Siho Kim

Pulmonic valve annular enlargement with valve repair in tetralogy of Fallot

We present an operative technique of pulmonic valve annular enlargement with concomitant valve repair using two pericardial patches to reduce pulmonary regurgitation after complete repair of tetralogy of Fallot. We have used this technique in 18 patients with tetralogy of Fallot with excellent results.

Early and late outcomes of total repair of tetralogy of Fallot: risk factors for late right ventricular dilatation

OBJECTIVES This study was undertaken to assess the early and long-term results of total repair of tetralogy of Fallot (TOF) and to identify the risk factors associated with late right ventricular (RV) dilatation. METHODS The medical records of 326 patients (male:female = 192:134) who underwent total repair of TOF at Pusan National and Dong-A University Hospitals between July 1991 and May 2011 were retrospectively reviewed. Median age and weight at the time of operation were 13.0 months and 8.7 kg, respectively. Right ventricular end-diastolic dimensions and left ventricular end-diastolic dimensions were obtained during follow-up echocardiography to identify the risk factors associated with late RV dilatation. RESULTS There were one operative death (0.3%) and 8 late deaths (2.5%). Of late deaths, two were related to operation-related cardiac problems. Overall survival rates at 5, 10, and 15 years were 97.0%, 95.4%, and 95.4%, and the corresponding freedom from cardiac death were 98.8%, 98.8%, and 98.8%, respectively. Freedom from re-operation and re-intervention were 84.4%, 74.2% and 74.2%. Six patients underwent pulmonary valve replacement during the follow-up period. Transannular patch (P = 0.036) and postoperative ventilator support period (P < 0.001) were found to be significant risk factors of late RV dilatation in multivariate analysis. CONCLUSIONS Total correction of TOF can be performed with a very low mortality rate. However, the postoperative re-operation or re-intervention rates remain relatively high. Late RV dilatation after total repair of TOF was found to be associated with transannular patch enlargement and a longer postoperative ventilator support period.

Successful hybrid management for a patient with tricuspid atresia and innominate vein obstruction

A 2-month-old and 5.65-kg baby, diagnosed with tricuspid atresia type IB with pulmonary stenosis and an unrestrictive ventricular septal defect, underwent a modified Blalock-Taussig shunt as an emergency due to intractable critical cyanosis. Even though he took aspirin 5 mg/kg/day after the modified Blalock-Taussig shunt, 11 months after the shunt, angiogram revealed complete occlusion of the innominate vein. The collateral veins drained into the superior vena cava through the haemiazygos vein and the azygos vein, and the multiple small collaterals also drained into the inferior vena cava (Figs. 1A, B). We, therefore, took the hybrid approach to include venous drainage from the left upper extremity into the planned right bidirectional cavopulmonary shunt. In the catheterisation laboratory, the coil embolisation of the distal accessory haemiazygos vein and the small collaterals was performed by a paediatric cardiologist. On the same day, the patient was transferred to the operating room to undergo a bidirectional cavopulmonary shunt. This bidirectional cavopulmonary shunt was successfully done including venous flow from the left upper trunk into the pulmonary bed leaving the azygos vein open. The patient was discharged without any clinical problems. Postoperative computed tomography (CT) showed U-shaped large azygos and accessory haemiazygos vein (Fig. 2). At 5 years of age, a Fontan operation was successfully performed using a 20-mm extracardiac Gore-Tex conduit. Aspirin and warfarin were used as anticoagulant medication after the Fontan operation. Good run-off to the previous Glenn shunt with the azygos vein open-wide was confirmed. The patient has been followed-up for 5 years without any problems taking the aspirin and warfarin. Usually, the azygos vein must be ligated during the bidirectional cavopulmonary shunt procedure. We, however, had a rare experience in which the azygos vein was an important venous route in a patient with innominate vein thrombosis in a bidirectional cavopulmonary shunt. In this case, the thrombosis was caused by a central venous line placed in the previous operation and angiogram showed that venous flow was completely occluded by the innominate vein thrombosis, which was drained via the haemiazygos azygos veins. We then successfully treated the innominate vein thrombosis in the patient facing a bidirectional cavopulmonary shunt with the trans-catheter procedure, followed by a bidirectional cavopulmonary shunt on the same day.