Open Access Case

Report DOI: 10.7759/cureus.50442

Rehabilitation in a Pediatric Patient Who

Underwent Correction Surgery for Tetralogy of
Received 11/08/2023
Fallot: A Case Report
Review began 11/29/2023
Review ended 12/13/2023 Sanjivani S. Bangde 1 , Vaishnavi M. Thakre 1 , Tejaswini Fating 1 , Aditi Dandekar 1
Published 12/13/2023

© Copyright 2023 1. Community Health Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and
Bangde et al. This is an open access article Research, Wardha, IND
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
Corresponding author: Sanjivani S. Bangde, bangdesanjivani24@gmail.com
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.

Abstract
Tetralogy of Fallot (TOF) is a congenital heart defect characterized by four distinct heart abnormalities,
which include an overriding aorta (where the aorta crosses both ventricles), a ventricular septal defect
(VSD), right ventricular hypertrophy (the right ventricle muscle is thickened), and pulmonary stenosis (the
pulmonary valve and artery are narrowed). Individuals suffering from TOF may exhibit pinkness, cyanosis at
baseline, or episodes of hypercyanosis. The pathoanatomy of the TOF allows blood from the pulmonary and
systemic circulations to mix. Cyanosis is caused by the addition of deoxygenated blood from a shunt that
runs from right to left to the systemic circulation. In this case report, we present a five-year-old female
patient with a known case of TOF. The results were recorded using the Pediatric Quality of Life (PedsQL)
Questionnaire, New York Heart Association (NYHA) Dyspnoea Scale, Wong-Baker Faces Pain Rating Scale,
and arterial blood gas analysis. Therapy goals were to improve overall functional ability, to remove
secretions from airway, and the return of acceptable cardiovascular function. This case report focuses on the
success of the cardiorespiratory rehabilitation program based on the patient's current state of health. The
outcome parameters confirm that patients can experience improved functional recovery.

Categories: Cardiac/Thoracic/Vascular Surgery, Physical Medicine & Rehabilitation, Therapeutics

Keywords: congenital heart disease, thoracic expansion, physiotherapy, ventricular septal defect, tetralogy of fallot

Introduction
Congenital heart conditions can be caused by abnormal cardiac structural alterations that start early in
pregnancy and persist through delivery. They affect roughly one in 125 babies, making them the most
prevalent birth abnormalities [1]. Tetralogy of Fallot (TOF), a congenital heart defect, is characterized by
four different heart abnormalities: pulmonary stenosis (narrowing of the pulmonary valve and artery),
ventricular septal defect (VSD), right ventricular hypertrophy (thickening of the right ventricle (RV) muscle),
and overriding aorta (thickening of the RV wall) [2]. Cyanosis can result from this disorder, which can cause
blood to be deficient in oxygen flowing from the heart to the rest of the body. Surgery is frequently used to
enhance blood flow and reduce symptoms [3]. TOF reveals aberrant septo-parietal trabeculations and
anterior cephalad distortion of the myocardial intraventricular septum, which results in sub-pulmonary
infundibular stenosis [4]. Individuals suffering from TOF may exhibit pinkness, cyanosis at baseline, or
episodes of hypercyanosis.

The degree of pulmonary stenosis and obstruction of the right ventricular outflow tract (RVOT) determine
their physiological functionality. With additional hypertrophy of the RV infundibular muscles, the risk of
hypercyanotic episodes increases with time [5]. The pathoanatomy of the TOF allows blood from the
pulmonary and systemic circulations to mix [6]. Cyanosis occurs due to a right-to-left shunt that introduces
oxygen-deprived blood into the systemic circulation. Near the VSD, this mixing frequently takes place [7].
The right-to-left shunt across the VSD is controlled by the relative pressure gradient between the RV and left
ventricle (LV). The right ventricular outflow tract obstruction (RVOTO) degree determines the amount of
pulmonary blood flow or the RV stroke volume [8]. Surgical intervention is available as a treatment option
for TOF shortly after the infant is born. The pulmonary valve is replaced or the RVOTO is widened during
surgery. A closure patch is commonly used to close the opening between both ventricles. The body's overall
blood flow, including to the lungs, will be enhanced by these actions [9]. TOF is identified shortly after birth.
Infants might have blue skin. While auscultating, a doctor may hear an unusual whooshing sound, often
known as a heart murmur [10]. Diagnostic tests for this condition include pulse oximetry, echocardiogram,
electrocardiogram, chest X-ray, and cardiac catheterization [11]. To prevent postoperative complications,
physiotherapy rehabilitation is commonly utilized. Various physiotherapeutic methods, like postural
drainage, positioning, thoracic expansion, and breathing exercises, can help in clearing secretions from the
lungs, improve ventilation, and decrease the work of breathing. It also enhances the well-being and the
patient's quality of life.

Case Presentation

How to cite this article

Bangde S S, Thakre V M, Fating T, et al. (December 13, 2023) Rehabilitation in a Pediatric Patient Who Underwent Correction Surgery for
Tetralogy of Fallot: A Case Report. Cureus 15(12): e50442. DOI 10.7759/cureus.50442
 We present the case of a five-year-old female patient diagnosed with TOF with hypoplastic pulmonary
artery stenosis that complained of breathlessness and easy fatigability while doing any activity.
Breathlessness was gradual in onset and progressive in nature, which is relieved upon rest and was graded 3
per the New York Heart Association (NYHA) Dyspnoea Scale. She also complains of frequent bluish
discoloration of nails and periphery since two months of age. She was admitted in 2021 for an episode of
fever, cough, and a cold in a pediatric ward. As her symptoms subsided, the patient was transferred to the
cardiac vascular and thoracic surgery (CVTS) ward for the surgical management of TOF. The patient
underwent a Blalock-Thomas-Taussig (BT) shunt on October 10, 2021. Since then, she has been on regular
follow-up and has come to the hospital for further treatment of her TOF. Investigations like chest X-rays and
2D echo were done. Due to a large subaortic VSD with severe valvular infundibulum and supravalvular
pulmonary stenosis, the patient underwent a transannular RVOT patch on October 6, 2023. The patient's
primary complaint post surgery was pain at the suture site while breathing, breathlessness, and easy fatigue
with limited activities. The pain was gradual in onset, stabbing in nature. Therapy for physical rehabilitation
began the day after the procedure.

Clinical examination
Consent was obtained from the patient's parents before the beginning of the clinical assessment. On general
examination, the patient was conscious, oriented, and cooperative. The patient was afebrile to touch, was
hemodynamically stable, and had a mesomorphic build. On inspection, the patient was observed in a sitting
position with bilaterally equal chest expansion. The bandage was seen over the sternum from a median
sternotomy incision. On palpation, the trachea was centrally placed, and tenderness was present over and
around the incision. Dull note was heard on percussion over the upper and lower zones of the lung field. The
apex heartbeat was found at the intercostal space, midclavicular line. On auscultation, there were bilateral
crepitation and a decrease in air entry in the upper and lower lung. Laboratory evaluations
demonstrated that most of the red blood cells in the peripheral smear are normocytic and normochromic and
there is only a little anisopoikilocytosis with a few microcyte and pencil cells. Antigen-presenting cells are
142000 cells/mm3, according to a cell counter, and there are no hemoparasites visible. Platelets are
decreased on smear. The chest X-ray is shown in Figure 1 and Figure 2 for residual VSD, dilated RV, and mild
pulmonary stenosis with a peak gradient (PG) of 20 mmHg. A thin pericardial effusion was seen.

2023 Bangde et al. Cureus 15(12): e50442. DOI 10.7759/cureus.50442 2 of 9

 FIGURE 1: Preoperative chest radiograph: posteroanterior view
The circle represents a boot-shaped heart with hyperlucent lungs

2023 Bangde et al. Cureus 15(12): e50442. DOI 10.7759/cureus.50442 3 of 9

 FIGURE 2: Postoperative chest radiograph
Square represents chest leads and cardiomegaly

Timeline
In October 2023, the patient was admitted to the pediatric ward. The timeline from previous surgery to
recent admission and discharge is given in Table 1.

Timeline

Previous surgery date 11/10/2021

Admission sate 4/10/2023

Surgery date 6/10/2023

Physical therapy rehabilitation date 8/10/2023

Discharge date 14/10/2023

TABLE 1: Timeline of the patient

Therapeutic interventions
Postoperative physiotherapy management focuses on improving breathing patterns, removing secretions,
enhancing ventilation, and avoiding physical deconditioning of the patient. Table 2 shows physiotherapy
goals and interventions for the five-year-old patient with TOF.

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 Physiotherapeutic
Physiotherapeutic rehabilitation Dosage
goals

The function of physiotherapists in the

The following physiotherapeutic interventions must be carried out, and
patients' treatment was explained to
Patient education caregivers must be educated and counselled regarding the patient's
caregivers at the start of the
condition
intervention

Positioning the patient in such a way that it reduces the work of Every two hours, an alternate position
To enhance ventilation
breathing and improves ventilation is achieved

The patient receives sustained low-frequency rhythmic compression for

Three sets of two to five thoracic
five seconds at end of inspiration when the physiotherapist places one
To restore lung volume compressions each per day are
hand on the anterior chest wall and the other on the posterolateral
included
aspect

To mobilize secretions 1) Chest percussion: Based on auscultatory results, a percussor cup is

from terminal used to tap on different parts of the chest wall Percussion and vibration are given for
bronchioles to the two to three minutes bilaterally
central airway 2) Vibrations

To avoid physical One to two to rounds walk in corridor,

Ambulation
deconditioning two times a day

To improve lung Pursed lip breathing

function and capacity
Paper blowing method 10 repetitionx1 set, three times a day
and to enhance
oxygenation Thoracic expansion exercises

To reduce muscle
tension, improve joint
Bilateral upper limb and lower limb AROM exercises 10 repetitionsx1 set, three times a day
stability, and increase
flexibility

TABLE 2: Postoperative rehabilitation program for patients with therapeutic goals, intervention,
and regimen
AROM: active range of motion

Figure 3 and Figure 4 show the patient performing thoracic expansion exercise to increase the lung capacity
and hallway ambulation to prevent deconditioning of the whole body under the therapist's supervision.

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 FIGURE 3: Patient performing thoracic expansion as physiotherapeutic
intervention

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 FIGURE 4: Patient performing ambulation along the hallway

Outcome measures
The Pediatric Quality of Life (PedsQL) Questionnaire, New York Heart Association (NYHA) Dyspnoea Scale,
Wong-Baker Faces Pain Rating Scale (Figure 5; Table 3), and arterial blood gas (ABG) analysis are outcome
measures for this case report. Before and after physiotherapy rehabilitation, both parameters were taken.
ABG analysis report is shown in Table 4.

FIGURE 5: Wong-Baker Faces Pain Rating Scale

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 Outcome measure scale Pretreatment score Posttreatment score

1 PedsQL 49 out of 100 84 out of 100

2 NYHA Dyspnoea Scale Grade 4 Grade 2

3 Wong-Baker Pain Rating Scale Hurts even more grade 3 Hurts little bit grade 1

TABLE 3: Outcome measures

PedsQL: Pediatric Quality of Life; NYHA: New York Heart Association

ABG analysis Postoperative day 1 On the day of discharge

PH 6.589 7.374

PaCo2 (mmHg) 50.2 38.2

PaO2 (mmHg) 114.2 72.6

HCO3 (mmol/L) 27.1 23.8

SaO2 (%) 90 96

TABLE 4: ABG analysis

PaCo2: partial pressure of carbon dioxide; PaO2: partial pressure of oxygen in the arterial blood; HCO3: bicarbonate; SaO2: arterial oxygen saturation;
ABG: arterial blood gas

Discussion
According to Rhodes et al., children with congenital heart disease (CHD) usually have reduced exercise
capacity. This depression is thought to be caused by persistent hemodynamic defects and physical
inactivity-related deconditioning [12]. As suggested by Hock et al., patients with TOF have reduced
pulmonary blood flow prior to surgical correction and persistent malfunction of the RV and pulmonary valve
throughout their lives, which affects their ability to exercise and their lung volumes. By improving
pulmonary blood flow and lung volume through inhalation training, exercise capacity can be increased [13].
Goldberg et al. reported that after surgical repair, physical training can help patients exercise more
effectively, allowing them to function at or near-normal levels of activity [14]. Miller et al. found that a
supervised physical activity intervention before and after surgery for a young patient scheduled for elective
cardiovascular surgery may lead to better results [15]. Following surgery for CHD, exercise training may
increase peak VO2 in children and adolescents; therefore, it should be considered for cardiac rehabilitation
[16].

Bhatt and colleagues suggested that spirometry testing of pulmonary function may be essential to
evaluating TOF. Exercise performance may be enhanced by interventions like exercise rehabilitation
programs that enhance chronotropic response and pulmonary health. Interventional studies are required to
determine these relationships' causality and assess the effectiveness of potential treatments to increase this
population's exercise capacity [17]. Norozi et al. reported that the children who underwent complex heart
surgery demonstrated significantly reduced mean normalized maximal performance [18]. However, it was
relatively uncommon in those with pulmonary atresia and VSD than in the group with TOF [19]. In this case,
treating a patient with various physiotherapeutic interventions like breathing techniques, thoracic
expansion, ambulation, active upper limb and lower limb exercise, chest percussion, and vibration leads to
improved lung function and increased functional capacity.

Conclusions
The physiotherapeutic purpose was to improve lung function, remove secretions from the airway, improve
the functional capacity of the patient, maintain the airway and breathing, and bring back normal
cardiorespiratory function. Cardiorespiratory physiotherapeutic interventions like breathing exercises,
thoracic expansion, chest percussions and vibration, and thoracic compressions show positive results in
improving the patient's functional capacity. The application of postoperative physiotherapy strategies helps
in recovery and avoids complications. Using various outcome measures like PedsQL, ABG analysis report,
Wong-Baker Faces Pain Rating Scale, and NYHA Dyspnoea Scale was directed to record the effect of

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 physiotherapeutic treatment and improvement in the patient.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Sanjivani S. Bangde, Tejaswini Fating, Vaishnavi M. Thakre, Aditi Dandekar

Acquisition, analysis, or interpretation of data: Sanjivani S. Bangde, Tejaswini Fating, Vaishnavi M.

Thakre, Aditi Dandekar

Drafting of the manuscript: Sanjivani S. Bangde, Tejaswini Fating, Vaishnavi M. Thakre, Aditi Dandekar

Critical review of the manuscript for important intellectual content: Sanjivani S. Bangde, Tejaswini
Fating, Vaishnavi M. Thakre, Aditi Dandekar

Supervision: Sanjivani S. Bangde, Tejaswini Fating, Vaishnavi M. Thakre, Aditi Dandekar

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

References
1. O'Brien P, Marshall AC: Cardiology patient page. Tetralogy of Fallot . Circulation. 2014, 130:e26-9.
10.1161/CIRCULATIONAHA.113.005547
2. Tetralogy of Fallot (TOF). (2019). Accessed: November 4, 2023:
https://www.hopkinsmedicine.org/health/conditions-and-diseases/tetralogy-of-fallot-tof.
3. Bailliard F, Anderson RH: Tetralogy of Fallot. Orphanet J Rare Dis. 2009, 4:2. 10.1186/1750-1172-4-2
4. Khan SM, Drury NE, Stickley J, et al.: Tetralogy of Fallot: morphological variations and implications for
surgical repair. Eur J Cardiothorac Surg. 2019, 56:101-9. 10.1093/ejcts/ezy474
5. Tetralogy of Fallot. (2015). Accessed: October 20, 2023: https://pedecho.org/library/chd/tetralogy-fallot.
6. Anderson RH, Jacobs ML: The anatomy of tetralogy of Fallot with pulmonary stenosis . Cardiol Young. 2008,
18:12-21. 10.1017/S1047951108003259
7. Right-to-Left Shunt. (2023). Accessed: November 4, 2023: https://en.wikipedia.org/wiki/Right-to-left_shunt.
8. Wilson R, Ross O, Griksaitis MJ: Tetralogy of Fallot. BJA Educ. 2019, 19:362-9. 10.1016/j.bjae.2019.07.003
9. Facts About Tetralogy of Fallot. (2023). Accessed: October 20, 2023:
https://www.cdc.gov/ncbddd/heartdefects/tetralogyoffallot.html.
10. What Is Tetralogy of Fallot? . (2023). Accessed: November 4, 2023: https://www.health.com/tetralogy-of-
fallot-overview-7489235.
11. Stout KK, Daniels CJ, Aboulhosn JA, et al.: 2018 AHA/ACC guideline for the management of adults with
congenital heart disease: a report of the American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines. Circulation. 2019, 139:e698-800. 10.1161/CIR.0000000000000603
12. Rhodes J, Curran TJ, Camil L, et al.: Impact of cardiac rehabilitation on the exercise function of children
with serious congenital heart disease. Pediatrics. 2005, 116:1339-45. 10.1542/peds.2004-2697
13. Hock J, Remmele J, Oberhoffer R, Ewert P, Hager A: Breathing training improves exercise capacity in
patients with tetralogy of Fallot: a randomised trial. Heart. 2022, 108:111-6. 10.1136/heartjnl-2020-318574
14. Goldberg B, Fripp RR, Lister G, Loke J, Nicholas JA, Talner NS: Effect of physical training on exercise
performance of children following surgical repair of congenital heart disease. Pediatrics. 1981, 68:691-9.
15. Miller TL, Horgan S, Lipshultz SE: Exercise rehabilitation of pediatric patients with cardiovascular disease .
Prog Pediatr Cardiol. 2005, 20:27-37. 10.1016/j.ppedcard.2004.12.002
16. Gomes-Neto M, Saquetto MB, da Silva e Silva CM, Conceição CS, Carvalho VO: Impact of exercise training in
aerobic capacity and pulmonary function in children and adolescents after congenital heart disease surgery:
a systematic review with meta-analysis. Pediatr Cardiol. 2016, 37:217-24. 10.1007/s00246-015-1270-x
17. Bhatt SM, O'Byrne ML, McBride M, Paridon SM, Goldmuntz E, Mercer-Rosa L: Chronotropic response and
pulmonary function are associated with exercise performance in children and adolescents with repaired
tetralogy of Fallot independent of cardiac function. Congenit Heart Dis. 2020, 15:101-15.
10.32604/CHD.2020.011287
18. van der Ven JP, van den Bosch E, Bogers AJ, Helbing WA: Current outcomes and treatment of tetralogy of
Fallot. F1000Res. 2019, 8:F1000 Faculty Rev-1530. 10.12688/f1000research.17174.1
19. Norozi K, Gravenhorst V, Hobbiebrunken E, Wessel A: Normality of cardiopulmonary capacity in children
operated on to correct congenital heart defects. Arch Pediatr Adolesc Med. 2005, 159:1063-8.
10.1001/archpedi.159.11.1063

2023 Bangde et al. Cureus 15(12): e50442. DOI 10.7759/cureus.50442 9 of 9

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