Galal El-Said

Dysrhythmias after mustard's operation for transposition of the great arteries☆

Abstract Dysrhythmias after Mustards operation for transposition of the great arteries were studied in 60 patients who survived the operation. Only 3 patients consistently had sinus rhythm after the operation. In 54 patients, low voltage atrial waves having the configuration of sinus P waves were seen at one time or another. The incidence of passive dysrhythmias remained nearly the same during the follow-up period. Eight patients showed at various times a specific pattern designated junctional rhythm with right inferior P axis. The mean P axis was directed downward, to the right and anteriorly, occurring either before or after the QRS complex with fixed PR or RP intervals. The characteristics of the junctional rhythm with right inferior P axis remained during subsequent attacks of supraventricular tachycardias. Whereas the incidence of sinus rhythm gradually decreased, the incidence of active dysrhythmias increased during follow-up study. There were no instances of second or third degree atrioventricular (A-V) block. Wolff-Parkinson-White syndrome, type A, developed and persisted in 1 patient. In 5 patients who died, presumably from rhythm disturbances, the histologie features of the sinoatrial (S-A) nodal area were examined. In a control group of normal hearts and 1 specimen with unoperated upon transposition, the S-A node and artery were readily identified. In the necropsy material from patients with transposition who had recently undergone Mustards operation, S-A nodal tissue was identified but fresh hemorrhage and acute inflammation were seen in and about the node. The S-A nodal artery in the 3 patients who died 4 months or more after operation was nearly or completely obliterated by intimai sclerosis and medial hypertrophy. The S-A node was replaced by dense connective tissue and fatty degeneration.

Early and Late Result of Saphenous Vein Graft for Anomalous Origin of Left Coronary Artery from Pulmonary Artery

The early and late postoperative angiographic status of the aortocoronary artery saphenous vein graft was studied in six children treated surgically for anomalous origin of left coronary artery from the pulmonary artery. Anastomosis was made to the main left coronary artery in five and to the left anterior descending coronary artery in one. At the first postoperative heart catheterization five of the six vein grafts were found to be patent without stenosis, dilatation, or wall irregularity. The second, late postoperative study performed in the five patients with initially patent grafts showed that one graft had occluded, two had stenosed at the site of the anastomosis with the coronary artery, and one had dilated distally. At the time of the second postoperative study, the treadmill exercise test was normal in three patients, slightly abnormal in the patient with graft stenosis at the site of anastomosis to the left anterior descending coronary artery, and distinctly abnormal in the patient with the occluded graft. Aortocoronary artery saphenous vein graft is a technically successful operation for anomalous origin of the left coronary artery from the pulmonary artery, but obliterative changes may occur in the vein graft in children who are apparently free from atherosclerotic coronary artery disease.

Natural hemodynamic history of congenital aortic stenosis in childhood

Abstract The natural hemodynamic history of 37 patients with congenital aortic stenosis (18 valvular, 10 valvular with slight or moderate aortic insufficiency, 6 discrete subvalvular and 3 supravalvular) was documented by 2 catheterizations using the same methods of study. In the majority of patients with valvular, discrete subvalvular and supravalvular aortic stenosis the anomaly increased in severity, as evidenced by (1) a statistically significant increase in left ventricular peak systolic pressure, left ventricular to aortic peak systolic pressure gradient and arteriovenous oxygen difference; and (2) by a significant decrease in cardiac index and stenotic orifice area per square meter body surface area. The changes were more severe in patients with supra- and subvalvular stenosis. There were no statistically significant changes in aortic pressure, heart rate, systolic ejection period or wedge pressure. Left ventricular end-diastolic pressure increased significantly only in patients with discrete subvalvular aortic stenosis. Although the stenotic area index was lower in all patients without aortic insufficiency, absolute stenotic area decreased in only a small percentage. In patients with both valvular aortic stenosis and insufficiency, there was a significant unfavorable change in cardiac index, arteriovenous oxygen difference and left ventricular end-diastolic pressure but no significant increase in left ventricular peak systolic pressure or left ventricular to aortic peak systolic pressure gradient. Ninety percent of the patients remained asymptomatic during the study. Aortic stenosis is likely to increase in severity, usually by an increase in flow across a “fixed” stenotic area as a result of body growth and sometimes by a concomitant actual decrease in stenotic area.

Atresia of the Left Coronary Artery Ostium Repair by Saphenous Vein Graft

Symptoms and electrocardiographic changes of acute myocardial ischemia in a 10-year-old boy resulted from congenital atresia of the ostium of the left coronary artery. At 14 years of age persistence of symptoms and a positive exercise test prompted surgical treatment by aortocoronary artery saphenous vein bypass graft. Two months postoperatively, the symptoms and the abnormal findings on exercise test had subsided and forward flow through the graft to the left coronary artery was demonstrated by contrast angiography.

Protection of the sinus node in Mustard's operation.

The occurrence of dysrhythmias after the Mustard operation for transposition of the great arteries was compared in 70 patients operated upon before and 58 patients operated upon after January 1972 when surgical modifications aimed at preserving the sino-atrial node and its arterial supply were initiated. The surgical modifications included changing the site of the superior vena cava (SVC) cannulation away from the SVC-right atrial junction, incision into the right atrial wall anterior to the sulcus terminalis, and sewing of the superior part of the baffle patch away from the sino-atrial node area.A significant decrease in the incidence of dysrhythmias occurred in the group of patients operated upon after the surgical modifications.The modifications in surgical technique have reduced but not avoided dysrhythmias.

Ascending Aorta to Right Pulmonary Artery Anastomosis Immediate Results in 123 Patients and One Month to Six Year Follow-up in 74 Patients

An intrapericardial ascending aorta-to-right pulmonary artery anastomosis was performed in 123 patients with cyanotic congenital heart disease associated with pulmonary stenosis or atresia during the eight year period from 1964 through 1971. While there were 20 early postoperative deaths (16%), 90% (93 patients) of the 103 survivors were symptomatically improved.In the postoperative evaluation, 74 patients (72% of the survivors) returned for follow-up examination, which included cardiac catheterization in 57. The anastomosis was nonfunctioning in ten (13.5%) of these 74 patients and in an additional 13 (17.5%) patients, clinically silent right pulmonary artery stenosis was demonstrated angiographically at the anastomosis site. Clinical improvement had been maintained in the 64 patients with an open anastomosis (audible continuous murmur or angiographically demonstrated patency) including the 13 patients with acquired pulmonary stenosis at the operative site. Persistent right pulmonary artery stenosis was demonstrated in nine of the 14 patients who had cardiac catheterization after intracardiac repair of the congenital heart defect and closure of the anastomosis, but this was insignificant in four of these nine.The ascending aorta-to-right pulmonary artery anastomosis provides symptomatic improvement for most patients with cyanotic congenital heart disease associated with pulmonary stenosis but may produce right pulmonary artery obstruction requiring attention at the time of total intracardiac repair.

Significance of pacemaker recovery time after the Mustard operation for transposition of the great arteries.

Pacemaker recovery time corrected for cycle length was measured in 24 patients 6 months to 3 years after the Mustard operation for transposition of the great arteries. This index of sinoatrial (S-A) nodal function was obtained by subtracting the control R-R interval from the first R-R interval recorded after 3 minutes of rapid atrial pacing at the superior vena caval-right atrial junction. Recovery times were compared with those of a control group of 54 children with various forms of congenital heart disease who had not had cardiac surgery and whose electrocardiogram revealed normal sinus rhythm. The longest corrected pacemaker recovery time in the control group was 250 msec. Recovery time was normal (mean 115 msec) in 13 of the 24 patients who had undergone the Mustard procedure and prolonged (mean 472 msec) in the other 11. In 4 of these 11 a junctional escape complex was recorded before recovery of the S-A node. The configuration of the P wave and the development of dysrhythmias in the postoperative follow-up period were compared in patients with a normal and a prolonged corrected pacemaker recovery time. The incidence of dysrhythmias was much smaller in the former group. Normal sinus rhythm after the first postoperative week was noted in 10 (76 percent) of patients with a normal corrected pacemaker recovery time but in only 2 (18 percent) of those with an abnormal recovery time. One patient with an abnormal recovery time died suddenly 26 months after operation in spite of good hemodynamic repair. A prolonged pacemaker recovery time after the Mustard operation for transposition of the great arteries indicated that rhythm abnormalities were likely to develop, but a normal recovery time did not exclude abnormal sinus nodal function.

Management of Total Anomalous Pulmonary Venous Return

The effects of age, type of return, presence of pulmonary venous obstruction, obstruction to left heart filling, systemic arterial oxygen saturation (Ao O2%), pulmonary-to-systemic flow ratio (Qp/Qp), pulmonary-to-systemic resistance ratio (Rp/Rs%), and mean pulmonary artery-to-mean systemic arterial pressure ratio (MPAP/MSAP%) in 35 cases of total anomalous pulmonary venous return seen in the last 5 years, were studied in relation to prognosis and management. The surgical mortality was increased in patients with anomalous venous return to the right common cardinal system (right superior vena cava and azygos vein) regardless of age and was significantly lower in patients over 6 months of age and in those who had preoperative intensive medical management. No relation was found between surgical mortality and Ao O2%, Rp/Rs, MPAP/MSAP%, or the presence of pulmonary venous obstruction. The small size of the left atrium rather than the small size of the left ventricle is felt to be one of the reasons for operative failure. The importance of obstruction to left heart filling at the atrial level was stressed. Until technics for surgical treatment of this group of anomalies in early infancy become more successful, we recommend balloon atrial septostomy in combination with intensive medical management as effective palliative treatment for most of these patients in the first 6 months of life.

Retrograde technique for catheterization of the pulmonary artery in transposition of the great arteries with ventricular septal defect

Abstract In patients with transposition of the great arteries associated with ventricular septal defect, passage of the prograde venous catheter into the pulmonary artery can sometimes be difficult and is not always successful. Retrograde femoral arterial catheterization by the percutaneous sheath technique proved to be a safe, rapid and effective method of entering the pulmonary artery in 10 patients after failure of the prograde venous approaches. The retrograde approach is especially advantageous in patients with transposition of the great arteries associated with ventricular septal defect and an intact interatrial septum as well as in patients with I-transposition of the great arteries and ventricular septal defect.