[Use of PTFE (Gore-Tex) in pulmonary systemic anastomoses. Apropos of 50 cases]

Between 1977 and 1981 palliative anastomosis procedures between the subclavian and pulmonary arteries using a PTFE (Gore-Tex) prosthesis for anatomical reasons (short subclavian artery or trajectory incompatible with a Blalock-Taussig anastomosis) were carried out in 50 patients from 1 day to 24 years of age with cyanotic congenital heart disease. Two groups of patients were identified: ten patients in which the PTFE prosthesis was used as an "extension" to the subclavian artery, and 40 patients in which the PTFE was interposed between the respected subclavian and pulmonary arteries. There were three deaths (6 p. 100) at 1,7 and 15 days after surgery (mean mortality 5,7 and 12,3 p. 100). There were no major complications in the survivors. Two prostheses became occluded, one of which was reanastomosed to the ascending aorta. The follow-up ranges from 6 months to 5,5 years. The angiographic investigations performed before complete repair demonstrated the patency and good function of these anastomoses.

Subvalvular aortic stenosis: long-term surgical results

Seventy-six patients, with a mean age of 11.6 years, presenting with congenital subvalvar aortic stenosis were operated upon between 1965 and 1979. Seventy had moderate subvalvular stenosis. Eighty-eight percent had myotomy combined with resection of the obstruction. Five patients (6.6%) died postoperatively. Of 48 survivors followed up between 6 months to 13 years postoperatively (mean 4.2 years), 4 underwent reoperation and 2 of them died. Survival at 5 years and 10 years was 96% and survival without reoperation at 5 years and 10 years was 91%. When last seen, 90% of the patients were asymptomatic, left ventricular hypertrophy on ECG had disappeared in 63%. No patient had atrioventricular block. Two thirds of the patients had no systolic thrill and of 13 patients recatheterized (3.2 years follow-up) 9 had a peak systolic gradient below 50 mmHg. If, postoperatively 60% of the patients had aortic insufficiency versus 31% preoperatively for the whole period, this percentage fell to 33% after 1976. As subaortic stenosis is a progressive disease and late surgical results are correlated to preoperative peak systolic gradient, early surgery is recommended. Close postoperative follow-up is needed since recurrence of aortic stenosis is possible (and acquired aortic insufficiency may persist).

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.

[Pacemakers in infants and young children. A new implantation technique (author's transl)]

Long-term stimulation of the heart in young children often raises technical problems, most of which are associated with the site of implantation of the pacemaker. For this reason, a new technique of implantation was devised with the following main stages: (1) the child is made to rest on its right side, with slight posterior declivity; (2) a pacemaker electrode is implanted on the left ventricle through a short left thoracic incision in the 5th intercostal space; (3) the pacemaker itself is implanted through a short lumbar incision into the space between the posterior peritoneum and the left renal fossa; it is attached to the costal grid. None of the complications usually reported (infection of the pacemaker cavity, displacement or exteriorization of the instrument) was observed in this series of 25 young patients.

[Aberrant subclavian artery in infants. Division and reimplantation into the common carotid artery through cervicotomy (author's transl)]

In infants, merely dividing an aberrant subclavian artery (ROSCA) through left-thoracotomy may result in severe cerebral circulatory disorders by vertebrobasilar arterial steal. The authors report on 3 cases where reimplantation of the ROSCA into the common carotid artery reproduced a normal brachiocephalic arterial trunk and resulted in normal revascularization. In 2 of these 3 cases, the ROSCA was approached through a right cervical incision, divided in the mediastinum, behind the oesophagus, and reimplanted by latero-lateral anastomosis into the right carotid artery. In the third case the same approach was preceded by left thoracotomy for easier division of the ROSCA close to the aorta. The three operations were uneventful and no complication occurred, except for transient and mild left hemiparesis without sequelae in one patient.

Tandem coarctation of the thoracic aorta. An unusual congenital anomaly

The coarctation involving the aortic isthmus, with hypoplasia of the upper aortic segment, was satisfactorily repaired in a 15-year-old girl. The technique used was subclavian flap arterioplasty followed by reimplantation of the distal subclavian artery into the left carotid artery. Suprisingly weak femoral pulses were noted postoperatively and prompted a control angiogram. This showed an intraluminal diaphragm 2 cm below the site of the previous repair, with a 100 mm Hg gradient. At reoperation, a centrally performed fibrous diaphragm was excised, and the aorta was enlarged with a small Dacron patch. The postoperative course was uneventful.

[Coarctation of the thoracic aorta with extensive segmental hypoplasia. A new surgical approach (author's transl)]

The authors describe a new surgical technique used for the repair of coarctations of the aorta with extensive segmental hypoplasia. The technique is divided into four stages: enlargement of part of the hypoplastic segment by arterioplasty, using a flap from the subclavian artery; the extent of possible enlargement is governed by the length of subclavian artery available; resection of the residual hypoplasia and of the coarctation area proper; end-to-end anastomosis of the two aortic segments; revascularization of the arm by direct implantation of the subclavian artery into the left common carotid artery.