John J. Lamberti

The Ross procedure: current registry results

BACKGROUNDnThe pulmonary autograft procedure for the treatment of aortic valve disease was developed and performed by Ross in 1967. The results he published in 1987 prompted increasing interest in the procedure. The International Registry of the Ross Procedure was established in 1993 to further examine longitudinal clinical outcomes.nnnMETHODSnThe results from the Ross registry document the continued and growing interest in the procedure with 2,523 patients currently enrolled, representing 122 centers and 166 surgeons worldwide.nnnRESULTSnMortality (1987 to present) reported in the registry is 2.5%. It should be noted that follow-up stands at 70%. The most important issues for the registry to track are the incidence of reoperation for autograft failure and the fate of the pulmonary homograft. Reoperation for all valve-related problems is low (5.4%), with an autograft explant rate of 1.9%. Overall registry data indicate that the right ventricular outflow tract revision rate is 2.8%, with this decreasing by half to 1.3% in the 1987 to present subgroup.nnnCONCLUSIONSnRigorous analysis of outcomes is difficult with registry follow-up currently at 70%; however, the general conclusions derived from the registry are supported by other individual series with excellent follow-up. Success of the registry depends on judicious efforts by all participating surgeons and coordinators in documenting long-term patient results and reporting them to the registry.

Cardiac Surgery in Patients Undergoing Renal Dialysis or Transplantation

The coexistence of organic cardiac disease and chronic renal failure presents a therapeutic dilemma. Cardiac operations have been performed on patients who were undergoing hemodialysis or who had had successful renal transplantation. There are several aspects of management of these patients which differ from those of the routine cardiac surgical patient. Guidelines for management are outlined and discussed.

Effects of hemodilution on acute myocardial ischemia

Systemic hemodilution with homologous plasma, Ringers lactate, Dextran-70, and Dextran-40 was carried out in 32 dogs between repetitive occlusions of the left anterior descending coronary artery. Ringers lactate and plasma produced no change in myocardial ischemia as determined by surface ECG mapping before and after LAD occlusion. Dextran-70 and Dextran-40 significantly (P < 0.01) improved the surface manifestations of ischemic myocardial injury as determined by ST segment elevation (Σ-ST) and number of sites of elevated ST segments (N-ST). D-70 administered after permanent ligation of the LAD also significantly (P < 0.05) decreased the number and magnitude of ST segment elevations. Radioactive microsphere determinations of regional coronary blood flow, before and after Dextran-70 hemodilution, indicated significant (P < 0.01) increases in coronary flow to nonischemic areas, but no increase in blood flow to the ischemic area itself. Dextran hemodilution reduces the surface manifestations of myocardial ischemia without increasing blood flow to the ischemic area. If Dextran hemodilution can be shown to result in improved survival of ischemic myocardium, its mechanism of action cannot be by increasing collateral blood flow but must be by altering myocardial oxygen demand in a fashion heretofore not described.

Local cardiac hypothermia for myocardial protection during correction of congenital heart disease.

Eighty-eight operations for correction of intracardiac congenital heart defects were performed using local cardiac hypothermia for protection of the ischemic myocardium. Twenty-six patients underwent repair of tetralogy of Fallot, 23 had patch closure of ventricular septal defect, 24 had correction of various types of congenital aortic stenosis, and 15 were operated upon for other complex lesions. The overall operative mortality was 5.6%. Ischemia times ranged from 9 to 119 minutes (mean, 48 minutes). Ischemic arrest protected by local cardiac hypothermia provides an optimal operative field, permitting repair of uncomplicated intracardiac defects in a precise, unhurried manner. No hemodynamic abnormalities attributable to the technique were encountered.

The aortic valve: To dilate, repair, or replace—That is the question

should be compared with the report by van Son and colleagues [4] that suggests that bicuspid, insufficient aortic valves cannot be successfully repaired. In contrast, Hawkins and associates were able to repair patients with bicuspid aortic valves disrupted by balloon valvuloplasty. They used multiple stepwise logistic regression analysis to define factors associated with successful valve repair. The most important factors determined were a shorter interval between BAV and aortic valve operation and a more recent year of operation. This is not surprising because the technical aspects of valve repair have been refined at an accelerated pace in the last decade and it is possible that an ongoing process of fibrosis and scarring renders the disrupted leaflet nonreparable if the repair operation is deferred for a considerable period of time. Hawkins and associates are cautious in their conclusions because the follow-up only averages 22 months. In the discussion, they hint at a much more important area of controversy in modern cardiovascular surgery. Balloon aortic valvuloplasty has become the procedure of choice for aortic stenosis at many centers. This decision has

Palliation of Univentricular Heart Without Increasing Ventricular Work

mong the factors considered important in determinA ing short-term and long-term survival as well as the quality of survival after the modified Fontan procedure are the pulmonary vascular resistance, the anatomy of the pulmonary arteries, the presence of systemic ventricular hypertrophy, the previous use of systemic to pulmonary artery shunts, the function of the atrioventricular valve, and the age of the patient. The current algorithm for the surgical treatment of infants born with a univentricular heart avoids volume and pressure overload of the single ventricle. Assuming the risk of a completed modified Fontan connection is increased during the first year of life, what alternatives are available? In this issue, Douville and associates [l] report their experience with the hemiFontan operation. Their approach allowed satisfactory palliation without exposing patients to the higher risk of a completed Fontan procedure or the potential long-term complications associated with a systemic to pulmonary artery shunt. The report provides detailed drawings of the operation. The reader can easily appreciate the technical details and the theoretical advantages of this approach to palliation. The hemi-Fontan operation is one of several similar therapies available for patients considered at increased

Intra-Aortic Balloon Counterpulsation and Coronary Revascularization for Left Ventricular Power Failure

Combined use of intra-aortic balloon counterpulsation (IABCP) and coronary revascularization was utilized in 28 patients with acute and chronic left ventricular power failure (LVPF) and ischemic dysrh

PEDIATRIC CARDIAC SURGERY

Now, in this thoroughly revised fourth edition, you again get trusted, complete coverage of the field with timely new features and expert reviews of critical topics including heart transplantation, emerging modalities for diagnosing congenital heart and tracheal defects, the surgical technique of Fontan conversion with arrhythmia surgery, the medical challenges of managing adult CHD patients, and more.