Long-term results after primary one-stage repair of transposition of the great arteries and aortic arch obstruction

OBJECTIVES: The study was designed to evaluate perioperative and late results after primary, single-stage arterial switch operation (ASO) associated with aortic arch obstruction repair. Outcome of patients with more than five years of follow-up were analyzed. BACKGROUND: The treatment of patients with transposition of the great arteries, or other forms of ventriculoarterial discordance suitable for an ASO, with coexisting arch obstruction is a difficult task. Single-stage repair has become the treatment of choice at many institutions, but large series with long-term results are seldom reported. METHODS: Between 1990 and 1998, a primary operation including aortic arch repair through a midline sternotomy was performed in 38 patients. The relief of arch obstruction was accomplished during a period of hypothermic circulatory arrest, employing a wide pericardial patch to enlarge the inner curvature of the entire arch in most patients. RESULTS: There were nine (24%) hospital deaths. None could be directly related to aortic arch repair, but additional risk factors for an ASO were common (right ventricular hypoplasia, complex coronary anatomy, uncommon relationship between the great vessels or severe pulmonary hypertension). There were no late deaths. Four patients required cardiac reoperation, whereas three underwent successful treatment of recurrent coarctation with balloon angioplasty. CONCLUSIONS: Infants with ventriculoarterial discordance and aortic arch obstruction represent a high-risk subgroup of candidates for an ASO. Despite a non-negligible operative mortality, single-stage primary repair represents the treatment of choice, and follow-up of operative survivors is favorable. Pericardial patch enlargement is a reliable technique for arch obstruction repair

An observational study of CoSeal for the prevention of adhesions in pediatric cardiac surgery.

We sought to evaluate the utility and safety of CoSeal Surgical Sealant (Baxter) for the prevention of cardiac adhesions in children. Seven cardiac surgery centers in Europe recruited consecutive pediatric patients requiring primary sternotomy for staged repair of congenital heart defects. Exclusion criteria included immune system disorder, unplanned reoperation, or reoperation within three months of primary repair. CoSeal was sprayed onto the surface of the heart at the end of surgery. Evaluation of adhesions took place at first reoperation. Data on safety, duration of surgery, and ease of CoSeal use were also collected. Seventy-nine pediatric patients were recruited between February 2005 and September 2007. Of these, 76 underwent major surgery to repair a wide range of congenital heart defects. Thirty-six patients underwent reoperation >3 months after primary repair, and were included in the efficacy analysis. Mean adhesions score was 8.3 (standard deviation [S.D.] 2.4; range 7-16). Six adverse events (5 serious) were possibly/definitely attributed to CoSeal. CoSeal's ease of use at primary operation was graded by surgeons as 12.1 mm (S.D. 9.8) on a visual analog scale of 0 ('very easy') to 100 mm ('very difficult'). Results of this prospective uncontrolled trial justify further investigation in a randomized, controlled trial

Late results after left-sided cardiac valve replacement in children.

Selection of types of cardiac valve substitutes for children remains controversial. Between 1976 and 1984, 166 children, 15 years of age or younger, underwent aortic (N = 53) or mitral valve replacement (N = 90) or both (N = 23). Biological prostheses were used in 84 patients and mechanical prostheses in 71; both a mitral bioprosthesis and an aortic mechanical valve were used in 11 patients. The overall early mortality was 9\%. Mean follow-up intervals were 4.1 years for the bioprosthesis group, 3.3 years for the mechanical valve group, and 3.5 years for the group receiving both. The 7 year survival rates (+/- standard error) were 63\% +/- 6\% in the bioprosthesis group and 70\% +/- 7\% in the mechanical valve group (p = NS). After aortic valve replacement the 7 year survival rates were 66\% +/- 14\% (bioprosthesis group) and 77\% +/- 9\% (mechanical valve group) (p = NS); after mitral valve replacement the rates were 65\% +/- 7\% (bioprosthesis group) and 54\% +/- 17\% (mechanical valve group) (p = NS). The incidence of thromboembolic events was 0.6\% +/- 0.4\% per patient-year in the bioprosthesis group (none after aortic valve replacement, 0.8\% +/- 0.6\% per patient-year after mitral valve replacement) and 1.4\% +/- 0.8\% per patient-year in the mechanical valve group (0.7\% +/- 0.7\% per patient-year after aortic valve replacement, 4.0\% +/- 2.8\% per patient-year after mitral valve replacement) (p = NS). The linearized rates of reoperation were 10.4\% +/- 1.8\% per patient-year (bioprosthesis group) and 2.3\% +/- 1.0\% per patient-year (mechanical valve group) (p less than 0.001). The 7 year probability rates of freedom from all valve-related complications were 43\% +/- 6\% in the bioprosthesis group and 86\% +/- 4\% in the mechanical valve group (p less than 0.001). In the aortic position, a mechanical adult-sized prosthesis can always be implanted, and satisfactory long-term results can be anticipated. In the systemic atrioventricular position, the results are less than satisfactory with either type of prosthesis; every effort should be made to preserve the natural valve of the child