Cristiane Martins

Fontan operation: a technique in evolution.

OBJECTIVES Recent experimental flow studies based on angiography and magnetic resonance have shown that total cavopulmonary anastomosis (TCPA) is a valid concept for surgical treatment of many congenital heart defects, but there is not agreement of the best surgical arrangement. Our purpose is to analyze the immediate results with three different techniques of TCPA. METHODS We sought to analyze retrospectively all TCPA realized from January 2005 to July 2008; there were 40 patients, all with previous Glenn anastomosis, with mean age of 6.4 +/- 3.2 years. Three different techniques were employed: Group 1 (G1) lateral tunnel, Group 2 (G2) extracardiac conduits, Group 3 (G3) intracardiac conduit directed to the left pulmonary artery. All patients had a fenestration done. RESULTS G1 had 11 patients, G2 10 patients and G3 19 patients. Preoperative data were similar in the 3 groups (P>0.05). Surgical mortality was higher in Groups 1 and 2 (9.1% and 10%) compared to Group 3 (0%) but there was no statistical significance (P=0.3841). Pleural effusion was absent in Group 3 (0%), which was statistically significant in relation to the other groups (P=0.0128). The hospitalization time was also significantly lower in G3 (8 days) in relation to G1 (18 days) and G2 (13 days) (P=0.0164). CONCLUSION Intracardiac TCPA was associated with lower postoperative morbidity and is currently our preferred technique.

Porcine stentless valve/bovine pericardial conduit for right ventricle to pulmonary artery

BACKGROUND AND OBJECTIVES We assessed the long-term outcome of a glutaraldehyde-preserved bovine pericardial conduit containing a stentless composite porcine aortic valve. METHODS Between November 1985 and May 1995, 33 stentless porcine valves attached to bovine pericardial conduits were used in 33 patients with complex congenital cardiac malformations. These patients required a conduit between the right ventricle and the pulmonary artery because of an absent or inadequate pulmonic artery. All patients were approached by midsternotomy. One patient with pulmonic atresia and an interventricular septal defect required left thoracotomy for ligation of collaterals. RESULTS Of the initial 33 patients, clinical follow-up was performed in 23 discharged patients (70%) for 1.7 to 10.5 years. The echo-Doppler analysis performed in each of the 23 followed patients showed excellent conduit and valve function in all but 4 patients, in whom a valve gradient of 60 mm Hg was noted. There was no tissue structural failure noticed in this study. CONCLUSIONS The SJM Biocor (Belo Horizonte, Brazil) bovine pericardial stentless valved conduit performed well as a substitute for the right ventricle to pulmonary artery connection.

Modified Norwood procedure for hypoplastic left heart syndrome

OBJETIVO: Apresentar os resultados do tratamento da sindrome de hipoplasia do coracao esquerdo (SHCE) com tecnica de Norwood modificada, na qual somente sao usados tecidos autologos para a reconstrucao do arco aortico. METODO: De janeiro a dezembro de 2002, cinco recem-nascidos com idade variando de dois a nove dias (media 5,0 dias) foram submetidos a operacao de Norwood modificada. O diâmetro da aorta ascendente variou de 5 a 8 mm (media 6,2 mm). Foi empregada tecnica na qual o arco aortico e seus ramos foram amplamente dissecados, permitindo a reconstrucao de um novo arco aortico tendo a arteria pulmonar como via de saida, e com a utilizacao exclusiva de tecidos do proprio paciente. Anastomose sistemico-pulmonar com politetrafluoretileno expandido de 3,0 mm foi utilizada em tres pacientes e de 3,5 mm em dois pacientes. Todos foram operados com parada cardiocirculatoria total. RESULTADOS: O tempo de parada cardiocirculatoria variou de 41 a 60 minutos (media 52,8 minutos). Todas as criancas sobreviveram ao ato operatorio e foram encaminhadas para a unidade de terapia intensiva com o esterno aberto. Ocorreu um obito no 9: dia de pos-operatorio por sepse, o que resultou numa taxa de sobrevivencia imediata de 80%. Ocorreu um obito tardio por pneumonia de aspiracao aos dois meses. Uma crianca foi submetida ao segundo estagio da operacao (cavo pulmonar) e encontra-se bem. Duas criancas estao em acompanhamento aguardando o proximo estagio. Em nenhuma delas existem evidencias de obstrucao do novo arco aortico. CONCLUSAO: A tecnica de Norwood modificada mostrou-se eficaz e com risco cirurgico aceitavel para o tratamento da SHCE, sem evidencias de obstrucao do arco aortico reconstruido.

Estratégia cirúrgica na transposição das grandes artérias associada à obstrução do arco aórtico

Objective: Our results on the transposition of the great arteries with aortic arch obstruction were analyzed to establish our present protocol.

Reconstrução da artéria pulmonar na operação de Jatene

INTRODUCTION: We describe our experience with Jatenes operation in the surgical treatment of transposition of great arteries (TGA) where pulmonary artery reconstruction was performed with two autologous pericardial patches in order to spare the maximum amount of native aortic tissue. MATERIAL AND METHODS: There were 52 children (38 simple TGA, 14 TGA + VSD) and their age ranged from 3 days to 17 months. Body weight ranged from 2.400 to 7.400 kg (m=3.377 kg). All patients were operated under moderate hypothermia with a single infusion of blood cardioplegia. Average extracorporeal circulation time was 110.6 min and average aortic cross-clamping time was 72.5 min. RESULTS: There were 3 (5.8%) early deaths caused by pulmonary infection in 2 of them and by obstruction of the endotracheal tube in 1. There were 2 late deaths; one in a reoperation of severe coronary ostial stenosis (6 months p.o.) and another owing to pneumonia (1 year p.o.). Late echocardiography was performed in 20 children who were operated in the neonatal period and had a minimum of 5 months follow-up (m=12.7). Supravalvular pulmonary stenosis was found in only 1 (5%) patient and results were consistent with an uniform pulmonary artery development. CONCLUSION: Reconstruction of the pulmonary artery in Jatenes operation for TGA should be carried out with maximal preservation of the native aortic tissue.

Cirurgia de Glenn bidirecional: importância da manutenção de fluxo "pulsátil" na artéria pulmonar

In order to evaluate the effects of pulsatile flow in the pulmonary artery of patients undergoing bidirectional cavopulmonary shunts (BCS), we reviewed the data of 36 patients operated upon from October 1990 to July 1994. Age at operation ranged from 11 months to 14 years (mean 4.4 ± 3.4 years) and diagnoses were as follows: tricuspid atresia (18), single ventricle (16), mitral atresia (1) and pulmonary atresia with intact ventricular septum (1). A total of 19 (52.8%) patients had a prior palliative operation done. Cardiopulmonary bypass was used in every case, with mild hypothermia in 11 cases and profound hypothermia and circulatory arrest in the remaining. The surgical technique was an anastomosis between the superior vena cava and the ipsilateral pulmonary artery in an end-to-side fashion. The main pulmonary artery was ligated only if the mean pressure taken at the site of the anastomosis was higher than 15 mmHg but in 2 recent cases with a very high mean pulmonary pressure, the main pulmonary artery was banded, adjusting the pressure to the desirable levels. The overall hospital survival was 91.7% (33 patients). One patient required a systemic to pulmonary shunt due to persistent low arterial oxygen saturation, 7 days after the BCS. Twenty-eight patients were followed for a mean of 1.8 ± 1.2 years (3 months to 4.1 years) and were divided in 2 groups: A-18 patients without pulsatile flow in the pulmonary artery, and B-10 patients with pulsatile flow. In Group B, the mean arterial saturation has ranged from 80% to 90% (mean 86 ± 3.8%) and is significantly higher than in Group A (68 to 85%, mean, 77.6 ± 5.5) (p<0.001). Two patients of Group A are in NYHA functional class III, whereas all patients of Group B are in class I or II (p=0.05). There was one late death and one patient required a subsequent Fontan procedure, both of Group A. Thus, the presence of pulsatile flow in the pulmonary artery improved the arterial oxigen saturation and exercise tolerance in patients submitted to a cavopulmonary shunt, without adverse effects on pulmonary circulation.

Oclusão percutânea do canal arterial com molas de liberação controlada

BACKGROUND: The percutaneous occlusion of patent ductus arteriosus is an effective and safe procedure and surgical intervention is restricted to specific unfavorable technical conditions, such as in premature infants. The controlledrelease coil has proven to be a low cost and safe method. We report our experience with this device, discussing technical aspects of the implant and coil characteristics. METHOD: From 2002 to 2009, 90 patients were referred for the percutaneous occlusion of patent ductus arteriosus. The size of the coil was based on the narrowest ductal luminal diameter. Diagnosis of all of the patients was based on clinical evaluation and transesophageal echocardiography. Aortic angiogram was performed immediately after the procedure to assess residual shunt and early complications. RESULTS: Age ranged from 4 months to 36 years (median: 3 years and 4 months). The patent ductus arteriosus diameter ranged from 0.2 mm to 6 mm (mean: 2.3 mm). According to Krichenkos morphological classification, the types of patent ductus arteriosus were divided as follows: type A, 80 (88.8%); type C, 4 (4.6%); and type E, 6 (6.6%). Success was achieved in 97.6% (81/83) of the cases. There was no evidence of hemolysis, endarteritis or vascular obstruction. We observed only one case of embolization where the device was retrieved back into the delivery catheter and repositioned successfully. CONCLUSION: This study showed that the controlled-release coil is safe and effective for the percutaneous occlusion of patent ductus arteriosus.

Mid- and Longterm Neo-Aortic Valve Regurgitation after Jatene Surgery: Prevalence and Risk Factors

Background Jatene surgery became the surgical procedure of choice to repair transposition of the great arteries (TGA) in neonates and infants. Late complications, mainly related to the pulmonary outflow tract and coronary arteries, are well known. The behavior of the neo-aortic valve is a cause of concern because of its potential for requiring late reoperation. Objectives To assess the prevalence and risk factors of neo-aortic valve regurgitation in 127 patients in the late postoperative period of the Jatene surgery. Methods Of the 328 survivors of the Jatene surgery at the Biocor Institute from October 1997 to June 2015, all patients undergoing postoperative follow-up were contacted via telephone, 127 being eligible for the study. The patients were divided into two groups, simple TGA and complex TGA groups, with follow-up means of 6.4 ± 4.7 years and 9.26 ± 4.22 years, respectively. Echocardiography was performed with adjusted measurements (Z-score) of the neo-aortic annulus, sinus of Valsalva, sinotubular region and ascending aorta, as well as quantification of the neo-aortic valve regurgitation grade. Results The incidence of mild neo-aortic valve regurgitation was 29% in a follow-up of 7.4 ± 4.7 years. Moderate regurgitation was identified in 24 patients with age mean (± standard-deviation) of 9.81 ± 4.21 years, 19 of whom (79%) in the complex TGA group. Those patients had a higher aortic annulus Z-score. The reoperation rate due to neo-aortic regurgitation associated with aortic dilation was 1.5%, all patients in the complex TGA group. Conclusion This study shows that, despite the low incidence of reoperation after Jatene surgery due to neo-aorta dilation and neo-aortic valve regurgitation, that is a time-dependent phenomenon, which requires strict vigilance of the patients. In this study, one of the major risk factors for neo-aortic valve regurgitation was the preoperative pulmonary artery diameter (p < 0.001).

A Slight Modification of the Intra-atrial Conduit Fontan Procedure

We read with great interest a recent article in the World Journal for Pediatric and Congenital Heart Surgery by Iacona and colleagues titled ‘‘Fontan operation for patients with complex anatomy: the intra-atrial conduit technique.’’ The authors described the use of an intra-atrial conduit to produce a total cavopulmonary connection in patients with a univentricular heart and dextrocardia in situs solitus anatomy or in patients with a univentricular heart in the setting of heterotaxy. Their technique is an adaptation of techniques described by Michielon, de Leval, and Stamm. In this context, we suggest a minor modification that we believe is important. That is, in our practice, since 2005, we have implemented an intra-atrial conduit directed through the interatrial septum to the roof of the left atrium. This technique utilizes a conduit which is short and straight to direct flow from the inferior vena cava to the left pulmonary artery (Figure 1). As described in our recent publication, this modification may be hydrodynamically advantageous. Its use has been associated with reduced pleural effusions and shorter postoperative hospital stay (N 1⁄4 19 patients). This technique is noteworthy because it can be used in a variety of anatomic situations. We are presently conducting a larger follow-up study of 60 consecutive patients in whom we performed the aforementioned modified procedure.

Estratégia cirúrgica na transposicão das grandes artérias com septo interventricular intacto após o período neonatal

OBJECTIVE To assess the surgical results in patients with transposition of the great arteries and intact ventricular septum undergoing surgery after the neonatal period. METHODS From January 1998 to March 2004, 121 children with transposition of the great arteries with intact ventricular septum were treated, 29 (24%) of whom after the neonatal period. Selection for surgical treatment was based on echocardiographic assessment by use of the calculation of left ventricular mass and configuration of the ventricular septum. Of the 29 children, 12 were selected for primary anatomic correction, 12 for 2-stage correction after surgical preparation of the left ventricle, and 5 underwent atrial correction. RESULTS In the group undergoing primary anatomic correction, one (8.3%) patient died at the hospital due to sepsis. In the group undergoing 2-stage correction, 5 patients underwent slow preparation with correction 3-6 months after the first stage, 4 of whom died after the first stage. This fact caused a change in our protocol, with adoption of the rapid preparation technique in the other 7 patients, of whom all achieved the second stage. Of the 8 children undergoing the second stage, one died at the hospital and another died later. Late clinical evolution of the children in both groups is excellent. CONCLUSION The echocardiographic selection allowed a safe choice of the best surgical approach for patients with transposition of the great arteries and intact ventricular septum after the neonatal period.