A. Eijgelaar

Influence of age on survival, late hypertension, and recoarctation in elective aortic coarctation repair. Including long-term results after elective aortic coarctation repair with a follow-up from 25 to 44 years.

The optimal age for elective repair of aortic coarctation is controversial. The optimal age should be associated with a minimal risk of recoarctation, late hypertension, and other cardiovascular disorders. The purpose of this retrospective study is to determine the actuarial survival after aortic coarctation repair 25 years or more after operation and to calculate the optimal age for elective aortic coarctation repair. From 1948 to 1966, 120 consecutive patients underwent aortic coarctation repair. Eighty-seven were male (72.5%). The mean age at operation was 15.5 years (SD +/- 9.1 years). Resection and end-to-end anastomosis was performed in 103 patients (85.8%). Early mortality occurred in 6 patients as a result of surgical problems, whereas late mortality in 15 patients was predominantly caused by cardiac causes. The mean follow-up period was 32 years (range 25 to 44.2 years). Ninety-two patients 96.8%) were in New York Heart Association class I. The probability of survival 44 years after operation was 73%. Patients younger than 10 years at operation had the highest probability of survival at 97%. Multivariate analysis produced age at operation as the only incremental risk factor for the occurrence of recoarctation, of late hypertension, and of premature death. So that these sequelae can be avoided, elective aortic coarctation repair should be performed around 1.5 years of age. At that age, the probability of recoarctation will have decreased to less than 3%, and the probability of upper body normotension and long-term survival will be optimal.

Decision making for the surgical management of aortic coarctation associated with ventricular septal defect

Coarctation of the aorta and associated ventricular septal defect may be repaired simultaneously or by initial coarctation repair with or without banding of the pulmonary artery. The question is whether specific preoperative criteria can enable the surgeon to choose the optimal surgical management. Between 1980 and 1993, 80 infants younger than 3 months with coarctation and ventricular septal defect were treated surgically. In 64 infants (multistage group), simple coarctation repair was performed through a posterolateral approach, with concomitant banding of the pulmonary artery in 10 infants. Twenty ventricular septal defects were closed as a secondary procedure and four were closed as a tertiary procedure. Sixteen infants (single-stage group) underwent one-stage repair through an anterior midline approach. The total in-hospital mortality rate was 7.5%. Freedom from recoarctation after 5 years was 91.3% in the multistage group versus 60.0% in the single-stage group (p = 0.018). Freedom from secondary ventricular septal defect treatment in the multistage group after 5 years was 40.7%, versus 100% in the single-stage group (p = 0.016). Thirty-seven ventricular septal defects (47.8%) closed spontaneously. In particular, the preoperative left-to-right shunt and extension of the perimembranous VSD into the inlet or outlet were risk factors for the need for eventual surgical ventricular septal defect closure after initial coarctation repair. On the basis of these two risk factors, the probability of the need for eventual surgical treatment of ventricular septal defect after initial coarctation repair can be calculated. This policy offers a well-considered choice between single-stage and multistage repair, weighing the risk of secondary ventricular septal defect treatment versus the risk of recoarctation. Finally, the number of surgical procedures per infant will be as low as possible.

Rates of thromboembolism with three different mechanical heart valve prostheses: randomised study

In 434 operations for valvular heart disease, patients were randomised to receive Björk-Shiley, Edwards-Duromedics, or Medtronic-Hall mechanical prostheses. At a median follow-up time of 37.5 months there were no differences in hazard of death or non-embolic events. In the first six postoperative months the incidence of thromboembolism was about the same for the three valves. Subsequently, however, the incidence of thromboembolism for the Edwards-Duromedics valve was 3.9 times higher than for the Björk-Shiley valve, and for the Medtronic-Hall valve 2.6 times higher than for the Björk-Shiley valve.

LEFT ATRIOVENTRICULAR VALVE AFTER SURGICAL REPAIR IN ATRIOVENTRICULAR SEPTAL-DEFECT WITH SEPARATE VALVE ORIFICES (OSTIUM PRIMUM ATRIAL SEPTAL-DEFECT) - AN ECHO-DOPPLER STUDY

Left atrioventricular (AV) valve dysfunction is the most frequent major postoperative hemodynamic complication in patients with AV septal defect. The anatomy and function of the left AV valve were investigated in 64 patients with separate valve orifices (ostium primum atrial septal defect) who had survived corrective surgery. M-mode and cross-sectional echocardiograms of the left AV valve were obtained. Doppler flow tracings were obtained at the left AV valve orifice to determine if regurgitation was present. The findings were related to the position of the commissures between the leaflets, the size of the 3 leaflets and the position of the papillary muscles. Left AV valve regurgitation was present in 29 of 51 patients (57%). These patients had a significantly different left AV valve leaflet configuration, characterized by a large mural leaflet and a small inferior bridging leaflet. The size of the superior bridging leaflet is not a determinant factor. Thus, the configuration of the left AV valve in AV septal defect is related to the postoperative functional result. Awareness of the echocardiographic anatomy may influence the surgical approach to this defect.

Long-Term Follow-Up of 133 Atrioventricular Septal Defects

From 1962 to 1986 we operated on 133 patients with atrioventricular (AV) septal defect. Median follow-up time was 8 years. Of these 133, 90 had separate AV orifices and 43 had a common AV orifice. Primary complete repair was done in 129, pulmonary artery banding was done in three, of whom two underwent subsequent repair, and one patient with a concomitant severe pulmonary stenosis received a shunt. Total (operative and late) mortality was 23 patients [17%, 70% confidence limits (CL): 14%–22%]. Left AV valve replacement was done in eight patients (6%; CL: 4%–9%), never at the primary correction; of these, four patients died (50%; CL: 27%–73%). Logistic regression analysis showed (a) common AV orifice; (b) inability to repair the left AV valve adequately; and (c) major associated anomalies to be incremental risk factors for death. Late follow-up was obtained in all patients. Doppler echocardiographic investigation — more than 1 year after correction — of the left AV valve was obtained in 78 of the 110 survivors. The Doppler severity of regurgitation was semiquantified and the left atrium (LA)/aorta (Ao) ratio was measured. No or little regurgitation was found in 66 patients (85%; CL: 79%–89%), moderate regurgitation in ten patients (13%; CL: 9%–18%), while severe regurgitation was found in only two patients (3%; CL: 1%–6%). There was no difference in regurgitation or LA/Ao ratio between patients with common or separate AV orifices. Our conclusion is that most survivors show some regurgitation, but LA/Ao ratio is usually in the upper range of normal. Most patients are able to lead a normal life without physical limitations. Residual severe left AV valve regurgitation remains a risk factor that should be avoided at all costs. This is even more compelling because of the high mortality associated with late left AV valve replacement.

Anatomic Correlations between Left Ventricular Inflow and Outflow Tract in Atrioventricular Septal Defect with Separate Valve Orifices

Surgical repair of atrioventricular (AV) septal defect with separate valve orifices (“ostium primum defect”) can be seriously complicated by dysfunction of either the inflow or outflow components of the left ventricle [1]. Surgery is focused on repair of the trifoliate left AV valve before closing the interatrial communication [2]. The concept of a trifoliate AV valve, as promoted by Carpentier [3], aids considerably in its successful repair, although this concept has only gradually gained acceptance. The left ventricular outflow tract, on the other hand, is not visible via the usual surgical approaches; therefore, it has largely escaped attention. However, outflow tract obstruction can pose a serious postoperative problem and may necessitate further surgery.

The Blood-gas Analyzer and Disposable Pressure Monitoring Systems as Sources of Infection

During a bacteriological study to detect the various sources of infection in open-heart surgery, we frequently sampled, amongst others, the surgical wound area during surgery and the oxygenator after surgery.