Congenital cardiac anomalies: one-stage repair in infancy

Cardiac surgery with deep hypothermic circulatory arrest produces less systemic inflammatory response than low-flow cardiopulmonary bypass in newborns

OBJECTIVE

We sought to compare low-flow cardiopulmonary bypass with deep hypothermic circulatory arrest in respect to the influence on the systemic inflammatory response.

METHODS

Twenty-three infants weighing less than 10 kg and scheduled for repair of congenital malformations were enrolled in a randomized, controlled study. Eleven patients underwent cardiac surgery with deep hypothermic circulatory arrest (the DHCA group). Low-flow cardiopulmonary bypass was used in another 12 patients (the LF group). Interleukin 6 and 8 and anaphylatoxin C3a levels were measured 6 times perioperatively. Also, perioperative weight gain and a radiologic soft-tissue index were compared.

RESULTS

All patients had an uneventful clinical course. Duration of deep hypothermic circulatory arrest was 40 +/- 4 minutes; the bypass time was significantly shorter in the DHCA group (85 +/- 8 vs 130 +/- 19 minutes). However, the duration of the operation was similar in both groups (245 +/- 30 vs 246 +/- 30 minutes). During cardiopulmonary bypass (rewarming), the concentration of C3a (3751 +/- 388 vs 5761 +/- 1688 ng/mL, mean +/- SEM) was significantly lower in the DHCA group than in the LF group. The interleukin 8 level was significantly lower, and the interleukin 6 level had a tendency to be lower in the DHCA group compared with levels in the LF group. There was less weight gain on the first postoperative day in the DHCA group (65 +/- 61 vs 408 +/- 118 g). The soft-tissue index suggested reduced edema formation in the DHCA group.

CONCLUSION

Deep hypothermic circulatory arrest produces less systemic inflammatory response than low-flow cardiopulmonary bypass. In addition, there is an indication of less fluid accumulation postoperatively.

Single-stage repair of aortic coarctation with ventricular septal defect using isolated cerebral and myocardial perfusion

OBJECTIVE

To avoid hypothermic circulatory arrest, we have repaired aortic coarctation with ventricular septal defect (VSD) in a one-stage procedure using an isolated cerebral and myocardial perfusion technique, and retrospectively compared this novel approach to the conventional two-stage approach.

METHODS

Between October 1991 and February 1999, 24 infants, aged 4-137 days (median, 27 days) and weighing 1.7-4.3 kg (median, 3.0 kg), underwent the repair of aortic coarctation with VSD either in one (group I, n=11) or two stages (group II, n=13). In Group I, an arterial cannula for cardiopulmonary bypass was inserted into the ascending aorta in six patients with coarctation only, or into a polytetrafluoroethylene (PTFE) graft which was anastomosed to the innominate artery in the remaining five who had hypoplastic arches. A cross-clamp was placed between the innominate and left carotid arteries. The bypass flow was reduced to 30-50% of full flow at 28 degrees C, thereby maintaining a radial artery pressure of 30-45 mmHg. At this point, the aortic coarctation was repaired by an end-to-end arch anastomosis, while maintaining brain perfusion and with the heart still beating. In five patients with hypoplastic aortic arches, the innominate artery proximal to the graft was then secured down and the arch anastomosis was extended to the distal ascending aorta, while providing isolated cerebral perfusion and cardioplegic arrest. After arch reconstruction was performed, the clamp was moved onto the ascending aorta, and the VSD was closed with systemic perfusion. In contrast, for group II patients, coarctation repairs were performed through a posterolateral approach, and existing VSDs were closed as secondary procedures.

RESULTS

The mean isolated cerebral and myocardial perfusion time for group I was 13 min (range, 7-20 min). The myocardial ischemic time did not differ between groups I and II (43+/-4 vs. 42+/-5 min, not significant). There were no hospital mortalities or neurological complications in either group, but one late death in each group.

CONCLUSION

Single-stage repair of aortic coarctation with VSD does not increase myocardial ischemic time compared to the traditional two-stage approach. The isolated cerebral and myocardial perfusion technique may offer substantial brain and myocardial protection during aortic arch reconstruction.

Pulmonary artery banding: analysis of a 25-year experience

A 25-year experience (May 1962 through April 1987) with pulmonary artery banding in 183 patients was reviewed and analyzed. Pulmonary artery banding was performed in a heterogeneous group of patients aged two days to 60 months (median, 10 weeks; mean, 21.8 weeks) and weighing 1.4 to 13.8 kg (mean, 4.2 kg). Diagnosis was ventricular septal defect in 76 (41.5%) and atrioventricular communis in 41 (22.4%). Pulmonary artery banding was also used in patients with d-transposition of the great vessels with ventricular septal defect, double-outlet right ventricle, univentricular heart, tricuspid atresia, and truncus arteriosus. Early death occurred in 39 of 175 patients who underwent pulmonary artery banding at Ochsner Foundation Hospital (22.3%). Definitive operation has been performed in 37 of the patients who underwent pulmonary artery banding since 1979 with excellent outcome in 32 (86.5%). Pulmonary artery banding is a useful palliative procedure for a diverse group of patients with congenital cardiac anomalies and unrestricted pulmonary blood flow. With improved results of primary repair of intracardiac anomalies in small infants, however, pulmonary artery banding should be reserved for severely ill patients with complex lesions not amenable to early definitive correction. Currently, pulmonary artery banding is indicated in patients with excessive pulmonary blood flow and single ventricle or tricuspid atresia. Pulmonary artery banding is also appropriate in certain patients with atrioventricular communis and in patients with muscular or multiple ventricular septal defects. Pulmonary artery banding is an option in patients with ventricular septal defect and coarctation of the aorta.

Indications and techniques for midline approach to aortic coarctation in infants and children

A variety of techniques have been described for the repair of aortic coarctation. Most of these use operative exposure through a left thoracotomy. There are, however, instances when a median sternotomy provides a more versatile approach and allows for equally acceptable repair. Twelve patients (age, 2 days to 16 years) with coarctation of the aorta serve to illustrate the value of the technique. All but 3 patients were under 3 years old. Five patients had repair of coarctation combined with repair of other congenital cardiac anomalies (atrial and ventricular septal defects, 2 patients; atrial septal defects, 2 patients; and valvular aortic stenosis, 1 patient). Six patients had complicated recurrences of previously repaired coarctations and 1 patient had a primary coarctation that involved the aortic arch. All repairs were accomplished through a median sternotomy with the use of cardiopulmonary bypass and periods of (1) total circulatory arrest (6 patients); (2) reduced flow (4 patients); or (3) normal flow with multiple sites of arterial inflow (2 patients). All patients did well with no operative mortalities and no sequelae to date (8 weeks to 4 years). Examples of various techniques are provided to demonstrate the flexibility obtainable with this method. Median sternotomy can provide a viable approach to difficult problems involving coarctation of the aorta.

Cardiac surgery in the critically ill infant during the first three months of life

Major advances have been made in the treatment of congenital heart disease in the past 10 years. Management of the 20 per cent of children who become critically ill during the first 3 months of life remains a major challenge because they represent the most extreme anatomic and physiologic derangements. A review of the recent data accumulated in the NERICP showed an overall mortality of 54 per cent in infants presenting for surgery in the first 2 months of life. We have reviewed our experience with over 400 procedures during the past 5 years in infants less than three months of age, and our overall mortality is 19 per cent. Primary repair remains our goal, but a disappointingly high mortality with primary repair in this group, by us and others, has caused us to perform palliative procedures when palliation in our experience offers an overall lower mortality.

Open-heart surgery in the first week of life

The high mortality of open-heart operations in infants with congenital heart disease has traditionally led to deferral of definitive operation and to use of medical therapy or palliative procedures. The technique of deep hypothermia with circulatory arrest and advances in intensive care have made early repair possible. Since 1973, we have repaired life-threatening but correctable lesions in 11 infants in the first week of life. There are 7 survivors. Four patients had total anomalous pulmonary venous drainage, 2 had truncus arteriosus (1 with aortic arch interruption), and 1 each had pulmonary atresia and intact ventricular septum, critical pulmonary stenosis and intact ventricular septum, D-transposition of the great vessels, tetralogy of Fallot, and left ventricular-aortic tunnel. Postoperative hypoglycemia (less than 50 mg per 100 ml) developed in 4 patients and hypocalcemia (less than 7 mg per 100 ml), in 5. These problems responded appropriately to replacement therapy. Three of the survivors experienced renal failure, a complication subsequently prevented by use of mild hemodilution perfusion. Two patients had major bleeding, which now is prevented by finer suturing and administration of vitamin K and platelets. One infant, moribund with pH of 6.8 when brought to operation, sustained a cardiac arrest with subsequent brain damage. We conclude that newborns with life-threatening malformations can undergo successful repair. Attention must be paid to their unique metabolic demands, and surgical technique must be meticulous. Early operation before clinical deterioration is essential.

Prognosis for the newborn with transposition of the great arteries

To determine the prognosis for the newborn with transposition of the great arteries, the clinical course of 112 consecutive neonates with dextrotransposition was reviewed. Patients were managed with balloon atrial septostomy at initial cardiac catheterization, palliative operation if needed in the 1st year of life and Mustard's intraatrial baffle repair. The 1st month of life was the period of greatest risk (8 percent mortality rate). Between balloon septostomy and baffle repair, 14 of 103 patients at risk (14 percent) either died or had a cerebrovascular accident. The mortality rate at baffle repair was 14 percent (10 deaths in 71 patients), and there were 3 late postoperative deaths. Actuarial analysis of the data indicates that with this plan of management, approximately 50 percent of newborns with transposition of the great arteries will survive 5 years with excellent function and an additional 15 to 20 percent will survive with one or more medical handicaps.

Anomalous origin of the right pulmonary artery from the ascending aorta associated with aortopulmonary window

A rare case of anomalous origin of the right pulmonary artery from the ascending aorta associated with an aortopulmonary window and severe pulmonary hypertension in a 13-year-old girl is reported. The window was closed using a Dacron patch and the continuity between the anomalous vessel and the main pulmonary artery was restored with a tubular Dacron graft. After operation the pulmonary pressure dropped to about one-half of the systemic pressure, and equal perfusion and ventilation of both lungs was demonstrated. Although early recognition and surgical treatment of this condition are mandatory to prevent the onset of irreversible pulmonary vascular disease, the presence of severe pulmonary hypertension did not contraindicate surgical correction in our patient.

Open heart surgery in the first six months of life

Intracardiac repair of a variety of cardiac anomalies was performed in 104 infants aged 10 days to 6 mo, presenting with severe hypoxia and/or intractable heart failure. Thirty-eight patients (33 less than three mo of age) did not survive the operation or died during the first postoperative month. Above 6 mo of age, correction of heart defects is often carried out on an elective basis, and results are more favorable. A more convenient choice between corrective and palliative procedures is suggested to achieve better results in the difficult group of patients who require surgery within the first 6 mo of life.

Repair of ventricular septal defect in the first two years of life using profound hypothermia-circulatory arrest techniques

Ventricular septal defect repair had been performed in 57 infants ages 21 days to 21 months and under 10 kg in weight using profound hypothermia-circulatory arrest technics. Severe congestive heart failure was the indication for operation in all but two infants under 6 months of age, and in those under 3 months there was usually an associated moderate or large sized atrial septal defect or patent ductus arteriosus or a coarctation. In infants over 6 months controlled heart failure was accompanied by failure to thrive and often recurrent respiratory infections. The main indication for surgery in three infants was repeated severe respiratory infections and in 7 infants, ages 10-15 months, an elevation of pulmonary vascular resistance of 6 units M2 or more. There were two hospital deaths among the 49 infants without coarctation (ages 6 and 20 months) and two among the 8 with coarctation. Postoperative respiratory and other complications were uncommon. On late review there was no significant residual VSD amongst the 11 recatheterized patients. Psychometric studies in 19 children who had reached the age of three to four years gave no evidence of cerebral damage due to the circulatory arrest period. In view of these results palliative pulmonary artery banding is no longer performed for VSD in infancy unless there is a Swiss cheese septum or an associated severe coarctation.