Adnan Cobanoglu

Aortico-Left Ventricular Tunnel: A Clinical Review and New Surgical Classification

This is a collective review of aortico-left ventricular tunnel (ALVT) in the English-language literature. We include the long-term follow-up of a previously reported patient, and a report on 2 new patients. To date, 37 cases of ALVT have been reported. Controversies regarding the definition, etiology, local anatomy, and treatment are discussed. The ages of the patients ranged from 1 day to 25 years old, and the male to female ratio was 2:1. There were associated anomalies in 27% of the patients, and moderate to severe heart failure in 59% of them. Mortality was 100% in the medically managed group; the surgical mortality was 16%. Previous surgical techniques utilized were simple closure, patch closure of the aortic end, and obliteration of the tunnel on both ends. Progressive aortic incompetence seems to be a common, but not well-documented problem on long-term follow-up. We have classified the lesion into four types (I, II, III, and IV) that have a bearing on the appropriate surgical techniques of repair, and describe a new technique for the repair of type III ALVT in which septal aneurysm is present.

Cardiac allografts from high-risk donors: Excellent clinical results☆

Rising waiting list mortality and increasing demand for donor organs have led to extension of traditionally accepted criteria for evaluation of cardiac grafts. From December 1985 to June 1992, 188 cardiac grafts were orthotopically transplanted into 178 recipients. Of these grafts, 38.3% (72/188) were defined as high-risk donors. Risk criteria included prolonged cardiopulmonary resuscitation, age greater than 40 years, high inotrope requirements, undersizing by more than 20% body weight, significant wall motion impairment by echocardiography, elevation of myocardial enzyme levels, and cold ischemia time greater than 4 hours. There were no recipient deaths attributable to primary graft failure in the perioperative period. Operative (30-day), 1-year and 5-year survival was 95.5%, 86.1%, and 77.3%, respectively, in the high-risk group compared with 93.7%, 86.0%, and 67.2%, respectively, in the low-risk donor cohort (p = 0.94). Comparison of duration of postoperative inotrope use, intensive care unit stay, total hospital stay, and in-hospital costs revealed no significant trends favoring either group in postoperative morbidity. Among long-term survivors, development of graft coronary disease was noted in 47.1% (24/51) of the high-risk donor group and only 17.4% (12/69) of the remaining group (p = 0.0005). Left ventricular ejection fractions in the high risk donor group were 0.58 +/- 0.01 at 2 years. Review of this series suggests that selective use of apparently compromised cardiac donors is compatible with excellent cardiac function and survival. Higher incidence of graft vasculopathy may cause significant morbidity during late follow-up.

Total correction of tetralogy of Fallot in the first year of life: late results.

BACKGROUND Correction of tetralogy of Fallot in patients less than 1 year of age offers the advantage of a more normal development; but in the majority of cases exposes the patient to the possibly of a higher mortality with one-stage primary repair, and to the long-term effects of a transannular patch, which is often necessary. METHODS A retrospective review of total correction of tetralogy of Fallot performed in 63 consecutive patients at less than 1 year of age was made. Risk factors for operative mortality and functional status at follow-up were analyzed. Follow-up was obtained from clinic appointments and telephone questionnaires. RESULTS The operative mortality was 6%, with three late deaths. Aortic cross-clamp time more than 60 minutes (p = 0.023), cardiopulmonary bypass time more than 90 minutes (p = 0.016), and frequent preoperative respiratory tract infection symptoms (p = 0.008) affected operative survival; whereas age less than 3.0 months or weight less than 6.0 kg did not. Mean follow-up is 11.6 years (+/- 0.6 years, standard error). Actuarial survival is 89% (+/- 4%) and freedom from reoperation is 96% (+/- 4%) at up to 20 years after correction. Eighty-seven percent of patients have normal echocardiographic right ventricular function. Only 4 patients have greater than moderate pulmonary regurgitation by echocardiography. Three of these four patients are asymptomatic. At more than 15 years postoperatively, 88% of patients have good-to-excellent functional status. CONCLUSIONS Early correction of tetralogy of Fallot at less than 1 year of age can have a low operative mortality and provide excellent asymptomatic long-term survival.

Idiopathic main pulmonary artery aneurysm

Main pulmonary artery aneurysms with no underlying pathology are very rare, and the role of surgery in this entity is not well defined. We report our experience of one case.

Depression in patients being evaluated for heart transplantation

In the evaluation of 68 consecutive heart transplant candidates, 37 (54%) had one or more depressive syndromes. Premorbid psychiatric risk factors of depression were prevalent throughout the group. Statistically significant associations with depression were found with age, educational and occupational levels, and a history of past depressive episodes, but not with family psychiatric history, parental loss in childhood, history of serious childhood illness, or history of substance abuse. Of the 43 patients transplanted, 16 of 22 who were depressed preoperatively required psychiatric intervention postoperatively compared to 8 of 21 who were not depressed; 75% had a beneficial response to treatment. We recommend that a diagnosis of depression not be considered reason to exclude otherwise suitable candidates for cardiac transplantation.

Total anomalous pulmonary venous connection in neonates and young infants: Repair in the current era☆

Total anomalous pulmonary venous connection has been one of the more challenging congenital heart defects in newborns and young infants despite improvements in surgical technique, cardiac anesthesia, neonatal myocardial preservation, and postoperative care. Since 1981, 30 patients with total anomalous pulmonary venous connection have undergone primary total correction. Mean age at operation was 28 +/- 6 days and mean weight, 3.3 +/- 0.7 kg. Essential features of the surgical approach in these small patients included early surgical intervention, profound hypothermia with total circulatory arrest, cardioplegic myocardial preservation, and a wide posterior anastomosis. Operative mortality was 13% +/- 6%. All four deaths were in patients having emergency operation within 24 hours of the surgical consult and requiring ventilator support preoperatively. The mean follow-up is 47 +/- 7 months. There have been two late deaths, and the 7-year survival rate is 79% +/- 8%. There have been two reoperations, and 91% +/- 6% of the patients are reoperation free at 7 years. Only 1 of the 24 surviving patients is symptomatic. Growth in survivors is closely monitored. The height growth percentile is less than 5% in 15% +/- 8% of survivors and the weight growth percentile, less than 5% in 17 +/- 8%. During the past decade, with a consistent surgical approach to neonates and infants with total anomalous pulmonary venous connection, it has been possible to achieve low early mortality, low attrition, and excellent late results.

Aortic Valve Replacement with the Starr-Edwards Prosthesis: A Comparison of the First and Second Decades of Follow-up

There are few prostheses in current use that allow 20-year follow-up. This report compares the rates of valve-related complications during the first and second decades following aortic valve replacement with the Silastic ball prosthesis. (table; see text) Valve-related complication rates with this prosthesis have been low overall. Performance characteristics of this valve have remained stable through the second decade of follow-up. These results should be used as the standard in the evaluation of long-term results with other more recently introduced mechanical and tissue valves.

Surgery for coarctation of the aorta in infants younger than 3 months: end-to-end repair versus subclavian flap angioplasty: is either operation better?

OBJECTIVE Recurrent coarctation is a complication which is seen at a consistent rate following all types of repair for coarctation of the aorta. Particularly disappointing late results are reported in younger infants, under 3 months of age. This retrospective analysis was undertaken to compare the outcomes on late follow-up between subclavian flap angioplasty and resection and end-to-end repair, in this age group. METHODS Over a 12-year period, between 1982 and 1994, 86 infants under 3 months of age underwent surgical repair of coarctation (39 resections and end-to-end repair, and 47 subclavian flap angioplasty procedures). Operative mortality was not significantly different (P = 0.6) between resection and end-to-end repair (5.1%) and subclavian flap angioplasty (8.5%). All operative deaths (six patients) were in infants with associated ventricular septal defects. The mean follow-up for all patients was 7.95 years +/- 4.10 (range 0-14.5 years). The 5-year survival for resection and end-to-end repair was 87 +/- 5%, compared to 75 +/- 7% for subclavian flap angioplasty (P = 0.2). RESULTS Recurrent coarctation occurred in nine patients who needed reoperation. The reoperation-free rates at both 5 and 10 years for resection and end-to-end anastomosis, and subclavian flap repair were 86 +/- 6% and 90 +/- 5%, respectively. The recurrence in the resection and end-to-end anastomosis group were due to constrictive scarring at the anastomosis, whereas periductal tissue and growth of posterior aortic ridge caused recurrence in the subclavian flap angioplasty group. There were no deaths during reoperation for recurrence. CONCLUSIONS Both procedures are extremely effective for coarctation repair in young infants and run a similar risk of recurrence, which are due to completely different mechanisms. The surgeons expertise is the major determinant of outcome.

HLA-DR mismatching correlates with early cardiac allograft rejection, incidence, and graft survival when high-confidence-level serological DR typing is used.

To determine if cardiac allograft outcome is improved among patients with fewer HLA-DR mismatches with their donors, we studied 132 recipients of a primary cardiac allograft who were transplanted between December 1985 and December 1991. These recipients and their donors all had high-confidence-level serological HLA-DR typing, previously shown to correlate highly with DNA DR typing. Patients were divided in two groups based on the HLA-DR mismatch with their donors. Group I consisted of 78 patients with 1 or zero DR mismatch and group II of 54 patients with 2 DR mismatches. Allograft outcome measurements included incidence of moderate rejection, incidence of allograft vasculopathy at 12 months, cardiac function measured as left ventricular ejection fraction (LVEF) and cardiac index (CI), and actuarial graft survival up to 7 years. Groups I and group II were not different with regard to recipient age, donor age, ischemia time, pulmonary vascular resistance, sex, or PRA greater than 0%. Group II had a higher incidence of moderate rejection on the first-week biopsy (47% vs. 25%, P = 0.019), and during the first month (84% vs. 58%, P = 0.006), but no difference was found in frequency of rejection from months 2 to 12. LVEF was not different in the groups at any point. CI was better in group I at 12 months (2.76 vs. 2.5, P = 0.03). No statistically significant difference was found in incidence of allograft vasculopathy (17% vs. 26%, P = 0.204). Actual graft survival at 1 year was better for group I (91% vs. 74%, P = 0.008), and actuarial graft survival at 6 years also favored group I (76% vs. 56%, P = 0.04). Using high-confidence-level serological HLA-DR typing assignments we demonstrated that HLA-DR mismatching correlates highly with cardiac allograft outcome. Implications are that heart transplant survival could be improved if prospective matching were feasible and prioritized or if immunosuppression were tailored to the HLA-DR match.

Predicting hospital charge and length of stay for congenital heart disease surgery

Three hundred twenty-two consecutive operations between December 1985 and December 1989 for 10 types of low-risk congenital cardiac malformations were reviewed to determine the hospital charge and postoperative length of stay. Multiple regression analysis of variance was used to predict the influence of the primary diagnosis and various preoperative parameters. The average hospital charge was