Robert Coelho

Right ventricular diastolic function after repair of tetralogy of Fallot.

The objective of this study was quantitate diastolic dysfunction in the postoperative phase of tetralogy of Fallot (TOF) and to correlate it with the type of surgical procedure and clinical parameters. Fifty consecutive patients (mean age, 5.0 years; mean weight, 13.5 kg), operated for TOF during the period November 2004 to May 2005, were prospectively studied [infundibular resection, 23; infundibular resection and transannular patch (TAP), 19; right ventricle→pulmonary artery conduit, 8). Detailed echocardiography was done on postoperative days 3 and 9 with a focus on Doppler indices of right ventricular (RV) function, Antegrade late diastolic flow in the right ventricular outflow tract (RVOT) was taken as the marker of restrictive RV physiology. The previous parameters were correlated to the type of surgery and clinical indices of RV dysfunction. There was no mortality. Twenty-four patients showed restrictive RV physiology. This finding correlated with lower values of E/A ratio (0.98 ± 0.17 vs 1.33 ± 0.49, p < 0.002), tricuspid valve E-wave deceleration time (86.9 ± 21.7 vs 151.4 ± 152 msec, p < 0.05), index of myocardial performance (0.15 ± 0.06 vs 0.26 ± 0.09, p < 0.001), isovolumic relaxation time (19.4 ± 17 vs 39±30 msec, p < 0.009), and a higher central venous pressure (15.1 ± 1.5 vs 12.7 ± 1.9, p < 0.001). Restrictive RV physiology correlated with prolonged intensive case unit (ICU) stay (5.1 ± 3.7 vs 2.8 ± 2 days, p < 0.015), longer duration of inotropic support (108.3 ± 56.2 vs 55.5 ± 28.3 hours, p < 0.02), and higher dosage of diuretics. RV diastolic dysfunction is demonstrable by Doppler echocardiography in the first week following surgery for TOF and tends to be worse with TAP. Restrictive physiology demonstrated by RVOT pulse Doppler predicts longer duration of inotropic support, prolonged ICU stay, and higher dosage of diuretics.

Novel techniques of bidirectional Glenn shunt without cardiopulmonary bypass

BACKGROUND We report novel techniques of performing bidirectional Glenn shunt (BDG) without cardiopulmonary bypass (CPB). METHODS Five cases of single ventricle and pulmonary stenosis (PS) complex were taken up for BDG without CPB. The criteria for case selection were an unrestrictive atrial septal defect (ASD), no atrioventricular (AV) valve regurgitation, and no other intracardiac defects requiring correction. A temporary shunt was established between the superior vena cava (SVC) and contralateral branch pulmonary artery (PA) for venous drainage during SVC clamping for BDG anastomosis in four cases. In case 5, a shunt was put between the SVC and right atrium (RA) for venous drainage, and modified Blalock Taussig shunt and patent ductus arteriosus (PDA) were left open until the completion of the BDG. RESULTS Central venous pressure (CVP) increased to a mean of 22.4 mm Hg during SVC clamping, with improvement of oxygen (O2) saturation from 62.4% to 82.4%. After Glenn shunt, CVP and O2 saturation maintained at 13.2 mm Hg and 87.4%, respectively. Postoperatively, there were no neurological abnormalities and no hospital mortality. CONCLUSIONS Our technique provides an excellent venous drainage with improvement of O2 saturation during SVC clamping. It avoids problems related to CPB and economy. It is easily reproducible, with excellent results in a selected group of patients without compromising the completeness of repair.

Role of limited posterior thoracotomy for open-heart surgery in the current era

BACKGROUND The earliest open-heart operations were performed employing the thoracotomy approach. Over the years, median sternotomy has become the routine way of approaching the heart. However, lately there has been progressive enthusiasm in minimally invasive techniques for accessing the heart. We present our technique of correction of congenital heart defects employing the limited posterior thoracotomy approach. METHODS From June 1997 to April 1998, 27 patients underwent correction for various intracardiac defects without any mortality. There were 19 ostium secundum defects, with or without other associated anomalies. There were six sinus venosus defects with partial anomalous pulmonary venous connections. Two patients had perimembranous ventricular septal defects, while 2 patients had partial atrioventricular defects. In 2 other patients, pulmonary stenosis was repaired, using pulmonary valvotomy in 1 patient, whereas the other patient required short transannular patch. RESULTS The median age was 7 years and the median weight was 20 kg. The median skin-to-skin time was 260 minutes. The median bypass time was 63.25 minutes and the median cross-clamp time was 35.0 minutes. All the patients were extubated within 12 hours following surgery and the median ICU stay was 24 hours. Three patients required blood transfusions in the ICU for significant blood loss and the mean chest drainage was 85 cc per 24 hours. None of the patients had phrenic nerve palsies. None of the patients required additional analgesics other than routine ibuprofen or ketorolac tromethamine. Short-term follow-up revealed no functional or physical disability of the thoracic wall and the right arm. All who underwent surgery with this approach were happy with the limited visibility of their scars. CONCLUSIONS Limited posterior thoracotomy offers a viable alternative for midsternotomy and submammary thoracotomy. It has the advantage of a scar in the back that does not impede the future growth of the breast tissue and the pectoralis major. Our approach does not need any new instruments and hence no contraptions are necessary to perform the operation with this approach. Our results have shown satisfactory short-term results and better cosmesis.

Evolving surgical management for ventricular septal defect, pulmonary atresia, and major aortopulmonary collateral arteries

BACKGROUND The purpose of this study was to evaluate the results of various surgical modalities that have been evolving for the treatment of ventricular septal defect, pulmonary atresia, and major aortopulmonary collateral arteries. METHODS From 1993 to May 1997, 14 patients (group 1) were treated with staged unifocalization through thoracotomies and final repair by midsternotomy. From June 1997 to February 1998, 10 patients (group 2) were treated with midsternotomy, single-stage complete unifocalization, and repair. RESULTS In group 1, 14 patients had 21 procedures (1.5 procedures per patient), of which 3 patients (21%) had final correction. There were two deaths (14%). One patient died of blocked shunt. Another patient who had aneurysmal dilation of homograft tubes that were used for unifocalization died after final repair because of low cardiac output. In group 2, 10 patients had ten surgical procedures for complete unifocalization and 9 of 10 (90%) of them achieved final correction. One patient with low cardiac output in whom we did not close the ventricular septal defect died (10%) of suprasystemic right ventricular pressure. CONCLUSION In single-stage complete unifocalization, more patients had final correction. It reduces the number of operations and hospitalization and hence is more cost effective than multistaged procedures.

Median sternotomy single stage complete unifocalization for pulmonary atresia, major aorto-pulmonary collateral arteries and VSD-early experience

OBJECTIVE It is a prospective study to assess the results of median sternotomy, single stage complete unifocalization and repair for ventricular septal defect (VSD), pulmonary atresia and major aorto pulmonary collateral arteries (MAPCAs). METHODS From June 97 to August 98, 20 patients were treated with single stage complete unifocalization and repair. Their ages ranged from 6 months to 11 years. Through median sternotomy, all MAPCAs were dissected and looped. On cardiopulmonary bypass, MAPCAs were anastomosed to native pulmonary arteries (PAs) or to MAPCAs. VSD was closed if possible and RV to PA continuity was established with a homograft conduit. If complete repair was not suitable, central shunt was done from ascending aorta to reconstructed PA with a polytetrafluroethylene graft. The patients were divided into three groups according to the arborization pattern in the lungs. Group 1 had well formed native PAs with MAPCAs, group 2 had hypoplastic PAs with MAPCAs and group 3 had only MAPCAs. RESULTS Twenty patients had 21 procedures. All MAPCAs were unifocalized with tissue-to-tissue anastomosis for future growth, except one in whom polytetrafluroethylene tube graft was used to attain the confluence. In group 1, all seven patients had complete unifocalization and repair. In group 2, four patients had RV to PA conduit and two patients had central shunt. In group 3, three patients had complete repair, three patients had RV to PA conduit and one patient had central shunt. There were three deaths, two in group 2 and one in group 3. The first patient died due to a wrong decision to close the VSD, the second patient died due to missed large MAPCA in preoperative angio and the third patient was a 7-year-old boy who died with irreversible pulmonary vascular changes due to unprotected MAPCAs. CONCLUSIONS To conclude, complete repair/RV-PA conduit/central shunt should be done according to the size of the total pulmonary vasculature in patients with group 1, 2 and 3 with protected PAs/MAPCAs and in hypoplastic or absent PAs with unprotected MAPCAs (less than 1 year) and protected MAPCAs. We are yet to determine the surgical procedure to be performed in hypoplastic/absent PAs with unprotected MAPCAs more than 1 year. It is very essential to delineate all the MAPCAs up to the level of the diaphragm preoperatively.

Outcome of Single Ventricle and Total Anomalous Pulmonary Venous Connection

Management of patients with single-ventricle physiology is significantly affected by anomalies of pulmonary venous return at all stages, whether primary palliation, bidirectional Glenn shunt, or completion of Fontan circulation. We treated 25 patients with pulmonary venous anomalies and single ventricle by staged palliation, from June 1996 to May 2005. Visceral heterotaxy with atrial isomerism was present in 19 of them. Primary palliation with a systemic-to-pulmonary artery shunt was undertaken in 15 patients. There were 5 early deaths, of which 4 were due to obstruction of pulmonary venous return. A bidirectional Glenn shunt was constructed in 17 patients including 10 who had it as a primary palliative procedure. There were 7 early deaths after the bidirectional Glenn procedure; only one was due to pulmonary venous obstruction. Five patients attained completion of the Fontan procedure. There was one early death after the Fontan operation. Anomalous pulmonary venous return can significantly complicate the management of patients with single ventricle, with an impact on survival in early infancy. Palliation with the aim of instituting extracardiac conduit Fontan circulation allows greater latitude and more streamlined management.

Arterial switch operation without coronary translocation: mid-term results.

We innovated a technique of arterial switch operation without coronary translocation in 1995, which avoids problems related to coronary artery translocation with good mid-term results. It is a better alternative for surgeons who are not well versed with coronary translocation of conventional arterial switch operation and with difficult coronary anatomy. This report deals with the mid-term results of our new technique.

One-stage repair of cardiac and arch anomalies without circulatory arrest.

Between 1999 and 2002, 23 patients underwent single-stage complete repair of cardiac anomalies and aortic arch obstruction, without circulatory arrest. Median age was 1.2 years. Intracardiac defects included ventricular septal defect in 9, double-outlet right ventricle in 6, d-transposition of the great arteries and ventricular septal defect in 2, subaortic obstruction in 3, and atrial septal defect in 3. Fourteen patients had coarctation of the aorta, 6 had coarctation with hypoplastic aortic arch, and 3 had interrupted aortic arch. Simple techniques were employed such as cannulation of the ascending aorta near the innominate artery and maintaining cerebral and myocardial perfusion. After correction of arch obstruction, intracardiac repair was undertaken. The mean cardiopulmonary bypass time was 169 min, aortic crossclamp time was 51 min, and arch repair took 16 min. There was no operative mortality or neurological deficit. In follow-up of 1–43 months, no patient had residual coarctation. This simplified technique avoids additional procedures, reduces ischemic time, and prevents problems related to circulatory arrest.