Robert A. Gustafson

An Alternative Method for Repair of Partial Anomalous Pulmonary Venous Connection to the Superior Vena Cava

The surgical management of 15 patients with partial anomalous pulmonary venous connection (PAPVC) to the high superior vena cava (SVC) is described. This new technique redirects the anomalous pulmonary venous flow into the left atrium through the cardiac end of the SVC, transected and oversewn above the anomalous pulmonary vein or veins, by coaptation of the atrial septal defect (or of the surgically created septal defect in patients with an intact atrial septum) to the intracardiac orifice of the SVC. Normal SVC-right atrial flow is reconstituted by atriocavoplasty to the cephalad portion of the transected SVC. A 31-year-old woman with severe pulmonary hypertension died early in the series; this was the only death. Surviving patients enjoy full activity. Except for one symptomatic SVC obstruction due to technical error (since relieved), this technique has achieved total correction of these congenital defects with marked reduction in the undesirable postoperative sequelae often associated with other methods of repair.

Biatrial approach to cardiac myxomas: A 30-year clinical experience

Early surgical intervention for atrial myxomas mitigates morbidity and usually offers cure. The operative approach to resect these tumors is controversial. The purpose of this study was to review our experience with the biatrial approach between 1964 and 1994. The location of the myxoma was left atrium in 17 and right atrium in 3. Mean preoperative New York Heart Association functional classification was 2.7. Surgical approach to the tumor was biatrial in all patients. There were no perioperative strokes, myocardial infarctions, or deaths. Mean follow-up was 7.5 years (range, 2 mo to 27 years) with a postoperative New York Heart Association functional classification of 1.4. One late death occurred, which was unrelated to the myxoma. Advantages of biatrial approach include (1) definition of tumor pedicle by direct visualization, (2) minimal manipulation of the tumor, (3) adequate margins of excision, (4) inspection of all heart chambers, and (5) secure closure of the atrial septal defect. Long-term follow-up demonstrates the efficacy of this operative approach to atrial myxomas.

Partial anomalous pulmonary venous connection to the superior vena cava

BACKGROUND Correction of partial anomalous pulmonary venous connection to the superior vena cava (SVC) is often complicated by sinus node dysfunction and occasional pacemaker insertion. METHODS Between 1964 and 1994 40 patients, ranging from 14 months to 52 years old, underwent an operative approach designed to minimize trauma to the sinus node and its blood supply. The SVC was transected and oversewn above the highest anomalous vein. The anomalous pulmonary veins were redirected across a sinus venosus atrial septal defect (33 patients) or a surgically created atrial septal defect (7 patients) into the left atrium. The atrial septal defect rim was coapted to the intracardiac SVC orifice in 23 patients. An intracardiac baffle was used in 17 patients. The cephalad SVC stump was anastomosed to the right atrial appendage. The origin of the pulmonary veins draining into the SVC was right upper lobe (all patients), right middle lobe (33 patients), and the entire right lung (9 patients). RESULTS One 31-year-old woman died of severe pulmonary hypertension. An early technical error resulted in one symptomatic SVC obstruction. All patients remained well over follow-up (6 months to 30 years), without residual intracardiac defects. Sick sinus syndrome developed late in only 1 patient (2.5%). No patient has required a pacemaker. CONCLUSIONS The very low incidence of late arrhythmias with cavoatrial reconstruction is most encouraging.

Early Primary Repair of Tetralogy of Fallot

Young age, low weight, and the requirement for transannular patch reconstruction of the right ventricular outflow tract (RVOT) are thought to adversely affect intracardiac repair of tetralogy of Fallot. Forty patients underwent complete repair between January, 1984, and January, 1987. Only infants with pulmonary atresia, complete atrioventricular canal, or coronary artery anomalies were shunted initially. The malalignment ventricular septal defect was closed with a Dacron patch. Infundibular resection was minimized. All atrial communications were left open. Thirty-four patients (85%) had a transannular RVOT patch, and 2 patients (5%) had a nontransannular patch. All 10 infants weighing 3.4 to 9.6 kg had a transannular RVOT patch at 7 weeks to 12 months of age. An RVOT patch was used in 26 of 30 children operated on between 1 and 6 years of age (median age, 24 months). No patient undergoing intracardiac repair died. Postoperative RVOT pullback gradients were between 0 and 35 mm Hg (mean, 18.5 mm Hg). Postoperative pulmonary artery saturation (mean, 73%) did not reveal any residual ventricular septal defect. The right ventricular/arterial pressure ratio was always less than 0.6 (mean, 0.4). All children are doing well at follow-up from two to 37 months. Serial echocardiograms reveal no residual ventricular septal defect and only 1 moderate RVOT gradient. Follow-up cardiac catheterization in 15 patients revealed no residual ventricular septal defect and RVOT gradients between 5 and 35 mm Hg. The right ventricular/left ventricular pressure ratio was always less than 0.6 (mean, 0.48). The early and late results justify continued primary repair of tetralogy of Fallot in symptomatic children, regardless of age or weight.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma antioxidant depletion after cardiopulmonary bypass in operations for congenital heart disease.

We describe the use of two in vitro tests to characterize plasma antioxidant capacity at the time of cardiac bypass in operations for congenital heart disease in 30 patients aged 3 days to 16 years (average 4.4 +/- 0.9 years [standard error]). Bypass and crossclamp time, circuit volume, and type of operation were recorded for each patient. First, a test of plasma radical antioxidant power measured chain breaking (secondary) antioxidant capacity of plasma to prevent oxidation of linoleic acid in vitro. Second, overall ability of plasma to prevent lipid peroxidation was assessed by a classic test of plasma inhibition of malondialdehyde formation in a beef brain homogenate. Plasma total radical antioxidant power level at baseline was 0.74 +/- 0.03 mumol/ml plasma, which decreased to 0.15 +/- 0.05 mumol/ml plasma after bypass (p < 0.001) and 0.26 +/- 0.08 mumol/ml plasma with recovery (n = 18, p < 0.001). Analysis of variance of postbypass total radical antioxidant power value showed age (p = 0.0002, r = 0.63) and bypass time (p = 0.009, r = 0.4677) to be significant factors. Pump prime volume in milliliters per kilogram and preoperative hemoglobin value were not significant factors. Beef brain malondialdehyde formation in vitro was limited 92% +/- 3% by normal plasma before operation versus 53% +/- 5% after operation (p < 0.001) and 51% +/- 5% at recovery after arrival in the pediatric intensive care unit (p < 0.001). Analysis of variance of the changes from before to after operation showed age p = 0.0015, r = 0.55) and bypass time (p = 0.033, r = 0.39) to be significant factors. Thus antioxidant capacity of plasma is significantly diminished after cardiopulmonary bypass in children. Young patient age and long duration of cardiopulmonary bypass are identified as factors that correlate positively with depletion of antioxidant capacity with bypass.

Intralobar sequestration. A missed diagnosis.

Intralobar pulmonary sequestration is an uncommon but distinct clinical entity that may be the unrecognized cause of recurrent pulmonary infections. Between 1967 and 1987, 10 patients, ranging in age from 5 to 39 years, were found to have an intralobar sequestration. Nine patients (90%) had a history of recurrent pulmonary infections, chronic cough, and intermittent fevers. One patient was asymptomatic. Many patients had been treated with antibiotics on numerous occasions. The delay in diagnosis varied between 3 months and 7 years (mean delay, 1.5 years). The chest roentgenogram was abnormal in all patients. The intralobar sequestration was present in the left lower lobe in 7 patients and the right lower lobe in 3 patients. Bronchography was abnormal in 4 patients in whom it was done. Bronchoscopy was performed in 7 patients, but it was only helpful in excluding other diagnoses. Preoperative thoracic arteriography in 9 patients visualized the systemic arterial supply from the thoracic or abdominal aorta to the intralobar sequestration and helped prevent any catastrophic surgical bleeding. A lobectomy was performed in 9 patients and a segmentectomy in 1 patient without morbidity or mortality. In patients with recurrent infections in the same lower lobe, a high index of suspicion for an intralobar sequestration should prompt early diagnostic arteriography and, if confirmed, early operative intervention.

Role of lung decortication in symptomatic empyemas in children

Despite appropriate antibiotics and pleural drainage, the condition of some children with empyema fails to improve. In a 5-year period, 10 children ranging in age from 2 to 16 years underwent lung decortication for a refractory, symptomatic empyema, which had developed 3 to 5 weeks after an initial pneumonic infiltrate. Responsible organisms included beta-hemolytic streptococci, Haemophilus influenzae, or Streptococcus pneumoniae in 6 children. Negative cultures were found in 4 children. The initial computed tomographic scan of the chest in 4 of 8 patients showed more than 75% limitation of lung expansion by the contents of the empyema cavity. In 4 other patients, an extensive pleural peel was seen on initial computed tomographic scan of the chest. Several studies also showed cystic lesions in the collapsed lung. Multiple computed tomographic scans in 3 patients confirmed the lack of clinical and chest roentgenographic improvement with conservative therapy. At decortication in each, the visceral and parietal pleural peel was completely removed, freeing the trapped lung. Two patients also had a concomitant lobectomy for a necrotic right upper lobe (1 patient) and left lower lobe (1). Clinical improvement was marked, with return of temperature, white blood cell count, and appetite to normal. Postoperative morbidity was minimal. Analysis of these patients in whom traditional conservative therapy failed suggested that the initial management during the early exudative phase was often delayed and was not aggressive enough from the standpoint of pleural drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

Intercostal muscle and myo-osseous flaps in difficult pediatric thoracic problems*

Intercostal muscle pedicle flaps have been successfully utilized in the treatment of recurrent tracheoesophageal fistulae and esophageal perforations in the pediatric age group. An intercostal myo-osseous pedicle flap was also created to repair a distal congenital tracheal stenosis at the carina. The viable intercostal flap has the advantage of multiplicity of uses and of considerable mobility. The presence of a blood supply assures healing. The option of retaining periosteum on the flap encourages bone regeneration at the site of tracheal or bronchial repair. The pleura of the flap provides an epithelial surface for intratracheal repair. The rib graft prevents stricture at the site of tracheal repair.

Analgesia for pediatric thoracostomy tube removal

Eutectic mixture of local anesthetics (EMLA®; Astra Pharmaceuticals, Wayne, PA) has been shown to reduce the pain of blood draws in children. We investigated the use of EMLA® versus IV morphine for providing analgesia during chest tube removal (CTR) in children. One hundred twenty pediatric cardiothoracic surgery patients were enrolled. Patients were randomly assigned to receive either morphine (0.1 mg/kg up to 10 mg IV 30 min before CTR) or EMLA® cream (5 g per chest tube cutaneously 3 h before CTR). A single, trained observer rated the patient’s pain before, during, and after CTR using a 10-cm visual analog scale. The sites were evaluated for adverse effect. Methylhe-moglobin levels were monitored in infants. Before CTR, the pain scores of the children who received morphine were rated lower than those who received EMLA® (P < 0.01). During CTR, there was no difference in the pain score between the morphine or EMLA® group. The change from baseline pain score in the morphine group was significantly larger than in the EMLA® group (P < 0.01). We conclude that EMLA® is safe and useful for blunting the pain of CTR. Implications Chest tube removal is one of the most painful parts of the cardiothoracic surgical experience. This study compared EMLA® (Astra Pharmaceuticals, Wayne, PA) >

Use of heparin-coated cardiopulmonary bypass

A 49-year-old man with unstable angina and a history of severe anaphylaxis to seafood and intravenous iodine needed myocardial revascularization. Because of concern of an intraoperative protamine reaction, preoperative treatment was instituted with steroids and with H1 and H2 blockers. Revascularization was accomplished using a heparin-coated cardiopulmonary bypass circuit. Complement activation and postoperative bleeding were minimal. Heparin-coated cardiopulmonary bypass is a safe, effective technique of bypass in select patients.