[The autologous pericardial tube-flap. A new technic for restoring the continuity between the right ventricle and the pulmonary artery]

Re-establishing continuity between the right ventricle and the division of the pulmonary trunk may prove difficult in surgical correction of transposition of the great vessels. Although prosthetic tubes, which had many drawbacks, have been replaced by direct anastomoses, partial reconstruction of the pulmonary arterial wall is still often necessary. The materials commonly used are segments of gore-tex, stored pericardium and fresh or glutaraldehyde-treated pericardium. However, retractions may develop in these reconstructions resulting in pulmonary stenosis. These complications have revived the debate on the best technique for re-establishing continuity, and it is mandatory to use a growing tissue to keep pace with the child's development. We report here an original technique used in an infant. Previous studies have shown that the autologous pericardial flap, transformed here into a tube, retains its potential for growth.

Anomalous left coronary artery from the pulmonary artery in infants. Which operation? When?

The surgical management of anomalous left coronary artery from the pulmonary artery in infants and small children remains controversial, because the ideal surgical procedure and the optimal time for operation are yet to be determined. From 1977 to 1985, 22 patients less than 4 years of age (mean age 18.2 months) underwent direct aortic reimplantation of the anomalous left coronary artery. There were five operative deaths (23%, confidence limits 13%-36%). The determinant risk factor of early mortality was the severity of preoperative left ventricular dysfunction (p = 0.05), not age at operation (p = 0.64) or preoperative clinical status (p = 0.36). There were not late deaths (mean follow-up 38 months). All survivors but one were symptom free. The reimplanted anomalous left coronary artery was patent in each reevaluated case (9/17). Left ventricular function improved significantly in all survivors. Moderate to severe preoperative mitral incompetence lessened in all patients but one, without mitral valve repair. When technically feasible, direct aortic reimplantation of the anomalous left coronary artery is an attractive procedure because it offers a high rate of patency and avoids the potential drawbacks of procedures involving autogenous venous or arterial tissue. Optimal intraoperative myocardial preservation and institution of temporary left ventricular assistance at the end of the operation may decrease the operative risk. Left ventricular function nearly always recovers after successful revascularization, and resection of left ventricular myocardium is rarely indicated, if ever. Mitral incompetence almost always lessens, and the mitral valve should not be repaired at initial operation; however, residual mitral incompetence may necessitate reoperation in a few cases. In infants with moderate left ventricular damage (usually asymptomatic with medical therapy), surgical treatment should be delayed until 18 to 24 months of age so that it can be performed with a low operative risk. Infants with severely impaired left ventricular function and persistent congestive heart failure should probably undergo operation as soon as the diagnosis has been made.

[Reconstruction of pulmonary artery branches with pedicled flaps from the autologous pericardium]

A new reconstruction technique using pedicled flaps from autologous pericardium was applied in a case of long hypoplastic segments of the two branches of the pulmonary artery in a 6-year old child. The pericardial sac was incised vertically on the midline, and two rotating flaps, one on the left, the other on the right, were created to bring the pericardium in front of the corresponding arterial branches. Each branch was split open all along its hypoplastic segment which was then widened to normal diameter, using the pericardial flap for reconstruction. Control echocardiography, performed one year later, showed that the excellent post-operative results persisted. This is of particular interest as it is well known that all other materials previously utilized to reconstruct the pulmonary artery do not grow or even shrink, resulting in progressive stenosis.

[Mitral stenosis with notable or important subvalvular changes. Complete open commissurotomies supported by chorda transfer]

Since 1983, 40 consecutive patients with mitral stenosis (MS) and significant disease of the subvalvular apparatus underwent open heart mitral commissurotomy (OHMC). The aim of the study was to evaluate the effects of an unrestricted dilatation of the two commissures followed by repair of the subsequent mitral regurgitation. The mitral regurgitation created by this procedure in 24 cases was corrected by transferring 2 to 6 chordae tendinae to the free border of the anterior and/or posterior leaflet in the commissural region. A central regurgitant lesion due to lack of coaptation of the valvular surfaces was treated by annuloplasty with a Carpentier prosthesis in 12 cases. The subvalvular abnormalities were treated by the conventional techniques of fenestration, resection and division of the papillary muscles. Thirty of the 38 survivors had no residual murmur, and 6 had a short low intensity systolic murmur. The 2D echocardiographic study showed no residual stenosis. The residual systolic murmurs were evaluated by pulsed Doppler and corresponded to very localised regurgitation. This extensive operative technique gives very good immediate valvular results which, associated with an adequate subvalvular procedure, are considered to be an important prognostic factor.

[A spectacular and benign syndrome of neonatal convulsions: deep sleep myoclonus]

Four case reports concerning neonates presenting, without any predisposing factors, severe and lasting myoclonus, occurring exclusively during sleep. These began between 1 and 4 days of age and stopped between 3 weeks and 5 months. Electro-encephalogram was normal, even during episodes of clonus which occurred during deep sleep. A predisposing genetic factor is likely. A better knowledge of this syndrome should avoid hospitalizations and misuse of anticonvulsive treatments.