[Tetralogy of Fallot with congenital absence of a pulmonary artery. Apropos of 4 cases]

Four patients aged between 3 1/2 and 16 years were treated surgically for tetralogy of Fallot associated with congenital absence of the left pulmonary artery. This absence, suspected from the chest X-ray, was confirmed preoperatively by angiography of the right and left cavities, aortography, left pulmonary wedged venography and radionuclide scan and substantiated by intraoperative exploration. Congenital absence differs physiopathologically from acquired destruction of a pulmonary branch. In all four patients, repair was performed exclusively on the right branch, without any attempt to introduce a valve in the pulmonary outflow tract and without regard for normal recommendations concerning acquired branch lesions. The only patient to retain a high right ventricular pressure was the one whose pulmonary ring looked sufficiently large to warrant preservation. In all four cases, the postoperative course was uneventful, and the clinical condition is very satisfactory with a follow up of two to twenty-four months. The conclusion would seem to be that the association of tetralogy of Fallot with congenital absence of the left pulmonary artery ascertained with certainty preoperatively, in no way modifies therapy.

[Rupture of a dissecting aneurysm of the ascending aorta 10 years after therapy of coarctation. Apropos of a case of a 10-year-old girl]

This is a rare but life-threatening association. After surgical repair of a coarctation, delayed aneurysm of the ascending aorta may occur, with dissection in some instances. The case we report exemplifies this possibility. Surgical repair is difficult. Data from the medical literature is consistent with the speculation that the aneurysm is not an acquired lesion above the coarctation but a distinct disease of the aortic wall which runs an independent course but which may be promoted by the arterial hypertension. The course and prognosis are so serious that, in spite of its low prevalence, patients should be screened at regular intervals for this condition by ultrasonography of the ascending aorta.

[Acute renal vein thrombosis after malposition of a Mobin-Uddin filter]

Renal malposition of Mobin-Uddin filters is exceptional. In the few cases published the patients were asymptomatic; they were operated upon for fear of an eventual nephrotic syndrome. In the case reported here, however, an emergency operation was imposed by the severity of the clinical signs. Since the operation is simple and since renal thrombosis might have important immediate or late consequences, all filters malpositioned in the renal vein should be surgically removed.

[Tricuspid surgery and tetralogy of Fallot. Observations apropos of 14 case reports]

14 patients underwent tricuspid surgery after radical surgery of tetralogy of Fallot using cardiopulmonary bypass. This series represents 11.5% of all patients with tetralogy of Fallot who were operated on during the same period (1970-1982). Two different pictures were seen: tricuspid pathology may be coincident with tetralogy of Fallot, with surgical repair being done during the same procedure; it may be discovered later on, resulting from trauma of the tricuspid valves, an overlooked valvular malformation, or a residual or recurrent ventricular septal defect. As tolerance is poor because of postoperative right ventricular insufficiency, tricuspid insufficiency must be promptly diagnosed and cured, either during radical surgery of the tetralogy of Fallot or as soon as it becomes clinically patent in the postoperative course.

[Pulmonary valvulotomy or valvulectomy with simple clamping of the vena cava in infants and young children]

In infants and young children pulmonary valvulotomy or valvulectomy under simple clamping of the vena cava is the treatment of choice for pulmonary valve stenosis with normal interventricular septum. The technique, performed without cardiopulmonary bypass, is described. In 40 patients operated upon, the peri-operative mortality was 10% and short-term clinical results were satisfactory.

Tricuspid atresia. Results of treatment in 115 children

We present our experience in the management of tricuspid atresia in 115 children. The anatomic data are categorized as follows: type I, 83.5%, type II, 16.5%. Type IB is the most frequent, representing 63.5% of all the cases. Each patient was operated upon one to four times. The age at first operation ranged from 10 days to 20 years. The first operation was a shunt in 94 children, a Fontan operation in four, and banding of the pulmonary artery in 17. Hospital mortality for the first operation was 12.2%, significantly higher in children under 6 months and in those having Waterston shunts. Potts and Blalock-Taussig operations give low long-term mortality; although few (six) have been done, Potts shunts also seem to give good long-term palliation in this series. The Glenn anastomosis is a good operation when performed after a systemic-pulmonary arterial shunt. The Fontan operation was performed in 24 children (hospital mortality 16.6%). There have been no late deaths after the third month postoperatively. Mean follow-up for this operation is only 2 years, but 88% of the survivors lead a normal life, two thirds of them receiving no treatment. There has been one reoperation for stenosis of a Dacron conduit with a good result. Late arrhythmias are well tolerated. In conclusion, the Fontan procedure is a good operation, but palliative procedures still allow good long-term survival.

[Complete atrioventricular canal associated with a tetralogy of Fallot. Results of surgical treatment. Apropos of 4 cases]

Complete atrioventricular canal with tetralogy of Fallot is a rare occurrence (8%). Diagnosis rests on the association with Down syndrome and on data from EKG, ultrasonography and angiography. The high operative risk explains why radical surgery is done at an older age (9 years) than in the usual form of complete atrioventricular canal without associated anomalies (33 months) and why antecedent surgical palliation with anastomotic procedures is so frequent (68% of the cases reported in the medical literature). The same surgical procedure was done in all patients: closure of the defects with two separate patches lined with pericardium, suture of the mitral cleft and relief of the infundibular and pulmonary obstruction without valvulation.

[Cor triatriatum: results of surgical treatment. A propos of a series of cases]

Cor triatriatum is a rare heart defect that may be surgically repaired, with good results when preoperative diagnosis is correct. Ultrasonography, angiography and catheterism reduce preoperative diagnostic errors such as abnormal pulmonary venous return. The authors report their experience with 7 cases, and discuss diagnostic problems and causes of errors.

Reconstruction of the pulmonary outflow tract without prosthetic conduit

New techniques of correction of complex congenital anomalies, avoiding the use of prosthetic conduits, are presented. In transposition of the great arteries (TGA) with ventricular septal defect (VSD) and pulmonary stenosis, the technique comprised the resection of infundibular septum, the suturing of an intraventricular baffle directing blood from the left ventricle to the aorta, and the reconstruction of the pulmonary outflow tract by direct implantation of the posterior rim of the pulmonary arterial trunk on the right ventricle, completed by an anterior patch. In most cases, the pulmonary bifurcation was translated anterior to the ascending aorta. This technique was feasible even in infants and in patients with a small VSD. Thirteen patients, from 3 months to 8 years of age, were treated by this technique, with four deaths, one residual VSD (reoperated), and eight good results (4 to 16 months). A similar repair was used in three cases of double-outlet right ventricle (DORV) with subpulmonic VSD and pulmonary stenosis or pulmonary artery banding, with two operative deaths and one good result. The same technique of pulmonary outflow tract reconstruction was used in four cases of truncus arteriosus. Two deaths were attributed to severe pulmonary regurgitation, a complication which should be prevented in future cases by a reliable method of inserting a valve in the pulmonary outflow tract. In pulmonary atresia with VSD and absent pulmonary trunk, the continuity between the right ventricle and the pulmonary branches was established via an arterial tube resected from the ascending aorta. This technique was successfully used in one child with extremely small pulmonary branches. These preliminary results led us to conclude that many complex congenital cardiac anomalies can be effectively treated without a prosthetic conduit.

[Iatrogenic arteriovenous fistulas in infants]

Iatrogenic arteriovenous fistulas in infants are usually due to an arterial puncture performed in the neonatal period. On the occasion of 5 cases who were operated on, the peculiar features of these fistulas are established. Surgery consists of endo-aneurysmorrhaphy.

[Results of the repair of isolated coarctation of the aorta during the 1st 6 months of life, Apropos of 46 cases]

Between 1972 and 1978, forty-six infants under six months of age underwent surgery for isolated coarctation of the aorta. These forty-six patients represent 32% of the total number of infants aged less than six months who had surgery for coarctation of the aorta during the same period. At the time of operation, 41% were aged less than one month and the youngest was five days old. The main cause for surgery was heart failure in infants under one month (14/19) and severe systemic hypertension (150 to 300 mm Hg) in the one to six month age group (18/27). Overall mortality rate in our series was 17%. Six of the eight infants who died were under one month of age. Recoarctation occurred in 31,5% of infants; in eight cases the first surgical procedure had been done before one month of age. A second procedure was necessary in four cases. Early surgical repair of severe coarctation diagnosed during the first six months of life leads to functional improvement and avoids residual hypertension. After repair, the main risk is recoarctation.

[Results of surgical treatment of aortic coarctations in the 1st 6 months of life. Apropos of 142 cases]

142 infants under 6 months of age were operated on for coarctation of the aorta from 1972 to 1978. Coarctation was isolated in 46 (32.4%) and associated with another heart defect in 96. Surgery was decided upon because of congestive heart failure sometimes associated with arterial hypertension refractory to medical treatment: 9 patients died during surgery. 89 underwent Crafoord's operation and in 44 ligature of the subclavian artery or aortoplasty using the subclavia were carried out. Early postoperative death rate was 30.9% and 13 patients (13.2%) died later. Recoarctations occurred in 25 patients (27%); more than half of these patients were less than 1 month-old at the time of surgery. Recoarctation was more frequent (46.4%) in cases with than in cases without (18.7%) aortic hypoplasia and it was more severe (5 out of 7 deaths) when there was an associated cerclage resulting in a double obstacle to right and left ventricles ejection.

[Atrioventricular valve replacement in congenital cardiopathies. A series of 25 surgically-treated patients under 10 years of age]

A series of 25 congenital malformations of the atrioventricular valves underwent valve replacement (10 mechanical and 15 bioprostheses). Seven children died during surgery. The operative mortality was higher before 2 years of age (4/7) than in older children (3/18). It was also higher when valve replacement was performed at second intention (5/14) than when decided on from the outset (2/11). With an average follow-up over 3 years, 9 of the 18 survivors are considered to be good surgical results. Of the other 9, 3 are considered to be moderate results (2 associated subaortic stenoses), 3 present indications of reoperation for calcification of the bioprosthesis, and 3 died in the late follow-up period. This series suggests that plastic surgery of congenital malformations of the atrioventricular valves should continue to be developed.

[Medium- and long-term results of palliative surgery in complex cyanotic cardiopathies. A propos of 228 cases and 292 operations]

The results of palliative surgery are assessed in a retrospective study of 228 children operated between 1968 and 1977 for complex cyanotic congenital cardiac malformations, the longest follow-up period being 10 years. The surgery consisted in revascularising the lung by systemo-pulmonary anastomoses: Blalock-Taussing, Potts, Waterston, cavo-pulmonary shunts or, on the contrary, of avoiding pulmonary hypertension by limiting pulmonary flow with banding. In addition to these two techniques, in some cases atrial septal defects were created to improve mixing of the two circulations; equalise the pressures between the two atria and relieve the left ventricle (Blalock-Hanlon procedure) or during catheterisation (Rashkind manoeuvre). The results of pulmonary revascularisation by systemo-pulmonary anastomoses were generally satisfactory with respect to the complexity of the malformations. There were 56% good results, 82 out of 146 cases. It often provided the time for curative surgery to be performed under better conditions for the children. The results were worse in children with pulmonary hypertension, with only 33% of good results, 25 out of 82 children, and there were many complications of banding which additional problems at the time of definitive repair. Despite the tendency to widen the indications of so-called curative surgery even in very small infants, palliative surgery retains a role in complex cardiac malformations either by allowing the children to reach an optimal age for repair or by being the only possible therapeutic attitude.

[Surgery in complex forms of transposition of the great vessels: long-term results in a series of 100 cases]

A series of 100 patients with complex forms of transposition of the great arteries (TGA) were operated upon over a 10 year period. Group 1 consisted of 13 TGA with pulmonary stenosis (PS), usually treated by an atrial baffle and direct repair of the stenosis. There was no operative or late mortality in this group and the long-term results were generally good (10/13). Group II comprised 29 TGA with ventricular septal defect (VSD) and PS. Seven Rastelli procedures gave 4 good results. Twenty two operations, associating atrial baffle, repair of VSD and PS (17 direct procedures, 5 left ventricle-pulmonary artery tube) were associated with a high mortality (5 operative and 4 late deaths) and 10 good long-term results. Group III comprised 58 TGA with VSD. Up to 1977 (n = 33) treatment consisted of atrial baffle + repair of VSD +/- removal of previous banding. Mortality was high (11 operative and 8 late deaths) with only 8 good long-term results. Since 1977, these patients have been treated by complete anatomical repair, the operative mortality of which is higher in the period under study (9/23) but the long-term results are much better. The surgical indications in our Department are based on the analysis of these results. In Group I only very significant PS is treated, either by left ventricle-pulmonary artery tube or direct repair depending on the form of the stenosis. In Group II, where the results based on atrial baffle are poor, a Rastelli procedure is preferred and especially its variants which avoid the use of prosthetic materials on the pulmonary trunk. In Group III, anatomical correction at the level of the great arteries is the routine procedure, the only point of discussion being the possibility of prior banding.

[Extrapleural implantation of epicardial pacemakers in infants (author's transl)]

In spite of the availability of small size models, intra-abdominal implantation of epicardial pacemakers is difficult in infants. The alternative, which is implantation within the pleural cavity, entails a risk of compression of the lung. These problems can be overcome by using a totally extrapleural thoracic approach.