Intracardiac teratoma in a newborn

Primary tumors of the heart are infrequent at all ages. We present a newborn with hypoxia and a heart murmur, in whom an echocardiogram revealed a large tumor filling the right ventricle and the pulmonary annulus. To maintain pulmonary blood flow, the patency of the ductus arteriosus was achieved by infusion of prostaglandin E1. Successful surgical resection was accomplished. The pathological examination was characteristic of a benign teratoma. The patient remains asymptomatic and has shown no evidence of recurrence of the tumor during a follow-up period of 34 months. This represents the eleventh case of intracardiac teratoma and only the fourth case to undergo successful surgical resection.

Primary pulmonary artery sarcoma in two children

The clinical and pathological features of primary pulmonary artery sarcoma in two children are reported. The first patient presented with right ventricular outflow obstruction and underwent successful surgical resection of his tumor. The second patient developed cardiac arrest following a relatively short period of symptoms of right heart failure and could not be revived. The pathological diagnosis in both patients was hemangiopericytoma. To the best of our knowledge, primary pulmonary artery sarcoma in children has not been previously reported.

Surgical and medical results of complete atrioventricular canal: a ten year review

The files of 121 patients who presented to Children's Hospital of Michigan over the last 10 years with complete atrioventricular (AV) canal were reviewed to evaluate long-term management and overall outcome. Of 121 patients, 70 underwent corrective surgery, 21 (30%) of whom died perioperatively. The surgical mortality rate was 13% when patients with hypoplastic left or right ventricle (n = 6), double-orifice mitral valve or extreme deficiency of mitral tissue (n = 5), and pulmonary vascular obstructive disease (n = 5) were excluded. Of the 49 patients who survived operation, 36 are in New York Heart Association class I, 1 patient requires a pacemaker and 3 died late. In 34 of the 51 patients (28%) who did not undergo operation, pulmonary vascular obstructive disease developed; it occurred within 12 months in 10 patients (8%). Eight other patients who did not undergo operation died before planned surgery (age 1 to 9 months). Although surgical prognosis in good candidates is acceptable, the overall prognosis for children with complete AV canal is guarded because of the risk of early death or early pulmonary vascular obstructive disease and frequently unfavorable anatomy.

Pulmonary hypertension postventricular septal defect repair treated by extracorporeal membrane oxygenation

Severe pulmonary hypertension complicating the correction of congenital cardiac defects is an unusual cause of early postoperative mortality. We present a case of a nine-month-old infant who developed paroxysmal pulmonary hypertension associated with severe hypoxemia after the successful repair of a large perimembranous ventricular septal defect (VSD). The pulmonary hypertension was refractory to all medical and pharmacologic therapy but was successfully treated with extracorporeal membrane oxygenation (ECMO). On ECMO, pharmacologic support was removed, pulmonary artery pressure reduced, and ECMO support withdrawn. To date, ECMO has been applied to pulmonary hypertension of the newborn, neonatal respiratory insufficiency, and for primary cardiac pump failure. Our experience with this case leads us to believe it is an effective therapy for acute pulmonary hypertension occurring after the repair of congenital cardiac anomalies.

Classic shunting operations for congenital cyanotic heart defects

A total of 297 consecutive classic systemic artery-pulmonary artery shunts were performed in 281 patients over the past 9 years. This experience includes 200 Blalock-Taussig shunts (67.3%), 84 Waterston shunts (28.2%), and 13 Potts shunts (4.3%). The overall early mortality after the Blalock-Taussig shunt (5.5%) was significantly lower (p less than 0.02) than for the Waterston shunt (13%). The early mortality after either the Blalock-Taussig or Waterston shunt was not statistically related to the age of the patient at operation. Both the Blalock-Taussig and Waterston shunts demonstrated a higher mortality (p less than 0.02) among patients in Group II (complex defects) than in patients in Group I (tetralogy of Fallot and pulmonary atresia with ventricular septal defect [VSD]). However, the Blalock-Taussig shunt had a significantly lower (p less than 0.04) probability of early postoperative death than the Waterston shunt among patients with complex lesions. The Blalock-Taussig shunt also revealed a lower incidence of important late postoperative complications and did not affect adversely the hemodynamic result after intracardiac correction, as evidenced by late postoperative cardiac catheterization. This study also confirms the feasibility of the Blalock-Taussig shunt during the neonatal period without significantly increased age-related risk of postoperative death (p = 0.13) and with good early and late long-term patency rates.

Surgical treatment of cor triatriatum

Six patients with cor triatriatum underwent surgical correction. They ranged for 1.5 to 93 months old (mean, 22 months). Congestive heart failure was present in 3 patients. Cardiomegaly and increased pulmonary vascularity were evident roentgenographically in all patients. Cardiac cineangiography demonstrated the subdividing left atrial membrane in 5 patients and suggested the correct diagnosis by revealing an abnormal configuration of the left atrium in the other patient. The opening in the anomalous left atrial membrane was stenotic in every instance. The proximal left atrial chamber communicated with the right atrium through an atrial septal defect in 5 patients and with the systemic venous circuit through a persistent left superior vena cava in the other patient, in whom the atrial septum was intact. A right atrial-transseptal approach provided ample exposure for complete excision of the obstructing membrane and repair of the atrial septum in all patients. One patient died of low cardiac output during the early postoperative period. The other 5 are alive and well at an average of 48 months after operation.

Retrotympanic odontoma

The clinical and histologic features of the second reported case of retrotympanic odontoma, which clinically presented as a cholesteatoma, are described. Origin from the posterior extension of the dental lamina is postulated. The dental lamina, the thickened oral ectoderm which outlines dental structures, is incorporated subendodermally in the lateral outpouching of the first pharyngeal pouch which produces the middle ear cavity. Histologically the odontoma was "complex," containing a haphazard arrangement of cementum, dentin, dental follicle and proliferating dental lamina, without the formation of recognizable teeth.

Results of total correction of tetralogy of Fallot with complete atrioventricular canal

Four patients with tetralogy of Fallot (TF) and complete atrioventricular canal (CAVC) underwent successful intracardiac repair. All patients had undergone preliminary palliative shunts. Associated cardiovascular lesions included muscular ventricular septal defect (VSD) and left superior vena cava (one patient), bilateral main pulmonary artery stenosis (one patient), and right aortic arch (two patients). The diagnosis was suspected clinically by electrocardiographic evidence of right ventricular hypertrophy and left anterior hemiblock, by echocardiographic findings suggestive of CAVC with aortic dextroposition, and by the association with trisomy 21. The diagnosis was confirmed by cardiac catheterization and cineangiography. Total correction consisted of closure of the VSD and atrial septal defect (ASD), reconstruction of the atrioventricular valves, and relief of the right ventricular outflow tract obstruction (RVOTO). There were no early or late postoperative deaths. Surgically induced complete heart block did not occur. One patient underwent successful reoperation for residual VSD and right ventricular outflow aneurysm. Late hemodynamic evaluation revealed good results in all patients. We recommend a staged treatment plan consisting of preliminary systemic--pulmonary artery shunting for symptomatic children under 4 to 5 years of age and total correction for older children. With proper preoperative diagnosis and accurate intracardiac repair, good results may be obtained after total correction of TF and CAVC.

Results of the Mustard operation for dextro-transposition of the great arteries

One hundred twenty patients with dextro-transposition of the great arteries (TGA) underwent intra-arterial baffle repair using thin Dacron fabric from 1971 to 1979. The ages of the patients ranging from 29 days to 17 years (mean age 28 months). Thirty-five patients had undergone 49 preliminary palliative operations. Early postoperative mortality was 4.8% for patients with simple TGA but was higher among patients with associated ventricular septal defect (26%), VSD and left ventricular outflow tract obstruction (28.5%) and intact ventricular septum with left ventricular outflow tract obstruction (12.5%). Early nonfatal postoperative complications included low cardiac output (23.3%), respiratory insufficiency (35.8%), junctional rhythm (34.1%), superior vena caval (SVC) obstruction (9.1%), and chylothorax (7.5%). Late postoperative mortality for all groups was 7.5% (nine patients). Late cardiac dysrhythmias occurred in 33 patients (40.7%). Normal sinus rhythm has been preserved in all patients since direct, high SVC cannulation was instituted. Late postoperative hemodynamic and angiographic evaluation in 61 patients revealed severe to total SVC obstruction in 12 patients (20.2%) and pulmonary venous obstruction in four patients (6.5%). Among the latter, two patients died following reoperation and another patient died without operation. SVC obstruction was clinically important in only three patients, two of whom have undergone successful reoperation. All other late survivors are acyanotic and clinically well. The Mustard operation has dramatically improved the survival rate and quality of life for patients with TGA. However, postoperative caval and pulmonary venous obstruction are problems which require additional technical modifications and stimulate the search for alternative corrective operations.

Early and late results of total correction of tetralogy of Fallot

Two hundred and nine patients underwent total repair of tetralogy of Fallot without congenital pulmonary atresia from 1971 to 1979. The age of the patients ranged from 22 months to 27 years (mean 6.8 years). Previous palliative shunts were present in 130 patients (62.2%). The right ventricular outflow tract obstruction was relieved by infundibulectomy in 31 patients (14.8%), by transannular patching in 142 patients (67.9%), and by insertion of a right ventricular--to--pulmonary artery prosthetic conduit in 10 patients (4.7%) with associated coronary artery anomalies. A porcine valve was inserted after transannular patching only in patients with undersized pulmonary arteries, unilateral pulmonary artery, or congenitally absent pulmonary valve. There were 10 early postoperative deaths (4.7%). Previous palliative shunts did not adversely affect early postoperative mortality rate. Surgically induced permanent complete heart block occurred in one patient (0.4%). Six patients (3%) died in the late postoperative period, three of them of unrelated causes. Late results were good in 170 patients (87%), fair in 10 patients (5.1%), and poor in 15 patients (7.6%). Poor results were due to residual stenosis at the origin of the pulmonary arteries in 13 patients (6.5%) and to residual ventricular septal defect in two patients (1%). The mean cardiothoracic ratio was 0.61 for patients with poor results and 0.54 for the entire group. Pulmonary valvular insufficiency was well tolerated postoperatively in the absence of distal pulmonary artery obstruction. This experience supports a policy of aggressive relief of the right ventricular outflow tract obstruction including liberal use of transannular patching and, when indicated, extensive reconstruction of the pulmonary artery branches. We also recommend a two-stage treatment program for symptomatic infants with unfavorable anatomy consisting of initial Blalock-Taussig shunt followed by total repair at about 3 years of age.

Results of two-stage surgical treatment of tetralogy of Fallot

One hundred nine consecutive patients underent 115 palliative shunts between 1971 and 1979 for the initial management of symptomatic tetralogy of Fallot. A single Blalock-Taussig shunt was done in 78 patients, including 38 infants below 12 months of age, with two deaths (2.5% mortality rate). Thirty-two patients underwent a Waterston shunt, with one death (3.1% mortality rate). The total early shunt mortality rate was 2.7% (three deaths among 109 patients). There was one later noncardiac death and one instance of nonfatal brain abscess between the two stages. Fifty-nine of the previously shunted patients have undergone total correction at a mean postshunt interval of 37.1 months, with one early postoperative death (1.6% mortality rate). The mean patient age at total repair was 4.8 years. The two-stage combined operative mortality rate was 3.6% (four deaths among 109 patients). The Waterston shunt is considered undesirable because it complicated the total repair and was associated with a high incidence of residual right pulmonary artery obstruction at postoperative cardiac catheterization. The Blalock-Taussig shunt had a low mortality rate, high long-term patency rate, absence of interval complications, and no adverse effect at the time of total correction. It is considered the shunt of choice in all symptomatic infants and small children with tetralogy of Fallot. Our experience suggests that, at the present time, the two-stage surgical approach compares favorably with primary total correction, especially in infants under 1 year of age.

Primary cardiac tumors in children

Case histories of five children with primary cardiac tumors are presented. The clinical and pathological features of the most frequent cardiac neoplasms in childhood are also reviewed. Cardiac tumors should be suspected in any child with unexplained heart murmurs, congestive heart failure, or cardiac arrhythmias. Echocardiography, cardiac catheterization, and biplane cineangiograms provide diagnostic confirmation. Prompt surgical resection is indicated in all symptomatic patients and in those with significant inflow and outflow tumor-related obstruction. Complete resection is not possible in many patients with cardiac rhabdomyoma or lipoma but removal of the obstructive portion of the tumor frequently provides long-term symptomatic relief.

Intrapericardial teratoma in infancy

Intrapericardial teratoma is a rare, congenital, pedunculated tumor, usually attached to the ascending aorta and associated with massive pericardial effusion, cardiac compression, and severe cardiorespiratory distress in infants and young children. Echocardiography and cardiac cineangiography are diagnostic and should be used promptly. The tumor is generally benign and early surgical removal is curative. The case reports of two infants who underwent successful surgical removal of their lesions are presented.

Surgical management of congenital vascular rings

Case histories of 53 patients with surgically treated vascular rings are presented. The diagnosis was strongly suggested in all patients by symptoms of tracheosophageal obstruction and was confirmed by barium esophagogram, which showed typical bilateral and posterior indentations in the esophagus. Angiography was rarely used although it is helpful in doubtful cases. Endoscopic studies were considered unnecessary and potentially harmful. A left posterolateral thoractomy afforded ample access for division of the ring in all patients. Two patients died who were operated upon during the early experience. There were no postoperative deaths among the last 45 consecutive patients. All survivors had excellent symptomatic relief although complete resolution of symptoms took several months in some patients. All survivors had excellent symptomatic relief although complete resolution of symptoms took several months in some patients. The importance of early diagnosis and prompt surgical division is emphasized.

[Experience in the use of porcine heterologous grafts of the Hancock type for replacement of the mitral valve. 4 years of continuous use]

We present a statistical analysis on the use of the Hancock porcine heterograft for mitral valve replacement in 151 consecutive cases. A 14% early, and 3.9% late mortality rate is found. An evaluation of the factors contributing to this figure shows that the most important is the degree of myocardial derangement prior to surgery, with 3.5% mortality for stage III and 32% for stage IV (New York Heart Association classification). Our rate for thromboembolism is 9%. Study of other conditions favoring this complication indicates that factors other than valve replacement are present in all cases, making the evaluation of the thrombogenic qualities of these prosteses difficult. In a period of study of 4 832 patient-months (21 average) or 5 526 valve-months (19 average) which nicludes all our Hancock prosteses. There have been no failures that can be traced to mechanical derangement nor biological deterioration. This fact together with their favorable hemodinamic characteristics, make us recommend this model for clinical use.

The sutureless electrode: comparison with transvenous and sutured epicardial electrode placement for permanent pacing

Consecutive series of 50 transvenous and 50 sutureless pacemaker insertions were reviewed and compared with a nonsimultaneous series of 50 patients who received sutured epicardial pacemakers. It is concluded that: (1) the sutureless electrode has a lower initial stimulation threshold than the transvenous type; (2) complications from sutureless electrodes are greater than with transvenous electrodes and similar to the incidence with sutured epicardial pacemakers; (3) initial pacing is more satisfactory with the sutureless electrode compared with the transvenous model; and (4) late electrode failure due to threshold rise is greater with the sutureless electrode than with the transvenous or sutured epicardial type.

Fibrous histiocytoma of the trachea

A histologically benign but locally infiltrating tumor of histiocytes, fibrous histiocytoma, was found in the trachea of a 26-year-old man. Partial resection of the trachea afforded the successful removal of the growth with no evidence of recurrence or metastases 27 months after surgery. Pathology and prognostic aspects of the tumor are discussed.