Double Switch With Hemi-Mustard and Bidirectional Glenn Procedure for “Anatomical” Repair of Corrected Transposition

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732-6 Resection of Aortic Coarctation and Modified Extended Anastomosis of Descending Aorta to Undersurface of Aortic Arch: Effect on Recurrence

Recurrent aortic coarctation is a frequent complication requiring reintervention following surgical repair of coarctation of the aorta (COA) in infants and neonates. Recoarctation is most commonly seen within the first year of life and is reported to be as high as 30%. Inadequate removal of ductal tissue, failure of growth in the primary anastomosis, and tension on the suture line have been cited as important factors using standard techniques of resection and end to end anastomosis (RETE) and subclavian flap arterioplasty (SFA). To address these issues, we have employed a technique of coarctation resection and modified extended anastomosis of the descending aorta to the undersurface of the aortic arch (RMEDA) since 1992. The salient features of this technique include extensive mobilization of the aortic arch and neck vessels, resection of the coarctation, careful trimming of all ductal tissue, and ligation of the isthmus just beyond the left subclavian artery (LSCA) allowing the distal arch to serve as an end vessel to the LSCA, and end to side anastomosis of the descending aorta to a separate incision in the undersurface of the proximal aortic arch. Fourteen neonates (median age = 12.5 days) and 5 infants (median age = 62 days) with a mean peak systolic gradient of 33±13 torr across the coarctation segment, underwent RMEDA repair of discrete COA and tubular hypolasia of the arch. Two of these infants had recurrent COA following an initial operation performed elsewhere in the neonatal period. Other procedures performed at the time repair of COA include PDA ligation (14), pulmonary artery banding (3), VSD closure (3), and ASD closure (2). Mean (±SD) aortic cross-clamp time was 19 (±6) minutes and mean intraoperative post-repair peak systolic gradient measured 2.3 (±4.7) torr. Early postoperative complications included a recurrent laryngeal nerve injury and a transient focal tonic clonic seizure. There was one early death from a subsequent surgical procedure. Eighteen late survivors at median follow-up of 12 months (range 3 to 24 monts) were free of recurrent COA by echocardiography and clinical examination and required no catheter or surgical reinterventions. In summary, the technique described herein eliminates the ductal tissue from the anastomotic site, and circumvents distal arch hypoplasia. In our experience, there has been no recurrence at midterm followup; however, further evaluation is needed to ascertain its efficacy in preventing late recurrence of coarctation

Regression of tricuspid regurgitation after two-stage arterial switch operation for failing systemic ventricle after atrial inversion operation

AbstractThe cases of five patients with previous Senning ( n = 4) or Mustard ( n = 1) operations and failing systemic ventricles in whom banding of the pulmonary artery was performed as an interim step toward an arterial switch procedure are reported. The rise in the ratio of left to right mean systolic ventricular pressure, from 0.35 before operation to 0.90 during operation and 0.80 on the first postoperative day, caused a shift of the ventricular septum from a leftward to a midline or nearly midline position. This shift was associated with a reduction of tricuspid regurgitation. At a median interval of 5.1 months after pulmonary artery banding, the mean left ventricular posterior wall thickness had increased to 8.2 mm, versus 5 mm before operation, and the mean left ventricular myocardial mass index had increased to 90 gm/m2, versus 55.6 gm/m2 before operation. After the arterial switch operation, which was performed in four patients, the tricuspid regurgitation decreased to a trivial amount ( n = 1) or disappeared completely ( n = 3). (J THORAC CARDIOVASC SURG 1996;111:342-7

Outcomes After Bidirectional Cavopulmonary Shunt in Infants Less Than 6 Months Old

AbstractObjectives. We sought to assess the results after bidirectional cavopulmonary shunt (BCPS) in infants <6 months old and to identify risk factors for poor outcome.Background. Although BCPS is a well established procedure for the palliation of patients with a single-ventricle heart, there have been very few reports of outcomes after BCPS in young infants.Methods. Since 1990, 42 infants between 0.8 and 6.0 months of age (mean [±SD] 3.7 ± 1.4) have undergone BCPS for primary (n = 16) or secondary (n = 26) palliation of tricuspid atresia (n = 13), hypoplastic left heart syndrome (n = 10) or other forms of functional single-ventricle heart (n = 19). Accessory pulmonary blood flow was included in 18 patients. Preoperative and perioperative data were gathered on retrospective review of patient records, and follow-up was conducted by means of direct physician contact or record review.Results. The overall hospital mortality rate, including that associated with reoperations, was 4.8% (2 of 42 patients). Seven patients (17%) required reoperation related to the BCPS or pulmonary blood flow in the early postoperative period: Procedures included take-down of the BCPS in four patients, with one early death, and procedures to decrease pulmonary blood flow in three patients. Age <1 month correlated significantly with early death and with early failure of the BCPS (death or take-down). Follow-up of the 37 patients discharged with intact BCPS was obtained at a mean ± SD of 14.3 ± 11.3 months postoperatively, during which time three patients died (at 6.5 ± 2.5 months). The 2-year actuarial survival rate for patients undergoing BCPS at <6 months of age was 86%. Overall freedom from death or take-down (including early and late events) was significantly lower in patients <2 months old than in those >2 months old. Four patients have undergone successful Fontan completion (18.3 ± 2.9 months postoperatively), and one patient whose BCPS was taken down subsequently underwent successful restoration of a BCPS.Conclusions. Outcomes after BCPS in young infants are comparable to those in older infants and children. However, our current preference is to defer this procedure until after 2 months of age.(J Am Coll Cardiol 1997;29:1365–70

Induced fibrillation is equally effective as crystalloid cardioplegia in the protection of fetal myocardial function

AbstractBackgroundFetal cardiac intervention represents a potential advance in the treatment of congenital cardiac lesions that increase in complexity during development. Prenatal repair of a primary defect might prevent pathologic blood-flow patterns that can result in hypoplasia of a cardiac chamber or great vessel. However, strategies to optimize fetal myocardial protection have not been studied. A biventricular working fetal heart preparation was used to evaluate the cardioprotective properties of induced fibrillation and crystalloid cardioplegia.MethodsHearts from 16 fetal lambs at 115 to 125 days’ gestation were harvested and perfused with Krebs-Henseleit solution. The descending aorta was ligated distal to the ductal insertion and the branch pulmonary arteries were ligated to simulate the parallel circulation of the fetus. Hearts were arrested with normothermic fibrillation (n = 8) or hypothermic crystalloid cardioplegia (n = 8) before reperfusion with Krebs-Henseleit solution. Baseline and postarrest myocardial function measurements were obtained from analysis of pressure-dimension relationships.ResultsFibrillatory and cardioplegic arrest were equally effective at preserving postarrest systolic function (left ventricle, 70% ± 5% vs 68% ± 15%, P = .52; right ventricle, 68% ± 4.5% vs 65% ± 4.5%, P = .26) and preventing increased diastolic stiffness (left ventricle, 32% ± 5.3% vs 38% ± 11%, P = .24; right ventricle, 25% ± 3.3% vs 27% ± 2.1%, P = .46). Myocardial water content was unchanged in hearts arrested with fibrillation and cardioplegia (84% ± 1.5% vs 83.7% ± 0.9%, P = .71).ConclusionsNormothermic fibrillation and hypothermic crystalloid cardioplegia provide equal protection of the fetal myocardium. In the setting of diminished fetal myocardial reserve and because of the limited ability to manipulate the surrounding temperature in the fetus, normothermic fibrillation may be preferable for in utero repairs of selected congenital heart defects

Accessory and anomalous atrioventricular valvar tissue causing outflow tract obstruction Surgical implications of a heterogeneous and complex problem

AbstractObjectives. The purpose of this study was to determine the effect of accessory or anomalous atrioventricular valvar apparatus on relief of outflow tract obstruction.Background. Outflow tract obstruction due to accessory tissue or anomalous attachments of the atrioventricular valvar apparatus is an unusual but well-recognized problem. In addition to obstruction, anomalous attachments of the atrioventricular valvar apparatus may interfere with procedures to relieve outflow tract obstruction or perform outflow tract reconstruction.Methods. Since 1992, we have operated on 21 patients (median age 4 years) with systemic (n = 13), pulmonary (n = 5) or bilateral (n = 3) outflow tract obstruction due to accessory atrioventricular valvar tissue and/or anomalous attachments of the subvalvar apparatus. Primary diagnoses were isolated obstruction of the systemic outflow tract or aortic arch (n = 7), transposition complexes (n = 6), previously repaired atrioventricular septal defect (n = 3), functionally single ventricle (n = 3) and ventricular septal defect with pulmonary outflow obstruction (n = 2). Outflow tract gradients ranged from 20–110 mm Hg (median 58 mm Hg).Results. Complete relief of obstruction due to atrioventricular valvar anomalies was possible in 14 patients. In six patients, the planned procedure either had to be modified or only partial relief of the obstruction was achieved. In the remaining patient, who had borderline functionally single ventricle heart disease (unbalanced atrioventricular septal defect) and systemic outflow obstruction due to accessory and functional valvar apparatus, support was withdrawn because the parents refused univentricular palliation and the valvar anomalies precluded a Ross-Konno procedure. There were two early deaths. At follow-up ranging from 1 to 66 months (median 27 months), there was one death, and there has been no recurrence of outflow tract obstruction or residual atrioventricular valvar tissue.Conclusions. Outflow tract obstruction caused by accessory or anomalous atrioventricular valvar structures is an uncommon and heterogeneous group of conditions that can have significant surgical implications. In the majority of cases, tailoring of surgical techniques will permit complete relief of obstruction. However, such anomalies may limit standard surgical options and necessitate an innovative approach in some patients