Loïc Macé

Right Anterolateral Thoracotomy for Repair of Atrial Septal Defect

BACKGROUND To procure a cosmetic incision in female patients, we performed operation on atrial septal defects through a right anterolateral thoracotomy. METHODS From 1984 to 1994, 80 female patients with a mean age of 24 +/- 13 years (ranging from 12 to 62 years) underwent right anterolateral thoracotomy for atrial septal defect repairs. Defects repaired included 62 ostium secundum, 12 sinus venosus, 2 low septal defect, and 4 ostium primum. The right iliac external artery was systematically used for arterial cannulation, through a cosmetic incision. Repairs were always performed under fibrillation, except in the 4 ostium primum defects, for which cardioplegia was used. RESULTS There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach. CONCLUSIONS The right thoracotomy incision appears to be a safe and effective alternative to median sternotomy for repair of atrial septal defects.

Bypass graft for complex forms of isthmic aortic coarctation in adults

BACKGROUND Bypass grafting for complex forms of coarctation has been poorly documented as an alternative to decrease the high complication rate associated with anatomic repair. METHODS Between mid-1980 and the end of 1994, 16 patients underwent bypass grafting for complex forms of isthmic aortic coarctation. Age ranged from 11 to 49 years (mean age, 28.4 +/- 13 years). Indications were atypical anatomic forms of coarctation (n = 12) and reoperation after multiple or complicated previous coarctation repair (n = 4). Lateroisthmic bypass grafts were performed in 14 patients and ascending aorta-descending aorta bypass grafts in 2. RESULTS There was no hospital mortality. Morbidity consisted of postoperative paradoxical hypertension in 3 patients. There were no spinal cord complications. One death 10 years postoperatively was unrelated to the surgical technique. One patient successfully underwent ascending aorta-descending aorta bypass grafting for a false aneurysm 10 years after lateroisthmic grafting. All patients were asymptomatic and all grafts, patent after a mean follow-up of 5.7 +/- 4 years. CONCLUSIONS On the basis of these results, bypass grafting appears to be a safe alternative in this select group of patients. The lateroisthmic bypass graft is the procedure of first choice, and the ascending aorta-descending aorta bypass graft should be reserved for failure of previous lateroisthmic bypass grafting.

Hemodynamics of different degrees of right heart bypass: experimental assessment

BACKGROUND Although their assessment could be of the utmost importance to determine the surgical treatment for patients with univentricular hearts, differences in ventricular performance between partial and complete right heart bypass remain to be defined. METHODS Three different degrees of right heart bypass were investigated in 5 mongrel dogs: (1) superior vena cava to both pulmonary arteries shunt (SCP); (2) inferior vena cava to both pulmonary arteries shunt (ICP); and (3) both venae cavae to both pulmonary arteries shunt (BCP). Hemodynamic studies included evaluation of the cardiac index and left atrial pressure as a function of the degree of right heart bypass. RESULTS By maintaining the mean left atrial pressure at 5 mm Hg, cardiac indexes were 1.98 +/- 0.25, 1.67 +/- 0.29, and 1.33 +/- 0.21 L.min-1.m-2 for SCP, ICP, and BCP shunts, respectively (p = 0.001). When keeping the cardiac index constant, mean left atrial pressures were 5.2 +/- 0.8, 5.5 +/- 0.9, and 7 +/- 0.7 mm Hg for SCP, ICP, and BCP shunts, respectively (p = 0.001). CONCLUSIONS Increasing degrees of right heart bypass are associated with a significant decrease in ventricular performance in this experimental model.

Surgical treatment of diffuse supravalvar aortic stenosis

Diffuse supravalvular aortic stenosis can be treated by a variety of surgical approaches. In this case of severe diffuse supravalvular aortic stenosis in a child, we used the combination of an apicoaortic conduit followed 6 years later by aortic valve replacement, replacement of the ascending aorta and aortic arch, and an ascending to thoracic descending aorta bypass graft.

Valved conduit bypass for extensively calcified tricuspid valve stenosis

A case of calcified tricuspid valve stenosis resulting from a complication of ventriculoatrial shunt implantation is presented. Tricuspid valve repair or replacement was not possible because of the prohibitive risk of damaging the right atrioventricular junction and conductive pathways. This rare lesion was treated successfully by insertion of an external right atrial-right ventricular valved conduit. The role of echocardiography in the detection of such a lesion is emphasized and the etiologic and therapeutic aspects are discussed.

Technical modification for anastomosis of low-lying coronary ostia in Bentall procedure.

Bentall procedure is not advisable when the origins of the coronary artery ostia cannot reach the composite valve graft at a satisfactory level for direct reimplantation. The other alternatives to coronary artery ostia reimplantation have some disadvantages. A technical modification of the Bentall procedure, successfully used in 3 patients and allowing direct coronary reimplantation without any tension on the suture line, is described.

Total Anomalous Pulmonary Connection With an Unusual Drainage

h F male infant was born at term with a complex cardiopathy. A detailed cardiac ultrasound examiation showed dextroisomerism, a total anomalous pulonary connection with an unusual drainage pattern, a ouble-outlet right ventricle, and moderate pulmonary tenosis. We performed cardiac computed tomography (CT) canning to clarify the anatomy. The volume-rendered T scan (Fig 1) shows the common pulmonary venous inus (A) draining the 4 pulmonary veins. An ascending ertical vein (green arrow) connects to the left innominate ein, and a descending vertical vein (red arrow) connects o the portal vein. This demonstrates a rare total anomlous venous connection. All 4 pulmonary veins drained n a common pulmonary sinus connected through an scending vertical vein to the left innominate vein and a escending vertical vein to the portal vein. The patient was operated on, and we identified the ulmonary confluence. We made a parallel incision on he posterior wall of the left atrium and then created an nastomosis of the pulmonary confluence to the left trium. Because of the pulmonary stenosis, we associated Blalock Taussig shunt with a 3.5-mm Gore-Tex graft W. L. Gore & Associates, Flagstaff, AZ). Unfortunately,

Ventricular septal defect creation for relief of tunnel subvalvular aortic stenosis

In infants, the management of severe tunnel subvalvular aortic stenosis associated with hypoplastic aortic annulus remains a major surgical challenge. We report a case of such lesion treated by rerouting the systemic blood flow through a created subpulmonary ventricular septal defect toward the right ventricular outflow tract and the pulmonary valve. This technique provided complete relief of the left ventricular outflow tract obstruction without the implantation of a systemic prosthetic valve.