Toyoki Fukuda

Continuous pulmonary perfusion during cardiopulmonary bypass prevents lung injury in infants

BACKGROUND Lung injury after cardiopulmonary bypass is a serious complication for infants with congenital heart disease and pulmonary hypertension. Excessive neutrophil sequestration in the lung occurring after reestablishment of pulmonary circulation implies that interaction between neutrophils and pulmonary endothelium is the major cause of lung injury. METHODS Thirty infants with either ventricular septal defect or atrioventricular septal defect and with pulmonary hypertension were enrolled in this study. We performed continuous pulmonary perfusion during total cardiopulmonary bypass on 16 patients (perfused group) and conventional cardiopulmonary bypass on 14 patients (control group). PaO2/FiO2 and neutrophil counts were assessed from immediately before surgery to 24 hours after termination of cardiopulmonary bypass. RESULTS PaO2/FiO2 was higher in the perfused group than in the control group, and the difference was significant throughout the study period. Neutrophil counts decreased below prebypass values in both groups at 30 minutes after aortic unclamping, and the difference was significant in the control group but was not in the perfused group. Duration of postoperative ventilatory support was significantly less in the perfused group. CONCLUSIONS Our study demonstrates that arrested pulmonary circulation during cardiopulmonary bypass is the major risk factor of lung injury and that continuous pulmonary perfusion is effective in preventing lung injury.

Primary cardiac angiosarcoma : 53 months' survival after multidisciplinary therapy

An 8-year-old girl underwent surgical excision of a tumor arising from the right atrium immediately after admission. Because histologic and immunohistochemical examination confirmed the diagnosis of angiosarcoma, adjunctive multidisciplinary therapy was administered for the following 2 years. She is leading a normal school life 53 months after the operation. Therapeutic strategy for this highly malignant cardiac tumor is discussed.

Successful Surgical Repair of Common Pulmonary Vein Atresia in a Newborn

Abstract. A 7-hour-old boy underwent an emergency operation with an anticipated diagnosis of total anomalous pulmonary venous connection. The precise diagnosis of common pulmonary vein atresia (CPVA) was made during the operation. A side-to-side anastomosis between the common pulmonary venous chamber and the left atrium was performed. All procedures were successfully carried out on the beating heart under the cardiopulmonary bypass. A tentative diagnosis of CPVA should always be borne in minds in neonates with clinical conditions such as deep cyanosis unresponsive to the oxygen therapy, stubborn acidosis, severe pulmonary venous congestion, and rapid deterioration. The corrective repair of CPVA with the heart beating appears to be the procedure of choice in the setting of seriously damaged myocardium of the immature heart. To the best of our knowledge, this is the youngest survivor of the corrective surgery for CPVA and operation at time of diagnosis is the important principle.

Shallow stitching close to the rim of the ventricular septal defect eliminates injury to the right bundle branch

BACKGROUND Complete right bundle branch block carries a deleterious effect on the long-term outcome of patients who undergo surgical treatment of the perimembranous ventricular septal defect. We describe a novel suturing method to reduce the prevalence of complete right bundle branch block. METHODS From March 1996 through December 2000, 48 consecutive patients with perimembranous ventricular septal defect underwent patch closure using shallow stitches placed close to the rim (group 1). The same number of patients was randomly selected from those who had previously undergone surgery using deep stitches placed distant from the rim (group 2). Postoperative electrocardiograms were reviewed to compare the prevalence of complete right bundle branch block between groups. A morphologic study of the conduction system was performed to identify the vulnerable segment of the right bundle branch where the surgical damage tended to occur. Additional analyses were made to determine whether younger age and right ventriculotomy increased the prevalence of complete right bundle branch block. RESULTS The prevalence of complete right bundle branch block in group 1 (6.3%) was significantly (p < 0.0001) lower than in group 2 (43.8%). The result was consistent with the morphologic finding that stitches of group 2 tended to damage the right bundle branch and those of group 1 did not. The younger age and right ventriculotomy did not increase the prevalence of complete right bundle branch block. CONCLUSIONS Shallow stitches placed close to the rim of the perimembranus ventricular septal defect eliminate injury to the right bundle branch.

Surgically created double orifice repair of tricuspid regurgitation in infants with congenital heart disease

Repair of tricuspid regurgitation (TR) in infants with congenital heart disease (CHD) is frequently associated with postoperative morbidity. Annuloplasty is a well-established surgical procedure for TR and is associated with a satisfactory postoperative outcome provided the deformity of the tricuspid leaflet is mild. However, in the presence of severe leaflet deformity, the reparative procedure remains a surgical challenge. The present study describes our experience with the surgically created double orifice repair of the tricuspid valve in infants with CHD and significant TR. Clinical Summary PATIENT 1. A 7-month-old male infant was referred to our hospital at 1 month of age with the diagnosis of double outlet from the right ventricle, pulmonary hypertension, TR, and bronchial stenosis. At 2 months of age, the clinical condition deteriorated progressively due to respiratory tract infection. Although he underwent pulmonary artery banding (PAB) at 3 months of age, weaning from the respirator was unsuccessful. At 7 months of age, he underwent a definitive operation, in which intraventricular rerouting was established with a 0.4-mm Gore-Tex patch (W. L. Gore & Associates, Inc, Flagstaff, Ariz) connecting the left ventricle with the aorta. The tricuspid valve was dilated to 23 mm and showed a diffuse degenerative change with deficient valvar tissue near the commissure between the anterior and septal leaflet (Figure 1, B). Because Reed’s annuloplasty at this area failed to alleviate TR, a double orifice repair was performed wherein the central free edge of the anterior leaflet was approximated to the facing edge of the septal leaflet with a 5-0 polypropylene mattress suture (Figure 1, C). The divided orifices were equal in size, each measuring 10 mm. The patient recovered uneventfully and was weaned from the respirator on postoperative day 5. The mean right atrial pressure ranged from 5 to 9 mm Hg in early postoperative days and was 3 mm Hg at 6 months after surgery. Postoperative Doppler echocardiography demonstrated a divided unobstructed flow through the tricuspid

Clinical and morphologic features of perimembranous ventricular septal defect with overriding of the aorta – the so-called Eisenmenger ventricular septal defect. A study making comparisons with tetralogy of Fallot and perimembranous ventricular defect without aortic overriding

The aim of our study was to elucidate the clinical and morphologic features of those perimembranous ventricular septal defects which extend between the ventricular outlets, particularly when found in association with anterior deviation of the muscular outlet septum and overriding of the aorta--the so called Eisenmenger ventricular septal defect. From 1990 through 1998, we have undertaken surgical correction in 203 patients with perimembranous ventricular septal defect. Of these, 15 patients had the Eisenmenger ventricular septal defect. We conducted retrospective analyses of the clinical records, catheterization data, and angiocardiographic and echocardiographic finding of these patients. Comparative studies were then made with the patients having tetralogy of Fallot, and those with simple perimembranous ventricular septal defects without overriding of the aorta. In the patients with the Eisenmenger ventricular septal defect, the extent of anterior deviation of the outlet septum was comparable with that seen in tetralogy of Fallot, but there was less rightward displacement of the aortic valvar orifice. In contrast to earlier investigators, however, we found evidence of progressive narrowing of the subpulmonary infundibulum in those with the Eisenmenger defect. These morphological features were reflected in the clinical features, since all patients showed evidence of increased pulmonary flow and congestive heart failure in early infancy, but with two-thirds of them subsequently developing right-to-left shunting. We conclude, therefore, that the Eisenmenger ventricular septal defect is a discrete cardiac abnormality in which the morphologic substrate of anterior deviation of the outlet septum gives rise to a potential for progressive narrowing of the subpulmonary infundibulum. Surgical management, therefore, needs to take account of such narrowing as an additional cardinal morphologic feature.

Recovery from congenital complete atrioventricular block

SummaryCongenital complete atrioventricular block without any other intracardiac anomaly reverted to sinus rhythm at the age of 7 years. The girl had had heart failure and Adams-Stokes attacks when aged 1 year, requiring pacemaker implantation. Electrocardiography confirmed sinus rhythm for the first time at the age of 7 years. At the same time, a treadmill test yielded a normal tracing without any arrhythmias.

Two-patch repair of complete atrioventricular septal defect using a small ventricular patch

Since 1992, 19 patients with an atrioventricular septal defect have undergone surgical treatment using a novel annuloplasty technique in which a small ventricular patch was used to reduce the anterior-posterior dimension of the atrioventricular orifice. All patients recovered uneventfully and needed no reoperation for the residual regurgitation or shunt. The results showed that the new annuloplasty technique was promising, although a long-term result is yet to be seen.

Successful surgical repair of a ventricular septal defect and high take-off of the right coronary artery in an infant

A 6-month-old boy was admitted in acute distress because of severe dyspnea and intractable congestive heart failure. With a diagnosis of the ventricular septal defect, pulmonary hypertension and deteriorated lung function due to the respiratory syncytial virus infection, he was taken to the operating room to undergo banding of the pulmonary artery. However, an intraoperative finding of the anomalous high take-off from the right coronary artery made us to discontinue the banding procedure. After intensive medical management, he underwent a successful surgical repair of the defect with no ischemic injury to the myocardium. Congenital cardiac defects having this particular subset of anomalies of the coronary artery need to be repaired primarily since the palliative procedure near the anomalous coronary artery has a potential hazard to compromise the flow of blood through this artery.

Modified End‐to‐End Anastomosis Combined with Subclavian Flap Aortoplasty for Repair of Coarctation of the Aorta with Extended Hypoplasia of the Aortic Isthmus

Recoarctation is a serious complication of the surgical repair of coarctation of the aorta. A combined technique using end‐to‐end anastomosis and subclavian flap angioplasty has shown good results. However, this technique is not entirely free from longitudinal traction in cases of extended hypoplasia of the aortic isthmus. To obviate these problematic sequelae, we have modified the combined technique for repair of coarctation of the aorta having extended hypoplasia of the aortic isthmus. Almost the entire aortic isthmus is left unresected and a lesser period of interruption of blood flow through the descending aorta is required. During the period from 1991 to 1998, five infants with this abnormality underwent surgical repair with the modified method. The results were excellent with no postoperative death and no recoarctation during the follow‐up period.