Ventricular function after anatomic repair in patients with atrioventricular discordance

Since June 1989, 18 patients with atrioventricular discordant anomalies under 15 years of age underwent anatomic correction, or double switch operation, with 2 hospital deaths (11%). Ages ranged from 1 year 4 months to 12 years (mean 7.2 years) and body weights ranged from 7.1 to 32.5 kg (mean 20.1 kg) at operation. Visceral situs was solitus in 12 and inversus in 6. Ventriculoarterial connection was discordant in 4 and double-outlet in 14. All had associated congenital cardiac anomalies consisting of ventricular septal defect in 17, atrial septal defect in 9, pulmonary atresia in 10, pulmonary stenosis in 6, systemic tricuspid regurgitation in 9, mitral regurgitation in 6, bilateral superior venae cavae in 6, patent ductus arteriosus in 6, Wolff-Parkinson-White syndrome in 2, and congenital atrioventricular block in 1. Previous palliation had been performed 19 times in 11 patients including systemic-pulmonary shunts in 10 patients and pulmonary banding in 1 patient. Anatomic correction consisted in the Mustard procedure in 12 or the Senning procedure in 6 at the atrial level and in external conduit repair in 14, arterial switch operations in 3, or direct anastomosis between the pulmonary artery and right ventricle in 1 at the ventriculoarterial level. The arterial switch operation was indicated in patients with a normal pulmonary valve, and external conduit repair was indicated for patients with pulmonic stenosis or atresia. Anatomic right ventricular end-diastolic volume showed significant reduction from 122.2% +/- 46.3% of normal to 78.8% +/- 24.0%, mainly owing to unloading of the ventricle after the operation (p < 0.0003). Right ventricular ejection fraction remained unchanged (56% +/- 8% to 56% +/- 6%). Anatomic left ventricular end-diastolic volume and left ventricular ejection fraction remained unchanged before and after the operation: volume 134.6% +/- 50.0% of normal to 127.3% +/- 32.8% and ejection fraction from 61% +/- 8% to 56% +/- 8%. Cardiac index averaged 3.1 +/- 0.5 L/min per square meter after the operation. The double switch operation is best indicated in patients with atrioventricular discordance associated with systemic tricuspid regurgitation and/or with poor systemic right ventricular function.

Autologous blood donation elective surgery in children

Studies were made on 59 children (cardiac 42, orthopaedic 13, miscellaneous 4) scheduled for autologous blood donation before elective surgery. The donor-patients' ages ranged from 3 to 15 years (mean 9.9 years) and their weights from 13 to 70 kg (mean 34 kg). All patients received 50-100 mg of oral iron sulphate per day. As a rule, about 10% of intravascular blood volume was drawn once a week. Before surgery, an average of 720 ml of autologous blood per patient was prepared. Two patients failed to donate autologous blood because of anxiety about the procedure; however, none of the donors was deferred due anaemia associated with the phlebotomy. Of the 53 patients undergoing surgery and participating in autologous predonation, 50 (94%) were able to avoid homologous blood transfusion. 600 ml of homologous blood were transfused to each of 2 orthopaedic patients and 400 ml to 1 cardiac patient. We conclude that a predeposit autologous transfusion programme is logistically possible in small children when the patients are cooperative.

Iron and erythropoietin measurement in autologous blood donors with anemia: implications for management

BACKGROUND

The importance of autologous blood donation for elective surgery is recognized, and the method is being used at many hospitals. Not all patients are able to deposit a sufficient amount of blood before surgery because they cannot recover rapidly enough from phlebotomy-induced anemia. The ability to donate sufficient blood for autologous use was studied in patients who are particularly susceptible to phlebotomy-induced anemia.

STUDY DESIGN AND METHODS

Of 840 patients who donated blood for autologous use in elective surgery from November 1987 through May 1993, 20 with rheumatoid arthritis, 24 with iron deficiency anemia, and 37 aged 65 years and above with normocytic anemia were compared with 24 nonanemic elderly patients who donated a total of 1000 mL of blood for autologous use. Patients received iron sulfate orally and donated blood once a week until operation.

RESULTS

The amount of blood collected before surgery per control patient was more than that in others. Consequently, there was a tendency to allogeneic blood transfusion in patients with rheumatoid arthritis or elderly patients. The ferritin levels in controls and in patients with iron deficiency anemia during the donation period were almost within the normal range in spite of iron supplementation, which implied a good utilization of iron sulfate for erythropoiesis. On the other hand, the rise in ferritin levels in the elderly and in patients with rheumatoid arthritis suggested inappropriate iron availability for erythropoiesis and resulted in an increase in iron storage. Since an adequate endogenous erythropoietin response to phlebotomy-induced anemia was not observed in these patients, impaired erythropoietin production was considered one of the reasons for anemia.

CONCLUSION

Patients with iron deficiency anemia are able to continue donating blood for autologous use so long as they have sufficient iron supplementation. However, the elderly or those with rheumatoid arthritis occasionally fail to donate a sufficient volume of blood before surgery as a result of phlebotomy-induced anemia, which is caused in turn by impaired erythropoietin production.

[Reoperations of extracardiac valved conduit for congenital cardiac defects]

Fifteen of 223 patients who have had extracardiac conduit repair at the Heart Institute of Japan from January, 1970, to April, 1991, have required conduits replacement because of conduit obstruction or infection. The main causes of obstruction were degeneration of the prosthetic valve and proliferative pseudo-intima in the conduit. The interval between initial conduit repair and conduit replacement was 2.2 to 18.3 years (mean 10.5 +/- 4.4). The average pressure gradient through the conduit decreased from 74.7 +/- 42.0 mmHg preoperatively to 12.3 +/- 7.1 mmHg postoperatively (p < 0.05). There was no early and late death. We concluded that xeno-pericardial roll conduits were superior to others and that conduit replacement procedure following the extracardiac conduit repair was safe and effective.

[A case of left ventricular outflow tract obstruction after repair of ostium primum defect]

We report a 3-year-old girl with left ventricular outflow tract obstruction after repair of ostium primum defect. The girl had closure of an ostium primum defect performed at the age of 1 year. Two years later, she developed left ventricular hypertrophy with systolic ejection murmur. Echocardiography showed discrete stenosis of the left ventricular outflow tract. Cardiac catheterization showed a peak systolic gradient of 63 mmHg across the left ventricular outflow tract. At the reoperation, the fibrous tissue was excised and myectomy was done. After the operation the peak systolic gradient across the left ventricular outflow tract disappeared. Since there is a possibility of occurrence of the left ventricular outflow tract obstruction after repair of atrioventricular septal defect, long term follow up is mandatory.

[The youngest case of isolated interruption of the aortic arch without associated cardiac anomalies]

A five-month-old girl was admitted to our institute because of the systolic blood pressure gradient of 42 mmHg between upper and lower extremities. Cineangiography revealed that the brachiocephalic artery originated from ascending aorta, while the left subclavian and left vertebral arteries took their origin from the descending aorta. However, the left common carotid artery was not visualized either on the angiogram or on the digital subtraction angiogram. No other associated cardiovascular anomalies, such as patent ductus or ventricular septal defect, were found. Therefore the diagnosis of isolated interruption of the aortic arch (IAA) Celoria-Patton type C, was made. As the heart failure gradually progressed, the aortic arch reconstruction with a extended polytetrafluoroethylene graft of 10 mm in diameter under extracorporeal circulation utilizing separate ascending aortic cannulation were performed. Her postoperative course was uneventful. The majority of cases with IAA associated with cardiac anomalies require surgical intervention in the neonatal period or in infancy. However, clinical course of isolated IAA generally resembles to that of the post ductal coarctation of the aorta, and most of the isolated interruption is diagnosed in adulthood. The infant is the youngest case with isolated IAA undergone aortic arch reconstruction with success ever reported in the literature.

Effects of 3 chemical treatments on in vitro fermentation of rice straw by mixed rumen microbes in the presence or absence of anaerobic rumen fungi

Rice straw (Rs) was treated by a sodium chlorite/acetic acid mixture (Sct), ammoniation (At) and alkaline hydrogen peroxide (Athp) methods. The objective was to compare their degradation and fermentation products in the presence or suppression of anaerobic fungi. Significant differences (P < 0.01) in degradation of straws were observed during all periods of incubation with Sct having the highest digestibilities during the 48-h and 72-h incubations. The degradation of Sct straw was highest in both of the incubations with whole rumen fluid (WRF) and WRF plus cycloheximide. In sacco digestion followed the order of Sct > At > Rs > Athp. Suppressing fungal activity with cycloheximide resulted in a decrease in dry matter degradation, with concomitant decrease in total volatile fatty-acid concentration. While the suppression of fungal activity with cycloheximide depressed acetate and butyrate production, it favored an increase in propionate production.

[A case of left atrial myxoma with ventricular septal defect and patent foramen ovale]

A 51-year-old female was referred to our institute because of chest oppressive feeling. Echocardiography and magnetic resonance imaging revealed a left atrial tumor with ventricular septal defect. At operation patent foramen ovale was recognized. After excision of the tumor including intraatrial septum, which defect was repaired using a Teflon patch, and the ventricular septal defect was closed directly.

Effect of fasting on serum insulin-like growth factor-I (IGF-I) levels and IGF-I-binding activity in cockerels

White Leghorn male chicks of 40 days of age were fasted for 5 days and then refed. Blood samples were collected from these chicks before, during and after fasting and serum levels of GH and insulin-like growth factor-I (IGF-I) and serum IGF-I-binding activity were determined. The fasting-induced reduction in body weight was accompanied by a significant rise in circulating GH and fall in IGF-I, coupled with increased serum IGF-I-binding activity. When pooled serum was chromatographed under neutral conditions, IGF-I binding activity and IGF-I immunoreactivity were mainly associated with a large (M(r) = 150,000) and a small protein (M(r) = 30,000). Fasting induced a marked increase in the IGF-I-binding activity of the 30 kDa IGF-I-binding protein (IGFBP) and refeeding restored activity to the normal levels seen before fasting. Ligand blotting of serum-binding proteins with 125I-labelled IGF-I, after first subjecting the samples to polyacrylamide gel electrophoresis and transfer to nitrocellulose, revealed that four IGFBPs (M(r) = 20,000, 30,000, 35,900 and 41,000) were present in chicken serum, and that the 125I-labelled IGF-I binding of the 30 kDa monomer was increased by fasting and restored to normal by refeeding in agreement with gel filtration profiles of IGF-I-binding activity. Western blot analysis suggested that the 30 kDa IGFBP is homologous to IGFBP-2 found in mammalian blood plasma. The results show that IGFBPs in chicken serum and their responses to fasting are similar to those in mammals.

A new technique of tricuspid valve replacement for Ebstein's anomaly

For surgical management of Ebstein's anomaly, a new technique of tricuspid valve replacement on the true annulus, avoiding injury to the conduction system, has been developed. At operation, the valve fixation sutures are placed around the true annulus except for a part of Koch's triangle. A 3 x 3 cm xenograft patch is sutured to cover the atrioventricular node and bundle of His. The remainder of the valve fixation sutures in Koch's triangle are placed only on the patch to prevent conduction injury, and the valve fixation annulus is completed. This new technique has been applied to three patients and has preserved atrioventricular conductivity well in all cases. It is concluded that this procedure of tricuspid replacement on the true annulus can be safely applied and is remarkably effective in preventing atrioventricular conduction disturbance.

[Tetralogy of Fallot with absent pulmonary valve--a successful surgical case at 40 days after birth]

A markedly symptomatic patient with tetralogy of Fallot and absent pulmonary valve underwent operation at 40 days after birth. The baby had severe cardiopulmonary insufficiency at neonatal period and needed surgical intervention. The operation is consisted of patch closure of ventricular septal defect, partial resection of dilated pulmonary artery, and right ventricular outflow reconstruction with unicusped prosthetic patch. The patient is growing and is well more than 2 years and 8 months after operation.

[Pre and postoperative left ventricular volume and function in infants and children with total anomalous pulmonary venous return]

From January, 1989, to December, 1991, 36 consecutive patients with total anomalous pulmonary venous return (TAPVR) underwent intracardiac repair (ICR) in our institute. We studied the relationship between the size of atrial septal defect (ASD), age and preoperative left ventricular end-diastolic diameter (LVEDD) in 28 patients with regression analysis. There was no statistical relationship between the size of ASD, age and LVEDD. We measured LVEDD, RV to LV pressure ratio (RVP/LVP) and LV fractional shortening (LVFS) using two dimensional echocardiography in 15 patients, prior to and following ICR. LVEDD increased from 1.16 +/- 0.40 cm to 1.62 +/- 0.28 cm immediately following ICR, and then increased to 1.79 +/- 0.34 cm one month following ICR again. LVFS decreased from 38% to 35% immediately following ICR but still remained within normal range (normal range 28-45%). RVP/LVP decreased from 1.0 to 0.69 immediately following ICR, and to 0.39 one month following ICR. We concluded that the decrease of preoperative LV end-diastolic volume in TAPVR was not due to the decrease of LV preload but to anterior deviation of the ventricular septum caused by high RV pressure. There was significant increase of LV volume immediately following ICR, but LVFS maintained in normal range. This study suggested that small LV volume in patients with TAPVR did not influence the surgical results.

Effects of thyroxine supplement on serum insulin-like growth factor-binding activity in propylthiouracil induced hypothyroid cockerels

In propylthiouracil (PTU)-fed (g/kg feed) hypothyroid cockerels, serum levels of growth hormone (GH), but not insulin-like growth factor (IGF)-1, tended to rise and those of IGF-binding activity to fall. Thyroxine (T4) supplement (200 micrograms/kg/day) to PTU-fed cockerels for 8 days produced a hyperthyroid state and reversed these serum parameters. A chromatographic analysis of serum proteins revealed that T4 supplement markedly enhanced the IGF-binding activity of a 30 kDa protein and slightly lowered that of a 150 kDa protein, suggesting that T4 increases unsaturated IGF-binding proteins by reducing circulating IGF-1 concentrations.

DNA conformation polymorphism analysis of DR52 associated HLA-DR antigens by polymerase chain reaction: a simple, economical and rapid examination for HLA matching in transplantation

HLA-DRB1 and -DRB3 alleles of DR52-associated (DR52ass) HLA-DR antigens were genotyped by a polymerase chain reaction (PCR) - based simple and practical method. Genomic DNAs from two hundred Japanese panels were subjected to PCR with two pairs of primers to separately amplify the DR52ass-DRB1 (DR3, 5, 6, and 8) alleles and DRB3 (DR52) alleles. The specific amplification revealed that 128 and 76 panels possessed DR52ass alleles and DRB3 alleles, respectively. PCR products from these panels were heat-denatured, electrophoresed in a non-denaturing polyacrylamide gel, and visualized by silver staining. Electrophoretic mobilities of the DNA samples were compared with those of the typing standards with known genotypes of DR52ass-DRB1 and DRB3 alleles. This method, designated PCR-DNA conformation polymorphism (DCP) analysis, allowed genotyping of the DR52ass-DRB1 and DRB3 alleles of panels without any sequence-specific oligonucleotide probe (SSOP) or restriction endonuclease, and the entire process after PCR could be completed within a few hours. Because the DR52ass-DRB1 and DRB3 alleles assigned by this method were shown to be identical to those determined by the PCR-SSOP method, PCR-DCP analysis was suggested to be a simple and practical HLA genotyping method.

[External valvuloplasty under preoperative angioscopic control]

Intraoperative angioscopy was applied to evaluate the venous valvular incompetence and perform external valvuloplasty in case of venous reflux. Sixty-seven limbs, 43 cases of primary varicose veins were examined using intraoperative angioscopy and the angioscopic findings of the incompetent venous valves were classified into three types as follows: valves with elongated and atrophic cusps 43 (50%)--type I, values with expanded and depressed commissures 36 (42%)--type II, and valves with perforated cusps or other changes 7 (8%)--type III, according to the angioscopie findings, external valvuloplasty was done in 31 subterminal valves of the long saphenous veins and 7 highest valves of the superficial femoral vein. Our external valvuloplasty consisted of two techniques. The first was the total plication technique for valvular annulus by a running suture of prolene and the second was by the venocuff sleeve of the autogenetic femorofascial band. The degree of plication was decided by angioscopic observation. Postoperative observation periods were from 2 to 28 months. There was no recurrence of varicose veins or prominent venous reflux. The application of intraoperative angioscopy is therefore useful for the choosing appropriate surgical procedures and for the evaluation of venous valvuloplasty.

Anatomic correction of atrioventricular discordance

Between June 1989 and September 1991, 11 patients underwent anatomic correction of atrioventricular discordance. Their ages at operation ranged from 1 to 11 years (mean 6.7 years) and their weights ranged from 7.1 to 31.8 kg (mean 19.1 kg). Atrial situs was solitus in nine and inversus in two patients. Ventriculoarterial connection was discordant in five and was double-outlet right ventricle in six patients. Associated congenital heart defects were seen in all patients, including 10 with ventricular septal defect, eight with atrial septal defect, nine with pulmonary stenosis or pulmonary atresia, seven with tricuspid regurgitation, and four with mitral regurgitation. Five patients had prior Blalock-Taussig shunts. One patient with an intact ventricular septum had repeated pulmonary banding. Anatomic correction consisted of the Senning and Rastelli procedures in three, the Mustard and Rastelli procedures in five, the Senning and arterial switch operations in two, and the Mustard and arterial switch operations in one patient. In addition, mitral valvuloplasty or valvular annuloplasty was performed in three patients. We did not encounter kinking or torsion of the translocated coronary arteries in our three patients with the arterial switch operation. There was one surgical death. The other patients pursued satisfactory postoperative courses (mean follow-up period of 12.6 months). We recommend that anatomic correction for atrioventricular discordance should be indicated, especially in patients with any sign of systemic right ventricular dysfunction.