Table 3.

Complications of surgery in late presenters of TOF and methods to minimize those

Complications	Causes	How to minimise
Arrhythmias	Myocardial fibrosis Altered conduction pathways	Careful selection of anesthetic agents. Monitoring to maintain hemodynamic stability Minimize arrhythmogenic triggers Avoid excessive β adrenergic support, Pacemaker
Bleeding	Coagulopathy due to chronic hypoxia Thrombocytopenia	Folic acid supplements Adequate blood products Hemostatic drugs Preoperative/intraoperative phlebotomy in operating room Minimally invasive approaches where feasible Avoid excessive endotracheal suction, proper hemostasis
Left heart return	MAPCAs Other collateral blood flow	Moderate hypothermia with cooling to 25–26 °C
Transient/persistent myocardial dysfunction	Effects of cardiopulmonary bypass Residual defects Myocardial ischemia Pulmonary regurgitation Tricuspid regurgitation	Minimizing the duration of bypass Avoid injury to coronary arteries Meticulous closure of ventricular septal defect (VSD) Attempt a purely trans right atrial approach or Trans-RV with a minimum ventriculotomy Avoid excessive infundibular resection Avoid liberal use of TAP Preservation of pulmonary valve function (reconstruction/replacement) Preservation tricuspid/pulmonary valve function Prefer milrinone as inotropic agent Need higher filling pressures due to RV diastolic dysfunction Optimize mode of ventilation, duration of ventilation and the degree of positive end expiratory pressure (PEEP)
Pulmonary artery complications	Narrowing Kinking Thrombosis
Infective endocarditis	Prosthetic materials

MAPCA; major aortopulmonary collateral arteries, RV; right ventricle, TAP; transannular patch, VSD; ventricular septal defect, PEEP; positive end expiratory pressure