Tokio Tamura

Annuloplastic reconstruction for common atrioventricular valvular regurgitation in right isomerism

Two patients who had common atrioventricular valvular regurgitation associated with right isomerism, univentricular heart of the right ventricular type, transposition of the great arteries, pulmonary stenosis, and both systemic and pulmonary venous anomalies underwent common atrioventricular valvular annuloplasty. They also underwent bilateral, bidirectional cavopulmonary shunt. A Carpentiers ring was used in patient 1 and a polytetrafluoroethylene tube was used in patient 2 to reduce the diameter of the common atrioventricular annuli. Postoperative catheterization confirmed complete elimination of regurgitation of the common atrioventricular valve in both patients.

Early and late results of repair of tetralogy of Fallot with subarterial ventricular septal defect. A comparative evaluation of tetralogy with perimembranous ventricular septal defect.

Between November 1966 and December 1990, 511 pediatric patients with tetralogy of Fallot underwent corrective operation at Tenri Hospital. There were 78 patients with subarterial ventricular septal defect. Mean age at repair was 5.6 +/- 3.3 years. The method of right ventricular outflow tract reconstruction was simple infundibulectomy in 14 patients, right ventricular ventricular outflow patch in 36, and transannular patch in 28. There were 7 (9.0%) early deaths as a result of low cardiac output syndrome and acute renal failure. The pressure ratio of the right ventricle to the left ventricle was 0.62 +/- 0.18 during the early postoperative catheterization. Follow-up was achieved for 442.6 patient-years and ranged from 0.5 to 27 years, with an average of 8.5 +/- 6.7 years. There were three late deaths (2 cardiac and 1 noncardiac). Actuarial survival was 94.8% +/- 4.0% at 20 years. Catheterization during late follow-up (6.8 +/- 4.7 years after repair) was done in 53 patients and the pressure ratio of the right ventricle to the left ventricle was 0.48 +/- 0.21. Fifteen patients underwent subsequent operation because of residual lesions, including ventricular septal defect in four patients, pulmonary stenosis in nine, combined ventricular septal defect and pulmonary stenosis in one, and pulmonary regurgitation in one, with no mortality. Actuarial rate of freedom from reoperation was 71.1% +/- 8.0% at 10 years and 58.8% +/- 16.8% at 20 years. Patients with tetralogy and subarterial ventricular septal defect were more likely to have the development of residual obstruction at the level of the pulmonary valve anulus after repair than were those with tetralogy and perimembranous ventricular septal defect.

Reoperation after Aortic Valvuloplasty for Aortic Regurgitation Associated with Ventricular Septal Defect

Five patients underwent reoperations because residual or recurrent aortic regurgitation occurred after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect. The mean age at reoperation was 22 years old, and the mean time interval between initial and second operation was 6 years, 10 months. The pathological findings of the aortic valves showed tears and perforation of repaired leaflets in four patients and a giant pseudoaneurysm of the Valsalva sinus in one. Aortic valvuloplasties were performed again in three patients, and aortic valves were replaced with prosthetic valves in two. Slight to moderate regurgitant murmurs are still audible in patients who underwent these valvuloplasties. Ventricular septal defects should be closed before aortic regurgitation develops. If it has developed, however, valvuloplasty should be considered as a first choice in young patients. For adult patients, aortic valve replacement is recommended.

Transposition of the great arteries associated with total anomalous pulmonary venous return

A case of a 1-year-old boy with combined transposition of the great arteries and total anomalous pulmonary venous return is reported. The anomalies were successfully repaired by a new atrial partitioning technique.

Bidirectional cavopulmonary anastomosis using vertical vein for right isomerism, pulmonary atresia, and TAPVR

An 8-year-old girl who was diagnosed as having right atrial isomerism, pulmonary atresia, butterfly-shaped juxtaductal pulmonary arterial stenosis, total anomalous pulmonary venous return of the supracardiac type, regurgitant common atrioventricular valve, and univentricular heart of the right ventricular type underwent bilateral, bidirectional cavopulmonary anastomosis using a vertical vein and anastomosis between the common pulmonary venous trunk and atrium. The surgical procedure in this patient is described.

Acute pulmonary edema after Blalock-Taussig anastomosis

Acute pulmonary edema developed in 2 patients after a Blalock-Taussig shunt procedure. Both patients had a univentricular heart complex with pulmonary stenosis. One patient underwent a modified Blalock-Taussig shunt using a polytetrafluoroethylene tube and the other underwent a classic Blalock-Taussig anastomosis. Acute pulmonary edema after the Blalock-Taussig shunt is rare, but once it has occurred, immediate treatment is obligatory.

Palliative reconstruction of right ventricular outflow tract in tetralogy with hypoplastic pulmonary arteries.

Twenty-five symptomatic patients with tetralogy of Fallot underwent palliative reconstruction of the right ventricular outflow tract without closure of the ventricular septal defect. Their ages ranged from 5 months to 20 years (mean age, 3.5 years). Eight patients had had 13 prior systemic-pulmonary arterial shunts. There were six hospital deaths (24%). Three patients needed a repeat right ventricular outflow reconstruction. There was one late death. The other patients manifested clinical improvement; hematocrit decreased from 0.54 to 0.43 (p less than 0.01) and arterial oxygen saturation increased from 63.0% to 83.2% (p less than 0.01). The size of the pulmonary artery, defined as the ratio of the sum of the diameter of the right and left pulmonary arteries to the diameter of the descending aorta, increased from 0.72 to 2.06 (p less than 0.01). Sixteen patients underwent a corrective operation 2.4 years after palliation. The results of palliative right ventricular outflow tract reconstruction suggest that it may be an optional strategy for the treatment of symptomatic patients who have tetralogy of Fallot with severely hypoplastic pulmonary arteries.

Multiple congenital aneurysms of the atria

Aneurysms of both the left and right atria are very rare congenital abnormalities. A 3-year-old boy underwent operation with preoperative diagnosis of aneurysms of both atria and supraventricular tachyarrhythmia. The multiple aneurysms were resected during cardiopulmonary bypass. The patient was asymptomatic after operation and has maintained sinus rhythm.

Evaluation of corrective surgery for tetralogy of Fallot from late results by multivariate statistical analysis

From 1966 to 1985, 469 pediatric patients with the tetralogy of Fallot (mean age, 4.9 years) were corrected (hospital mortality 11.9%). There were 9 late deaths (1.9%). In 186 patients, hemodynamic studies were performed 2-14 years postoperatively (mean age, 10.4 years). An increased cardiothoracic ratio (CTR) of 60% or more was found in 42 patients with impaired postoperative physical activity. The factors affecting the late results were investigated in relation to CTR by the quantification method of multivariate analysis. As for the enlarged CTR, pulmonary regurgitation was more of a contributing factor than pulmonary stenosis. In pulmonary regurgitation, the pulmonary artery area index (PAAI) and reconstruction of the right ventricular outflow tract (RVOT) were highly significant factors. For pressure gradient, the VSD site was the most significant factor. These analyses suggest that preservation and/or reconstruction of the pulmonary valve, or trans-annular patching with the necessary minimal area for the RVOT (PAAI) not to exceed 4 cm2/m2 at the time of operation is important for satisfactory late results.

Brachiocephalic arterial stenosis associated with atypical aortic coarctation

T he patient was a 3-year-old girl. Precordial murmur was discovered 6 months after birth. At 1 year and 2 months of age, she was diagnosed as having stenosis of the brachiocephalic artery, coarctation of the aorta and hypertension of the upper extremities. At age 3, she had surgical correction. She was 64 cm tall and weighed 13 kg. Arterial pulses could be clearly palpated in the right brachial artery, but were faint in the left brachial artery and both femoral arteries. Blood pressure was 126/82 mm Hg in the right upper arm, 102/50 mm Hg in the left upper arm and 6450 mm Hg in the right thigh. Auscultation revealed rough pansystolic murmur at the basal area. Electrocardiography re