Dominique Vala

Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency

OBJECTIVES Our goal was to evaluate the midterm results of aortic valve repair by a more sophisticated tailoring of cusp extension-taking into account the dimensions of the native aortic cusps-with the use of fresh autologous pericardium. PATIENTS AND METHODS Forty-one children who had severe rheumatic aortic insufficiency (mean age 11.5 +/- 2.7 years) underwent aortic valve repair by means of this cusp extension technique over a 5-year period. Twenty-four of them underwent concomitant mitral valve repair for associated rheumatic mitral valve disease. All children were then followed up by transthoracic echocardiography before discharge, at 3 and 6 months after the operation, and at yearly intervals thereafter. RESULTS Follow-up was complete in all patients and ranged from 3 months to 5 years (median 3 years). No operative and no early postoperative deaths occurred. Only 1 patient died, 9 months after the operation, of septicemia and multiple organ failure. Actuarial survival was 97% at 1 year and has remained unchanged at 3 years. On discharge, the degree of aortic insufficiency was grade 0 for 27 children and grade I for 14. Exacerbation of aortic insufficiency from grade I to grade II was observed in only 1 patient, and none of the children required reoperation for aortic insufficiency during the follow-up period. Mean peak systolic aortic valve gradients at discharge were lower than preoperative values (P =.04), and no significant increase in the peak systolic transvalvular gradient was detected thereafter during the follow-up period. Mean left ventricular dimensions were significantly reduced at discharge when compared with preoperative values (P <.0001). CONCLUSIONS Functional results of aortic valve repair with cusp extension using fresh pericardium have been satisfactory at medium term, particularly in children with a small aortic anulus at the time of initial repair, because the expansion potential of fresh autologous pericardium is equivalent to that of the growing sinotubular junction and aortic anulus diameters.

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency

BACKGROUND This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children. METHODS From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism. RESULTS All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair. CONCLUSIONS Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.

Ascending aortic aneurysm associated with aortic insufficiency due to Takayasu’s arteritis

We report the case of a child with an ascending aortic aneurysm associated with aortic insufficiency. Histopathological examination of the ascending aorta and aortic valve showed findings in favor of Takayasus arteritis, and subsequent evaluation of the entire aorta demonstrated the presence of multiple steno-occlusive lesions. This unusual clinical problem in the young population is discussed with regard to other eventual pathologies that should be taken into account in the differential diagnosis.

Aorticoright atrial tunnel.

Two unusual cases of aorticoright atrial tunnel are described. Both patients were referred to our institution for evaluation of a continuous heart murmur best heard along the right upper sternal border. Ascending aortography showed the tunnel taking its origin from the aortic root and entering the right atrium through a tortuous link. Both patients underwent surgical closure. In addition, a review of similar cases in the literature is presented.

Acute Type I Aortic Dissection With Concomitant Pulmonary Artery Dissection

A 55-year-old white male with hypertension and acute type I aortic dissection diagnosed on the basis of transthoracic echocardiography underwent emergency surgery. A large hematoma was found on the left lateral aspect of the ascending aorta, infiltrating the pulmonary trunk. A “hemi-arch” repair was performed with an open distal anastomosis technique using a standard tubular …

Ascending aorto-superior mesenteric artery bypass as a surgical option for revascularization in mesenteric ischemia associated with type B aortic dissection

We report the case of an acute ischemia of the superior mesenteric artery (SMA) after endovascular fenestration of a complicated acute type B aortic dissection. An initial attempt for endovascular revascularization of the SMA failed, and an ascending aorto-superior mesenteric artery bypass was urgently performed to salvage the small bowel. Surgery of patients in these specific settings is more complex because an adequate, more distal inflow vessel is often not present due to the dissected aorta and iliac arteries. This surgical option could be lifesaving and should be part of the vascular surgeons armamentarium.

Successful palliation of acute superior vena caval obstruction after the Senning operation

Superior vena caval obstruction after an intraatrial baffle procedure can lead to acute cerebral complications and hence requires immediate management. We present a case of successful palliation of acute superior vena caval obstruction after a Senning procedure by establishing a venous shunt between the innominate vein and pulmonary artery. This technique resulted in immediate hemodynamic and functional improvement that subsequently allowed for the enlargement of the superior vena cava-right atrial junction with a pericardial patch.

Choice of Graft Material at Primary CABG Influences Cardiac Death and Reintervention Rates

Objectives: To evaluate long-term survival and need for reintervention (redo CABG or percutaneous coronary artery transluminal angioplasty, PTCA) as a result of graft materials employed at the primary coronary artery bypass grafting (CABG). Subjects and Methods: 2,327 patients who underwent primary CABG between 1980 and 1990 were followed with regard to survival and reintervention requirements for a period of 10 years. There were three groups of patients. In group 1, CABG was performed between 1980 and 1982 using veins only. Group 2 subjects had CABG done from 1983 to 1985 using veins and internal thoracic artery (ITA). Those in group 3 received two ITAs (double ITA) from 1985 to 1990. Redo CABG and PTCS were performed as needed. Results: The 10-year cumulative survival figures for the groups were 92.8 % (group 1), 94.8% (group 2) and 95.4% (group 3). The difference between the groups was statistically significant (p < 0.001). Cardiac event-free survival was 74.4% (group 1), 83.5% (group 2) and 92.6% (group 3), with p < 0.0001. Myocardial infarction occurred more frequently in group 1 (4.7%) than in groups 2 or 3 (2.2 and 1.3%, respectively). The redo rates for CABG were 13.6% (group 1), 8.1% (group 2), and 1.3% (group 3). The corresponding PTCA rates for the three groups were 7.1, 3.7 and 1.6%, respectively (p < 0.0001). Conclusions: Double ITA, compared with single ITA and/or vein grafts, was the optimal graft material at the time of primary CABG because it had the lowest reintervention rate. It also did not increase postoperative morbidity.

Cardiac Sarcoma Originating from the Tricuspid Valve

Primary cardiac sarcomas are uncommon. We report an unusual presentation of a cardiac sarcoma that originated from the posterior leaflet of the tricuspid valve. This tumor, which provided a working diagnosis of tricuspid valve myxoma before and during surgery, should be considered in the differential diagnosis of right atrial and ventricular masses.

Systemic pulmonary artery shunt using a bovine mesenteric venous graft in newborns.

Abstract  A new bovine mesenteric venous graft 3 or 4 mm in diameter was used for performing systemic pulmonary artery shunts in six cyanotic newborns (aged 2 to 30 days) from March 1997 onward. Clinical and echocardiographic studies proved that all shunts were patent and functioning well after an average of 8.8 months despite no postoperative anti‐coagulation or antiplatelet regimen. Histological examination of two grafts explanted at the time of bidirectional cavopulmonary anastomosis showed no dense fibrotic mural infiltration, calcification, or anastomotic hyperplasia. Bovine mesenteric venous grafts can be used for the construction of systemic pulmonary artery shunts with advantages similar to that of human vein allografts, such as the facility of implantation, good short‐ and mid‐term patency, easy takedown, and avoidance of complications presumably specific to polytetraflu‐oroethylene.