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Early and late results of mitral valve repair in children

Mitral valve repair in children has the advantage of avoiding mitral valve replacement with its attendant need for anticoagulation and reoperation. Seventy-nine children between the ages of 2 months and 17 years (mean 4.9 years) underwent mitral valve repair between May 1982 and April 1993. There were five patients with mitral stenosis and 74 patients with mitral regurgitation, and 19 children were less than 2 years of age. Patients were divided into anatomic subgroups on the basis of the primary cardiac pathologic condition. Forty-three had severe mitral regurgitation, 21 had moderate mitral regurgitation, and 12 patients with primum atrial-septal defect and 2 patients with univentricular hearts had minimal to moderate mitral regurgitation. Associated cardiac anomalies were present in 68 patients and 85% of the patients required concomitant intracardiac procedures. The methods of mitral valve repair included annuloplasty in 68 (86%), repair of cleft leaflet in 41 (52%), chordal shortening in 9 (11%), triangular leaflet resection in 8 (10%), splitting of papillary muscles with resection of subvalvular apparatus in 7 (9%), and chordal substitution in 1 (1%). The technique of annuloplasty was modified to allow for annular growth. Follow-up was available from 1 to 10 years (mean 4 +/- 2.5 years). There were three early deaths (4%), all occurring as a result of low output cardiac failure in patients with minimal postoperative mitral regurgitation. Three late deaths (4%) occurred in patients with persistent moderate to severe mitral regurgitation and progressive cardiac failure and eight patients (10%) required either rerepair or replacement of the mitral valve. Actuarial survival was 94% at 1 year, 84% at 2 years, and 82% at 5 years, and actuarial freedom from reoperation was 89% at 8 years. All patients received postoperative echocardiography with 82% having minimal to no mitral regurgitation and 98% of long-term surviving patients being free of symptoms. We conclude that mitral valve repair can be done with low early and late mortality. The need for reoperation is relatively low and valve growth has occurred with the use of a modified annuloplasty.

Modification of the Fontan Procedure Superior Vena Cava to Left Pulmonary Artery Connection and Inferior Vena Cava to Right Pulmonary Artery Connection With Adjustable Atrial Septal Defect

BACKGROUND A modification of the Fontan procedure with unidirectional cavopulmonary connection is described in which the superior vena cava (SVC) is connected to the left pulmonary artery (PA) and the inferior vena cava (IVC) is connected to the right PA via a lateral tunnel with a snare-controlled, adjustable atrial septal defect (ASD). This allows matching of the SVC and IVC flows with the lung of appropriate size. The obligatory left Glenn shunt provides an adequate arterial oxygen saturation, and the elevation in SVC pressure is well tolerated. The adjustable ASD allows selective decompression of the IVC that maintains cardiac output and reduces fluid accumulation in the serous cavities. METHODS AND RESULTS Since March 1992, we have performed this procedure in 18 patients. There were 17 children and 1 adult. Median age was 3 years and 9 months (range, 13 months to 36 years). Six patients had been staged with a previous bidirectional Glenn shunt. Preoperative cardiac catheterization revealed a PA pressure of 13 +/- 2 mm Hg and a transpulmonary gradient of 5 +/- 3 mm Hg. Ventricular function was satisfactory in all patients. At the completion of bypass, the pressures in the SVC and IVC were 16 +/- 4 mm Hg and 10 +/- 3 mm Hg, respectively (P < .01). The left atrial pressure was 6.0 +/- 3.0 mm Hg and the arterial O2 saturation on 100% oxygen was 93 +/- 3%. There was one death as a result of intractable atrial arrhythmias. The remaining 17 patients had a mean hospital stay of 9.7 days (6 to 18 days). The length of pleural drainage was 7 +/- 3 days. The ASD was adjusted in 11 patients before discharge. Oxygen saturation at discharge was 85.4 +/- 4%. Nine patients had repeat catheterization. The ASD was completely closed in 6 patients, an average of 2.5 months after surgery (range, 3 weeks to 5 months). After ASD closure, the arterial oxygen saturation was 96 +/- 3%, and the SVC and IVC pressures were both 13 +/- 3 mm Hg. CONCLUSIONS The Fontan procedure with unidirectional cavopulmonary connection and adjustable ASD has several advantages that may reduce mortality and morbidity for the high-risk Fontan candidate.

Cardiac Decompression After Operation for Congenital Heart Disease in Infancy

Between January 1987 and July 1992, 641 infants (less than 1 year of age) underwent cardiac surgical procedures through a median sternotomy incision at the UCLA Medical Center. In 36 (5.6%), to achieve cardiac decompression, the chest was left open after the operation, or was re-opened immediately postoperatively because of low cardiac output. The incidence of cardiac decompression was 31% (4/13) after the Norwood procedure and 24% (7/29) after truncus arteriosus repair. Opening of the chest reduced intrathoracic pressure and allowed complete expansion of the lungs. Delayed sternal closure was carried out in 27 patients at a mean of 5 days (range, 2 to 14 days) postoperatively. By the time of chest closure, left atrial pressure had decreased from a mean of 12 +/- 1.4 to 8.4 +/- 0.8 mm Hg (p < 0.004), and inotropic drug support with dopamine and dobutamine had also decreased significantly. Thirteen (36%) patients died of low cardiac output and multiorgan failure (4 of them after delayed chest closure) that was complicated by sepsis in 2. The incidence of sternal wound infection was relatively low at 5.6% (2/36); 1 patient died of generalized sepsis complicating multiorgan failure and the second case occurred in a patient who survived long term after sternectomy. With optimal ventilatory and inotropic drug support and meticulous wound care, delayed sternal closure may improve the survival of infants in low cardiac output after cardiac surgical procedures.

Effect of late postoperative atrial septal defect closure on hemodynamic function in patients with a lateral tunnel fontan procedure

OBJECTIVES The aim of this study was to evaluate prospectively the effect of late atrial septal defect closure on cardiac output and oxygen delivery in patients who have undergone the Fontan procedure. BACKGROUND An adjustable atrial septal defect is incorporated in patients undergoing the Fontan procedure who have increased pulmonary vascular resistance or poor ventricular function, or both. After the Fontan procedure, the atrial septal defect is test occluded. Patients with mean right atrial and pulmonary artery pressures > 15 mm Hg are discharged with the atrial septal defect open. METHODS Twelve patients (20 months to 12 years old) underwent evaluation and closure of the atrial septal defect at a mean interval of 3.8 months (range 1 to 18) after the Fontan procedure. Each patient underwent full right and left heart catheterization. Cardiac output was obtained using the cine-volume method. The study included six patients with a high transpulmonary gradient or poor ventricular function preoperatively, or both (high risk group) and six who had only borderline increased pulmonary vascular resistance (low risk group). Patients in both groups had a mean right atrial pressure > 15 mm Hg when the atrial defect was test occluded in the first week after the Fontan procedure. RESULTS All results are given as mean value +/- SD. Ventricular end-diastolic pressure was significantly lower (p = 0.03) with the atrial septal defect open in low risk patients (6 +/- 3 mm Hg) than in high risk patients (10 +/- 3 mm Hg). With the atrial septal defect open, low risk patients had a significantly higher (p = 0.04) cardiac index (4.87 +/- 0.81 liters/min per m2) than the high risk patients (3.96 +/- 0.47 liters/min per m2). There was no significant difference (p = 0.14) in cardiac index between the two groups with occlusion of the atrial septal defect. Oxygen delivery was also significantly higher (p < 0.05) with the atrial septal defect open in low risk patients (836 +/- 99 ml/min per m2) than in high risk patients (704 +/- 106 ml/min per m2). There was no significant difference (p = 0.89) in oxygen delivery between the two groups with occlusion of the atrial septal defect. With the atrial septal defect open, the interatrial gradient was not significantly different in low risk patients (4 +/- 1 mm Hg) from that in high risk patients (4 +/- 1 mm Hg). CONCLUSIONS These data show that an interatrial communication results in increased postoperative systemic perfusion and oxygen delivery in patients with good diastolic ventricular function after the Fontan procedure.

Preoperative duplex scan assessment of the inferior epigastric artery as a coronary bypass conduit

The inferior epigastric arteries are currently being evaluated as alternative autologous arterial conduits for coronary artery bypass operations. The inferior epigastric arteries are variable in diameter and length and require harvesting through separate abdominal incisions. There is a need, therefore, for a method to preoperatively assess the diameter and length of the inferior epigastric arteries to determine their suitability as a coronary artery bypass graft. We have found that the duplex scan is a valuable noninvasive preoperative imaging modality to evaluate the inferior epigastric arteries.

Surgery for valvar and supravalvar aortic stenosis

Abstract Valvar aortic stenosis is the most common cause of congenital left ventricular outflow tract obstruction. Patients may present as neonates with congestive heart failue from critical aortic stenosis or as children with minimal symptoms or an asymptomatic murmur. Surgical repair is indicated for severe symptoms and for transvalvar pressure gradients >50 mm Hg. Open surgical valvotomy is the procedure of choice, although repeat valvotomy or valve replacement may be required subsequently. Supravalvar aortic stenosis is an unusual form of left ventricular outflow tract obstruction with focal or diffuse narrowing of the aorta above the sinuses of Valsalva. Indications for surgery are the same as for valvar aortic stenosis, and the techniques of aortoplasty are described.