Balloon pulmonary valvuloplasty for pulmonary valve stenosis with atrial septal defect

We performed successful balloon pulmonary valvuloplasty (BPV) in 6 patients with pulmonary valve stenosis and atrial septal defect (ASD) accompanied by atrial left-to-right shunt without an increase of shunting immediately after BPV. It suggests that such patients should be treated by BPV initially and the need for ASD repair can be assessed during long-term follow-up.     

Single-stage repair of aortic arch obstruction and associated intracardiac defects with pulmonary homograft patch aortoplasty

PURPOSE: To investigate the involvement of the cornea during endotoxin-induced uveitis (EIU) in the rat and the effect of Ngamma-nitro-L-arginine methyl ester (L-NAME) as nitric oxide synthase (NOS) inhibitor, administered by iontophoresis. METHODS: EIU was induced in Lewis rats that were killed at 8 and 16 hours after lipopolysaccharide (LPS) injection. The severity of uveitis was evaluated clinically at 16 hours, and nitrite levels were evaluated in the aqueous humor at 8 hours. Corneal thickness was measured, 16 hours after LPS injection, on histologic sections using an image analyzer. Transmission electron microscopy (TEM) was used for fine analysis of the cornea. Transcorneoscleral iontophoresis of L-NAME (100 mM) was performed either at LPS injection or at 1 and 2 hours after LPS injection. RESULTS: At 16 hours after LPS injection, mean corneal thickness was 153.7+/-5.58 microm in the group of rats injected with LPS (n=8) compared with 126.89+/-11.11 microm in the saline-injected rats (n=8) (P < 0.01). TEM showed stromal edema and signs of damage in the endothelial and epithelial layers. In the group of rats treated by three successive iontophoreses of L-NAME (n=8), corneal thickness was 125.24+/-10.36 microm compared with 146.76+/-7.52 microm in the group of rats treated with iontophoresis of saline (n=8), (P=0.015). TEM observation showed a reduction of stromal edema and a normal endothelium. Nitrite levels in the aqueous humor were significantly reduced at 8 hours by L-NAME treatment (P=0.03). No effect on corneal edema was observed after a single iontophoresis of L-NAME at LPS injection (P=0.19). Iontophoresis of saline by itself induced no change in corneal thickness nor in TEM structure analysis compared with normal rats. CONCLUSIONS: Corneal edema is observed during EIU. This edema is significantly reduced by three successive iontophoreses of L-NAME, which partially inhibited the inflammation. A role of nitric oxide in the corneal endothelium functions may explain the antiedematous effect of L-NAME.     

Minimally invasive repair of atrial septal defects

BACKGROUND: Minimally invasive pediatric cardiac surgical techniques continue to evolve and remain challenged by technologic advances in percutaneous devices developed to treat congenital heart disease exclusive of cardiopulmonary bypass. Public tenacity for "incisionless" operations, however, must remain balanced scrupulously against the collective safety of the surgical procedure. METHODS: Twenty-three pediatric patients underwent repair of atrial septal defects through a partial sternal split and a limited skin incision (5 to 7 cm) at our institution between July 1995 and October 1996. RESULTS: The average age of the patients was 6 years and 2 months (range, 19 months to 15 years) and the average weight was 23.3 kg (range, 11.3 to 61.7 kg). The average bypass time was 35 minutes (range, 19 to 81 minutes). Fourteen patients had a single dose of blood cardioplegia administered, whereas 9 had ventricular fibrillation electrically induced. Twenty-two patients had ostium secundum defects and 1 had a sinus venosus defect. The average length of the hospital stay was 3.6 days (range, 3 to 6 days). There were no operative or late deaths. CONCLUSIONS: Modifications of this technique continue to evolve as an effective cosmetic alternative to submammary and thoracotomy approaches. Advantages of this modification include excellent cosmetic results in all age groups and the concomitant security and familiarity of mediastinal access and full sternotomy when required.     

Atrioventricular valve function after single patch repair of complete atrioventricular septal defect in infancy: how early should repair be attempted?

BACKGROUND: Though repair of complete atrioventricular septal defect in infancy has become routine at most centers, it is not unusual for very young infants to be managed medically because of concerns about the fragility of the atrioventricular valve tissue. METHODS: Since July 1992, seventy-two infants have undergone primary repair of complete atrioventricular septal defects at a median age of 3.9 months (40% < 3 months). A single-patch technique was used in all patients. The cleft was closed completely in 61 patients and partially (n = 10) or not at all (n = 1) in select patients at risk for valve stenosis. Left atrioventricular valve annuloplasty was performed in 18 patients. On the basis of transesophageal echocardiographic findings, 10 patients were returned to bypass for revision of the valve repair. RESULTS: There was one early death in a patient with single left papillary muscle, no early reoperations, and no new permanent arrhythmias. Only three patients had moderate left atrioventricular valve regurgitation at discharge. During a median follow-up of 24 months, there was one late death and five reoperations for left atrioventricular valve regurgitation (n = 2) and/or systemic outflow obstruction (n = 4). Follow-up left atrioventricular valve regurgitation was moderate in three patients, mild in 14, and none/trace in 54. Age had no relation to postoperative atrioventricular valve regurgitation, death, or reoperation. CONCLUSIONS: Despite concerns about fragility of valve tissue in very young patients, excellent results can be achieved with meticulous techniques. From neonates to older infants, age at repair does not influence outcome or valve function.     

Double patch closure of ventricular septal defect with increased pulmonary vascular resistance

BACKGROUND: Closure of a large ventricular septal defect (VSD) in children with elevated pulmonary vascular resistance is associated with significant morbidity and mortality. Pulmonary hypertensive episodes continue to be a major cause of postoperative morbidity and mortality. We designed a fenestrated flap valve double VSD patch in an effort to decrease the morbidity and mortality associated with the closure of a large VSD with elevated pulmonary vascular resistance. METHODS: Eighteen children (mean age, 5.7 years) with a large VSD and elevated pulmonary vascular resistance (mean, 11.4 Wood units) underwent double patch VSD closure using moderately hypothermic cardiopulmonary bypass and cardioplegic arrest. The routine VSD patch was fenestrated (4 to 6 mm) and on the left ventricular side of the patch, a second, smaller patch was attached to the fenestration along its superior margin before closure of the VSD. RESULTS: All children survived operation and were weaned from inotropic and ventilator support within 48 hours postoperatively. Postoperative pulmonary artery pressures were significantly lower than preoperative values. One child died 9 months postoperatively. CONCLUSIONS: Closure of a large VSD in children with elevated pulmonary vascular resistance can be performed with low morbidity and mortality when a flap valve double VSD patch is used.     

Transxiphoid approach without median sternotomy for the repair of atrial septal defects

BACKGROUND: Interest in minimally invasive procedures has recently increased because it results in less surgical trauma, decreased patient discomfort, short hospital stay, reduced costs, and better cosmetic appearance. Based on these facts, we have been using the transxiphoid process approach without sternotomy for the correction of atrial septal defects. METHODS: From July 1996 to January 1997, the xiphoid process window approach was performed in 10 patients with ostium secundum atrial septal defect. Ages ranged from 6 months to 14 years (mean, 5.3 years). In all patients, extracorporeal circulation was carried out by means of cannulation of the femoral artery and both caval veins and of aortic cross-clamping. Videothoracoscopy was used to improve visualization of the aorta. RESULTS: There were no intraoperative or postoperative complications, and in all but 1 patient, extubation was possible while in the operating room. CONCLUSIONS: The xiphoid process window, with no median sternotomy, permitted closure of the atrial septal defects with good results and could be used as a less invasive technique for their correction.     

Autosomal dominant hereditary atrial septal defect with heart conduction defects and mitral valve insufficiency

An autosomal dominant inherited ASD with conduction defects in one family is described. 6 members of 4 generations were fallen ill. In 4 patients the diagnosis was made clinically, in 2 sisters the diagnosis was confirmed by operation. Moreover, the last 2 patients had a mitral insufficiency--probably congenital. The ecg-findings of 4 patients additionally showed conduction defects in form of AV-and bundle branch blocks.     

The use of epoxy patch grafts for the repair of experimentally-created diaphragmatic defects in dogs

Canine pericardium which had been treated with polyepoxy compounds (Denacol EX-313) was used as a patch graft for the correction of experimentally-created diaphragmatic defects in five dogs belonging to the same litter. Clinical, macroscopic and histological examinations were conducted every month up to five months after suturing of the patch graft. Clinical examination of the patch graft showed no apparent abnormalities. Macroscopic examination conducted during autopsy showed that the patch graft maintained adequate elasticity for five months after suturing, the surface of the patch graft was covered with a thin membrane and neovascularization was observed. Histological examination showed that the surface of the patch graft was covered with a thin membrane. Inflammatory tissue reactions were observed at one month, but gradually decreased from the second month onwards. In addition, the patch graft had excellent tissue affinity.     

Systemic collateral and pulmonary artery stenosis in patients with congenital pulmonary valve atresia and ventricular septal defect

Angiograms of 30 patients with congenital pulmonary valve atresia, ventricular septal defect, and large systemic-pulmonary collateral arteries (SPCAs) were evaluated. All had aortography, 28 had SPCA arteriography, and 26 had right ventriculography. Seventeen (65%) of 26 patients had a right ventricular infundibulum, 23 (77%) had a pulmonary artery confluence, and five of the nine patients without a right ventricular infundibulum had a confluence. Sixty-six SPCAs of aortic origin were seen; 28 (42%) had narrowing and 21 patients (70%) had one or more narrowed SPCAs. Five patients had collaterals from internal mammary, subclavian or innominate arteries. Fourteen (47%) had hilar pulmonary artery stenosis. Of these 14 patients mild peripheral stenosis was demonstrated in five. Right aortic arch was present in 15 patients (50%). Complete angiographic delineation of pulmonary vasculature is an essential procedure for preoperative detection of pulmonary and SPCA stenoses in these patients.     

Results of left atrioventricular valve reconstruction after previous correction of atrioventricular septal defects

OBJECTIVE: The objective of this study was to determine causes of severe left atrioventricular (AV) incompetence and the factors leading to the success of valve repair later after correction of atrioventricular septal defects (AVSD). METHODS: A total of 28 patients aged 5 months to 38 years (mean age 6.7 years) were operated for significant (grade II-III) left AV valve incompetence (LAVVI), two months to twenty-five years (median 1.5 years) after correction of complete (11 patients) or partial atrioventricular septal defects. Fourteen patients had initially undergone surgery during infancy. RESULTS: At reoperation a completely open or partially sutured cleft was found in 16 patients combined with dysplastic valve tissue in four cases, with a fibrotic valve in three cases, with posterior leaflet prolapse in two cases, with a double orifice valve in three cases, and a parachute valve in two cases. Partial or complete reopening of a previously sutured cleft caused by suture dehiscence was found in 12 cases combined with a fibrotic valve in five cases, with a dysplastic valve in one case and with severe deformity of valve in one case. A combination of these anomalies was observed in seven patients in both groups. Left atrioventricular valve repair including cleft closure combined with annuloplasty and other surgical procedures resulted in the disappearance or significant diminishing of LAVI in 18 patients (64%). Severe SAVI persisted in six patients, five of them exhibiting a combination of several additional left AV valve anomalies (fibrotic or dysplastic valve, parachute valve). Five of these six patients underwent successful left AV valve replacement with a mechanical prosthesis 7 days to 2 years after reoperation. The presence of additional left AV valve anomalies was the single statistically significant factor for recurrent major LAVVI after reoperation (P = 0.0106). There were two postoperative deaths in patients with mild LAVVI after surgery, and no late deaths. CONCLUSION: An open cleft is the major factor of late severe SAVVI after correction of AVSD. Although suturing the cleft in conjunction with performing annuloplasty improved valvular function in most of the cases, the presence of severe left AV valve anomalies increased the risk of recurrent LAVVI and the need for valve replacement, thus playing a major role in determining the outcome of valve reconstruction in patients after reoperation.     

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair

OBJECTIVE: This study compares the quality of valve replacement and repair performed through minimally invasive incisions as compared to the standard operation for aortic and mitral valve replacement. SUMMARY BACKGROUND DATA: With the advent of minimally invasive laparoscopic approaches to orthopedic surgery, urology, general surgery, and thoracic surgery, it now is apparent that standard cardiac valve operations can be performed through very small incisions with similar approaches. METHODS: Eighty-four patients underwent minimally invasive aortic (n = 41) and minimally invasive mitral valve repair and replacement (n = 43) between July 1996 and April 1997. Demographics, procedures, operative techniques, and postoperative morbidity and mortality were calculated, and a subset of the first 50 patients was compared to a 50-patient cohort who underwent the same operation through a conventional median sternotomy. Demographics, postoperative morbidity and mortality, patient satisfaction, and charges were compared. RESULTS: Of the 84 patients, there were 2 operative mortalities both in class IV aortic patients from multisystem organ failure. There was no operative mortality in the patients undergoing mitral valve replacement or repair. The operations were carried out with the same accuracy and attention to detail as with the conventional operation. There was minimal postoperative bleeding, cerebral vascular accidents, or other major morbidity. Groin cannulation complications primarily were related to atherosclerotic femoral arteries. A comparison of the minimally invasive to the conventional group, although operative time and ischemia time was higher in minimally invasive group, the requirement for erythrocytes was significantly less, patient satisfaction was significantly greater, and charges were approximately 20% less than those in the conventional group. CONCLUSIONS: Minimally invasive aortic and mitral valve surgery in patients without coronary disease can be done safely and accurately through small incisions. Patient satisfaction is up, return to normality is higher, and requirement for postrehabilitation services is less. In addition, the charges are approximately 20% less. These results serve as a paradigm for the future in terms of valve surgery in the managed care environment.     

Nitric oxide treatment for pulmonary hypertension after neonatal cardiac operation

This report describes a newborn with transposition of the great arteries who underwent a Blalock-Taussig shunt with transient improvement in oxygenation, but required emergent insertion of a central shunt later the same day due to progressive hypoxia and cardiac arrest. Two hours after central shunt insertion, sudden episodes of hypoxia and hypotension developed that were resistant to all pharmacologic therapy. Inhaled nitric oxide (25 ppm) was then administered with dramatic improvement in oxygenation and hemodynamics within minutes. The patient's condition stabilized after these measures, and nitric oxide therapy was discontinued after 2 days.     

Atrial septal displacement for repair of anomalous pulmonary venous return into the right atrium

BACKGROUND: In the repair of anomalous connection of the pulmonary veins to the right atrium, the use of a baffle of pericardium to divert the pulmonary venous blood into the left atrium could cause pulmonary venous obstruction as a result of thickening of the pericardial patch. Anomalous pulmonary venous drainage to the right atrium caused by malposition of the atrial septum primum can be repaired by displacing the shifted septum primum to the normal position. METHODS: In 5 patients with total (n=2) or partial (n=3) anomalous pulmonary venous drainage into the right atrium, the septum primum was shifted toward the left atrium and the pulmonary veins drained into the anatomic right atrium despite their normal connection with the posterior wall of the left atrium. This method consisted of incision of the posterior edge of the atrial septum primum and displacement of the incised atrial septum between the anomalous pulmonary veins and both venae cavae. No patch was used. RESULTS: Postoperative echocardiography showed a wide pathway from the pulmonary veins to the left atrium with no stenotic portions. No atrial arrhythmias occurred after the operation. CONCLUSIONS: This technique may be advantageous because it allows for future growth of the route of the pulmonary venous pathway and avoids postoperative supraventricular arrhythmias.     

Evaluation of pulmonary arterial trunk on frontal chest radiograph in patients with atrial septal defects

Atrial septal defect (ASD) is one of the most common congenital cardiac anomalies encountered in adulthood. The evaluation of the pulmonary hypertension in ASD is clinically important for operative indication and prognosis. The pulmonary vasculature in chest radiographs in patients with ASD is characterized as dilatation of the central pulmonary arteries and increase of the peripheral pulmonary vessels in patients without pulmonary arterial hypertension (PH) and constriction of the peripheral pulmonary arteries in those with pulmonary hypertension. While the dilatation of the main pulmonary artery occurs in the patients both with and without pulmonary hypertension, its precise radiographic evaluation with regard to the morphological and hemodynamic change of the right ventricle and pulmonary arteries has not been reported. This study was to determine if the contour of the main pulmonary artery segment of the cardiac silhouette in the conventional frontal chest radiograph could be used 1) as indicators of PH or raised right ventricular pressure and 2) as a reliable base for evaluation of the size of the right ventricule (RV) in ASD. The intersection of the line (line A) drawn tangentially to the lateral lower margin of the main pulmonary artery segment to the horizontal line at the left hemidiaphragm is closely related to the apex of RV as measured by right ventricular angiography in supine position. The ratios of the distance of the intersection from the midline of the frontal chest radiograph to the internal diameter of the left hemithorax in normal subjects were 0.50 +/- 0.08 (mean +/- standard deviation) for male and 0.54 +/- 0.09 for female. The ratio increased with increasing left-to-right shunt [0.59(Qp/QS < 2), and 0.71 (Qp/QS > 2)] and shows a tendency of decrease with raised right ventricular systolic pressure (0.52-0.64 in normal subjects and patients with mild raised right ventricular systolic pressure and 0.43 in patients with severe raised right ventricular systolic pressure). The measurement of the angle of the line A from the vertical line tends to show increasing decrease with raised pulmonary arterial and right ventricular systolic pressure (20.1 degrees +/- 4.9 in mild PH and 10.3 degrees +/- 4.1 in moderate to severe PH). The decrease of the angle of the line A to the vertical line was well correlated with conventional radiographic criteria of the right and left central pulmonary arteries of PH.(ABSTRACT TRUNCATED AT 400 WORDS)     

An interventricular septal defect, pulmonary stenosis and bicuspid pulmonary valve in a Welsh pony foal

A 6 month Welsh pony filly with an interventricular septal defect in conjunction with a pulmonary stenosis due to a bicuspid pulmonary valve is described. The animal had poor exercise tolerance, a loud pansystolic murmur and a precordial thrill. Blood pressure and oxygen tension values obtained during cardiac catheterization suggested the diagnosis which was confirmed at autopsy.