Tjalling W. Waterbolk

An effective treatment of severe intractable bleeding after valve repair by one single dose of activated recombinant factor VII.

IMPLICATIONS The successful treatment with recombinant factor VIIa of a patient experiencing intractable bleeding after cardiac surgery is described.

Comparison of longevity, pacing, and sensing characteristics of steroid-eluting epicardial versus conventional endocardial pacing leads in children

OBJECTIVE Because of either cardiac anatomy or small size, pacing in children often occurs by means of epicardial leads. The disadvantage of epicardial leads is the shorter longevity of these leads compared with endocardial leads. During short-term follow-up, improved stimulation thresholds were found for the newer steroid-eluting epicardial leads. The longevity of these leads may be better than that of conventional epicardial leads. An improved longevity of epicardial leads may influence the choice to either epicardial or endocardial pacing in children. METHODS We studied the longevity and the pacing and sensing characteristics of 33 steroid-eluting epicardial pacing leads (group I, 15 atrial, 18 ventricular) implanted between November 1991 and October 1996 in 20 children with a mean age of 7.6 +/- 6.5 years (mean +/- SD), and 29 endocardial pacing leads (group II, 15 atrial, 14 ventricular) implanted during the same period in 21 children with a mean age of 11.7 +/- 4.7 years. RESULTS The mean follow-up in group I was 2.9 +/- 1.6 years and in group II 3.1 +/- 1.7 years (P =.61). The 2-year survival of the leads in group I was 91% +/- 5% and in group II 86% +/- 7% (P =.97). Lead failure occurred in both groups in 4 leads (P =.85). Chronic stimulation and sensing thresholds were similar. CONCLUSIONS Steroid-eluting epicardial leads have the same longevity as the conventional endocardial leads. Pacing and sensing thresholds were similar and did not change during follow-up. Therefore steroid-eluting epicardial pacing leads are a good alternative for endocardial leads in small children and in children with congenital heart disease.

Relocation of supra-aortic vessels to facilitate endovascular treatment of a ruptured aortic arch aneurysm

Minimally invasive surgery creates new options for patients having a very high risk for morbidity and mortality during conventional operations. A patient with a ruptured thoracic arch aneurysm and a very high comorbidity profile could be treated with these novel techniques. We report on a combined procedure including off-pump coronary bypass grafting, open relocation of the brachiocephalic and left carotid artery, and endovascular exclusion of the thoracic arch aneurysm.

Increasing cyanosis after total cavopulmonary connection treated by banding a separate liver vein

An increasing right-to-left shunt after a total cavopulmonary connection was treated by banding the separate liver vein. As a variation on a fenestrated total cavopulmonary connection, this liver vein was not connected with the intercaval tunnel. After a few days, the shunt increased to an unacceptable level. This was treated by banding the liver vein, which was connected with the right-sided atrium and turned out to be only part of the venous drainage of the liver.

The right auricle tunnel as intercaval tunnel in total cavopulmonary connection may prevent atrial flutter

OBJECTIVE Total cavopulmonary connection (TCPC) is a routine operation for palliation of children with cardiac anomalies in whom biventricular repair is impossible. The original technique consists of the creation of a semi-prosthetic intercaval tunnel. A substantial proportion of these patients develop atrial flutter. We developed a technique for creating an intercaval tunnel that uses the tissue of the right auricle as intercaval tunnel. This technique avoids suture lines in the neighbourhood of the blood supply of the sinus node and leaves the terminal crest free. Since atrial flutter frequently occurs after Mustard and Senning operations in which suture lines are similar as for creating the lateral tunnel in TCPC we postulated that our technique for creating the intercaval tunnel without prosthetic material might prevent atrial flutter. METHODS All the children that qualified for a TCPC were included. Whenever possible our operative technique was applied. In the other cases a semi-prosthetic conduit was used for creating the intercaval tunnel. Of 47 consecutive patients 30 (64%) had a tunnel of right auricle tissue, 12 (26%) had a tunnel of prosthetic material. Five patients did not need an intercaval tunnel and were omitted in this study. Only surviving patients were included in this study. Patients that needed more atrial surgery then necessary for TCPC were also omitted. Postoperative ECGs and Holter monitorings were studied. RESULTS Overall mortality was 7 of 47 patients (14.9% 70% CL 9.4-22.2%). There was no mortality due to rhythm disturbances. Atrial flutter occurred in 3 of 31 included patients (9.7, 70% CL 4.3-18.5%). In the right auricle group 1 of 22 patients (4.5, 70% CL 0.6-14.6%) had atrial flutter compared to 2 of 9 patients (22.2, 70% CL 7.5-45.0%) in the prosthesis group (P=0.13). CONCLUSION The use of the right auricular technique for creating the intercaval tunnel TCPC is applicable in the majority of patients qualifying for a TCPC. Mortality and morbidity are equal comparing the two techniques. However, markedly less atrial flutter occurs in the group where the right auricle was used as intercaval tunnel. Therefore, we recommend the use of our technique for total cavopulmonary connection.

Quantification of Ventricular Volume Load in the Context of a Bidirectional Cavopulmonary Shunt: A Theoretical Treatise

BACKGROUND Functional univentricular hearts are currently palliated by a staged procedure of which the bidirectional cavopulmonary shunt is usually the second stage. In addition to this stage, a calibrated amount of additional pulmonary blood flow may be preserved to promote pulmonary artery growth and increase the length of the interval preceding the total cavopulmonary connection. However, additional pulmonary blood flow can be deleterious for ventricular functioning and development as it increases functional ventricular volume load. METHODS Using the Fick principle we devised a theoretic framework to estimate the ventricular volume loading caused by additional pulmonary and collateral aortopulmonary flow. To use this framework, blood samples need to be taken intraoperatively from the aorta, pulmonary veins, and inferior caval vein to determine oxygen saturations. The oxygen saturation samples have to be taken sequentially with and without additional pulmonary blood flow. RESULTS The objective of this paper is to provide a theoretic framework to estimate the ventricular volume loading caused by collateral aortopulmonary flow and additional pulmonary blood flow in the context of a bidirectional cavopulmonary shunt in the staged palliation of univentricular hemodynamics. The formulas have not yet systematically been applied in vivo. CONCLUSIONS The added volume loading of the ventricle caused by additional pulmonary blood flow can theoretically be estimated using the newly devised formulas so as to calibrate ventricular volume loading to a desired level intraoperatively.

Transposition of the great arteries and isolated origin of the sinus node artery

We report the cases of 2 newborns who underwent at 7 days of age an arterial switch operation for transposition of the great arteries with a rare coronary anomaly: the left and right coronary arteries originated with a single ostium from sinus 1 and the sinus node artery had an isolated origin from sinus 2. The sinus node artery was reimplanted into the new aorta in both patients. Both babies were discharged in sinus rhythm. Preserving the vascularization of the sinus node may avoid the occurrence of postoperative atrial rhythm disturbances.