Hallman Gl

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 Pue5f8R or Rue5f8P 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.

Management of surgical complete atrioventricular block in children

Because there is disagreement concerning the efficacy of and indication for permanent pacemaker implantation in children with postoperative complete (third degree) atrioventricular (A-V) block, experience in the management of this problem at one institution was reviewed. Thirty-four patients with postoperative complete atrioventricular block were identified. They ranged in age from 4 months to 22 years and in weight from 4 to 60 kg and were evaluated from 1 month to 20 years postoperatively. Complete A-V block developed within 24 hours of operation in 28 of the 34 patients. A permanent pacemaker was implanted in 13 of the 28. Death occurred in 4 of these 13 patients and in 5 of the remaining 15 patients who did not have an artificial permanent pacemaker. Complete A-V block developed later than 1 day (2 days to 4 months) postoperatively in 6 of the 34 patients; all 6 of these patients survived, and only 3 required permanent pacemaker implantation. Intracardiac electrophysiologic studies were performed by 14 of the 34 patients. The site of complete block was above the His bundle in 5, within the His bundle in 2, and below the His bundle in 4; it was undetermined in 3. The results of intracardiac electrophysiologic studies are important in delineating the natural history of surgically induced complete A-V block and in the clinical management of this lesion. Permanent pacemaker implantation is indicated if complete A-V block persists longer than 2 weeks postoperatively and if the site of the block is within or below the bundle of His.

Hemodynamic observations in patients with left ventricle to aorta conduit

Fourteen patients who had a left ventricular apex to abdominal aorta composite conduit implanted for relief of severe left ventricular outflow tract obstruction were studied at cardiac catheterization 7 days to 19 months postoperatively (median 12 days). Analysis of pressure, angiographic and blood flow velocity data showed the following: (1) The left ventricle to aorta pressure gradients were reduced from an average preoperative value of 100.6 mmHg (range 54 to 140) to an average of 22.1 mm Hg (range 0 to 60) postoperatively; (2) postoperative left ventricular end-diastolic volume averaged 87.5 percent of normal (range 51 to 146); (3) cardiac index and ejection fraction were normal postoperatively in all but one patient. Left ventricular and aortic angiography revealed blood flow through both the ascending aorta and conduit in all patients and retrograde flow of blood from the conduit to the aortic arch in four. An average of 36 percent (range 16 to 50) of the left ventricular output was ejected through the conduit. It appears that this operation is effective in relieving severe and otherwise inoperable left ventricular outflow tract obstruction and in preserving or improving left ventricular function and aortic hemodynamics.

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.

Aortico-left ventricular tunnel with ventricular septal defect: two-dimensional/Doppler echocardiographic diagnosis.

Aortico-left ventricular tunnel is a rare congenital anomaly that presents as aortic regurgitation and congestive heart failure in childhood. Its association with a ventricular septal defect is even more rare. Because of the distortion of the normal anatomy around the aortic valve and the rarity of this combination of defects, the diagnosis of aortico-left ventricular tunnel with ventricular septal defect may be difficult. The two-dimensional and Doppler echocardiographic findings of aortico-left ventricular tunnel are described.

Epsilon-Aminocaproic Acid for Bleeding After Cardiopulmonary Bypass

Abstract The effect of epsilon-aminocaproic acid (EACA) in reducing bleeding after cardiopulmonary bypass was studied in 73 patients who underwent open-heart operations for the repair of intracardiac lesions and resection of ascending aortic aneurysms. Forty-eight patients received EACA prior to the onset of bypass and 25 did not receive EACA. Bleeding during and immediately after operation in patients with acquired lesions was substantially less in the treated group than in those who had not received EACA. The results of the study indicate that EACA may be effective in reducing bleeding after cardiopulmonary bypass for acquired cardiac disease and that further use and study of this agent is justified.

Multiple pulmonary artery aneurysms. New use for magnetic resonance imaging

The first patient in whom multiple pulmonary artery aneurysms were detected by magnetic resonance imaging is described. The patient was successfully treated with surgery.

Taussig-Bing Anomaly: Total Repair with Closure of Ventricular Septal Defect Through the Pulmonary Artery

Total surgical repair of a Taussig-Bing malformation in an 8-year-old boy was accomplished successfully after previous palliative procedures. The child had undergone a Rashkind septostomy when he was 10 days old, banding of the pulmonary artery and division of a patent ductus arteriosus when he was 2 weeks old, and a Blalock-Hanlon septectomy when he was 1 year old. Complete repair involved patching the ventricular septal defect (VSD), debanding and patching the pulmonary artery, and rerouting the venous return by performing a Mustard procedure. Because of its high location, the VSD could not be reached properly through the tricuspid valve and was approached through the pulmonary arteriotomy. Excellent exposure was obtained by retracting the pulmonary valve, and patch closure of the defect was achieved without difficulties. We believe this approach to the VSD is preferable because no incision is necessary in the right ventricle. This is important since the right ventricle becomes the systemic ventricle after the Mustard operation.

False Aneurysm of the Ascending Aorta from an Expanded Polytetrafluoroethylene (Gore-Tex) Aortopulmonary Shunt

A false aneurysm of the ascending aorta developed in a 25-month-old male infant with tetralogy of Fallot because of an expanded polytetrafluoroethylene (PTFE) shunt that had been inserted between the ascending aorta and right pulmonary artery when the patient was 3 months of age. Surgical repair of tetralogy of Fallot with ligation of the PTFE graft was performed at 19 months of age. The false aneurysm at the site of the systemic anastomosis to the shunt was discovered 6 months later and was successfully repaired. Because of the potential for graft dehiscence secondary to growth, we recommend that PTFE shunts be removed completely or, at least, ligated and divided at the time of corrective surgical intervention.