# Staged therapeutic surgery for progressive pulmonary regurgitation and pacemaker induced cardiomyopathy after the tetralogy of fallot repair

## TL;DR

This paper presents a successful staged treatment approach for a patient with heart failure after tetralogy of Fallot repair.

## Contribution

The novel contribution is a staged therapeutic strategy combining medication, surgery, and cardiac resynchronization therapy.

## Key findings

- Staged treatment improved symptoms in a patient with biventricular failure.
- Combination of pulmonary valve replacement and epicardial lead implantation was effective.
- Cardiac resynchronization therapy adjustment post-surgery contributed to recovery.

## Abstract

Recently, improvements in the repair of tetralogy of Fallot have increased the need for reoperation in adulthood, and it’s not rare that these reoperation candidates suffer from biventricular failure. However, there are no firm treatment guidelines, and each country, and even each facility, treats each case individually.

We report the successful staged treatment of pulmonary regurgitation and pacemaker-induced cardiomyopathy with biventricular failure in adulthood in a case of complete atrioventricular block after tetralogy of Fallot repair in childhood. We planned a staged therapeutic strategy with preoperative left ventricular volume reduction with medication, following surgical pulmonary valve replacement concomitant epicardial lead implantation on the lateral basal wall, placed just beneath the generator pocket through 3rd intercostal space. in addition to postoperative intervention with a defibrillator to adjust cardiac resynchronization therapy, resulted in improvement of symptoms.

In a patient with biventricular failure after TOF repair, a staged treatment strategy involving medication, PVR, and CRT with a combination of epicardial and intravenous leads could be a useful treatment worth trying before heart transplantation.