Anomalous left coronary artery arising from the pulmonary artery: a series of 27 infants undergoing operation in the first years of life

Between 1977 and 1987, 27 infants (aged 3 to 54 months) underwent surgical treatment for correction of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA). All had a direct aortic reimplantation. The overall operative mortality was 18.5% (five deaths). The follow-up period was from 2 months to 8 years (mean, 38 months). No late deaths occurred. During the 10 years, modifications of the surgical procedure and myocardial preservation were introduced (ie, complete resection of the pulmonary trunk made anastomosis easier; since 1982, cardioplegia in both coronary systems has been used, and left atrial-to-aortic assistance was introduced). The latter was carried out when surgical repair was associated with acute cardiac failure and a high left atrial filling pressure at the end of cardiopulmonary bypass. In view of the results during the latter part of this series, it is felt that surgery should not be restricted in younger patients (< 12 months). If medical treatment is unsuccessful, surgery aims to avoid irreversible left ventricular dysfunction and development of severe endocardial fibroelastosis.

[Cardiac transplantation in the infant and young child. Preliminary results]

Between January and December, 1987, a programme of heart transplantation in paediatrics was designed and carried out in 9 children by the medical and surgical teams of the Necker/Enfants Malades-Laënnec hospitals group, Paris. Six of the patients were infants of less than 2 years (4 were under one year), and the oldest child was 10 years old. All patients seemed to be condemned to an early death either because their congenital heart disease was beyond the resources of conventional surgery (6 cases) or because their dilated cardiomyopathy was refractory to all medical treatments. Three children died at the end of the operation or a few days afterwards, due to poor quality graft (1 case), fulminating bacterial superinfection (1 case) or intractable pulmonary hypertension (1 case). The remaining 6 children are now living as normally as possible in their respective families. The long-term immunosuppressive treatment consists of cyclosporine and azathrioprine; corticosteroids are only used at the very beginning of treatment or in case of graft rejection. Only two episodes of rejection, confirmed by endomyocardial biopsy, were observed in the same patient during the first postoperative month. Biopsy was never performed systematically in order to spare the patient's vein, and the diagnosis of rejection was suspected on clinical grounds.(ABSTRACT TRUNCATED AT 250 WORDS)

Coarctation of the aorta in infants: which operation?

In this series, 178 infants (age, less than or equal to 3 months old) underwent repair of aortic coarctation. Pure coarctation was present in 63 patients (Group 1), 47 infants had additional ventricular septal defects (Group 2), and 68 patients had associated complex heart disease (Group 3). Subclavian flap angioplasty was used in 26 patients, limited resection and end-to-end anastomosis in 45 patients, extended resection and end-to-end anastomosis in 99 patients, and miscellaneous procedures in 8 infants. The early mortality was 8% for the first group, 11% for the second group, and 37% for the third group (p less than 0.001). Mean follow-up was 32 months and included 97% of patients. Actuarial survival at five years was 90% for the first group, 84% for the second group, and 40% for the third group. Recoarctation occurred in 15 operative survivors (11%); 7 necessitated reoperation. Freedom from recoarctation at five years was 89% after subclavian flap angioplasty, 81% after end-to-end anastomosis, and 86% following extended resection and end-to-end anastomosis. Early mortality and late results were not influenced by the type of coarctation repair but were determined by the clinical status and the presence of associated major cardiac anomalies. These results suggest that the surgical procedure should be individualized for each infant to optimize the aortic anatomy.

Anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect. II. Clinical results in 50 patients with pulmonary outflow tract obstruction

From November 1980 to November 1985, 50 patients underwent anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction. The technique used was one that we have previously described, which we call REV. The principles of this technique are resection of the infundibular septum, construction of a tunnel connecting the left ventricle to the aorta, and direct anastomosis, without a prosthetic conduit, of the pulmonary arterial trunk with the right ventricle. The tunnel is situated beneath the aortic valve and occupies very little space in the right ventricular cavity. Age at operation ranged from 4 months to 13 years (mean 3.5 years). Twenty-six patients had a classic type of transposition of the great arteries; all other patients had various types of anomalies of ventriculoarterial connection in which it was impossible, after the intraventricular connection of the left ventricle to the aorta, to use the natural pulmonary orifice for the pulmonary outflow tract reconstruction. There were nine hospital deaths (18%) and one late death. Twenty-six of 29 patients whose follow-up time exceeded 1 year had an excellent clinical result. No stenosis of the aortic outflow tract was found. Four patients had significant pressure gradients on the pulmonary outflow tract. Our present experience with REV suggests that this technique allows anatomic repair in a wide variety of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction, even in infants, with an acceptable rate of mortality and morbidity.

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.

Intrauterine creation and repair of pulmonary artery stenosis in the fetal lamb. Weight and ultrastructural changes of the ventricles

Fetal lamb experimental models were employed for intrauterine creation and repair of pulmonary artery stenosis. The study group was composed of 51 fetal lambs including 29 models of pulmonary artery stenosis and 22 control lambs. Gestational age was 89 days at creation of pulmonary artery stenosis. Fourteen fetal lambs (Group A) were studied after creation of the stenosis at 131 days of gestation and compared to normal age-matched control lambs. The systolic right ventricular pressure was significantly higher after creation of pulmonary artery stenosis (76.6 +/- 17.8 versus 50.3 +/- 23.5 mm Hg), but the systolic pulmonary artery pressure was unchanged. The mean right ventricular weight and the mean right ventricular/left ventricular weight ratio were significantly greater after pulmonary artery stenosis than in normal control animals. The transverse myocyte diameter was not modified by pulmonary artery stenosis, but on electron microscopic study the myocytes appeared mature. Ten lambs (Group B) underwent intrauterine repair of pulmonary artery stenosis at 131 days of gestation without cardiopulmonary bypass. The pulmonary artery was clamped and patched. Immediately after repair the right ventricular pressure fell significantly from 85.8 +/- 18.9 to 62.2 +/- 14.6 mm Hg. At birth, 7 +/- 6 days after repair, Group B was compared to Group C (unrepaired pulmonary artery stenosis, five fetuses) and to normal control lambs. The mean right ventricular weight and the mean right ventricular/left ventricular weight ratio were not statistically different in Group B and in the control group. There were no ultrastructural changes after intrauterine repair. We conclude that intrauterine creation of pulmonary artery stenosis causes right ventricular hypertrophy with more mature myocytes. Intrauterine repair of pulmonary artery stenosis is feasible without cardiopulmonary bypass and rapidly abolishes the preponderance of right ventricular weight over left ventricular weight.

Late results after left-sided cardiac valve replacement in children

Selection of types of cardiac valve substitutes for children remains controversial. Between 1976 and 1984, 166 children, 15 years of age or younger, underwent aortic (N = 53) or mitral valve replacement (N = 90) or both (N = 23). Biological prostheses were used in 84 patients and mechanical prostheses in 71; both a mitral bioprosthesis and an aortic mechanical valve were used in 11 patients. The overall early mortality was 9%. Mean follow-up intervals were 4.1 years for the bioprosthesis group, 3.3 years for the mechanical valve group, and 3.5 years for the group receiving both. The 7 year survival rates (+/- standard error) were 63% +/- 6% in the bioprosthesis group and 70% +/- 7% in the mechanical valve group (p = NS). After aortic valve replacement the 7 year survival rates were 66% +/- 14% (bioprosthesis group) and 77% +/- 9% (mechanical valve group) (p = NS); after mitral valve replacement the rates were 65% +/- 7% (bioprosthesis group) and 54% +/- 17% (mechanical valve group) (p = NS). The incidence of thromboembolic events was 0.6% +/- 0.4% per patient-year in the bioprosthesis group (none after aortic valve replacement, 0.8% +/- 0.6% per patient-year after mitral valve replacement) and 1.4% +/- 0.8% per patient-year in the mechanical valve group (0.7% +/- 0.7% per patient-year after aortic valve replacement, 4.0% +/- 2.8% per patient-year after mitral valve replacement) (p = NS). The linearized rates of reoperation were 10.4% +/- 1.8% per patient-year (bioprosthesis group) and 2.3% +/- 1.0% per patient-year (mechanical valve group) (p less than 0.001). The 7 year probability rates of freedom from all valve-related complications were 43% +/- 6% in the bioprosthesis group and 86% +/- 4% in the mechanical valve group (p less than 0.001). In the aortic position, a mechanical adult-sized prosthesis can always be implanted, and satisfactory long-term results can be anticipated. In the systemic atrioventricular position, the results are less than satisfactory with either type of prosthesis; every effort should be made to preserve the natural valve of the child.

[Spontaneous rupture of the ascending aorta. A surgically treated case]

Rupture of the ascending aorta may follow thoracic trauma or complicate an aortic aneurysm or acute dissection. It is otherwise extremely rare. The authors report a case of spontaneous rupture of the ascending aorta occurring in a patient with a pre-existing incomplete rupture of the ascending aorta, and treated surgically. The clinical presentation was of acute dissection with pericardial effusion. This diagnosis was excluded by aortography with multiple views which showed abnormalities of the aortic wall: an abnormal notch, continuity of the internal wall and extravasation of the contrast medium. These abnormalities are often minimal but should be recognised and surgery proposed as this is the only chance of a favourable outcome.

[Isolated coarctations of the aorta. Early repair by aortoplasty with the left subclavian artery. 15 cases]

When medical treatment is ineffective, isolated aortic coarctation must sometimes be surgically repaired during the first months of life. For these early operations the Crafoord resection-anastomosis technique seems to be disappointing, with a high recurrence rate. Between 1979 and 1983, 15 infants under 6 months of age underwent repair of their coarctation by a different technique: longitudinal aortoplasty using the left subclavian artery. One child died of septic rupture of the aorta, and another was lost sight of. The remaining patients were examined 35 +/- 15 months after surgery. The blood pressure usually returned to normal with no pressure gradient, at rest, between the right upper limb and the lower limbs. One child, however, had a slight (10 mm Hg) residual gradient corresponding to discreet alterations at two-dimensional echocardiography. These good results at rest after aortoplasty seem to be better in medium term than those of resection-anastomosis. The left subclavian flap aortoplasty appears to be the technique of choice in children under 6 months for the treatment of isolated coarctation.

Surgical repair of tetralogy of Fallot with complete atrioventricular canal

Total repair of tetralogy of Fallot and complete atrioventricular canal remains a surgical challenge; however, good results can be obtained if the lesions are repaired properly at operation. Our technique involves a combined right atrial and right ventricular approach with closure of the ventricular septal defect through the ventriculotomy, double-patch closure of the septal defects without dividing the bridging atrioventricular leaflets, and functional repair of the newly constructed mitral valve.

Cor triatriatum and total anomalous pulmonary venous connection: a rare, surgically correctable anomaly

Two cases of a very uncommon congenital association (cor triatriatum and total anomalous pulmonary venous connection) are presented. This association should be suspected in any infant with signs of pulmonary venous obstruction.

[Interruption of the aortic arch and malformative cardiac lesions requiring repair under extracorporeal circulation. Apropos of 3 cases]

Interruption of the aortic arch is practically always associated with intracardiac malformations of variable complexity, at the least, a ventricular septal defect. Surgery is usually performed in two stages: aortic repair and pulmonary artery banding after intravenous prostaglandin administration. The second stage comprises debanding and repair of the intracardiac lesions under cardiopulmonary bypass. However, in some cases, interruption of the aortic arch is associated with intracardiac lesions which necessitate correction under cardiopulmonary bypass from the onset, this was the situation in two of the three cases described by the authors: aorto-pulmonary window, a lesion which can only be corrected under circulatory arrest and deep hypothermia. One of these two children, operated in the neonatal period, did not survive: the other, operated at 6 weeks, had an excellent result. In the third case, the association of tricuspid atresia and a restrictive ventricular septal defect necessitated enlargement of the septal defect and therefore, open heart surgery under circulatory arrest; the results were favourable.

[Antenatal cardiac surgery. Creation of an experimental model of pulmonary stenosis in the fetus and repair in utero]

An experimental model of pulmonary stenosis was created in ewes, fetus and repaired before birth by making use of the materno-foetal circulation. Eighteen ewes fetus underwent pulmonary artery banding at an average of 87 +/- 8 days' gestation (normal 135-145 days). All were reoperated before term at 132 +/- 6 days' gestation. They were divided into two groups : group I (7 fetus) was used to evaluate the experimental model of pulmonary stenosis by measuring right ventricular pressures (80 +/- 16 mmHg compared to 58 +/- 10 mmHg in control models), and the increase in right ventricular mass (2.8 +/- 0.5 X 10(-3) g vs 1.9 +/- 0.2 X 10(-3) g), left ventricular mass (2.2 +/- 0.3 X 10(-3) g vs 1.8 +/- 0.4 X 10(-3) g) and septal mass (1.8 +/- 0.3 X 10(-3) g vs 1.3 +/- 0.2 X 10(-3) g). In group II (11 fetus) the pulmonary stenosis was repaired by total clamping and patch repair. After repair and during the days just before birth, the ventricular masses decreased (RV = 2 +/- 0.3 X 10(-3) g; LV = 1.8 +/- 0.4 X 10(-3) g; septum = 1.8 +/- 0.3 X 10(-3) g) approaching values of normal control fetus. This experimental model shows that it is possible to correct cardiac lesions in utero by making use of the materno-fetal circulation and that antenatal repair of an arterial obstruction can rapidly reverse the reactional ventricular hypertrophy.

Anatomic correction of transposition of the great arteries associated with ventricular septal defect: midterm results in 50 patients

From May 1977 to August 1982 50 patients who were 1.5 to 44 months old underwent anatomic correction of transposition of the great arteries (TGA) and closure of ventricular septal defect (VSD) at our institution. Thirty-nine patients underwent preliminary pulmonary arterial banding. Hospital mortality was 32%: four patients died as a result of technical problems, seven as a result of associated lesions, three of pulmonary hypertension, and two of left ventricular failure. Three other patients died after the first postoperative month (one of mediastinitis, one at reoperation for a residual VSD, and one of pulmonary hypertension). All 31 survivors are in excellent clinical condition and are in sinus rhythm after a mean follow-up period of 31 +/- 14 months. Twenty-five patients were reinvestigated by echocardiography (M mode and two-dimensional) and/or catheterization. Parameters of left ventricular contractility were within normal limits, but systolic aortic diameter was larger than normal (p less than .01). Seven patients had stenosis of the right ventricular outflow tract and five of these required reoperation. The two persistent problems with the anatomic correction of TGA associated with VSD are a relatively high operative mortality and secondary right outflow tract stenosis. However, use of this procedure results in better left ventricular function and fewer arrhythmias than does use of atrial repair techniques and also results in the use of the anatomically left ventricle as the systemic ventricle.

[Surgical treatment of total abnormal pulmonary venous return. Value of the interaortico-caval approach]

Technical details concerning surgery of supracardiac total anomalous pulmonary venous return are still controversial. It seems to us that approaching the lesion through the cleft that exists between the aorta and the superior vena cava fulfills the two requirements of the surgical procedure: a wide anastomosis between the common pulmonary vein and the left atrium can be created on the heart in situ and therefore without any risk of anatomical distorsion, and the small size of atrial incisions reduces the risk of post-operative arrhythmias.

[Reoperations after surgical correction of tetralogy of Fallot]

Between 1970 and 1981, 40 patients (6%) were reoperated after surgical correction of Fallot's tetralogy. The average age of these patients was 7,5 years (range 2 months to 37 years). The usual anatomical form was present in 30 cases and severe forms accounted for the other 10 cases (pulmonary atresia with septal defect were excluded). The 40 patients were divided into 3 groups according to the anatomical lesions corrected at reoperation: Group I: 16 patients with a residual isolated VSD; Group II: 14 patients with one or two residual right heart anomalies (RRHA) but without a septal defect; Group III: 10 patients with a residual VSD and RRHA. The only clinical difference between the patients of these 3 groups was the delay of onset of symptoms: the patients with residual VSD (Groups I and III) often developed cardiac failure immediately, whilst in those without residual VSD (Group II) cardiac failure was usually observed secondarily. Four patients (10%) died early after reoperation (less than 1 month). Three others died later, two during a third operation. The total mortality was similar in the three groups. The surgical result was assessed clinically after an average follow-up of 4,5 +/- 3 years: patients with a residual isolated VSD (Group I) had the best long-term results. In 12 patients, M mode and 2D echocardiography showed normal left ventricular function but the ratio of end diastolic right ventricular and left ventricular dimensions was increased to an average of 0,72 +/- 0,2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Plastic reconstruction of the pulmonary outflow tract in truncus arteriosus communis]

A new technique of correction of the truncus arteriosus avoiding the use of a prosthetic conduit is presented. The procedure described comprises anterior translation of the pulmonary bifurcation, reconstruction of the pulmonary outflow tract with a rim transected from the truncus, and direct implantation of the pulmonary artery.