J Stark

Fate Of Subpulmonary Homograft Conduits: Determinants Of Latehomograft Failure

PATIENTS AND METHODS Between 1971 and 1993, 656 conduits were placed in the subpulmonary position. Patients receiving heterografts or valveless conduits and patients dying within 90 days of insertion were excluded; thus 405 homograft conduits were studied. There were 293 aortic homografts, 94 pulmonary, and 18 of unknown type. The end point of conduit failure was defined by conduit replacement for whatever reason, balloon dilation of the conduit, or death of the patient with the conduit in place. The following factors were analyzed: aortic versus pulmonary homograft, antibiotic preservation versus cryopreservation, ABO and Rh compatibility, type of material used for conduit extension, age at operation, size of the conduit, diagnosis, and reoperations. Conduit number (1 to 405) in the series was included in the multivariable model. RESULTS First conduits and conduits inserted earlier in the series appeared to last longer than second and subsequent conduits and those inserted later in the series (p = 0.001 and 0.003, respectively). Overall survival of conduits at 5, 10, and 15 years was 84% (95% CL, 80% to 88%), 58% (95% CL, 50% to 66%), and 31% (95% CL, 19% to 43%). Corresponding figures for the first conduits were 88% (95% CL, 84% to 92%), 65% (95% CL, 56% to 73%), and 34% (95% CL, 20% to 47%). The longest surviving homograft conduit in our series lasted 22.7 years. Regarded univariately, reoperation (redo worse), order number (recent worse), type of conduit (pulmonary worse than aortic), preservation (cryopreserved worse than antibiotic preserved), and age at operation (older patients worse) were statistically significant. However, in multivariable analysis, including all the above in the model, only reoperation and order number had significant predictive power. When patient survival was considered, patients operated on more recently survived longer despite the fact that their conduits were being replaced earlier. Overall, survival of patients at 5 and 15 years was 95% (95% CL, 93% to 98%) and 85% (95% CL, 77% to 92%), respectively. CONCLUSIONS Pulmonary and aortic homografts, both cryopreserved and preserved in nutrient antibiotic solution, give similar results. All conduits will probably have to be replaced during the lifetime of the patient. In view of the worse performance of replacement conduits, techniques of repair that avoid the use of conduits should be further explored. Despite gradual deterioration of homograft conduits, they remain an important tool in the correction of many complex lesions with excellent 15-year patient survival.

Pulmonary atresia and intact ventricular septum: surgical management based on a revised classification.

Sixty patients with pulmonary atresia and intact ventricular septum (PA:IVS) presenting from 1970 to 1980 are reviewed. Three groups of patient are discussed: those with tripartite right ventricles, those with no trabecular portion to the cavity, and those with neither trabecular nor infundibular portions. The decrease in early mortality for neonates with PA:IVS since 1977 (one death in 15 patients) supports our current management policy of preoperative prostaglandin El infusion with transpulmonary valvotomy (for patients with an infundibular cavity) combined with a left modified Blalock‐Taussig shunt using a Gore‐Tex prosthesis. Tricuspid valve growth, estimated by serial angiograms in 12 patients, was greater if right ventricle‐to‐pulmonary artery continuity was established. Later definitive repair was attempted in nine patients, with two early deaths; five underwent right ventricular outflow tract reconstruction and four had modified Fontan procedures. Neonates with critical pulmonary stenosis are also discussed. Their neonatal mortality (nine deaths in 20 patients) was similar to that of comparable patients with PA:IVS, but their actuarial survival at 5 years (55%) was superior (36% at 5 years).

Acute renal failure complicating cardiopulmonary bypass surgery.

Acute renal failure developed in 24 (5.3%) of 456 children undergoing cardiopulmonary bypass surgery during a 2-year period. It was more common in younger children, in those with complex cardiac lesions, and in those with long overall bypass times. Fourteen (58%) recovered renal function; renal failure was responsible for death in only two. Early vigorous peritoneal dialysis is advocated after cardiopulmonary bypass surgery if there is oliguria (less than or equal to 1.0 ml urine/kg per hour) resistant to volume repletion, dopamine infusion and diuretics, intractable fluid overload, or hyperkalaemia.

Management of pulmonary venous obstruction after correction of TAPVC: risk factors for adverse outcome

OBJECTIVE Recurrent pulmonary venous obstruction (PVO) occurs in 0-18% of infants undergoing correction of total anomalous pulmonary venous connection (TAPVC). Limited published data suggest that PVO usually develops within 6 months of primary repair, and that outcomes of reoperations are poor. This study aimed to review our experience of reoperations for PVO post-TAPVC repair and to identify risk factors for adverse outcome. METHODS Twenty patients underwent reoperation for PVO between 1982 and 2002. Clinical data were reviewed. TAPVC was mostly infracardiac (11 patients). TAPVC was obstructed in nine patients. PVO developed early (<6 months) in seven patients, and late in 13 (>6 months). Time of presentation was unrelated to type of PVO (anastomotic vs. ostial). Repair was accomplished using various techniques (anastomotic enlargement with native atrial tissue, enlargement with pericardium, free or in situ, or other prosthetic material). Follow-up ranged from 1 month to 15 years (average 44 months). RESULTS Thirteen patients received one reoperation, while seven had multiple reoperations. In 13 patients, PVO was defined as new onset (no obstruction post-TAPVC repair), and in seven patients as residual (minimal obstructive changes post-TAPVC repair that progressed to PVO). Ten patients presented with anastomotic PVO, six with anastomotic and ostial PVO (involving the PVs), three with ostial PVO, and one with coronary sinus-left atrial junction stenosis. Mortality was 25% (5/20). Six of the ten patients with anastomotic PVO underwent one reoperation (2/6 died); the other four developed ostial PVO after reoperation, requiring multiple procedures (2/4 died). Mode of presentation (new onset vs. residual), site of obstruction (anastomotic vs. ostial), preoperative RV pressure (<0.8 vs. >0.8 systemic), number of reoperations (single vs. multiple), residual obstruction (presence or absence), and operative approach (Gore-tex or not) did not seem to affect outcomes. Risk factors for death were early presentation (<6 months) and persistence of pulmonary hypertension after reoperation; early presentation was also a risk factor for multiple reoperations. CONCLUSIONS Our findings support the conclusion that early presentation and postoperative pulmonary hypertension have the greatest adverse impact on outcome. Of these, failure to achieve a low-pressure pulmonary vascular system seems to be the variable that most strongly prevents survival. In our series, neither ostial PVO nor multiple re-interventions significantly increased surgical risk. The negative impact of postoperative residual obstruction on outcome was not striking. However, an aggressive surgical approach to this disease is still warranted. Although the role of each technique in obtaining long-lasting relief of PVO remains to be established, the use of artificial material seems unwise.

Expanded PTFE Membrane to Prevent Cardiac Injury During Resternotomy for Congenital Heart Disease

BACKGROUND Resternotomy for repair of congenital cardiac defects can result in cardiac injury. Closure of the pericardium during the initial operation may prevent this, and several pericardial substitutes have been tried, with variable results, in patients in whom primary pericardial closure is not possible. We conducted a multicenter observational study of the use of the expanded polytetrafluoroethylene membrane (Preclude Pericardial Membrane, formerly called the Gore-Tex Surgical Membrane; W. L. Gore & Associates, Flagstaff, AZ) in patients likely to undergo reoperation for treatment of congenital heart disease. METHODS Data were collected retrospectively on all patients in whom the expanded polytetrafluoroethylene membrane was inserted at the initial operation for congenital heart disease at 12 centers in 1984 to 1993. RESULTS A total of 1,085 patients (mean age, 55 +/- 2.5 months) received the membrane. During follow-up ranging from 1.3 to 10.5 years, 105 reoperations were performed. Injury during resternotomy occurred in only 1 patient (1% of reoperations). There were no membrane-related deaths or complications in the entire series of 1,085 patients. CONCLUSIONS The expanded polytetrafluoroethylene membrane was safe and effective in helping to prevent cardiac injury during resternotomy for treatment of congenital heart disease.

Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. Effect of systemic pulmonary anastomosis.

In nine patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries, the effect of a systemic-pulmonary anastomosis on the lung was studied by comparison of pre- and postoperative cine angiograms. Selective injections into the collateral arteries were performed in all patients and the source of blood supply to each bronchopulmonary segment was sought. Central pulmonary arteries were present in six children and absent in three, as confirmed at thoracotomy. After insertion of a shunt, central pulmonary arteries increased in size, but the intrapulmonary vessels with which they connected remained abnormally small and were frequently stenosed. In addition, in each case the central pulmonary arteries increased flow to only five to 11 segments of lung. In the absence of central pulmonary arteries, shunting to a hilar or a lobar pulmonary artery increased perfusion to five to nine segments of lung per case. In all these three cases the pulmonary arteries at lobar level showed aneurysmal dilatation proximal to a severe stenosis. Sixty-eight per cent of collateral arteries were stenosed. The findings suggest that in this anomaly, when the central pulmonary arteries are hypoplastic, the intrapulmonary branches are also hypoplastic, emphasising the need for early surgical intervention to increase blood flow while the lung still has growth potential. Further, one collateral artery may connect with at least as many bronchopulmonary segments as does a central pulmonary artery, and the peripheral intrapulmonary arteries with which it connects may appear at least as normal angiographically as do vessels connected to central pulmonary arteries. These observations suggest that segments of lung connected to collaterals alone should, and sometimes can, be connected to central pulmonary arteries, the aim being to produce a unifocal blood supply as a prelude to total correction.

CURRENT SURGICAL TECHNIQUE TO REPAIR FALLOT'S TETRALOGY WITH ABSENT PULMONARY VALVE SYNDROME

The experience with surgical repair of Fallots tetralogy and absent pulmonary valve syndrome is reviewed. Twenty-two patients aged 1 day to 8 years were treated between 1982 and 1989 using one surgical technique. This consisted of resection of the main pulmonary artery and large parts of the anterior wall of the right and left pulmonary artery. The ventricular septal defect was closed with a patch, and an aortic or pulmonary homograft (size, 8 to 24 mm) was interposed between the right ventricle and the pulmonary artery. Two of the 8 infants operated on died; there was one late death. All 14 older children survived the operation. All survivors are well up to 7 years follow-up (mean follow-up, 3.6 years). We recommend early treatment of infants; older children can be treated electively. The technique used in our series gives excellent results.

Outcomes After Delayed Sternal Closure in Pediatric Heart Operations: A 10-Year Experience

BACKGROUND Open heart operations in young children may lead to myocardial swelling and increased lung water. Decreased intrathoracic space may then make sternal closure difficult. Delayed sternal closure may be beneficial in this setting. Potential risks of delayed sternal closure are sepsis and sternal instability. METHODS To assess these risks, we reviewed retrospectively 150 consecutive children who underwent delayed sternal closure after repair of complex congenital cardiac defects. RESULTS Diagnoses included transposition of the great arteries (66), total anomalous pulmonary venous drainage (11), and complete atrioventricular septal defects (10). Age at operation was 229 +/- 51 days (mean +/- standard error of mean). Sixteen patients required extracorporeal membrane oxygenation. Survival was 88% (133 patients). The sternum was left open for 3.86 +/- 0.29 days. Fifteen patients had minor wound infections requiring antibiotics. No patient required reexploration for mediastinitis and no patient had an unstable sternum. CONCLUSIONS Delayed sternal closure with sternal stenting and silicone membrane skin closure is a safe procedure in infants and children with compromised cardiac output after repair of congenital cardiac defects.

Experience with Fibrin Seal (Tisseel) in Operations for Congenital Heart Defects

Tisseel (human fibrin seal) was used in 38 children with complex congenital heart defects (2.8% of all operations for congenital heart defects) between July, 1980, and August, 1983. Control of bleeding was excellent in 31 patients, good in 6 patients, and unsatisfactory in 1 patient. Best results were achieved when Tisseel was applied on collagen substrate. If bleeding was particularly difficult to control, a combination of Tisseel with pharmacological hypotension (sodium nitroprusside) was used. We recommend the use of Tisseel to preseal Dacron conduits and to control bleeding from multiple suture lines (conduits, arterial switch operations, complex reconstructions of the pulmonary arteries), near major coronary arteries, from Gore-Tex patches in high-pressure systems, and from the raw areas of the heart at reoperation.

Infective endocarditis in children with congenital heart disease: comparison of selected features in patients with surgical correction or palliation and those without.

The diagnostic and prognostic features of 44 episodes of infective endocarditis in 42 children with congenital heart disease were reviewed. Endocarditis occurred in 18 patients who had not had surgical correction or palliation of the defect (non-operated group). There were 26 episodes in 24 patients who had been treated surgically (operated group) (16 open and eight closed cardiac operations). Endocarditis occurred soon after open heart surgery in eight patients and as a late complication in the other 16. It recurred in two patients (operated group). Invasive monitoring and low cardiac output were consistent features in those patients who had endocarditis soon after open heart surgery whereas dental treatment was a common feature in non-operated cases and after closed cardiac operations. Late cases of endocarditis after open heart surgery had various microbiological features that were not typical of infection after dental problems. Gram positive infections occurred in non-operated patients and in those who had had closed cardiac operations. The group that had open heart surgery had infections caused by Gram positive, Gram negative, and anaerobic bacteria and fungi. Fever, anaemia, leucocytosis, and positive blood cultures were the only consistent findings. Vegetations were seen in nine of 12 patients at cross sectional echocardiography. All 12 (four non-operated, one closed, and seven open cases) needed acute surgical treatment. The mortality from infective endocarditis was 17% for non-operated cases, 0% for those who had had closed heart surgery, and 50% for those who had had open heart surgery. Infective endocarditis after open heart surgery differs from that in the other subgroups in terms of microbiology, source of infection, and outcome and its early diagnosis depends on a thorough investigation of minimal symptoms and signs.