[Surgical treatment of pulmonary atresia with ventricular septal defect]

Pulmonary atresia with ventricular septal defect (PAVSD) is a complex cardiopathy represented by a complete obstruction between the right ventricle outflow and the pulmonary trunk associated with a ventricular septal defect (VSD) and major aortopulmonary collaterals (MAPCA). The goal of the unifocalization in the PAVSD is to prepare the pulmonary tree for the complete repair by connecting the MAPCAs to the central pulmonary arteries that should be enlarged. After that we can made the VSD or other intracardiac repair. This is a retrospective study on 31 patients. We report our results discussing the PAVSD classification and the strategy of the complete repair in comparison with other reported results.

Surgically created double-orifice left atrioventricular valve: a valve-sparing repair in selected atrioventricular septal defects

OBJECTIVES

Some features of the left atrioventricular valve (large mural leaflet, dystrophic tissue) represent a challenge for repair of atrioventricular septal defects without postoperative regurgitation. A retrospective study was conducted to evaluate the results of surgically creating a double-orifice left atrioventricular valve in such circumstances. Clinical results were analyzed according to valvular and subvalvular left atrioventricular valve measurements in pathologic specimens with atrioventricular septal defects.

METHODS

Among 157 patients operated on for atrioventricular septal defect since October 1989, 10 patients underwent primary repair (n = 8) or reoperation (n = 2) by this procedure. Median age at repair was 3.3 years (0.1-33 years). Anatomic types were complete (n = 3), intermediate (n = 5), and partial (n = 2). Preoperative moderate to severe left atrioventricular valve regurgitation was present in 6 patients. After the repair (two-patch technique in complete atrioventricular septal defect, cleft closed in each case), these 10 patients were found to have moderate to severe residual regurgitation not amenable to repair by annuloplasty. The top edge of the mural leaflet was anchored to the facing free edge of the cleft.

RESULTS

No hospital death or morbidity was observed. Left atrioventricular valve regurgitation was absent or trivial (8 patients) and mild (2 patients). Color-coded echocardiography did not show significant left atrioventricular valve stenosis. The mean diastolic pressure gradient across the left atrioventricular valve was 3.2 +/- 1.1 mm Hg (1.4-4.5 mm Hg). At a median follow-up of 72 months (6-91 months), there was 1 late death, unrelated to left atrioventricular valve malfunction, due to pulmonary vascular obstructive disease. Left atrioventricular valve regurgitation did not increase over time, except in 1 patient in whom regurgitation recently progressed from mild to moderate. At rest, the mean diastolic pressure gradient across the left atrioventricular valve was 3.8 +/- 2.9 mm Hg (1.5-11.2 mm Hg). One child had an early moderate stenosis without pulmonary hypertension. Studies on pathologic specimens (n = 34) indicated that long chordal lengths and large mural leaflet size are essential independent anatomic features to assess its feasibility.

CONCLUSIONS

Surgical creation of a double-orifice left atrioventricular valve is an effective additional procedure for repair of atypical cases of atrioventricular septal defect. The operation may decrease the need for reoperation or left atrioventricular valve replacement.

Changes in venous return parameters associated with univentricular Fontan circulations

To clarify the physiology of venous return (Q(vr)) in Fontan circulations, venous return conductance (G(vr)) and mean circulatory filling pressure (P(mcf)) were determined in pentobarbital sodium-anesthetized pigs. Relationships between Q(vr) and right (biventricular, n = 8) or left (Fontan, n = 8) filling pressures are described by straight lines with significant correlation coefficients. Estimated P(mcf) values were correlated with observed P(mcf) values in either circulations (P </= 0.02). G(vr) was smaller in Fontan than in biventricular circulations (4.51 +/- 0.36 vs. 7.83 +/- 0.69 ml. min(-1). kg(-1). mmHg(-1), P = 0.002) and inversely correlated with pulmonary vascular resistances in Fontan circulations (P = 0.01). Estimated P(mcf) (20.5 +/- 1.4 vs. 11.1 +/- 0.9 mmHg, P = 0.001) and observed P(mcf) (21.8 +/- 1.3 vs. 10.6 +/- 0.8 mmHg, P < 0.001) were higher in Fontan versus biventricular circulations, respectively. Pulmonary artery pressure in Fontan circulations was correlated with either P(mcf) (P < or = 0.04). We conclude that in Fontan circulations 1) pulmonary vascular resistances induce a proportional decrease in G(vr); and 2) volume loading, while increasing P(mcf) (similar to pulmonary artery pressure), allows the gradient for Q(vr) to increase and maintains systemic blood flow at a biventricular level.

"Swiss cheese" septal defects: surgical closure using a single patch with intermediate fixings

BACKGROUND

Residual ventricular septal defects and ventricular and septal dysfunctions are surgical drawbacks of "Swiss cheese" defects. We developed a technique that uses a single patch with intermediate fixings to cover the right side of the septum without producing a septal bulging, through a right atriotomy.

METHODS

Since April 1993, 5 children with "Swiss cheese" defects have been operated on using this procedure (mean age, 17 +/- 12 months). Three patients had associated lesions including tetralogy of Fallot, Taussig Bing heart, and mitral stenosis.

RESULTS

There have been no early or late deaths. The mean follow-up time is 29 +/- 18 months. All patients are asymptomatic. Echocardiography revealed either an intact septum (n = 4) or insignificant color jets at the apical portion of the septum (n = 1). The septal wall motion was preserved in 4 children and was hypokinetic in the fifth child.

CONCLUSIONS

This technique can be an additional tool to provide a secure closure of "Swiss cheese" defects even in the presence of associated cardiac lesions. Long-term consequences of this procedure on septal wall motion remain to be determined.

Surgical treatment of aortic root aneurysm related to Marfan syndrome in early childhood

The prognosis of Marfan syndrome in both adult and pediatric patients is primarily related to the cardiovascular complications. In infantile Marfan syndrome, although involvement of the mitral valve is the most frequently encountered cardiovascular lesion, the aortic root can be more worrisome because of its excessive dilatation, leading to aortic insufficiency or dissection. If the role of elective surgery is relatively well defined for adult patients, it is still debated during childhood. We report two patients, aged 22 months and 5 years, each presenting an aortic root aneurysm related to Marfan syndrome, and each treated with the Bentall procedure without specific age-related mortality or morbidity. These two patients experienced normal growth and were free of any complication for a follow-up period of 8 and 2 years, respectively. More than an absolute value of the aortic root dimension, it is the conjunction of the rate of progression of the aortic root dilatation, the degree and the duration of the aortic valve regurgitation, and its resulting left ventricular dysfunction that must be taken into consideration in choosing the surgical option.

[Value of the spiral angio-scanner with three-dimensional reconstruction in the surgical strategy of unifocalization. Apropos of a case]

One of the difficulties of surgical treatment of pulmonary atresia with patent septum by unifocalisation resides in the accurate diagnosis of the different collateral vessels to the lung in order to optimise the surgical approach: anterior or posterolateral thoracotomy, and to determine the type of operation: one or two stages repair. Conventional angiography, even using different views, cannot always give an accurate representation of the anatomy of the different collateral vessels, especially their relationship to the bronchial structures. The authors report the contribution of spiral angioscanner with three dimensional reconstruction in the determination of the operative strategy of a case of pulmonary atresia with patent septum.

Bidirectional inferior vena cava-pulmonary artery shunt

BACKGROUND

Bidirectional superior vena cava-pulmonary shunt is widely used as an interim palliation for patients with univentricular hearts. Bidirectional inferior vena cava-pulmonary artery shunt, as an alternative approach of partial Fontan circulation, may offer the advantage of performing the complete Fontan circulation more easily due to the already constructed inferior vena cava lateral tunnel.

METHODS

We used bidirectional inferior vena cava-pulmonary artery shunt in 2 patients. Contraindications to a complete Fontan circulation were due to, respectively, a volume-overloaded systemic ventricle and an irregular pulmonary arterial tree.

RESULTS

Postoperative courses were uneventful. There were no significant pleural effusions. Transcutaneous oxygen saturations were 77% and 78%. Pulmonary-to-systemic blood flow ratios were 0.57 and 0.63. A complete Fontan circulation was safely performed 8 and 12 months later, without any "Fontan-related" complications.

CONCLUSIONS

Bidirectional inferior vena cava-pulmonary artery shunt can be useful in selected patients with univentricular hearts, although its place in the field of "partial Fontan operations" cannot be determined as yet.

[Late complications of percutaneous closure of atrial septal defects with the Sideris occluder]

Between June 1992 and January 1996, 27 patients aged 3.9 to 74 years with an ostium secundum (22 patients) or patent foramen ovale with right-to-left shunts (5 patients) underwent percutaneous closure of their atrial septal defects with the Sideris occluder. After a thromboembolic complication, transesophageal echocardiography was performed routinely after the procedure in 15 patients between 1 month and 2 years, and in 6 patients on the 15th day. Two patients died, on the 2nd day and 21st month, of non-related causes. After an average follow-up of 33 months, 59% of patients had complete occlusion of the atrial septal defects or only a minimal residual shunt. Displacement of the prosthesis was defects or only a minimal residual shunt. Displacement of the prosthesis was observed in 7 cases with no relationship to size: 4 parallel to the septum with reappearance or increase in shunt, 3 with tilting of the prosthesis. All of these patients had a large residual defect compared with 20% with a normally positioned prosthesis (p < 0.05). Tilting of the occluder was associated with left atrial thrombosis (present in 40% of these patients), complicated by systemic embolism in one case: there were no cases of left atrial thrombus in the 9 with complete occlusion and the 5 patients with an isolated residual defect (p < 0.05). Occlusion of atrial septal defect with the Sideris device is effective and a safe method in the majority of cases. However, a badly positioned prosthesis with a residual shunt should be extracted as seen as possible or within three weeks if displacement is observed at control echocardiography.

Total repair of congenital heart disease in the very young

Total repair of congenital heart disease in the very young is nearly always feasible when two balanced ventricles are present. Refinements in antenatal and fetal cardiology, and progress in pediatric cardiac surgery have improved both the surgical results and the long-term outcome of these critically ill infants.

[Surgical treatment of atrial septal defects by right anterolateral thoracotomy]

Motivated by esthetic considerations, the authors undertook surgical cure of atrial septal defects by a right antero-lateral thoracotomy in 80 patients with an average age of 24 +/- 13 years (range: 12-62 years) between 1984 and 1994. The pathologies operated were ostium secundum (62), superior sinus venosus defects (12), low atrial septal defects (2) and ostium primum lesions forming partial atrioventricular canals (4). Mortality rate was nil. The esthetic result was satisfactory overall. The authors suggest that a right antero-lateral thoracotomy provides an esthetic result whilst respecting the essential factor of maximal security.

Right anterolateral thoracotomy for repair of atrial septal defect

BACKGROUND

To procure a cosmetic incision in female patients, we performed operation on atrial septal defects through a right anterolateral thoracotomy.

METHODS

From 1984 to 1994, 80 female patients with a mean age of 24 +/- 13 years (ranging from 12 to 62 years) underwent right anterolateral thoracotomy for atrial septal defect repairs. Defects repaired included 62 ostium secundum, 12 sinus venosus, 2 low septal defect, and 4 ostium primum. The right iliac external artery was systematically used for arterial cannulation, through a cosmetic incision. Repairs were always performed under fibrillation, except in the 4 ostium primum defects, for which cardioplegia was used.

RESULTS

There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach.

CONCLUSIONS

The right thoracotomy incision appears to be a safe and effective alternative to median sternotomy for repair of atrial septal defects.

[Techniques of correction of partial right abnormal pulmonary venous return associated with atrial septal defect]

Many techniques have been described for correcting partial right anomalous pulmonary venous drainage to avoid the possible complications of stenosis of the systemic or pulmonary venous return, residual shunt or arrhythmias. Between 1985 and 1994, 33 patients aged 1 to 69 years underwent repair of this malformation. The anomalous drainage was situated at the cavo-atrial junction or above in 25 cases and to the right atrium in 8 cases. Depending on the level of the drainage of the anomalous pulmonary veins, the size of the superior vena cava, the site of atrial septal defect and the age of the patient, 3 techniques were used: simple tunneling, tunneling with widening of the superior vena cava by a patch, tunneling with section of the superior vena cava and its transposition to the right atrium. There was no hospital mortality. Postoperative echocardiography showed a minimal residual shunt which regressed at the two months control examination. No cases of restriction of the systemic or pulmonary venous return were observed. Six patients developed arrhythmias during the hospital period. At the end of follow-up, all patients were asymptomatic without residual shunts or restriction of venous drainage. Persistent arrhythmias were observed in one case (3%). There were no differences in the results of the three techniques used. By using the most appropriate technique of repair for the anatomical form allows correction of this malformation with the minimal number of postoperative complications.

"Classic" repair of congenitally corrected transposition and ventricular septal defect

BACKGROUND

This study examined the results of "classic" repair of congenitally corrected transposition of the great arteries and ventricular septal defect.

METHODS

From 1974 to 1994, 52 patients underwent a classic complete repair of lesions associated with congenitally corrected transposition. They were divided into two groups: ventricular septal defect plus left ventricular outflow tract obstruction (group I, 37 patients) and isolated ventricular septal defect (group II, 15 patients). Tricuspid plasty or replacement was performed primarily in 1 patient of group I (3%) and in 8 patients of group II (53%).

RESULTS

The overall operative mortality was 15% (8/52 patients), and the incidence of postoperative atrioventricular block was 27% (14/52 patients). Eight patients died secondarily, 5 of heart failure. Survival rates were 83% +/- 6% at 1 year and 55% +/- 14% at 10 years for group I and 86% +/- 9% at 1 year and 71% +/- 12% at 10 years for group II (not significant). Redo tricuspid plasty or replacement was performed in 12 patients.

CONCLUSIONS

Results of classic complete repair of lesions associated with congenitally corrected transposition are not satisfactory in our experience because (1) the operative mortality and the incidences of tricuspid valve replacement and atrioventricular block are high and (2) secondary heart failure is frequent. However, a retrospective review of morphologic findings shows that "anatomic" complete repairs would not have been feasible in 6 of our patients.

[Pulmonary arborization abnormalities in complex forms of pulmonary atresia with ventricular septal defect: unification, unifocalization and complete repair]

The presence of intrapulmonary arborization abnormalities in patients with pulmonary atresia and ventricular septal defect remains a therapeutic challenge. The aim of this study was to assess the value of procedures of pulmonary unifocalization, i.e. pulmonary unification, remodelling of the central pulmonary arteries and creation of an unifocal pulmonary blood supply, thereby resulting in complete repair. From october 1989 to october 1995, 27 unifocalization procedures were performed in 19 patients. The number of pulmonary segments dependant on non-communicating systemico-pulmonary collaterals was 14.7 +/- 5.4 per patient. The number of non-communicating systemico-pulmonary collaterals was 3.4 +/- 1.2 per patient. The Nakata index was 71 +/- 83 mm2/mm2. There were 3 deaths after an unifocalization procedure (mortality rate 15.8%). In 12 patients (63.2% of cases) a pulmonary arterial tree compatible with a complete repair was obtained. Eight complete repairs, with no mortality, following one or several pulmonary unifocalization procedures with a right to left ventricular systolic pressure ratio of 0.61 +/- 0.12 (range 0.4 to 0.75). Pulmonary unifocalization increases the recruitment of pulmonary segments and thereby the possibilities of complete correction in forms of pulmonary atresia with ventricular septal defect and arborization abnormalities of the pulmonary arterial tree.

Surgical treatment of diffuse supravalvular aortic stenosis

Diffuse supravalvular aortic stenosis can be treated by a variety of surgical approaches. In this case of severe diffuse supravalvular aortic stenosis in a child, we used the combination of an apicoaortic conduit followed 6 years later by aortic valve replacement, replacement of the ascending aorta and aortic arch, and an ascending to thoracic descending aorta bypass graft.

Hemodynamics of different degrees of right heart bypass: experimental assessment

BACKGROUND

Although their assessment could be of the utmost importance to determine the surgical treatment for patients with univentricular hearts, differences in ventricular performance between partial and complete right heart bypass remain to be defined.

METHODS

Three different degrees of right heart bypass were investigated in 5 mongrel dogs: (1) superior vena cava to both pulmonary arteries shunt (SCP); (2) inferior vena cava to both pulmonary arteries shunt (ICP); and (3) both venae cavae to both pulmonary arteries shunt (BCP). Hemodynamic studies included evaluation of the cardiac index and left atrial pressure as a function of the degree of right heart bypass.

RESULTS

By maintaining the mean left atrial pressure at 5 mm Hg, cardiac indexes were 1.98 +/- 0.25, 1.67 +/- 0.29, and 1.33 +/- 0.21 L.min-1.m-2 for SCP, ICP, and BCP shunts, respectively (p = 0.001). When keeping the cardiac index constant, mean left atrial pressures were 5.2 +/- 0.8, 5.5 +/- 0.9, and 7 +/- 0.7 mm Hg for SCP, ICP, and BCP shunts, respectively (p = 0.001).

CONCLUSIONS

Increasing degrees of right heart bypass are associated with a significant decrease in ventricular performance in this experimental model.

Bypass graft for complex forms of isthmic aortic coarctation in adults

BACKGROUND

Bypass grafting for complex forms of coarctation has been poorly documented as an alternative to decrease the high complication rate associated with anatomic repair.

METHODS

Between mid-1980 and the end of 1994, 16 patients underwent bypass grafting for complex forms of isthmic aortic coarctation. Age ranged from 11 to 49 years (mean age, 28.4 +/- 13 years). Indications were atypical anatomic forms of coarctation (n = 12) and reoperation after multiple or complicated previous coarctation repair (n = 4). Lateroisthmic bypass grafts were performed in 14 patients and ascending aorta-descending aorta bypass grafts in 2.

RESULTS

There was no hospital mortality. Morbidity consisted of postoperative paradoxical hypertension in 3 patients. There were no spinal cord complications. One death 10 years postoperatively was unrelated to the surgical technique. One patient successfully underwent ascending aorta-descending aorta bypass grafting for a false aneurysm 10 years after lateroisthmic grafting. All patients were asymptomatic and all grafts, patent after a mean follow-up of 5.7 +/- 4 years.

CONCLUSIONS

On the basis of these results, bypass grafting appears to be a safe alternative in this select group of patients. The lateroisthmic bypass graft is the procedure of first choice, and the ascending aorta-descending aorta bypass graft should be reserved for failure of previous lateroisthmic bypass grafting.

Valved conduit bypass for extensively calcified tricuspid valve stenosis

A case of calcified tricuspid valve stenosis resulting from a complication of ventriculoatrial shunt implantation is presented. Tricuspid valve repair or replacement was not possible because of the prohibitive risk of damaging the right atrioventricular junction and conductive pathways. This rare lesion was treated successfully by insertion of an external right atrial-right ventricular valved conduit. The role of echocardiography in the detection of such a lesion is emphasized and the etiologic and therapeutic aspects are discussed.

[Influence of anatomo-pathological involvement of the aorta on results of Bentall's operation]

The results of 51 patients undergoing the Bentall procedure for aneurysmal pathology of the ascending aorta during the last 10 years are analysed with respect to the nature of the pathology of the lesions of the arterial wall. The study population comprised 39 men and 12 women with a mean age of 47 +/- 17 years (range 2-76 years). They were divided into two groups, Group I (n = 38) with degenerative cystic medianecrosis, Group II (n = 13) with atheromatous lesions. The overall results were satisfactory with a hospital mortality of 3.9% and 5 and 10 year survival rates of 94 and 74% respectively. No difference in results was observed with respect to the anatomical site of the aneurysm, the presence of dissection or the technique used for repair. The results in degenerative lesions (Group I) were excellent but the accent should be placed on prevention to reduce the number of patients operated in a context of acute dissection. The presence of atheromatous lesions identifies a high risk group (Group II) due to advanced age, hypertension and associated vascular and coronary lesions. The hospital mortality in this group was 15.4% compared to almost nil when the aneurysmal pathology was due to degenerative lesions of the media. The extramortality of this group is directly related to the presence of atheromatous lesions (mesenteric infarction due to atheromatous embolism) and incites special attention to the mesenteric sphere in the postoperative period. The preoperative work-up should include transoesophageal echocardiography of the thoracic aortic wall, probably the source of the postoperative emboli.

[Cardiac transplantation for old congenital heart diseases after multiple surgery]

Of the 100 consecutive patients undergoing cardiac transplantation between January 1988 and October 1993, 4 patients had terminal cardiac failure related to congenital heart disease after multiple prior palliative procedures (transposition of the great arteries, N = 1, tricuspid atresia, N = 1, single ventricle, N = 2). The prior palliative or curative operations (average 3.75 procedures per patient) modified essentially the systemic venous return and the pulmonary arteries. The technique of "subtotal" cardiac transplantation enabled anatomical reconstruction without prosthetic material in all cases by extensive usage of the donor tissue. There was no hospital mortality. There were no specific postoperative complications. The long-term results were comparable to those of the rest of the transplanted population. Patients with congenital heart disease in a terminal condition should be considered as candidates for cardiac transplantation. The difficulties related to anatomical abnormalities caused by prior surgery may be overcome and should not be considered a contra-indication to transplantation, providing pulmonary arterial resistances are taken into consideration.

[Cardiac surgery: predictive mortality index, severity and care of illness. 243 cases]

OBJECTIVES

Medical teams are keenly aware of the need to evaluate health care quality and the cost/benefit ratio. We prospectively applied three proposed indexes, designed for predicting mortality, for evaluating disease gravity, and for evaluating health care in intensive care patients, in two populations of patients undergoing heart surgery.

METHODS

From January to June 1991, 243 patients (mean age 58.1; 55 females, 188 males) underwent coronary bypass surgery (n = 116; mean number of bypasses = 2.94 per patient) or valve replacement (n = 127). The patients were divided into 3 groups of increasing gravity on the basis of the preoperative presentation (Groups 1, 2 and 3 for Parsonnet's index, a specific index for predicting mortality in patients with acquired cardiopathies undergoing heart surgery = 0-9, 10-19 and > 20 respectively). A comparison was then performed for each population (bypass surgery and valve replacement) between the predicted mortality and the APACHE II index of disease gravity and the OMEGA index of intensive care.

RESULTS

Overall mortality was 3.7% (2.85% in the bypass population and 4.72% in the valve population). The specific Parsonnet index (PI) for cardiac surgery gave a good indication of mortality risk (observed deaths 0.7% for PI = Group 1; 2.6% for PI = Group 2; 13.1% for PI = Group 3) and of postoperative morbidity since inotropic support was required in 18, 45 and 59% for PI Groups 1, 2 and 3 respectively. For patients in the PI Group 3, postoperative care in the intensive care unit lasted > 3 days and required ventilatory support for > 24 hours. APACHE II and OMEGA did not contribute to evaluating the Parsonnet index.

CONCLUSION

A high risk population undergoing cardiac surgery can be defined among patients with a Parsonnet index above 20. Under this threshold, the risk of mortality falls to 1.4%.

Molecular cloning and developmental expression of human cardiac troponin T

We have isolated a full-size cDNA coding for cardiac troponin T (cTnT) from a human adult heart library, using a slow skeletal TnT probe. This cDNA detected a 1.2 kb mRNA in fetal and post-natal human heart, the amount of which increased during ontogenic development. Interestingly, a similar transcript was coexpressed in fetal skeletal muscle, together with the 0.9 kb slow skeletal muscle mRNA, and its expression was down-regulated during further development.

Technical modification for anastomosis of low-lying coronary ostia in Bentall procedure

Bentall procedure is not advisable when the origins of the coronary artery ostia cannot reach the composite valve graft at a satisfactory level for direct reimplantation. The other alternatives to coronary artery ostia reimplantation have some disadvantages. A technical modification of the Bentall procedure, successfully used in 3 patients and allowing direct coronary reimplantation without any tension on the suture line, is described.

Ventricular septal defect creation for relief of tunnel subvalvular aortic stenosis

In infants, the management of severe tunnel subvalvular aortic stenosis associated with hypoplastic aortic annulus remains a major surgical challenge. We report a case of such lesion treated by rerouting the systemic blood flow through a created subpulmonary ventricular septal defect toward the right ventricular outflow tract and the pulmonary valve. This technique provided complete relief of the left ventricular outflow tract obstruction without the implantation of a systemic prosthetic valve.

[Criteria for choice of the donor in heart transplantation in adults]

Among 66 consecutive adult heart transplant recipients operated on from January 1988 to October 1991, 11 experimented early graft dysfunction (4 of them died). Mean donor's age was 37.4 +/- 11 years; 9 patients were older than 50 years; 85 percent of donors received dopamine. Were found without any significant influence on early graft function: donor's age, weight mismatch, duration of donor's intensive care, dose of dopamine administered, external cardiac massage and relative hemodynamic instability, and ischemic time. Conversely, a history of chronic alcoholism in the donor is of pejorative significance, which is not without consequences in view of the current scarcity of donors.

Adult heart transplantation: adverse role of chronic alcoholism in donors on early graft function

Because of the increasing shortage of heart donors, selection criteria have been gradually extended. The purpose of this study was to determine the donor-related factors implied in early graft dysfunction and to define new selection criteria. The 70 consecutive adult patients who underwent heart transplantation in our institution between January 1988 and February 1992 were retrospectively studied. Mean donor age was 38 +/- 11 years (10 donors were more than 50 years of age; two donors were more than 60 years of age). Mean ischemic time was 130 +/- 39 minutes. An important proportion of donors (20%) had a history of chronic alcoholism. Thirteen patients experienced immediate graft dysfunction; five of them died within the first operative month. The different parameters studied, which were found to have no significant influence on the early graft function, were the age of the donor, the duration of inotropic support and the dose administered, a relative hemodynamic instability, resuscitation maneuvers, chest trauma, and weight mismatch between donor and recipient. Ischemic time was significantly longer in patients who died of cardiac dysfunction (p < 0.05). Chronic alcoholism in the donor was a very detrimental factor: 54% of patients who had early graft dysfunction versus only 12% of patients who had immediate normal graft function had received a graft from an alcoholic donor (p = 0.003). Excluding such alcoholic donors or reserving them for critically-ill recipients, with an increased risk of early graft dysfunction would be preferable.

Transposition of the great arteries, ventricular septal defect, and pulmonary outflow tract obstruction. Rastelli or Lecompte procedure?

During a 10-year period (1980 to 1990), 62 patients underwent complete repair for transposition of the great arteries, ventricular septal defect, and pulmonary outflow tract obstruction. Twenty-two patients (35%) (mean age 8.1 +/- 7.2 years) underwent the Rastelli operation: The ventricular septal defect was enlarged anteriorly in eight patients, and right ventricular-pulmonary artery continuity was established with an extracardiac valved (9/22) or nonvalved (13/22) conduit. Forty patients (65%) (mean age 3.3 +/- 3.2 years) underwent the Lecompte modifications: The conal septum was extensively excised when present (30/40), anterior translocation of the pulmonary bifurcation was performed in 32 patients, and right ventricular-pulmonary artery continuity was established by direct anastomosis without a prosthetic conduit. There were seven early deaths (11%; 70% confidence limits, 7% to 17%): two after the Rastelli procedure (9%; 70% confidence limits, 3% to 20%) and five after the Lecompte operation (12.5%; 70% confidence limits, 7% to 20%). Four patients were lost to follow-up, yielding a 93% complete follow-up (mean follow-up 55 months). There were two late deaths (one in each group). Actuarial probability of survival (+/- standard error) at 5 years was 83% +/- 9% after the Rastelli operation and 84% +/- 6% after the Lecompte procedure. All long-term survivors (except one in the Rastelli group) were in functional class I. Five patients in the Rastelli group underwent late reoperation for obstruction of the extracardiac conduit (28%; 70% confidence limits, 16% to 42%). Three late reoperations (10%; 70% confidence limits, 4% to 19%) were required after the Lecompte operation (one for residual ventricular septal defect and two for residual pulmonary outflow tract obstruction). At most recent examination, residual pulmonary outflow tract obstruction was present in seven patients of the Rastelli group (39%; 70% confidence limits, 26% to 53%) and in six patients of the Lecompte group (19%; 70% confidence limits, 12% to 29%). The combined likelihood of reoperation for pulmonary outflow tract obstruction and residual pulmonary outflow tract obstruction was significantly higher in the Rastelli group (67% versus 26%; p = 0.005). Both procedures provide satisfactory early and late results. The Lecompte operation allows complete repair in infancy, is feasible in patients with anatomic contraindications to the Rastelli operation, and may reduce the need for reoperation and the prevalence of residual pulmonary outflow tract obstruction.

Surgical management of diffuse subaortic stenosis: an integrated approach

An integrated approach to the surgical management of diffuse subaortic stenosis has been designed to provide adequate relief of left ventricular outflow tract obstruction whatever the anatomical features encountered at operation. This approach was used in 22 patients with tunnel subaortic stenosis (19 patients) or diffuse hypertrophic obstructive cardiomyopathy (3 patients). The obstructive tissue was resected through an aortoseptal approach. In 18 patients, associated hypoplasia of the aortic orifice necessitated aortic valve replacement using the Konno procedure; in 4 patients with a normal-sized aortic orifice, the native aortic valve was preserved. There were two early deaths and one late death (all after a Konno operation). Long-term adequate relief of left ventricular outflow tract obstruction was achieved in all survivors. Operation for diffuse subaortic stenosis should be performed with two main goals: (1) to obtain complete relief of the left ventricular outflow tract obstruction by the appropriate procedure and (2) to preserve the native aortic valve whenever possible, particularly in young patients.

Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors

The contraindication to curative excision of mediastinal and pulmonary cancers because of invasion of the superior vena cava is now challenged by the existence of vascular prostheses that are suitable for venous replacement. Between 1979 and 1990 22 patients underwent resection of lung cancer (n = 6) or malignant mediastinal tumors (n = 16) involving the superior vena cava. Resection was done with concomitant venous reconstruction, and polytetrafluorethylene grafts were used. All bronchogenic carcinomas necessitated right pneumonectomy, whereas the excision of mediastinal tumors had to include pulmonary resections in nine patients (five lobectomies and four sublobar resections) and the right phrenic nerve in 12 patients. Venous reconstruction was performed by interposition of a large polytetrafluoroethylene graft between the proximal and cardiac ends of the superior vena cava (n = 8), or between one (n = 10) or both brachiocephalic veins (n = 4) and the right atrium. One patient died postoperatively (4.5%), and another had mediastinitis that was successfully treated by omentopexy. Chemotherapy was administered preoperatively to five patients and postoperatively to seven patients; radiotherapy was administered to two and 10 patients, respectively. The overall actuarial survival rate is 48% at 5 years, with 11 patients presently alive. The survival rate of patients with mediastinal tumors is 60% at 5 years. Among the patients with lung cancer, two with N1 disease are alive at 16 and 51 months, and one died at 38 months; the two patients with N2 disease died at 6 and 8 months. Only one graft occlusion occurred in the postoperative period; another occurred 14 months after operation and was precipitated by insertion of a central venous catheter. The patency of all remaining grafts was demonstrated after an average time of 23 (1 to 98) months. On the basis of these results, polytetrafluoroethylene graft replacement of the superior vena cava should be part of the planning and execution of radical excision with curative intent of mediastinal and right pulmonary malignant tumors that are not present with other contraindications, such as pleural or distant metastasis and severe systemic disease.

[Cavo-bipulmonary anastomosis. Apropos of 3 cases]

Cavo-bipulmonary anastomosis (CBPA) in an anastomosis between the superior vena cava and the right pulmonary artery in continuity with the left pulmonary artery. This shunt is used in complex cyanotic congenital heart disease with pulmonary stenosis. It is the first stage of a total cavo-pulmonary shunt (TCPS). Thirty patients underwent this procedure at Laënnec Hospital between April 1988 and April 1990. The surgical indications were retained when TCPS appeared to be too risky, mainly because of the associated malformations, the correction of which was performed at the same time. There were to early deaths; one patient was lost to follow-up and 27 patients have been followed up for an average period of 12 +/- 6 months. The surgical result was judged according to the degree of cyanosis; a poor result was defined as systemic saturation of less than 75% and a haematocrit of over 55%. One child died 5 months after surgery; there were 16 good results and 10 poor results. Seven patients were reoperated to carry out the second stage of the TCPS. The average gain in saturation was 9.7% in our series. Analysis of the patients who died or who had poor surgical results showed an anatomic cause in 11 of the 13 cases (pulmonary arteriovenous fistula, stenosis of the branches of the pulmonary artery, regurgitation of an atrioventricular valve) or a physiopathological cause (mean pulmonary artery pressure greater than 20 mmHg, or ventricular failure). The CBPA is a palliative procedure to reduce ventricular load, repair stenosis of the right pulmonary artery and to prepare the patient for a total cavopulmonary shunt.

Pulmonary embolectomy: a 20-year experience at one center

Between 1968 and 1988, 96 consecutive patients with acute massive pulmonary embolism underwent pulmonary embolectomy under cardiopulmonary bypass. The operative mortality rate was 37.5%. We analyzed 12 clinical and hemodynamic variables by univariate and multivariate analyses to assess the predictive factors of postoperative outcome. Multivariate analysis disclosed that cardiac arrest and associated cardiopulmonary disease were independent predictors of operative death. Long-term follow-up (range, 2 to 144 months; mean, 56 months) information was available for 55 of the 60 discharged patients: 6 had died, and 5 complained of persistent mild or severe exertional dyspnea (New York Heart Association class II). These results help assess the preoperative risk in patients undergoing pulmonary embolectomy. They also show that, in the few patients who do not benefit from optimal medical therapy, pulmonary embolectomy remains an acceptable procedure in view of the long-term results.

[Endoluminal occlusion, using a catheter, of patent ductus arteriosus in an adult]

The risk of surgical closure of the ductus arteriosus in the adult is greater than in children. The ductus arteriosus can now be occluded by venous catheterisation using a Rashkind umbrella. This procedure vas performed in a 63 year old woman. The diagnosis was confirmed and the anatomy of the lesion defined by catheterisation with aortography. The patent ductus was then occluded with a balloon catheter to assess the reversibility of the pulmonary hypertension. A 17 mm Rashkind umbrella was then used to completely occlude the ductus. The advantages of the method over surgical closure are: absence of morbidity related to thoracotomy, to general anaesthesia, to blood transfusion and the reduction of hospital stay to 3 days.

Heart transplantation in children: risk factors of early and late mortality

In order to identify predictive risk factors of poor outcome following heart transplantation in children, we performed a retrospective analysis of our pediatric recipient population: 31 children, aged 15 days to 15 years (mean = 5.2 +/- 4.9 years). The preoperative diagnosis was cardiomyopathy in 17 (55%), congenital heart disease in 13 (42%) and end-stage valvular disease in 1 (3%). There were 5 operative deaths: hyperacute rejection (2), low cardiac output syndrome (3); 4 in-hospital deaths: infection (2), multiorgan failure (2) and 4 late deaths: acute rejection (1), chronic rejection (1), lymphoma (1), unknown (1). The actuarial probability of survival (+/- SE) was 62% +/- 10% at 1 year and 53% +/- 12% at 2 years. Univariate analysis was used to evaluate the following risk factors: age, diagnosis, hemodynamic decompensation, previous cardiac surgery, ischemic time of the graft, technique of graft preservation, preoperative pulmonary artery pressure, occurrence of postoperative low cardiac output syndrome (LCOS) with pulmonary hypertension (PHT). The occurrence of early LCOS with PHT significantly increased both early and late mortality (78% early mortality, 100% overall mortality). This syndrome occurred in 9 patients (29%) and was attributed to primary graft failure in 2, increased pulmonary vascular resistances in 6 and multiple factors in 1. Although not significant, two factors may increase early survival: young age (less than or equal to 1 year) at operation and improved technique of graft preservation.

[Coronary artery bypass with bovine internal mammary artery graft]

Ten of 1,025 patients undergoing coronary bypass surgery received one or two bovine internal mammary artery grafts. Surgery consisted in quadruple coronary bypass in 1 case, triple coronary bypass in 3 cases and double coronary bypass in 6 cases using 4 autologous saphenous vein grafts, 6 autologous internal mammary artery grafts and 13 bovine internal mammary artery grafts. It was necessary to use bovine internal mammary artery grafts because of total bilateral venous stripping in 5 patients, diffuse, bilateral varicose veins in 4 patients and because of the insufficient length of the vein in 1 patient. Short and medium-term (12 months) angiographic studies of the bovine grafts showed 5 occluded grafts, 2 proximal graft stenoses, and 1 patient graft up to the time of his death of extracardiac causes, with a maximum follow-up of 13 months. One of these 10 patients died in the early postoperative period of extracardiac causes with a patent bovine coronary graft. Another patient died in the 5th postoperative month during reoperation motivated by occlusion of the two implanted bovine coronary grafts. The other 8 patients are alive and stable from the coronary view point. Bovine internal mammary artery grafts may be used to manage an acute episode of coronary insufficiency by providing the time for the collateral circulation to develop but it does not provide a complete and durable method of revascularisation. Their use should therefore be reserved for exceptional cases.

[Mitral valve replacement in atrioventricular septal defect]

This study reports the cases of 14 patients aged 5 months to 13 years (average: 3.5 years) at the time of the initial repair of an atrioventricular septal defect (AVSD). The AVSD was partial in 5 and complete in the other 9 cases. After failure of the initial mitral valvuloplasty, the patients underwent mitral valve replacement with a prosthesis at the age of 1 to 29 years, after an interval of 0 days to 15 years. A second valvuloplasty had been attempted in 3 cases beforehand. The aim of this paper was to analyse the causes of failure of mitral valvuloplasty and to determine the conditions of mitral valve replacement and the specific complications of this type of surgery. Failure of mitral valvuloplasty was related to complex valvular malformations (5 cases), technically inadequate valvuloplasty procedures (4 cases), deterioration of an initially satisfactory valvuloplasty (5 cases). Four bioprostheses were implanted (repeat valvular replacement was necessary in 3 patients). Early mortality was 28% (4 patients). The postoperative complications specific to this condition were: immediate atrioventricular block (8 cases) but only 1 persistant complete atrioventricular block; traumatic fistula between the left ventricle and right atrium (4 cases); moderate stenosis of the left ventricular outflow tract (4 cases). There was one late death (due to isolated cardiac arrhythmia).(ABSTRACT TRUNCATED AT 250 WORDS)

[Tumors of the heart in newborn infants and infants. Apropos of 5 cases]

Between February 1985 and March 1987, 5 children underwent resection of primary cardiac neoplasms, 3 of them in the first days of life and 2 before the age of 6 months. Routine echocardiographic follow-up of pregnancies allowed detection of cardiac tumors in 2 foetuses 30 and 36 weeks old. In 3 children the diagnosis was suspected by the discovery of cardiac murmur or congestive heart failure. The first case was a hemangioma, originating from outside the left ventricular wall, and was resected without cardiopulmonary bypass (CPBP). The other case was a pseudomyxoma, spreading extensively in to the right atrium. The third case was a rhabdomyoma arising from the pulmonary infundibulum with clinical manifestations of tuberous sclerosis. The last two patients had intraseptal lesions, just above the aortic valve; complete resection was therefore impossible, particularly in one patient with multiple tumors. There was one death related to congestive heart failure. The remaining four survivors were followed up for an average of 18.4 months (+/- 12.9) and all were in functional class I. Echocardiographic follow-up showed evidence of a residual subaortic lesion in one asymptomatic patient.

Modified Blalock-Taussig shunts: results in infants less than 3 months of age

The optimal procedure for shunting palliation in cyanotic infants remains to be determined. Sixty-two infants less than 3 months of age underwent 63 modified Blalock-Taussig shunts. Their age range at operation was 1 to 84 days (mean, 16 +/- 20 days). Shunts were constructed using 5-mm polytetrafluorethylene tubes in 20 patients and 4-mm polytetrafluoroethylene grafts in 43 patients. There were 13 early deaths (21%; CL, 15% to 27%) of which three deaths (5%; confidence limits, 2% to 9%) were shunt related. The survivors were followed up from 6 to 53 months (mean, 29 +/- 12.5 months). Shunt failure (occlusion, inadequate palliation) occurred in 27 patients. The overall probability rate of adequate shunt function was 58% +/- 8% at 2 years. Univariate and multivariate analyses showed that the size of the graft was a risk factor of shunt failure. Severe distortion of the pulmonary arterial branch was noted in 12 patients. The inferences are: (1) modified Blalock-Taussig shunts provide satisfactory early palliation but late shunt failure is frequent; (2) similar results should be obtained with other shunting procedures; and (3) the optimal procedure should be selected for each cyanotic infant on an individual basis.

Intrauterine versus postnatal repair of created pulmonary artery stenosis in the lamb. Morphologic comparison

Experimental lamb models were used for intrauterine creation of pulmonary artery stenosis and later intrauterine repair or postnatal repair. Intrauterine creation of pulmonary artery stenosis was performed in 23 fetal lambs at 90 +/- 1 days of gestation. Eight lambs underwent intrauterine repair of pulmonary artery stenosis at 135 +/- 1 days of gestation and were studied 110 +/- 13 days after repair. Seven lambs underwent postnatal repair at 57 +/- 9 days after birth and were studied 162 +/- 32 days after repair. Eight fetal lambs with unrepaired pulmonary artery stenosis were studied 89 +/- 18 days after birth. All study lambs were compared with normal control lambs. The systolic right ventricular pressure was significantly higher after unrepaired stenosis (78.6 +/- 6.8 mm Hg) than in other lambs, but there was no statistically significant difference after intrauterine repair (23.3 +/- 2.9 mm Hg), postnatal repair (25.9 +/- 3.4 mm Hg), and normal lambs (21.6 +/- 1.1 mm Hg). The systolic pulmonary artery pressure was also not statistically different in these three groups. The weight measurements were age-adjusted for comparison of postnatal and intrauterine repair with normal lambs. The adjusted heart weights were similar in the three groups. The comparison of the adjusted heart weight/adjusted body weight ratio (10(-3) showed a significantly higher ratio in postnatal repair (7.4 +/- 0.1) than in intrauterine repair (6.1 +/- 0.1). The adjusted right ventricular weight/adjusted left ventricular weight ratio was significantly higher in the postnatal repair group (0.71 +/- 0.01) than in both the intrauterine repair group (0.59 +/- 0.01) and normal lambs (0.59 +/- 0.01). The transverse myocyte diameter was not statistically different in all groups of animals and there were no ultrastructural changes even when the pulmonary stenosis was unrepaired. We conclude that intrauterine repair was more satisfactory than postnatal repair in terms of age-adjusted heart weight results, but we did not find any advantages of intrauterine repair in terms of histologic and ultrastructural changes.

[Results of the surgical treatment of tetralogy of Fallot before 6 months of age. A consecutive series of 62 cases with 49 complete repairs]

From January 1980 to July 1988, 62 infants aged under 6 months with an uncomplicated Tetralogy of Fallot (single ventricular septal defect, normal coronary arteries, no localised pulmonary artery branch stenosis) underwent 64 surgical procedures. The indications for surgery were increasing cyanosis and/or anoxic spells. Fourteen systemic-pulmonary shunts (21.5%), 49 complete repairs (75.4%) and one enlargement of the right ventricular outflow tract and of the main pulmonary artery without closure of the ventricular septal defect, were performed. The results of palliative shunts are preoccupying: cumulative mortality of 36 per cent; high rate of early reoperation for complete repair: 14 per cent. Complete repair was associated with an operative mortality of 14 per cent. Only one child had to be reoperated. There was no late death after complete repair compared with 2 late deaths after shunt. Ultimate results of complete repairs are good. Some risk factors were statistically significantly associated with complete repair: age (2.5 months or less), weight (4,500 g or less), measurements of the pulmonary arteries estimated by the diameter of the right pulmonary artery (5 mm or less). Conversely there was no death in the subgroup of 31 infants aged more than 2.5 months without major pulmonary hypoplasia (diameter of the right pulmonary artery over 3.5 mm). One-stage complete repair give the best short and medium-term surgical results in treatment of uncomplicated Tetralogy of Fallot in infants, irrespective of age and weight providing they have no diminutive pulmonary arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary repair of tetralogy of Fallot in infancy

From June 1983 to April 1988, 100 consecutive infants with symptomatic tetralogy of Fallot (without pulmonary atresia) were operated on. Ages ranged from 0.5 to 12 months (mean 7.3 +/- 3.7). Twenty patients were 0.5 to 3 months, 21 were 3 to 6 months, and 59 were 6 to 12 months of age. Mean weight was 6.5 kg +/- 1.7. Seventy patients received a transannular patch. The hospital mortality rate was 3% and there were no late deaths. Cumulative follow-up was 180 patient-years. Causes of death included hypoplastic pulmonary arteries (4 and 5 months old) and right ventricular failure (4 months old). The most important factors influencing right ventricular outflow tract reconstruction were neither weight (p = 0.90) nor age (p = 0.05) but rather were the ratio between weight and pulmonary arterial outflow tract diameter (p = 0.0005) and the ratio between body surface area and pulmonary arterial outflow tract diameter (p less than 0.0001). The last 48 patients were operated on with no deaths. During this period, operative management differed essentially in myocardial protection with blood cardioplegia. The predicted 30-day survivorship after repair was 90% to 99% (95% confidence limits). No ventricular arrhythmias have been detected after repair (mean follow-up 22.2 months). Mean right ventricular/left ventricular end-diastolic dimension ratio was (0.53 +/- 0.10 with M-mode echocardiography. These early results encourage us to proceed with primary repair of infants with symptomatic tetralogy of Fallot thanks to improved surgical management and enhanced myocardial protection.

[Atresia of the left coronary ostium. Repair in a 2-month-old infant]

A case of atresia of the left coronary ostium revealed by neonatal heart failure is reported. The initial diagnosis was anomalous origin of the left coronary artery from the pulmonary artery. At surgery performed in this 6-week old infant the diagnosis was amended and the malformation was repaired. Soon after the operation the child rapidly developed hypertrophic "myocardiopathy" of the left ventricle. Seven and a half months later, he is asymptomatic and the echocardiographic parameters of left ventricular systolic function are gradually returning to normality. Atresia of the left coronary ostium is an exceptional anomaly which must be considered, together with the other anomalous origins of the left coronary artery, when confronted with a case of severe heart failure caused by coronary ischaemia during the first months of life. The diagnosis rests on opacification of the coronary network during cardiac catheterization. Coronary "revascularization" may be performed either by aortocoronary bypass or by anatomical repair of the malformation.

Heart- and heart-lung transplantation in children

Since January 1987, 16 prepubertal children have undergone heart (13) or heart-lung (3) transplantation. Immunosuppression included cyclosporine and azathioprine and excluded steroids except in case of rejection. The indications for heart transplantation were hypoplastic left heart syndrome (4 infants, mean age = 2 months), congenital heart disease (4 patients, mean age = 5.7 years) and cardiomyopathy (5 patients, mean age = 2.8 years). There were 4 early deaths (acute graft failure in 2, pulmonary hypertension in 1, infection in 1) and 1 late death (heart failure at 3 months). The 8 survivors had a mean follow-up of 12 months (range 1-19 months). Late complications were minimal. There were 4 episodes of rejection in 2 patients. There was no infection, normal somatic growth and no systemic hypertension. Renal function remained within normal limits although mild-to-moderate tubulointerstitial lesions were found in 4 renal biopsies. Three children (9-11 years old) underwent heart-lung transplantation. The early postoperative course was difficult with 6 episodes of rejection and 5 infections. One patient died at 3 months from infectious complications. One child has a complete rehabilitation 8 months posttransplantation. The last patient is clinically well at 7 months but has a residual tracheal stenosis. The long-term fate of these children, and particularly the long-term effects of cyclosporine therapy are unknown. Heart and heart-lung transplantation remain under investigation but may be reasonable approaches for infants and children with end-stage cardiac and/or pulmonary disease.

[Hancock pericardial prosthesis. Intrinsic dysfunctions]

The frequency of primary dysfunction of 432 Hancock pericardial bioprosthesis was evaluated during a mean follow-up period of 53.1 months per patient. This frequency was 3.20% valve-year in mitral valve prosthesis and 0.92% valve-year in aortic valve prosthesis. Only one case of calcification was noted. Dysfunction was usually due to tearing of one or several pericardial cusps (25 cases), occasionally to tissue retraction (4 cases). Pathological examination of the explanted valves showed fibrin formation followed by organization into fibrous tissue in the host, retracting or fragilizing the pericardial valvular tissue. A preliminary study of the same group had led to discontinuation of Hancock prosthesis. The long follow-up period makes it possible to compare the results obtained with those of pericardial prosthesis of the same generation, to stress the need for echocardiographic monitoring of the implanted valves and to hope that new techniques of pericardial valve fitting will improve the mechanical reliability of prosthesis which, from the point of view of thrombogenesis and haemodynamics, have unquestionable advantages.

Anomalous left coronary artery arising from the pulmonary artery in infancy: is early operation better?

From January 1975 to January 1987, 21 consecutive infants aged less than six months (mean (SD) 2.6 (1.2] were admitted with anomalous origin of the left coronary artery from the pulmonary artery. In the first 12 patients, who were seen up to 1982, operation was performed after the age of one year (mean (SD) 29 (29) months) (group 1). The next nine infants, seen from 1983 to 1987, had their operations within a few weeks of the onset of symptoms (mean (SD) age 4.8 (1.4) months) (group 2). In group 2 the left coronary artery was relocated into the aorta, whereas in group 1 there was additional resection of the left ventricular wall or mitral valvoplasty or both. At presentation there were no differences in age, clinical condition, heart enlargement, and echocardiographic left ventricular dysfunction between groups 1 and 2. Seven of the 12 patients in group 1 died, five while they were awaiting operation (three died suddenly at home) and two at operation. The five survivors are doing well 6.4 (3.1) years after operation with normal left ventricular function which improved slowly over several months after operation. Two of the nine patients in group 2 died; both deaths occurred at or soon after operation. The seven survivors are doing well 1.8 (0.9) years after operation. In three, left ventricular function recovered within three weeks; and there was even partial or total regression of the Q waves in the supposedly necrotic areas. In the remaining four the pattern of improvement in left ventricular function resembled that in group 1. Operation should be undertaken early in infants with anomalous left coronary artery arising from the pulmonary artery because the procedure is relatively safe, prevents a high natural mortality, and offers a better chance of a faster recovery of left ventricular function.

Aortic coarctation with hypoplastic aortic arch. Results of extended end-to-end aortic arch anastomosis

Between 1980 and 1986, 80 infants (less than or equal to 3 months old) with symptomatic aortic coarctation and associated severe tubular hypoplasia of the transverse aortic arch underwent surgical treatment. Extended end-to-end aortic arch anastomosis was used in an attempt to correct both the isthmic stenosis and the hypoplasia of the transverse arch. After complete excision of the coarctation tissue, a long incision was made in the inferior aspect of the aortic arch, which was then anastomosed to the obliquely trimmed distal aorta. Pure coarctation was present in 17 patients (group I); 24 infants had an additional ventricular septal defect (group II), and 39 patients had associated complex heart disease (group III). The overall early mortality rate was 26% (confidence limits 21% to 32%) (18% in group I, 17% in group II, and 36% in group III). The early risk declined with time and was 18% (confidence limits 12% to 26%) for the last 2 years (seven deaths in 39 patients). Follow-up was 100% for a mean of 19 months. Actuarial survival rate at 3 years was 82% for group I, 78% for group II, and 32% for group III. Recurrent coarctation (gradient greater than or equal to 20 mm Hg) occurred in six operative survivors (10%, confidence limits 6% to 16%) and necessitated reoperation in three. Freedom from recoarctation at 4 years was 88%. Because extended end-to-end aortic arch anastomosis provides adequate correction of the aortic obstruction and entails a low risk of restenosis, it is our procedure of choice in infants with coarctation and severe hypoplasia of the aortic arch.