Peter W. Grant

Conversion of atriopulmonary to cavopulmonary anastomosis in management of late arrhythmias and atrial thrombosis

The original atriopulmonary connection or classic Fontan operation is associated with several late complications such as arrhythmias, right atrial dilatation, and thromboembolism. This report describes our experience with 3 patients who presented with the acute onset of atrial arrhythmias and upon further evaluation were found to have significant hemodynamic lesions. After failing medical management, all 3 patients were treated successfully with surgical conversion of their atriopulmonary connection to a lateral tunnel cavopulmonary Fontan. The postoperative course of these patients was uneventful. However, long-term evaluation is needed to assess the efficacy of this technique in the prevention of postoperative morbidity.

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.

Aortic implantation of anomalous left coronary artery: An improved surgical approach

Anomalous origin of the left coronary artery from the pulmonary artery may present a technical challenge. Direct implantation of the anomalous left coronary artery into the aorta to provide a two coronary artery system is the preferred surgical approach. We describe a modification of this technique to allow anastomosis of the anomalous left coronary artery with the excised button of pulmonary artery from within the lumen of the aorta. We have used this procedure in six children and one adult with anomalous left coronary artery with favorable outcome. The potential benefits of this modified technique are (1) improved operative exposure, (2) ability to implant the anomalous left coronary artery in the appropriate sinus, (3) avoidance of aortic valve damage or distortion because of improved exposure, and (4) applicability to patients of all ages.

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

BACKGROUNDnA 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.nnnMETHODS AND RESULTSnSince 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.nnnCONCLUSIONSnThe Fontan procedure with unidirectional cavopulmonary connection and adjustable ASD has several advantages that may reduce mortality and morbidity for the high-risk Fontan candidate.

Ultra-low dose aprotinin decreases transfusion requirements and is cost effective in coronary operations

BACKGROUNDnThe recommended dose of aprotinin has been shown to reduce blood loss and need for blood transfusions, but the cost precludes its routine use. This study was designed to determine whether a less expensive, ultra-low dose of aprotinin is effective when used in coronary artery bypass grafting with left internal mammary artery.nnnMETHODSnPatients (n = 202) were randomized to receive either placebo or aprotinin, 0.5 million KIU before incision and 0.5 million KIU during initiation of cardiopulmonary bypass. Differences in quantity of blood transfused were analyzed. Further groups were analyzed to account for the effect of aspirin. Multivariable analysis was performed to determine risk factors for transfusion. Direct costs of blood products and aprotinin were tabulated for each group.nnnRESULTSnThere was an important reduction in the proportion of patients transfused, and number of blood units transfused when aprotinin was given before coronary artery bypass grafting. These differences were even more important in patients on aspirin preoperatively. Independent predictors for increased number of transfusions were aspirin continued before operation, smaller body surface area, and the use of placebo instead of ultra-low dose aprotinin. There was no difference in morbidity between treatment groups. There was a reduction in direct costs associated with the use of aprotinin.nnnCONCLUSIONSnThese data support the routine use of aprotinin 1 million KIU in coronary artery bypass grafting with left internal mammary artery to reduce cost and transfusion requirements.

Aortic to right ventricular shunt for pulmonary atresia and intact ventricular septum.

Acute or chronic myocardial ischemia may develop in patients with pulmonary atresia with intact ventricular septum and right ventricular-dependent coronary circulation. In such cases an aorta to right ventricle shunt may be used to reverse this ischemia. This report summarizes our experience with the placement of an aortic to right ventricular shunt in 5 patients. The shunts were made of Gore-Tex and ranged from 4 mm to 8 mm. Associated procedures were bidirectional Glenn (n = 2) and Fontan (n = 2). All 5 patients survived the procedure with documented early graft patency and no evidence of ischemia.

Traumatic pulmonary arteriovenous malformation presenting with massive hemoptysis 30 years after penetrating chest injury

A 39-year-old man presented with massive hemoptysis requiring emergency double lumen endobronchial intubation, bronchial arteriography and embolization, and subsequent right lower lobectomy. He had suffered a shrapnel blast injury to the right chest as a 9-year-old boy. Pathology of the resected specimen revealed lodged metallic foreign body with traumatic arteriovenous malformation. We present this case to alert thoracic surgeons to this extremely rare clinical entity that can present itself many years after the penetrating trauma, which requires urgent surgery.

Vascular Ring: Right Aortic Arch, Mirror Image Branching with Kommerell's Diverticulum

Images of vascular ring-right aortic arch, mirror image branching with Kommerells diverticulum and a brief comment on its management.