Florentino J. Vargas

Complete Atrioventricular Canal and Tetralogy of Fallot: Surgical Considerations

A review of 13 autopsy specimens and of 13 patients who were operated on for complete atrioventricular (AV) canal and tetralogy of Fallot between 1975 and 1985 revealed a number of anatomical details that are important in the successful repair of this combined lesion. A bridging anterior leaflet was present in 25 hearts. A septum primum was present and attached to leaflet tissue in 13. In all 26, a ventricular septal communication was present beneath the bridging anterior leaflet and extended anteriorly, but in 14 there was no ventricular septal defect underneath the posterior leaflet. Additional pathological features included the following: leaflet tissue deficiency (4 hearts), single left papillary muscle (3), accessory valve orifice (4), and left ventricular (4) or right ventricular (RV) (1) dominance. All 26 had infundibular stenosis, and 10 had hypoplastic pulmonary annuli. One had pulmonary atresia, and 6 had branch pulmonary artery stenosis. Surgical technique was modified to include incision of the septum primum in 7. Because of rightward displacement of the anterior ventricular septum and also to minimize the risk of causing subaortic stenosis, the bridging anterior leaflet was divided more toward the tricuspid orifice so as to parallel the crest of the ventricular septum. Transannular RV outflow patches were used in 10 patients, and a right ventricle-pulmonary artery conduit was placed in 1 patient. Three required repair of branch pulmonary artery stenosis. There were no hospital deaths. Three patients died late of residual AV valve regurgitation and branch pulmonary artery stenosis (2) and sepsis (1).(ABSTRACT TRUNCATED AT 250 WORDS)

Tricuspid Annuloplasty and Ventricular Plication for Ebstein’s Malformation

BACKGROUND Seven patients with the diagnosis of Ebsteins malformation of the tricuspid valve were operated on. Mean age was 12 years (range, 7 to 16 years). All were cyanotic, with severe tricuspid regurgitation. Thromboembolism was not present. No associated cardiac malformations were present. METHODS Surgical repair included tricuspid annuloplasty associated with longitudinal plication of the atrialized portion of the right ventricle. This was attained by approximating the anterior-posterior commissure with either the posterior-septal commissure or the septal leaflet remnant. The thin atrialized ventricular wall thus excluded remained as a cul du sac and was plicated by suturing along the longitudinal axis of the heart. When present, the dysplastic posterior leaflet was included in the plication. In essence, a monocuspid right atrioventricular valve was fashioned out of the anterior leaflet. The remaining septal leaflet played a minimal functional role. No additional procedures for treatment of arrhythmia were associated with the technique described. RESULTS The postoperative course was uneventful in all patients. Mean follow-up is 4.3 years (range, 1 to 10 years). Doppler echocardiographic studies reveal satisfactory monocusp valve function in all patients, with adequate coaptation of the anterior leaflet and the septal structures. CONCLUSIONS This technique seems applicable to most forms of Ebsteins malformation and is reproducible. The technique relies on the adequate mobilization of the anterior leaflet. Occasionally it is necessary to free fibrous adhesions of the leaflet to the underlying ventricular surface.

Atrioventricular valve repair or replacement in atriopulmonary anastomosis: surgical considerations.

Three patients who underwent a modified Fontan-Kreutzer (F-K) operation required additional procedures to correct left atrioventricular valve regurgitation. Valve replacement was performed in two additional procedures, and initial annuloplasty with a Carpentier ring was carried out in the third. All 3 survived the combined procedures and are doing well after a follow-up period ranging from five months to three years. More frequent presentation of these types of patients can be expected with broadening indications for F-K procedure to more complex lesions.

Aortico–right ventricular tunnel

A successful operation on an infant with a tunnel through which the aorta communicated with the right ventricle is reported. The diagnosis was suspected preoperatively on the basis of two-dimensional Doppler color echocardiography and confirmed by cardiac catheterization. The aortico-right ventricular tunnel originated independently from the left coronary ostium and above the sinus of Valsalva. Patch closure from inside the tunnel under deep hypothermia was successfully performed. Follow-up is satisfactory 5 years later.

Bidirectional cavopulmonary shunt in patients with multiple risk factors

BACKGROUND Twenty-five patients in whom a modified Fontan operation was deferred because of multiple risk factors underwent a bidirectional cavopulmonary shunt. Two or more of the following risk factors were present in all: age less than 1 year, severe pulmonary artery distortion, impaired left ventricular function, subaortic obstruction, anomalous systemic-pulmonary venous connection, atrioventricular valve incompetence, and increased mean pulmonary artery pressure. METHODS Additional procedures included take-down of systemic-pulmonary artery shunt, atrial septectomy, pulmonary artery reconstruction, bulboventricular foramen enlargement, and atrioventricular valve repair. RESULTS There were three hospital deaths (12%). Mean follow-up is 21 months. There was no late mortality. Mean oxygen saturation increased from 71% to 83%. Results obtained from pulmonary artery reconstruction, enlargement of bulboventricular foramen, and atrioventricular valve repair were satisfactory for the patients in whom these risk factors were present preoperatively. Ventricular function also improved in the survivors in whom it was previously deteriorated, this being related to the suppression of the sources of ventricular volume overload. CONCLUSIONS In this risk group of patients for a modified Fontan operation, a bidirectional cavopulmonary shunt provided adequate palliation at reasonable low risk. Early bidirectional cavopulmonary shunt would minimize complications originating from systemic-pulmonary shunts such as pulmonary artery distortion and the potential harm of chronic ventricular volume overload.

Repair of Corrected Transposition Associated with Ventricular Septal Defect and Pulmonary Stenosis

Five patients with the diagnosis of classically corrected transposition of the great arteries, ventricular septal defect (VSD), and pulmonary outflow tract obstruction underwent surgical repair. A variant of a previously described technique was used to avoid injury to conduction tissue. Through an incision into the anatomical left ventricle, the VSD patch was sutured inferiorly to the right and away from the edges of the defect and superiorly to the epicardial border of the ventriculotomy. The pulmonary artery was opened, and its proximal end was closed with a suture. A pouch containing the conduction tissue was therefore obtained. Pulmonary ventriculoarterial continuity was reestablished using a valved or nonvalved Dacron or pericardial conduit. The postoperative course of the patients was uneventful. No changes were demonstrated on comparison with preoperative cardiac rhythm. Good hemodynamic performance was noted in 2 patients in whom postoperative catheterization was performed.