenital heart disease it is essential to remember that most patients with TOF repair do well&#46; But&#44; as in many other fields of medicine&#44; physicians need to be aware of the negative effects that may develop as a result from sequelae&#44; residuae and complications&#44; or simply as a late consequence of the nature of the original disease&#46; Only by doing so will they be able to provide the personal and compassionate attention that each individual patient expects from his physician&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
Tetralogy of Fallot after repair: A heritage of modern cardiac surgery
Tetralogia de Fallot após reparação: uma herança da cirurgia cardíaca moderna
Fernando A. Maymone-Martins
Past President and Honorary Member, The Association for European Paediatric and Congenital Cardiology
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Repair of tetralogy of Fallot &#40;TOF&#41; is one of the greatest achievements of congenital cardiac surgery&#46; The first surgical palliation was in 1944 and repair was introduced 10 years later&#44; more than 60 years ago&#44; before the first coronary artery bypass surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#8211;3</span></a> This was followed by remarkable advances in the many areas that contribute to good surgical results&#44; which have enabled many patients not only to survive&#44; but to live largely normal family and working lives&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In an internal review at our institution 10 years ago&#44; 85&#37; of TOF patients with ages ranging from 18 to 63 years&#44; most of them operated long before&#44; had good functional capacity&#46; This is corroborated by the paper by Cruz et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> in which 90&#37; of patients are reported as asymptomatic&#46; Our review included several women who became mothers&#46; One of them is now a physician working as a general practitioner in the Portuguese hinterland&#46; I myself worked as a fellow in Chicago with a resident pediatric cardiologist who had undergone TOF repair&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Even so&#44; not all patients do well&#46; The paper by Cruz et al&#46; draws our attention again to the problems that may arise in relation with a dilated ascending aorta &#40;AAo&#41;&#46; Cardiologists in charge of patients after TOF repair should be aware of this possibility&#59; they actually need to be aware of quite a significant number of possible negative developments&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Indeed&#44; personal attention to each individual person remains a major aspect of clinical medicine&#46; Regardless of how important averages&#44; standard deviations and percentiles may be&#44; the subject of medical practice is still that person sitting in front me with his&#47;her own and unique condition&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">He needs that I understand what he suffers from&#44; even if he is not able to provide me with a full medical history&#46; I will recall some of the problems he may have&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Did he start by having palliative surgery&#44; or did he have a primary repair&#63; &#40;You may get help by looking at his chest&#46; Does he have a lateral thoracotomy scar&#63; Or a sternotomy scar&#44; or both&#63; This might be indicative&#44; although current central palliative shunts are often done via a sternotomy&#41;&#46; If he had a Blalock-Taussig anastomosis&#44; was this a modified or a classic anastomosis&#63; Was the subclavian artery sacrificed&#63; Can blood pressure be measured reliably in the ipsilateral arm&#63; Did he suffer from complications of palliation&#63; Could he have diaphragmatic palsy due to phrenic nerve injury&#63; Could he have pulmonary artery branch stenosis&#63; Did he have&#44; or does he need a ventilation&#47;perfusion scan&#63; What type of corrective surgery was performed&#63; Did he have a transannular patch&#63; or a conduit&#63; or an infundibular resection with pulmonary valvotomy&#63; Does he have a right ventricular outflow aneurysm&#63; Did he have surgical atrioventricular block&#63; Does he have&#44; or need&#44; a pacemaker&#63; Did he have major collaterals&#63; Were they ligated&#63; embolized&#63; Does he have a residual left-to-right shunt&#63; a residual collateral&#63; a residual surgical anastomosis&#63; a residual ventricular septal defect &#40;VSD&#41;&#63; Is there pulmonary valve regurgitation&#63; Is the right ventricle dilated&#63; How severely&#63; Is he in danger of ventricular arrhythmias&#63; Does he need a pulmonary valve replacement&#63; Should this be done surgically or percutaneously&#63; Has he had regular echocardiographic studies&#63; Holter recordings&#63; exercise tolerance tests&#63; Should he undergo cardiovascular magnetic resonance imaging &#40;MRI&#41;&#63; or computed tomography&#63; To look at what&#63;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The purpose of these comments is not to address each and all of these questions&#46; But both the pediatric cardiologist in charge of operated congenital patients and the adult cardiologist with expertise in congenital heart disease need to be familiar with all these issues&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the paper by Cruz et al&#46; the authors address again the possibility of dilatation of the AAo becoming problematic with time&#46; AAo dilatation in TOF is a well-known occurrence&#46; As Cruz et al&#46; point out&#44; it has been postulated that longstanding volume overload of the aorta before TOF repair may be responsible for aortic dilatation&#46; They also mention that a wide range of prevalence of aortic dilatation in TOF has been published&#46; The morphologic features of TOF&#44; which are present since intrauterine life&#44; stimulate aortic development beyond normal&#44; as all right-to-left blood shunting at the ventricular level increases aortic blood flow and promotes aortic growth&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">According to the findings of Cruz et al&#46;&#44; this appears to be more likely to happen in men who underwent repair later in life&#44; and may eventually lead to aortic valve regurgitation&#46; Left ventricular mass index is the only factor independently associated with AAo dilatation in this study&#46; Aortic valve regurgitation is more common in patients with pulmonary valve atresia with VSD&#44; a patient group the authors decided not to include&#46; This decision could be viewed as arguable&#44; since pulmonary valve atresia with VSD and TOF may be no more than different degrees of the same basic disease&#46; The condition is in fact also often called &#8216;TOF with pulmonary atresia&#8217;&#46; In addition&#44; it is not certain that groups 1 and 2 &#40;without and with AAo dilatation&#44; respectively&#41; in Cruz et al&#46;&#8217;s study represent anything more than variations in severity&#44; or time-related differences between patients belonging to the same group&#46; Nevertheless&#44; the study has the merit of stressing the importance of progressive AAo dilatation and the risk of Ao valve incompetence&#46; It is reassuring to note that aortic dissection is rare&#46; It is difficult to ascertain whether the possible intrinsic histological abnormalities of the aortic wall&#44; to which the authors refer&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> are a cause or a consequence of the disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">As the authors point out&#44; there could be some institutional bias in their study resulting from its single-center nature&#46; Still&#44; this large prospective cardiovascular MRI study is relevant and suggests that the new imaging techniques are becoming widespread and an ever more useful tool&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Cruz et al&#46; consider that AAo dilatation following TOF repair is best assessed by cardiovascular MRI&#44; due to its accuracy and lack of ionizing radiation&#44; and they suggest that this should be done at three-year intervals&#46; This is perhaps one of the most interesting take-home messages of this paper&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In dealing with the most common form of cyanotic congenital heart disease it is essential to remember that most patients with TOF repair do well&#46; But&#44; as in many other fields of medicine&#44; physicians need to be aware of the negative effects that may develop as a result from sequelae&#44; residuae and complications&#44; or simply as a late consequence of the nature of the original disease&#46; Only by doing so will they be able to provide the personal and compassionate attention that each individual patient expects from his physician&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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