Background. Based on earlier observations that the thickness of the intima and structure of the media may have an impact on the long-term patency of arterial conduits and the lack of detailed histologic studies of the right gastroepiploic and inferior epigastric arteries, we subjected both vessels to morphometric analysis with emphasis on their suitability as conduits in myocardial revascularization.Methods. The right gastroepiploic and inferior epigastric arteries were harvested from 28 unselected individuals (mean age, 73.2 years) at autopsy, and the luminal diameter and the width of the intima and media were measured.Results. At all levels of measurement (origin, 10 cm, and 15 cm), the luminal diameter of the inferior epigastric artery was significantly smaller than that of the right gastroepiploic artery (p < 0.05). The right gastroepiploic artery demonstrated only mild intimal hyperplasia. In contrast the inferior epigastric artery showed substantial intimal hyperplasia within the first 1-cm segment (mean, 134 +/- 131 mu m versus 50 +/- 49 mu m for the corresponding segment of the right gastroepiploic artery; p = 0.01). Intimal hyperplasia was only mild in the remainder of the inferior epigastric artery. In both vessels, the media was muscular with rare dispersed elastic fibers. The mean thickness of the media ranged from 380 +/- 116 mu m proximally to 155 +/- 70 mu m distally for the right gastroepiploic artery, and from 316 +/- 86 to 165 +/- 70 mu m, respectively, for the inferior epigastric artery.Conclusions. In myocardial revascularization, use of the right gastroepiploic artery may generally be preferable to use of the inferior epigastric artery. This recommendation is based on the larger luminal diameter of the right gastroepiploic artery as compared with the inferior epigastric artery, the significantly greater intimal hyperplasia in the first segment of the inferior epigastric artery, and the limitation that the inferior epigastric artery can be used only as a free graft. The rate of development of intimal hyperplasia in the right gastroepiploic artery, if used as an in situ coronary artery bypass graft, may be slow, approximating that of the right gastroepiploic artery in its natural environment. (C) 1997 by The Society of Thoracic Surgeons.

Background. Critical aortic stenosis with severe concentric left ventricular hypertrophy and endocardial fibroelastosis has a substantial mortality rate when the conventional therapeutic strategy, ie, open surgical or balloon valvuloplasty, is applied. During the last decade, univentricular repair (Norwood operation) and heart transplantation have evolved as the only viable therapeutic options. An alternative in patients with borderline hypoplastic left heart syndrome consists of performance of a Ross-Konno operation with surgical enlargement of the left ventricular cavity, a procedure that has the advantage of achieving a two-ventricle repair.Methods. Two neonates and 2 young infants with critical aortic stenosis, concentric left ventricular hypertrophy, and severe endocardial fibroelastosis, with echocardiographically documented antegrade flow in the ascending aorta, underwent a Ross-Konno operation combined with extensive endocardial and myocardial resection of the left ventricular septum and free wall. The incision in the ventricular septum was closed with a wide cuff of infundibular muscle that was harvested in continuity with the pulmonary autograft.Results. In all 4 patients, the operation resulted in normal aortic valve function, marked reductions of width of the left ventricular septum (median, 6.5 mm, versus 11 mm preoperatively) and the left ventricular posterior free wall (median, 8.5 mm, versus 15.5 mm preoperatively), and enlargement of the left ventricular end-diastolic volume (median, 12.5 cm(3), versus 6.5 cm(3) preoperatively). Three patients had an uneventful recovery, with gradual improvement of left ventricular diastolic and systolic function during the first postoperative week; 1 neonate with associated mitral regurgitation died of left ventricular failure.Conclusions. The Ross-Konno procedure with resection of endocardial fibroelastosis may be a valuable adjunct for achieving a two-ventricle repair in borderline hypoplastic left heart syndrome. The operation results in enlargement of the left ventricular stroke volume and improvement of left ventricular diastolic function; in addition, resection of endocardial fibroelastosis relieves the mechanical impairment of myocardial. function and therefore may promote the potential for left ventricular growth. (C) 1997 by The Society of Thoracic Surgeons

Intraoperative thermal coronary angiography was successfully applied in 9 patients who underwent operative correction of congenital heart defects: arterial switch operation for transposition of the great arteries (n = 5), Ross operation for valvar aortic stenosis with regurgitation (n = 3), and aortic implantation of the left coronary artery for anomalous connection of the left coronary artery to the pulmonary artery (n = 1). Intraoperative thermal coronary angiography allows early detection and surgical correction of coronary ostial obstruction. (C) 1997 by The Society of Thoracic Surgeons.

A modified technique is reported for unroofing of the intramurally coursing segment of the left main or right coronary artery with anomalous aortic origin. This technique avoids detachment and resuspension of the intercoronary commissure and thus lessens the risk of post-operative aortic valve regurgitation.

AbstractIn 3 patients with isomeric morphologically left atrial appendages, univentricular atrioventricular connection, concordant ventriculoarterial connections, bilateral superior caval veins, with the left one draining via the coronary sinus, together with absence of any communicating vein, interruption of inferior caval vein with drainage via a right-sided (n=2) or left-sided (n=l) azygos vein, the hepatic venous blood was rerouted via the large coronary sinus into the pulmonary arterial circulation. In a fourth patient with similar pathology, having interruption of the left-sided inferior caval vein with drainage to the left-sided superior caval vein via a left-sided azygos vein and a large communicating vein, the pathway from the left superior caval vein to the coronary sinus was correspondingly small. An extracardiac conduit was therefore constructed between the hepatic veins and the left pulmonary artery so as to reroute the hepatic venous blood into the pulmonary arterial circulation. At a mean follow-up of 8.5 months, all patients are clinically well and none of them have developed pulmonary arteriovenous malformations. To avoid the latter complication in Fontan physiology, especially in the setting of an interrupted inferior caval vein with drainage via the azygos vein, we believe that it is preferable to reroute the hepatic venous blood into the pulmonary circulation.

Intraoperative patency control of internal thoracic artery (ITA) grafts in minimally invasive direct coronary artery bypass graft (MIDCAB) operations is hampered by a limited surgical access. A new method to intraoperatively assess graft patency was developed with the use of an endoscopic thermal scanner that can be operated through a part or inserted directly through a small thoracotomy incision. MIDCAB operations with the ITA to graft the left anterior descending coronary artery (LAD) were performed in six male patients (aged 52 to 68 years) with isolated disease of the LAD. Four patients had a history of single or multiple percutaneous angioplasties. Left ventricular function was within normal limits in all patients (ejection fraction > 50%). Patients were anesthetized and placed in a supine position. Through a small anterolateral thoracotomy (6 to 8 cm) in the fourth intercostal space, the ITA was harvested. Two patients underwent cardiopulmonary bypass with endoaortic clamping and cardioplegic arrest by means of the Port-Access System (Heartport, Inc., Redwood City, Calif.).1Stevens JH Burdon TA Peters WS Siegel LC Pompili MF Vierra MA et al.Port-access coronary artery bypass grafting: a proposed surgical method.J Thorac Cardiovasc Surg. 1996; 111: 567-573Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar In the other four patients we operated on the beating heart with temporary LAD occlusion and local ventricular wall immobilization using the CTS system (Cardio Thoracic Systems, Cupertino, Calif.).2Boonstra PW Grandjean JG Mariani MA Improved method for direct coronary grafting without CPB via anterolateral small thoracotomy.Ann Thorac Surg. 1997; 63: 567-569Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar After completion of the distal anastomosis and before release of the vascular clamp, an endoscopic thermal scanner (Infracam, Inframetrics, North Billerica, Mass.) was introduced through the thoracotomy incision. The scanner based on a platinum silicon (PtSi) focal plane array detector (256 ×256 elements) operates at a wavelength of 3.4 to 5.0 μm (mid-infrared spectrum) with a spatial resolution of 0.6 mrad. A 30 cm endoscope with an indium antimony (InSb) lens allows the scanner to operate through a 10 mm port. After placement of the endoscope above the surface of the heart and after local topical cooling, the vascular clamp on the ITA graft was released. The thermal gradient generated by the inflow of warm blood through the graft delineated the anastomosis and the distal vascular bed. The resulting heat picture was transformed online into an angiographic picture on a conventional video screen. In all patients graft flow was also confirmed by transit-time Doppler-flow measurements (Transonic Systems Inc., Ithaca, N.Y.). All patients underwent a second angiogram before discharge (postoperative days 3 to 6). All operations were uneventful. Median ITA takedown was 33 minutes and median operation time was 117 minutes. Placement of the endoscope was performed through the thoracotomy incision in all cases. Fig. 1 shows a typical intraoperative thermal angiogram of an ITA graft to the LAD that was performed on the beating heart. Fig. 1Intraoperative endoscopic thermal coronary angiogram of an ITA graft to the LAD during minimally invasive surgery on the beating heart. a, Homogeneous surface temperature of the heart before release of the vascular clamp after local topical cooling. Forceps indicates level of the anastomosis (A). b, After release of the vascular clamp, there is perfusion of the distal LAD as well as retrograde perfusion of a first diagonal branch (D1).View Large Image Figure ViewerDownload (PPT)Before release of the vascular clamp, the surface of the heart shows a homogeneous temperature distribution. The forceps indicates the site of anastomosis(Fig. 1, a). After release of the vascular clamp, thermal coronary angiography shows immediate antegrade perfusion of the LAD, as well as retrograde filling of a first diagonal branch, documenting graft and anastomotic patency. Thermal coronary angiography revealed patency of the ITA graft in all six patients. Median graft flow as measured by transit-time Doppler ultrasonography was 46 ml/min (32 to 70 ml/min). No patient showed signs of myocardial ischemia in the perioperative period (normal electrocardiogram, no significant elevation of cardiac enzymes). Median intubation time was 10 hours. ICU stay and time of hospitalization were 1 day and 8 days, respectively. On postoperative angiography, all ITA grafts were patent and showed good runoff. Control of intraoperative graft patency is important to avoid the catastrophic consequences that can be caused by ITA graft failure. Especially in MIDCAB operations, in which grafting is technically more demanding and access to the heart is limited, there is a need for intraoperative quality control. Thermal coronary angiography has been developed for intraoperative noninvasive testing of anastomotic patency in conventional coronary artery bypass graft operations.3Mohr FW Matloff J Grundfest W Chaux A Kass R Blanche C et al.Thermal coronary angiography: a method for assessing graft patency and coronary anatomy in coronary bypass surgery.Ann Thorac Surg. 1989; 47: 441-449Abstract Full Text PDF PubMed Scopus (44) Google Scholar Thermal coronary angiography has been shown to correctly identify anastomotic failures during the operation and has led to graft revision in routine coronary artery operations.4Mohr FW Falk V Krieger H Likungu J Abu Aisha N Coppola R et al.IMA-graft patency control by thermal coronary angiography during coronary bypass surgery.Eur J Cardiothorac Surg. 1991; 5: 534-541Crossref PubMed Scopus (17) Google Scholar, 5Falk V Walther T Philippi A et al.Thermal coronary angiography for intraoperative patency control of arterial and saphenous vein coronary artery bypass grafts: results in 370 patients.J Card Surg. 1995; 10: 147-160Crossref PubMed Scopus (44) Google Scholar The method not only provides a noninvasive angiographic picture of the graft and the attached coronary artery but also reflects graft flow by the velocity of the induced temperature changes. Although conventional thermal imaging has been used to document ITA graft flow to the LAD in a MIDCAB procedure, the obtained images were of poor quality and did not visualize the vascular bed completely.6Emery RW Emery AM Flavin TF Nissen M Mooney MR Arom KV Revascularization using angioplasty and minimally invasive techniques documented by thermal imaging.Ann Thorac Surg. 1996; 62: 591-593Abstract Full Text PDF PubMed Scopus (2) Google Scholar Because of the limited surgical access, ceiling or tripod-mounted thermal imaging systems cannot be positioned accurately. The endoscopic thermal scanner that can be directly placed through the thoracotomy incision or through a separate port is therefore far superior. The system allows for optimal imaging in the region of interest. After brief topical cooling, heat contrast was sufficient to demonstrate graft flow even on the beating heart. Intraoperative flow measurement, as well as postoperative angiography, confirmed the results of thermal coronary angiography. As a noninvasive method, thermal coronary angiography does not require any manipulation of the graft. As again demonstrated in this series, intraoperative flow measurements using transit-time Doppler ultrasonography are awkward in MIDCAB procedures. Because of the limited access, positioning of the flow probe is difficult and also requires skeletonizing of the pedicle, which can be potentially harmful. Furthermore, the Doppler method only provides a flow curve, whereas thermal coronary angiography visualizes the complete vasculature in an angiographic fashion. On the beating heart, generation of a temperature gradient by short-term local topical cooling (sponge soaked in saline solution) immediately before thermal imaging improves image quality. A digital substraction method to further enhance contrast is currently under investigation. If applied during a closed chest technique with cardioplegic cardiac arrest (Port-Access method), endoscopic thermal coronary angiography provides even higher quality images. In conclusion, endoscopic thermal coronary angiography is a useful adjunct in MIDCAB surgery. It allows for a no-touch intraoperative graft patency control.

OBJECTIVE To describe a modification of a surgical technique for relief of subaortic stenosis in patients with atrioventricular canal. MATERIAL AND METHODS We report an etiology-oriented modified technique of repair of subaortic stenosis after previous repair of atrioventricular canal, without (N = 2) or with (N = 1) a restrictive interventricular communication. RESULTS In addition to a generous myectomy of the left ventricular septum, the technique consists of complete detachment of the left and right atrioventricular valves from the ventricular crest, patch augmentation of the concavity of the ventricular crest, and attachment of both atrioventricular valves at the superior aspect of the ventricular septal patch; thus, the septal leaflet of the left atrioventricular valve--in particular, its superior component--is lifted away from the elongated left ventricular outflow tract. CONCLUSION This modification (as opposed to detachment of only the superior component of the septal leaflet of the left atrioventricular valve, as performed in previously proposed techniques) may be a valuable adjunctive technique to relieve subaortic obstruction associated with atrioventricular canal. In addition, this modification allows a secure anchoring of the patch to the right of the ventricular septum and therefore is associated with minimal risk of damaging the conduction tissue and of causing regurgitation of the left atrioventricular valve.

AbstractSurgical Management of straddling tricuspid valve and associated defects is a complex problem. Between August 1992 and August 1995, 5 patients with major straddling of the tricuspid valve underwent a complete or partial biventricular repair. All patients had either an inlet ventricular septal defect (n=4) or a ventricular septal defect with an inlet component (n=1), Co-existing cardiac lesions included hypoplasia of the right ventricle (n=3), discordant ventriculoarterial connections (n=1), tetralogy of Fallot (n=1), and multiple muscular vetricular septal defects (n=2). At the time of presentation to our institution, two of these patients had previously been palliated in preparation for a Fontan procedure, having undergone construction of a bidirectional superior cavopulmonary shunt. One patient was referred specifically for a Fontan procedure. The tricuspid valve was repaired by transecting all of the straddling cords and reattaching them in the right ventricle or onto the right side of the patch used to close the ventricular septal defect. Associated procedures included closure of the septum in all patients, an arterial switch procedure in one, repair of tetralogy of Fallot in one, and construction of a bidirectional superior cavopulmonary shunt in one. There has been no early or late mortality. Complete heart block requiring insertion of a pacemaker occurred after surgery in three patients. At a median follow-up of 32 months, functional integrity of the tricuspid valve is well maintained, with only one patient having moderate tricuspid regurgitation. None of the patients are receiving any cardiac medication.

Objective: To study the phenomenon of potential subaortic outflow obstruction after surgical volume unloading of the heart in patients with univentricular atrioventricular connection, discordant ventriculoarterial connection, and bulboventricular foramen (BVF)-dependent systemic flow.Material and Methods: Intraoperative transesophageal echocardiography was used in five patients with tricuspid atresia (N = 3) or double-inlet left ventricle (N = 2) with rudimentary right ventricle and BVF who were scheduled to undergo a bidirectional cavopulmonary anastomosis (N = 3) or completion of the Fontan procedure after previous banding of the pulmonary artery (N = 2). The BVF diameter was measured in two orthogonal views, and the area was calculated by using the formula for an ellipse. Left ventricular posterior wall thickness and left ventricular internal diameter were also measured, Intraoperative prerepair and postrepair gradients across the BVF were measured by echocardiography.Results: Volume unloading of the left ventricle resulted in instantaneous contraction of left ventricular size (decrease of median left ventricular internal diameter from 38 to 34 mm and increase of median left ventricular posterior wall thickness from 5 to 7 mm), decrease of median BVF area index (from 1.82 to 1.55 cm(2)/m(2)), and development of a median gradient of 60 mm Hg across the BVF. At a mean follow-up of 19.6 months, all patients were clinically well and had no echocardiographic evidence of BVF obstruction.Conclusion: In hearts with univentricular atrioventricular connection, discordant ventriculoarterial connection, and BVF-dependent systemic flow, a decrease in ventricular volume is associated with an instantaneous alteration in ventricular geometry, diminution in BVF size, and potential for subaortic outflow obstruction. Intraoperative transesophageal echocardiography is of paramount importance in excluding development of subaortic outflow obstruction in this setting.

Background. Knowledge is limited regarding the histology of the internal and right gastroepiploic arteries that have been functioning as coronary artery bypass conduits.Methods. Four internal mammary arteries, 3 right gastroepiploic arteries, and 1 saphenous vein graft that had been functioning as coronary artery bypass grafts were harvested and examined histologically in 3 male patients who had died at 19, 38, and 47 months after coronary revascularization.Results. All grafts were patent. The mean thicknesses of the intima in the proximal, middle, and distal segments were 41.0, 31.8, and 25.8 mu m for the internal mammary artery and 58.0, 40.3, and 34.3 mu m for the right gastroepiploic artery. The saphenous vein graft showed severe focal atherosclerosis.Conclusions. This histologic study in a small number of patients corroborates the reported excellent patency rates at medium- to long-term follow-up of the internal mammary and right gastroepiploic arteries used as coronary artery bypass grafts. (C) 1997 by The Society of Thoracic Surgeons.

Background. Regurgitation of the common atrioventricular valve in patients with univentricular atrioventricular connection has a negative impact on outcome in the Fontan operation. Because severe regurgitation of the common atrioventricular valve may not be sufficiently reduced by a volume-reducing operation alone, the addition of a valvuloplasty may be a necessary adjunct to achieve competence of the common atrioventricular valve. A modified technique of valvuloplasty of the common atrioventricular valve and its medium-term results are presented.Methods. Two infants and 1 young child with isomeric right atrial appendages, complete atrioventricular canal, univentricular atrioventricular connection with a double-inlet right ventricle through a common atrioventricular valve, pulmonary atresia (n = 2) or pulmonary stenosis (n = 1), and bilateral superior venae cavae presented with marked dilatation of the annulus of the common atrioventricular valve and severe regurgitation between the bridging leaflets. All 3 patients previously had been palliated with a generous central aortopulmonary shunt. The repair technique consisted of patch augmentation of the central bridging leaflets with an autologous pericardial patch. In addition, bilateral bidirectional cavopulmonary anastomoses were constructed and additional sources of pulmonary blood flow were eliminated.Results. Intraoperative echocardiography demonstrated competence of the large central leaflet, excellent coaptation between the central leaflet and the bilateral mural leaflets, and decrease of the anteroposterior diameter of the annulus of the atrioventricular valve from 24, 29, and 34 mm preoperatively to 20, 23, and 29 mm, respectively. In all 3 patients, echocardiographic follow-up at 17, 14, and 6 months showed continued competence of the atrioventricular valve.Conclusions. Pericardial patch augmentation of the bridging leaflets may be a valuable adjunctive technique in the reconstruction of the regurgitant common atrioventricular valve in hearts with univentricular atrioventricular connection, especially if a volume-reducing operation alone does not result in competence of the valve. (C) 1997 by The Society of Thoracic Surgeons.

A young adult patient, in whom 20 years previously a secundum atrial septal defect had been closed surgically, presented with symptoms of a Budd-Chiari syndrome, cirrhosis of the liver, ascites, and edema of the lower legs. The inferior vena cava-right atrial junction was obstructed by a calcified Teflon patch and shrinkage of the surrounding tissue. Augmentation of the inferior vena cava-right atrial junction with a Gore-Tex patch resulted in unobstructed inflow into the right atrium.

The unroofed coronary sinus syndrome is a spectrum of cardiac anomalies in which part or all of the common wall between the coronary sinus and the left atrium is absent; in most cases the anomaly is associated with a persistent left superior vena cava (SVC).1Helseth HK Peterson CR Atrial septal defect with termination of left superior vena cava in the left atrium and absence of the coronary sinus: recognition and treatment.Ann Thorac Surg. 1974; 17: 186-192Abstract Full Text PDF PubMed Scopus (18) Google Scholar In the absence of the coronary sinus, the left SVC connects with the left upper corner of the left atrium, between the opening of the left atrial appendage and the orifice of the left superior pulmonary vein.2Shumacker Jr, HB King H Waldhausen JA The persistent left superior vena cava: surgical implications, with special reference to caval drainage into the left atrium.Ann Surg. 1967; 165: 797-805Crossref PubMed Scopus (68) Google Scholar A coronary sinus atrial septal defect (ASD) is present in the posteroinferior region of the atrial septum, in the usual position of the coronary sinus orifice. The innominate vein is absent in 80% to 90% of patients with the unroofed coronary sinus syndrome and left SVC.3Sherafat M Friedman S Waldhausen JA Persistent left superior vena cava draining into the left atrium with absent right superior vena cava.Ann Thorac Surg. 1971; 11: 160-164Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 4Quaegebeur J Kirklin JW Pacifico AD Bargeron Jr, LM Surgical experience with unroofed coronary sinus.Ann Thorac Surg. 1979; 27: 418-425Abstract Full Text PDF PubMed Scopus (98) Google Scholar The diagnosis of isolated unroofed coronary sinus syndrome with persistent left SVC usually is an indication for operation to avoid long-term arterial desaturation and its detrimental sequelae. In the absence of an innominate vein, the preferred repair consists of excision of the entire atrial septum except the anterior limbus, which is preserved as a protection for the atrioventricular node and bundle,5Chiu IS Hegerty A Anderson RH de Leval M The landmarks to the atrioventricular conduction system in hearts with absence or unroofing of the coronary sinus.J Thorac Cardiovasc Surg. 1985; 90: 297-300PubMed Google Scholar followed by placement of a pericardial patch in such a fashion that all of the pulmonary veins drain under the patch to the mitral valve orifice. A second useful method of repair consists of rerouting the coronary sinus to the roof of the left atrium in addition to reconstruction of the atrial septum.6Sand ME McGrath LB Pacifico AD Mandke NV Repair of left superior vena cava entering the left atrium.Ann Thorac Surg. 1986; 42: 560-564Abstract Full Text PDF PubMed Scopus (19) Google Scholar In the presence of a physiologically unrestrictive or moderately restrictive innominate vein (defined as absence of a rise in pressure and a rise in pressure in the cranial left SVC to less than 20 mm Hg resulting from temporary occlusion of the distal left SVC, respectively), the left SVC is simply divided and oversewn below the innominate vein and the coronary sinus ASD is closed with a patch. We report an alternative technique of repair of unroofed coronary sinus with left SVC that is applicable in the presence of a physiologically restrictive innominate vein. A 9-week-old prematurely born female infant with a body weight of 3.1 kg was admitted for surgical correction of an echocardiographically diagnosed unroofed coronary sinus, left SVC, and coronary sinus ASD. The clinical picture was dominated by mild cyanosis (systemic arterial oxygen saturation of 94%). At operation through a median sternotomy, a left SVC was seen to enter the left superior portion of the left atrium; a small innominate vein (diameter 3 mm) connected the two SVCs. Temporary occlusion of the left SVC close to its entrance into the left atrium increased the pressure in the cranial segment of the left SVC to 24 mm Hg. On the basis of this observation, ligation of the left SVC was deemed inappropriate. A large pericardial patch was harvested; the majority of the patch was stored in saline solution and the remainder in 0.6% glutaraldehyde solution. After aortic and single venous cannulation, the patient was rapidly cooled to a rectal temperature of 18° C, circulatory arrest was established, and the venous and arterial cannulas were removed. An incision was made in the superior aspect of the innominate vein and the proximal 0.5 cm of the medial aspects of the right brachiocephalic vein and the left internal jugular vein, and a large rectangular untreated pericardial patch was sewn in place with 7-0 polypropylene suture (Prolene, Ethicon, Inc., Somerville, N.J.) in a continuous fashion (Fig. 1, A and B). Fig. 1Technique of repair of unroofed coronary sinus with persistent left SVC, coronary sinus ASD, and restrictive innominate vein. A, Dashed line indicates incision of superior aspect of innominate vein and proximal and medial aspects of the right brachiocephalic vein and the left internal jugular vein. B, Augmentation of innominate vein with untreated rectangular pericardial patch. The left SVC is divided and both ends are oversewn.View Large Image Figure ViewerDownload (PPT)Subsequently, the left SVC was divided close to its entrance into the left atrium and both ends were oversewn with 6-0 Prolene suture. Finally, the coronary sinus ASD was closed with a glutaraldehyde-treated pericardial patch. After the infant was weaned from cardiopulmonary bypass, pressure measurements in the right brachiocephalic vein and the left internal jugular vein demonstrated absence of a pressure gradient between the two. The postoperative course was uncomplicated; notably, there was absence of facial edema, venous engorgement, or chylothorax. At 9-month follow-up, the infant is in excellent physical condition. In unroofed coronary sinus with a persistent left SVC in the presence of a restrictive innominate vein, the technique of pericardial patch augmentation of the innominate vein, as reported here, may be a valuable alternative repair technique. The main advantage of this technique is avoidance of construction of a complex intraatrial baffle with its inherent potential complications related to the creation of a small and low-compliant left atrial compartment (with resultant impaired left ventricular filling) and pulmonary venous obstruction. Untreated pericardial patch is preferable to glutaraldehyde-treated pericardial patch for augmentation of the innominate vein, because the former is more mobile and pliable and therefore better adjusts to the low-pressure systemic venous system. We recommend anticoagulation treatment for an arbitrary period of 3 months to avoid thrombus formation in the patch-augmented innominate vein.

A modified repair technique in anomalous connection of the left coronary artery to the main pulmonary artery is reported in which transfer of the origin of the vessel into the aortic root is facilitated by augmentation with native aortic and pulmonary tissue flaps. This modification reduces tension on the anastomosis and may enhance the likelihood of successful transfer of the left coronary artery into the aortic root.

In patients with origin of the right (RPA) or left pulmonary artery from the ascending aorta, the RPA or, much less commonly, the left pulmonary artery arises from the ascending aorta in the presence of separate aortic and pulmonary valves and without the interposition of ductal tissue.1,2 The RPA usually originates from the right posterior aspect of the ascending aorta.3 Physiologically, the alteration creates a large left-to-right shunt. The contralateral lung is therefore subjected to the entire right ventricular output in addition to flow contributed by associated anomalies, such as patent ductus arteriosus, aortopulmonary septal defect, atrial septal defect, or ventricular septal defect, which have been present in greater than 60% of previous reports.

Management of the mitral valve is the most critical component of the repair of common atrioventricular canal (CAVC).1Carpentier A Surgical anatomy and management of the mitral component of atrioventricular canal defects.in: Paediatric cardiology. Churchill Livingstone, Edinburgh1978: 477-486Google Scholar, 2Weintraub RG Brawn WJ Venables AW Mee RB Two-patch repair of complete atrioventricular septal defect in the first year of life: results and sequential assessment of atrioventricular valve function.J Thorac Cardiovasc Surg. 1990; 99: 320-326PubMed Google Scholar Patients with normal karyotype have a significantly higher reoperation rate for postoperative mitral valve regurgitation (as great as 50%) than do patients with Down syndrome (as great as 10%).2Weintraub RG Brawn WJ Venables AW Mee RB Two-patch repair of complete atrioventricular septal defect in the first year of life: results and sequential assessment of atrioventricular valve function.J Thorac Cardiovasc Surg. 1990; 99: 320-326PubMed Google Scholar This difference may be caused primarily by tissue scarcity, deficiency of the superior or inferior bridging leaflets, or both. On the basis of these observations, we recently developed a modified surgical technique for reconstruction of the tissue-deficient bridging leaflets of the mitral valve, with the objective of decreasing the prevalence of postoperative regurgitation in this difficult subset of cases. In the repair of CAVC, we prefer to close the atrioventricular septal defect with a single glutaraldehyde-preserved pericardial patch. To avoid iatrogenic regurgitation of the mitral valve, the tricuspid valve, or both, it is imperative not to use too wide a patch. After assessment of valve anatomy, with particular attention to the coaptation of the bridging leaflets, a marking suture is placed to identify the point of creation of the base of the cleft in the mitral valve. Subsequently, the superior and inferior bridging leaflets are divided slightly to the right ventricular side. If sufficient valve tissue is available, the cleft separating the bridging leaflets is closed with multiple interrupted 6-0 polypropylene sutures (Prolene; Ethicon, Inc., Somerville, N.J.), up to the point at which the first set of chordal attachments is approached. The neoseptal leaflets of the tricuspid and mitral valves are anchored to the atrioventricular septal patch with multiple 5-0 braided sutures supported with small felt pledgets. Scarcity or deficiency of leaflet tissue of the bridging leaflets may render closure of the cleft impossible. In this setting, patch augmentation of the tissue-deficient bridging leaflets may be a valuable technique. As a first step in the repair, if possible without causing undue tension, the free edges of the bridging leaflets are approximated with one or two interrupted 6-0 Prolene sutures (Fig. 1). An untreated autologous pericardial patch is tailored to the size and configuration of the defect. If the tissue defect extends up to the atrioventricular septal patch, the pericardial patch is first anchored to that patch with braided 5-0 sutures supported with felt pledgets. Subsequently, the pericardial patch is sutured to the edges of the bridging leaflets with 6-0 Prolene sutures, preferably with an interrupted suture technique. If the free edges of the bridging leaflets cannot be approximated without causing undue tension, the pericardial patch augmentation is extended up to the free edge of the neoseptal leaflet (Fig. 2). Fig. 2If free edges of bridging leaflets cannot be approximated without causing excessive tension, pericardial patch is extended up to level of free edges of bridging leaflets.View Large Image Figure ViewerDownload (PPT)After repair of the mitral valve, the tricuspid valve, or both,3Falk V van Son JA Mohr FW Pericardial patch augmentation of right atrioventricular valve in atrioventricular canal.Ann Thorac Surg. 1996; 62: 288-290Abstract Full Text PDF PubMed Scopus (7) Google Scholar valve function is tested by forceful injection of normal saline solution into the respective ventricles. The atrial component of the atrioventricular septal defect is closed with the remaining glutaraldehyde-preserved pericardial patch. Echocardiography is routinely used to assess atrioventricular valve function and to exclude residual interatrial or interventricular communications and left ventricular outflow tract obstruction. The reported technique was performed in five cases (median patient age 3 months, range 1 month to 3 years) of CAVC with little (n = 3) or no (n = 2) bridging of the superior leaflets and normal karyotype; four patients had moderate regurgitation of the mitral valve and three patients had associated mild left ventricular outflow tract obstruction. In four cases, the free edges of the bridging leaflets could be approximated; in the remaining case, the pericardial patch was extended up to the free edge of the bridging leaflets. In three patients, all of whom had a diminutive inferior bridging leaflet, the inferoposterior commissure was also regurgitant; a single-stitch annuloplasty resulted in a competent commissure in all three of these patients. At a median follow-up of 11 months, all patients are alive and clinically well. Echocardiography demonstrated a competent mitral valve in two patients and trivial central regurgitation in three patients. Although the cleft between the bridging leaflets in CAVC may physiologically function as a commissure and be competent, we have major objections to the use of the term commissure in this setting. We believe that the term commissure (derived from the Latin cum and mittere, meaning "to send together"), as originally proposed by Carpentier1Carpentier A Surgical anatomy and management of the mitral component of atrioventricular canal defects.in: Paediatric cardiology. Churchill Livingstone, Edinburgh1978: 477-486Google Scholar and later propagated by Anderson and coworkers,4Anderson RH Zuberbuhler JR Penkoske PA Neches WH Of clefts, commissures, and things.J Thorac Cardiovasc Surg. 1985; 90: 605-610PubMed Google Scholar should be reserved for a breach in the leaflet skirt of the atrioventricular valve that is supported by fan-shaped chordae tendineae inserting into a single papillary muscle group. By contrast, the chordae that are attached to the free edge of the superior and inferior bridging leaflets at the end of the cleft insert into two opposite papillary muscles: the chordae that control the superior bridging leaflet insert into the anterolateral papillary muscle group, whereas those controlling the inferior bridging leaflet insert into the posteromedial papillary muscle group. The tensor apparatus around the cleft does not pull the superior and inferior bridging leaflets together, but rather pulls them apart. Moreover, the cleft between the bridging leaflets is not supported by chordae. In our experience and that of others,2Weintraub RG Brawn WJ Venables AW Mee RB Two-patch repair of complete atrioventricular septal defect in the first year of life: results and sequential assessment of atrioventricular valve function.J Thorac Cardiovasc Surg. 1990; 99: 320-326PubMed Google Scholar, 5Van Praagh R Papagiannis J Bar-El YI Schwint OA The heart in Down syndrome: pathologic anatomy.in: Heart disease in persons with Down syndrome. Paul H Brooks, Baltimore1996: 69-110Google Scholar in patients with CAVC and normal karyotype (as opposed to patients with Down syndrome), related to the often tenuous presence of two atrioventricular valve orifices, the bridging leaflets of the atrioventricular valve may scarcely be developed, are usually displaced inferiorly, and are (partially) attached to the "scooped out" ventricular crest, resulting in a marginal area of coaptation between the bridging leaflets and potential crowding of the left ventricular outflow tract. In this setting, even mild dilatation of the common atrioventricular valve orifice or mitral valve orifice as a result of volume loading of the left ventricle (as is the case after repair of CAVC) may render the mitral valve regurgitant, especially if it has been repaired in a trileaflet fashion. Although the trileaflet atrioventricular valve concept in CAVC, as propagated by Carpentier1Carpentier A Surgical anatomy and management of the mitral component of atrioventricular canal defects.in: Paediatric cardiology. Churchill Livingstone, Edinburgh1978: 477-486Google Scholar and Anderson and coworkers,4Anderson RH Zuberbuhler JR Penkoske PA Neches WH Of clefts, commissures, and things.J Thorac Cardiovasc Surg. 1985; 90: 605-610PubMed Google Scholar is attractive from a surgical viewpoint because it allows preservation of the mitral valve in a natural configuration, we and others who have used this technique2Weintraub RG Brawn WJ Venables AW Mee RB Two-patch repair of complete atrioventricular septal defect in the first year of life: results and sequential assessment of atrioventricular valve function.J Thorac Cardiovasc Surg. 1990; 99: 320-326PubMed Google Scholar have found that it can lead to unpredictable early and long-term results. Although there has been concern that bileaflet repair of the mitral valve may lead to leaflet scarring at the cleft closure site, potentially resulting in regurgitation or stenosis in the long-term, a recent clinical series in which the cleft was routinely approximated demonstrated that this type of repair holds up with time.6Bando K Turrentine MW Sun K Sharp TG Ensing GJ Miller AP et al.Surgical management of complete atrioventricular septal defects: a twenty-year experience.J Thorac Cardiovasc Surg. 1995; 110: 1543-1554Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar At a mean 59 months after repair, 137 of 146 survivors (94%) had only trivial or mild regurgitation of the mitral valve, and none had substantial stenosis.6Bando K Turrentine MW Sun K Sharp TG Ensing GJ Miller AP et al.Surgical management of complete atrioventricular septal defects: a twenty-year experience.J Thorac Cardiovasc Surg. 1995; 110: 1543-1554Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar This information eliminates one of our major concerns regarding the bileaflet approach. The technique of patch augmentation of the tissue-deficient mitral valve described here is a useful adjunct for reconstruction of atrioventricular valves in CAVC,3Falk V van Son JA Mohr FW Pericardial patch augmentation of right atrioventricular valve in atrioventricular canal.Ann Thorac Surg. 1996; 62: 288-290Abstract Full Text PDF PubMed Scopus (7) Google Scholar with encouraging medium-term results. It is important to use untreated pericardial patch, as opposed to glutaraldehyde-preserved pericardial patch, because untreated patch is more mobile and pliable. In our experience, it has superior properties as a leaflet replacement material. The technique described here may be especially valuable in the occasional case of a patient with marginal or absent coaptation of the bridging leaflets in whom closure of the cleft results in excessive tension on the cleft repair, with inherent risk of dehiscence. Another, possibly even greater benefit of this technique is that maximal height of the reconstructed neoseptal leaflet can be obtained because the bridging leaflets are approximated truly side by side, resulting in the largest possible distance between the atrioventricular septal patch and the free edge of the neoseptal leaflet and adding more surface for coaptation with the mural leaflet. In the standard technique of closure of the cleft, this height is likely to be reduced to minimize tension on the cleft repair by anchoring the central segment of the cleft to the atrioventricular septal patch, rather than closing it side by side. Finally, an additional annuloplasty (especially of the inferoposterior commissure) may be necessary to achieve complete competence of the mitral valve.

Absent pulmonary valve syndrome is a subset of tetralogy of Fallot, with a reported prevalence of 2.6% to 6.0% among patients with tetralogy of Fallot.1McCaughan BC Danielson GK Driscoll JD McGoon DC Tetralogy of Fallot with absent pulmonary valve: early and late results of surgical treatment.J Thorac Cardiovasc Surg. 1985; 89: 280-287PubMed Google Scholar, 2Nagao GI Daoud G McAdams AJ Schwartz DC Kaplan S Cardiovascular anomalies associated with tetralogy of Fallot.Am J Cardiol. 1967; 20: 206-215Abstract Full Text PDF PubMed Scopus (63) Google Scholar, 3Lev M Eckner FA The pathologic anatomy of tetralogy of Fallot and its variants.Chest. 1964; 45: 251-261Crossref Scopus (101) Google Scholar This pathologic and clinical status is denoted by a vestigial pulmonary valve with pulmonary insufficiency; the pulmonary valve anulus frequently is moderately hypoplastic. Severe tracheobronchial compression may result from massive aneurysmal dilatation of the main pulmonary artery and its first- and second-order branches and from abnormal branching of segmental arteries.2Nagao GI Daoud G McAdams AJ Schwartz DC Kaplan S Cardiovascular anomalies associated with tetralogy of Fallot.Am J Cardiol. 1967; 20: 206-215Abstract Full Text PDF PubMed Scopus (63) Google Scholar, 3Lev M Eckner FA The pathologic anatomy of tetralogy of Fallot and its variants.Chest. 1964; 45: 251-261Crossref Scopus (101) Google Scholar, 4Ilbawi MN Idriss FS Muster AJ Wessel HU Paul MH DeLeon SY Tetralogy of Fallot with absent pulmonary valve: should valve insertion be part of the intracardiac repair?.J Thorac Cardiovasc Surg. 1981; 81: 906-915PubMed Google Scholar, 5Fischer DR Neches WH Beerman LB et al.Tetralogy of Fallot with absent pulmonic valve: analysis of 17 patients.Am J Cardiol. 1984; 53: 1433-1437Abstract Full Text PDF PubMed Scopus (62) Google Scholar, 6Rabinovitch M Grady S David I et al.Compression of intrapulmonary bronchi by abnormally branching pulmonary arteries associated with absent pulmonary valves.Am J Cardiol. 1982; 50: 804-813Abstract Full Text PDF PubMed Scopus (90) Google Scholar, 7Waldhausen JA Friedman S Nicodemus H Miller WW Rashkind W Johnson J Absence of the pulmonary valve in patients with tetralogy of Fallot: surgical management.J Thorac Cardiovasc Surg. 1969; 57: 669-674PubMed Google Scholar, 8Stafford EG Mair DD McGoon DC Danielson GK Tetralogy of Fallot with absent pulmonary valve: surgical considerations and results.Circulation. 1973; 47: III24-III30Google Scholar, 9Arensman FW Francis PD Helmsworth JA et al.Early medical and surgical intervention for tetralogy of Fallot with absence of pulmonic valve.J Thorac Cardiovasc Surg. 1982; 84: 430-436PubMed Google Scholar, 10Stellin G Jonas RA Goh TH Brawn WJ Venables AW Mee RB Surgical treatment of absent pulmonary valve syndrome in infants: relief of bronchial obstruction.Ann Thorac Surg. 1983; 36: 468-475Abstract Full Text PDF PubMed Scopus (40) Google Scholar, 11Corno A Picardo S Ballerini L Gugliantini P Marcelletti C Bronchial compression by dilated pulmonary artery: surgical treatment.J Thorac Cardiovasc Surg. 1985; 90: 706-710PubMed Google Scholar, 12Ilbawi MN Fedorchik J Muster AJ et al.Surgical approach to severely symptomatic new-born infants with tetralogy of Fallot and absent pulmonary valve.J Thorac Cardiovasc Surg. 1986; 91: 584-589PubMed Google Scholar, 13Karl TR Musumeci F de Leval M Pincott JR Taylor JF Stark J Surgical treatment of absent pulmonary valve syndrome. 1986; 91: 590-597Google Scholar, 14Heinemann MK Hanley FL Preoperative management of neonatal tetralogy of Fallot with absent pulmonary valve syndrome.Ann Thorac Surg. 1993; 55: 172-174Abstract Full Text PDF PubMed Scopus (19) Google Scholar, 15Hosking MP Beynen F Anesthetic management of tetralogy of Fallot with absent pulmonary valve.Anesthesiology. 1989; 70: 863-865Crossref PubMed Scopus (7) Google Scholar The degree of respiratory compromise and heart failure associated with left-to-right shunting are the chief determinants of the clinical presentation. Neonates at the severe end of the spectrum have an extremely high mortality rate despite aggressive attempts at medical and surgical management. In this report, we describe an alternative management option for this subset of absent pulmonary valve syndrome. A 2.9 kg, 4-day-old male neonate with profound cyanosis and respiratory acidosis was found to have tetralogy of Fallot with absent pulmonary valve syndrome. Limited transthoracic echocardiographic examination demonstrated a massive dilatation of the main pulmonary artery (diameter 17 mm) and both branch pulmonary arteries (diameter 16 mm). Adequate ventilation could only be achieved with the patient in the prone position. Operative intervention was considered the only chance for survival of the patient. The patient was repositioned from the prone to the supine position only shortly before performance of the median sternotomy. Sternotomy resulted in an immediate improvement in the mechanical gas exchange, as documented by a decrease in arterial carbon dioxide tension and an increase in arterial oxygen tension (Table I). Because of the gravity and the duration of the preoperatively existing metabolic derangement and a persistent moderate acidosis, however, it was decided to leave the sternotomy open without definitive repair to allow a prolonged period of resuscitation in the intensive care unit. After removal of the sternal retractor, there was a slight increase in the arterial carbon dioxide tension (Table I). It was therefore decided to leave the sternal retractor in place and to cover the sternotomy wound with Steri-Drape film (3M Company, St. Paul, Minn.). This maneuver resulted in a stable hemodynamic situation and absence of arterial carbon dioxide retention in the supine position. This favorable clinical condition allowed for a detailed transesophageal echocardiographic examination. After 24 hours, a complete repair of the lesion, consisting of ventricular septal defect closure, aneurysmorrhaphy of the anterior and posterior walls of the dilated central pulmonary arteries, resection of the main pulmonary artery and vestigial pulmonary valve, and implantation of a valved pulmonary allograft to reconstruct the right ventricular outflow tract, was performed. The length of the allograft was kept short to lift the branch pulmonary arteries from the tracheobronchial structures.Table IRespiratory and metabolic status dataIntraoperative————————————————————PreoperativeBefore sternotomyAfter sternotomy————————————————————————VariableSupineProneProneSupineWithout retractor (20 min)With retractor (30 min)Pco2 (mm Hg)683940724234Po2 (mm Hg)25606965340375pH7.217.337.347.257.327.38Fio20.40.40.41.01.01.0VentilationSIMVSIMVSIMVCMVCMVCMVPco 2 , Partial pressure of carbon dioxide in arterial blood; Po 2 , partial pressure of oxygen in arterial blood; Fio 2 , fraction of inspired oxygen; SIMV, synchronized intermittent mandatory ventilation; CMV, continuous mandatory ventilation. Open table in a new tab Pco 2 , Partial pressure of carbon dioxide in arterial blood; Po 2 , partial pressure of oxygen in arterial blood; Fio 2 , fraction of inspired oxygen; SIMV, synchronized intermittent mandatory ventilation; CMV, continuous mandatory ventilation. The postoperative course was relatively uneventful. The patient was successfully weaned from the ventilator on the fifth postoperative day. There was constant subsequent improvement in respiratory status. At 6-month follow-up, the patient is doing well; another echocardiogram showed the right ventricular outflow tract and central pulmonary arteries to be of normal caliber. Despite early surgical correction of tetralogy of Fallot with absent pulmonary valve syndrome, mortality is still considerable. This high mortality rate is related mainly to the extremely poor clinical condition of these neonates and infants as a result of tracheobronchial compression and heart failure.1McCaughan BC Danielson GK Driscoll JD McGoon DC Tetralogy of Fallot with absent pulmonary valve: early and late results of surgical treatment.J Thorac Cardiovasc Surg. 1985; 89: 280-287PubMed Google Scholar, 4Ilbawi MN Idriss FS Muster AJ Wessel HU Paul MH DeLeon SY Tetralogy of Fallot with absent pulmonary valve: should valve insertion be part of the intracardiac repair?.J Thorac Cardiovasc Surg. 1981; 81: 906-915PubMed Google Scholar, 5Fischer DR Neches WH Beerman LB et al.Tetralogy of Fallot with absent pulmonic valve: analysis of 17 patients.Am J Cardiol. 1984; 53: 1433-1437Abstract Full Text PDF PubMed Scopus (62) Google Scholar, 7Waldhausen JA Friedman S Nicodemus H Miller WW Rashkind W Johnson J Absence of the pulmonary valve in patients with tetralogy of Fallot: surgical management.J Thorac Cardiovasc Surg. 1969; 57: 669-674PubMed Google Scholar, 8Stafford EG Mair DD McGoon DC Danielson GK Tetralogy of Fallot with absent pulmonary valve: surgical considerations and results.Circulation. 1973; 47: III24-III30Google Scholar, 9Arensman FW Francis PD Helmsworth JA et al.Early medical and surgical intervention for tetralogy of Fallot with absence of pulmonic valve.J Thorac Cardiovasc Surg. 1982; 84: 430-436PubMed Google Scholar, 10Stellin G Jonas RA Goh TH Brawn WJ Venables AW Mee RB Surgical treatment of absent pulmonary valve syndrome in infants: relief of bronchial obstruction.Ann Thorac Surg. 1983; 36: 468-475Abstract Full Text PDF PubMed Scopus (40) Google Scholar, 11Corno A Picardo S Ballerini L Gugliantini P Marcelletti C Bronchial compression by dilated pulmonary artery: surgical treatment.J Thorac Cardiovasc Surg. 1985; 90: 706-710PubMed Google Scholar, 12Ilbawi MN Fedorchik J Muster AJ et al.Surgical approach to severely symptomatic new-born infants with tetralogy of Fallot and absent pulmonary valve.J Thorac Cardiovasc Surg. 1986; 91: 584-589PubMed Google Scholar, 13Karl TR Musumeci F de Leval M Pincott JR Taylor JF Stark J Surgical treatment of absent pulmonary valve syndrome. 1986; 91: 590-597Google Scholar Nursing of the baby in a prone, head-up position is recommended as soon as the condition is recognized; this position allows the aneurysmally enlarged central pulmonary arteries to fall forward and away from the trachea and bronchi, particularly the right bronchus.9Arensman FW Francis PD Helmsworth JA et al.Early medical and surgical intervention for tetralogy of Fallot with absence of pulmonic valve.J Thorac Cardiovasc Surg. 1982; 84: 430-436PubMed Google Scholar, 14Heinemann MK Hanley FL Preoperative management of neonatal tetralogy of Fallot with absent pulmonary valve syndrome.Ann Thorac Surg. 1993; 55: 172-174Abstract Full Text PDF PubMed Scopus (19) Google Scholar, 15Hosking MP Beynen F Anesthetic management of tetralogy of Fallot with absent pulmonary valve.Anesthesiology. 1989; 70: 863-865Crossref PubMed Scopus (7) Google Scholar Even if the patient responds well to this maneuver, we believe that operation should not be deferred. The only rational treatment for symptomatic absent pulmonary valve syndrome consists of correction of the anatomic substrate for the tracheobronchial compression and the intracardiac defect. In the absence of severe respiratory compromise and secondary metabolic derangement, consideration should be given to early primary repair, including closure of the malalignment ventricular septal defect; reduction plasty of both the anterior and posterior walls of the main, left, and right pulmonary arteries; and valved allograft reconstruction of the right ventricular outflow tract. In the presence of severe respiratory compromise associated with acidosis and metabolic derangement, performance of a median sternotomy usually results in immediate improvement in gas exchange as a result of mechanical decompression of the tracheobronchial tree.14Heinemann MK Hanley FL Preoperative management of neonatal tetralogy of Fallot with absent pulmonary valve syndrome.Ann Thorac Surg. 1993; 55: 172-174Abstract Full Text PDF PubMed Scopus (19) Google Scholar Depending on the subsequent trend in clinical improvement in terms of gas exchange and resolution of acidosis, as observed in the operating room, the surgeon must judge whether the clinical status of the baby allows primary repair of the underlying defect at that time or whether a prolonged period of resuscitation in the intensive care unit is likely to be necessary. If, as in the case of our patient, prolonged resuscitation is selected as the management option, the sternotomy wound is temporarily closed with a prosthetic patch such as a silicone rubber patch reinforced with Dacron polyester fabric mesh or a polytetrafluororethylene patch. Alternatively, in the presence of severe tracheobronchial compression that is incompletely relieved by median sternotomy, the sternal retractor can be left in place to aid in continuous decompression and the wound can be sealed with Steri-Drape plastic film.16Van Son JA Primary elective open sternum with only Steri-Drape film coverage after cardiac operations in pediatric patients.J Thorac Cardiovasc Surg. 1995; 109: 1262-1263Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Such staged management may reduce the risk of the subsequent operation in these critically ill patients, and it allows further diagnostic studies if needed. Complete repair of the underlying anomaly can then be undertaken after a period of 24 to 72 hours.

A young child with [S, L, L] segmental anatomy, double-inlet left ventricle, transposition of the great arteries, rudimentary right ventricle, and mildly restrictive bulboventricular foramen is reported, in whom intraoperative temporary snaring of the modified Blalock-Taussig shunt resulted in instantaneous and dramatic volume contraction of the left ventricle, decrease in bulboventricular foramen size, and increase of the gradient across the latter from 10 mm Hg preoperatively to 50 mm Hg. A modified Damus-Stansel-Kaye procedure using autogenous aortic tissue resulted in unobstructed aortic outflow; in addition, a bidirectional cavopulmonary shunt was performed. The importance of early relief of actual or potential aortic outflow obstruction in hearts with restrictive bulboventricular foramen is emphasized.

Untreated pericardial patch was successfully used to augment tissue-deficient bridging leaflets of the right atrioventricular valve in a patient after previous repair of complete common atrioventricular canal. Medium-term echocardiographic follow-up showed excellent tricuspid valve function with trivial central regurgitation.

Background. Recurrent aortic coarctation after primary operative repair in the neonate and small infant is seen most commonly within the first year of life. Inadequate removal of ductal tissue, failure to address hypoplasia of the aortic arch, and suture line tension have been cited as important factors in early recurrence.Methods. To address these issues, we have used a technique of coarctation resection and extended anastomosis of the descending aorta to the undersurface of the aortic arch. The salient features of this approach include extensive mobilization of the aortic arch and neck vessels, careful trimming of all ductal tissue, ligation of the isthmus just beyond the left subclavian artery, and end-to-side anastomosis of the descending aorta to a separate incision in the undersurface of the aortic arch proximal to all tubular hypoplasia. Between July 1992 and January 1995, 19 consecutive neonates (median age, 13 days) and 4 consecutive infants under 3 months of age (median age, 69 days) with a mean peak systolic upper to lower extremity resting gradient of 27.9 +/- 16.9 mm Hg underwent repair of aortic coarctation and tubular hypoplasia of the arch. Other procedures performed at the time of repair included ligation of a patent ductus arteriosus (n = 19), pulmonary artery banding (n = 3), and closure of ventricular septal or atrial septal defect (n = 3).Results. There were no perioperative deaths. Early postoperative complications included a recurrent laryngeal nerve injury and a transient focal tonic clonic seizure. There was one late death, after a subsequent intracardiac surgical procedure, at a median follow-up of 16 months (range, 1 to 29 months). Twenty-one of 22 late survivors were free of recurrent aortic coarctation by echocardiography findings and clinical examination, with a median upper to lower extremity gradient of 0 mm Hg. Reintervention for recurrent aortic coarctation was not required in any survivor.Conclusions. The technique described herein completely removes all potentially abnormal tissue from the aorta, including ductal tissue and all tubular hypoplastic tissue proximal to the coarctation site.