Vivek Allada

Aortic implantation of anomalous left coronary artery: An improved surgical approach

Anomalous origin of the left coronary artery from the pulmonary artery may present a technical challenge. Direct implantation of the anomalous left coronary artery into the aorta to provide a two coronary artery system is the preferred surgical approach. We describe a modification of this technique to allow anastomosis of the anomalous left coronary artery with the excised button of pulmonary artery from within the lumen of the aorta. We have used this procedure in six children and one adult with anomalous left coronary artery with favorable outcome. The potential benefits of this modified technique are (1) improved operative exposure, (2) ability to implant the anomalous left coronary artery in the appropriate sinus, (3) avoidance of aortic valve damage or distortion because of improved exposure, and (4) applicability to patients of all ages.

Staged surgical approach to neonates with aortic obstruction and single-ventricle physiology

BACKGROUND The surgical management of neonatal systemic outflow obstruction and complex single ventricle pathology is variable. METHODS In 15 neonates (12 boys and 3 girls) with complex forms of single-ventricle pathology and aortic coarctation or interruption, an initial strategy of banding the pulmonary artery and repair of the obstruction from a left thoracotomy was undertaken. RESULTS The median age at operation was 6 days (range 2 to 33 days) and the median weight was 3.3 kg (range 2 to 4.6 kg). There were no early deaths and one late death after the initial surgical palliation. Of the 14 survivors, 8 have undergone a bidirectional cavopulmonary anastomosis. The median age for bidirectional Glenn was 9.75 months (range 3.5 to 26 months). Seven infants have required Damus-Kaye-Stansel reconstruction for subaortic obstruction (one early death). The median age of the Damus-Kaye-Stansel procedure was 4 months (range 3 weeks to 9 months). Thirteen of 15 patients (87%) are alive and 6 have proceeded to a Fontan operation (median follow-up 68 months). A single failing Fontan required takedown to bidirectional Glenn and central shunt. CONCLUSIONS Our experience suggests that this high-risk subgroup of neonates with aortic obstruction and single-ventricle pathophysiology is safely managed by initial pulmonary artery banding palliation and repair of aortic obstruction. This strategy, careful surveillance, and early relief of subaortic stenosis can maintain acceptable anatomy and hemodynamics for later bidirectional Glenn and Fontan procedures.

Aortic to right ventricular shunt for pulmonary atresia and intact ventricular septum.

Acute or chronic myocardial ischemia may develop in patients with pulmonary atresia with intact ventricular septum and right ventricular-dependent coronary circulation. In such cases an aorta to right ventricle shunt may be used to reverse this ischemia. This report summarizes our experience with the placement of an aortic to right ventricular shunt in 5 patients. The shunts were made of Gore-Tex and ranged from 4 mm to 8 mm. Associated procedures were bidirectional Glenn (n = 2) and Fontan (n = 2). All 5 patients survived the procedure with documented early graft patency and no evidence of ischemia.

Percutaneous transluminal coronary angioplasty in an infant with coronary artery stenosis after arterial switch operation

The arterial switch operation (ASO)l has improved the outlook for the neonate with transposition of the great arteries (TGA). The results of immediate and mid-term follow-up of these patients have been encouraging. However, recent studiesz5 justify the theoretical concern about coronary artery reimplantation. We present a case report of an infant with severe coronary artery stenosis after ASO. The diagnosis, management, and results of percutaneous transluminal coronary angioplasty (PTCA) are described. R.M. was a 5 lb full-term newborn male infant. At age 35 days, the patient developed respiratory distress with cyanosis. The cardiac catheterization showed d-TGA, nonrestrictive ventricular septal defect (VSD), patent ductus arteriosus (PDA), and type A coronary arteries. Oxygen saturation was 77 % , and balloon atria1 septostomy was performed. Two days later, the patient underwent AS0 with VSD closure. Postoperatively the patient did well; the electrocardiogram (ECG) showed no ischemic changes and the echocardiogram (ECHO) showed good left ventricular (LV) function. The patient was discharged on postoperative day (POD) 12. He presented at age 11 weeks in profound cardiogenic shock. ECG showed ST-T wave changes consistent with LV ischemia. Creatinine phosphokinase (CPK) was 2628 IU/L, and the ECHO showed severe global LV dysfunction with an ejection fraction (EF) of 19 % . After stabilization, cardiac catheterization showed moderate mitral valve insufficiency and a large left ventricle with LVEF of 12%. Aortogram did not demonstrate coronary artery stenosis. Selective left coronary angiogram was done using a 4F JL-1 catheter (Jorgensen Laboratories, Loveland, Colo.) that was fashioned to engage the left coronary ostium. This coronary angiogram showed 80 % stenosis of the proximal left coronary artery (LCA) (Fig. 1) with poststenotic coronary diameter of 1.8 mm. Because the coronary artery was small, surgical intervention was considered a high risk. Therefore PTCA was done after obtaining the parents’ informed consent. The patient received 75 units/kg body weight intravenous heparin. An 0.014 inch standard guide wire (Advanced Cardiovascular

The incisional pulmonary artery band

Occasionally early definitive repair of congenital heart disease carries prohibitive mortality, and interval pulmonary artery banding is necessary to protect the pulmonary arterial bed and improve systemic perfusion or prepare a systemic left ventricle for a later arterial switch operation. We describe our technique for effectively banding the pulmonary artery.

528 ARTERIAL SWITCH OPERATION IN INFANTS WITH ABNORMAL CORONARY PATTERNS: CLINICAL OUTCOMES.

Objective To determine the short- and midterm outcome of the arterial switch operation (ASO) in infants with normal and abnormal coronary artery patterns. Methods A retrospective analysis was conducted of the experience with the ASO at one institution over the span of 20 years from 1985 through 2005. Two hundred eight consecutive ASOs were performed by the same surgeon for transposition and double-outlet ventricle complexes. Of the 208 coronary artery patterns, 159 (76%) and 49 (24%) were normal and abnormal, respectively. These were classified into 4 groups: Type I (n = 159, 76%) had the typical dual arrangement (1AD, Cx; 2R), Type II (n = 26, 13%) had a dual system other than the typical, Type III (n = 11, 5%) had a single ostium coronary system, and Type IV (n = 12, 6%) included any pattern that had an intramural coronary course or commissural take-off. The primary end points were short- and long-term mortality. Results There was no difference at operation in weight, gender, preoperative inotropic support, presence of VSD and RVOTO between the normal and abnormal groups. There were a total of 16/208 deaths over 20 years (7.7%), with a mean follow-up time of 7.2 years (range 3 months to 19 years). There was no significant difference in the early mortality rate for the normal coronary patterns, 6 out of 159 (3.7%) and the abnormal coronary patterns, 3 out of 49 (6.1%) (p = .29). Similarly, there was no difference in late deaths in the normal, 4 (2.5%), and abnormal, 3 (6.1%), groups (p = .12). Conclusions The existence of abnormal coronary patterns is not a risk factor for early or late mortality after ASO. The impact on late ventricular function awaits determination.