Kathleen N. Fenton

Total anomalous pulmonary venous drainage in newborns with visceral heterotaxy

Children with visceral heterotaxy often present with total anomalous pulmonary venous drainage (TAPVD) associated with univentricular congenital heart disease. We reviewed our experience with the primary surgical management of this lesion under these circumstances. Over a recent 10-year span, 38 patients within the first 3 days of life were admitted to our institution and underwent primary palliation. Twenty-one of them had TAPVD, 18 to a systemic vein. Twelve (67%) of these 18 were seen with obstruction of the anomalous connection and underwent emergency operation. In 7 patients, repair of TAPVD was combined with a systemic-pulmonary artery shunt because of additional obstruction of the pulmonary blood supply, with two deaths. One patient had primary shunting and then repair of TAPVD. Four patients underwent repair of TAPVD alone. Two of them then showed signs of insufficient pulmonary blood flow, received a shunt in a second procedure, and subsequently died. Early mortality in the group with obstructed TAPVD was thus 4 (33%) of 12 patients. Statistical analysis of all 38 patients (univariate analysis, chi 2 testing) showed that neither the presence of TAPVD (p = 0.7) nor TAPVD repair alone (p = 0.8) or with shunting (p = 0.8) was a definite risk factor for early death. The performance of a shunt during the first operation, however, was associated with lower early mortality (p = 0.03). Total anomalous pulmonary venous drainage is a common finding in newborns with visceral heterotaxy. Its presence and its subsequent early repair (requiring cardiopulmonary bypass) do not increase the mortality risk. The need of a concomitant shunt in obstructed TAPVD can initially be underestimated.

Fate of small homograft conduits after early repair of truncus arteriosus

Neonatal repair of truncus arteriosus is being performed in a number of centers, often with the use of small homograft conduits. The fate of the homograft and the risk of replacement were the subjects of this study. Between January 1987 and October 1991, 43 infants aged less than 3 months (range, 3 to 90 days) underwent primary repair of truncus arteriosus including implantation of a valved homograft conduit (diameter, 7 to 12 mm). Twenty-nine had follow-up of more than 6 months (range, 6 to 65 months; mean, 21.9 months). After a mean period of 31 months (range, 8 to 65 months), 7 patients showed obstruction with right ventricular pressures at least 75% systemic and underwent either a conduit change (n = 5) or a patch augmentation (n = 2). Mean cardiopulmonary bypass time at reoperation was 99 minutes; mortality was zero. Five other children are known to have a right ventricular pressure of 50% to 60% systemic, 2 having undergone balloon dilation. Statistical comparison of the patients with conduit reoperation or high right ventricular pressure (n = 12) with the rest of the population (n = 17) revealed an elevated pulmonary artery to right ventricular pullback gradient on postoperative day 1 after the repair (7.7 versus 1.3 mm Hg; p = 0.001) and choice of an aortic over a pulmonary homograft (100% versus 64.7%; p = 0.065) as significant risk factors. Age and weight at repair, postoperative pulmonary artery pressure, length of follow-up, and size of the homograft showed no significant differences between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term survivors of fetal cardiac bypass in lambs

The initial experience with cardiac bypass in fetal lambs resulted in early fetal death from placental insufficiency. Subsequent work in our laboratory indicated that vasoactive cyclooxygenase products were released as mediators of this response. The placental dysfunction could be blocked by the administration of indomethacin, allowing longer fetal survival. This unmasked a more subacute (but fatal) problem: fetal surgical stress resulted in diminished fetal cardiac output and progressive metabolic acidosis and contributed to the placental vasoconstriction. In acute studies, when indomethacin was given and the stress response was inhibited by the use of total spinal anesthesia, the fetus maintained normal blood gas levels, cardiac output, placental blood flow, and acid-base status for several hours after bypass. We hypothesized that beyond this point, no further fetal or placental compromise would occur and that this management technique would thus allow long-term fetal survival. With the use of total spinal anesthesia and sterile technique for long-term study, 12 fetal lambs at 120 days (80%) gestation underwent exposure, line placement, and cannulation for fetal cardiac bypass. Indomethacin was given intravenously on obtaining venous access. After 20 minutes of normothermic cardiac bypass at flow rates of 250 to 300 ml/kg/min, the fetus was weaned from bypass, the cannulas and lines were removed, the uterus and abdomen were closed, and the ewe and fetus were allowed to recover. There was one maternal death (pneumonia) and one early abortion (of twins); the remaining 10 ewes progressed to term. At term, five healthy lambs that had undergone fetal cardiac bypass were delivered (including one twin), four ewes delivered a mummified study fetus and one or two healthy siblings, and one delivered a dead term fetus. With the use of techniques that inhibit fetal stress and block placental vasoconstriction, cardiac bypass can be performed in single-gestation fetal lambs with a high degree of recovery and survival (80% in this study). The cause of the elevated abortion rate associated with twin gestation is unclear.

Should a Thoracic Surgeon Transfer a Complicated Case to a Competing Medical Center Against the Hospital’s Order?

Robert M. Sade, MD The Patient Protection and Affordable Care Act was signed into law several years ago, but the future of the emerging health care system remains unclear. The law is not popular and the political outlook for many of its key components is in doubt. Certain aspects of health care can be predicted with considerable confidence, however: an increasing role for bureaucracies and decreasing power of physicians. These trends pose dilemmas for surgeons, particularly when a conflict of loyalties is created when hospital administrators demand that physicians place the interests of the medical center before the interests of patients. The question of how to respond to such conflicts of loyalties was debated at the 61st Annual Meeting of the Southern Thoracic Surgical Association. The session focused on the case of a surgeon faced with a complex clinical situation that would require operative management, either in her own hospital, as demanded by an administrator, or in a competing hospital after referral to a surgeon more experienced in handling such cases. A Case of Divided Loyalties Dr. Elizabeth Black, a young cardiothoracic surgeon in a 400 bed community hospital, receives a call from the emergency department regarding a patient with a confirmed diagnosis of perforated esophagus, which occurred more than 24 hours ago. The patient is stable, but has early sepsis and multiple co-morbidities, including alcohol abuse. The hospital where the surgeon works has 2 groups of cardiothoracic surgeons in competition with one another, all of whom do cardiac surgery and most of whom also do some general thoracic surgery. None of the surgeons has special expertise with esophageal surgery — they generally refer elective esophageal cases to a large university hospital 50 miles away, which has an international reputation in the management of esophageal disease. Dr. Black feels it would be in the patients best interest to be transferred to the university hospital instead of caring for him locally. When arrangements for transfer are begun, the hospital administrator informs the surgeon that she must accept the patient and care for him. The hospital is in the same market catchment area as the university and does not wish to lose patients to its competitor, especially a patient who has already been seen in its emergency department. Dr. Black feels uncomfortable in accepting this patient, and does not feel confident in her ability to optimize his chances of survival. Nonetheless, financial arrangements and competition with the other group of surgeons make it very difficult to refuse the hospitals demand – she is board-certified and through her education and training, she knows the correct care of the patient, and has done similar cases as a resident. The patients social situation (no apparent family members) and current medical condition do not allow him to make an informed decision about his locus of care. In case of a bad outcome, legal repercussion are highly unlikely. Dr. Black asks two of her out-of-state surgical colleagues to advise her on what she should do.

Does Declaration of Brain Death Serve the Best Interest of Organ Donors Rather Than Merely Facilitating Organ Transplantation

he concept of brain death has been contentious since Tits formulation in 1968, and the controversy about whether death by neurologic criteria accurately describes death of a human being has increased over the succeeding decades. Organ transplantation was in its infancy in the 1960s when the problem of too few organs to meet the need was recognized. In response, a committee of Harvard Medical School led by anesthesiologist Henry Beecher proposed an additional definition of death, based on the concept of irreversible loss of all brain function, which has come to be known as brain death [2]. After several years of widespread discussion and debate, the idea was formulated into law in 1980, the Uniform Determination of Death Act (UDDA) [3]. The UDDA defines brain death in this way: