[Congenital heart defects with tracheal and bronchial stenoses: surgical treatment with extracorporeal circulation]

We present our experience with the surgical management of congenital cardiac defects when tracheal or bronchial stenosis is present. Concerning pulmonary artery sling, we think that it is necessary to correct the cardiac malformation and trachea-bronchial stenosis at the same time. After surgical correction, if the patient cannot be weaned from mechanical ventilation (10-15 days), it is mandatory to rule out the presence of tracheo-bronchial tree lesions in order to perform surgery without delay. The operation should be performed under cardiopulmonary by-pass at the same time as the surgical correction of the cardiac malformation. We believe that the best technique for localized obstruction is resection of the stenotic area, followed by termino-terminal anastomosis (one case in our patient group). However, when the length of the obstruction is longer, our election is to enlarge the stenotic area with pre-molded cartilage (four cases).

[The treatment of the tracheobronchial stenosis by extracorporeal circulation]

Six children with tracheobronchial stenosis secondary to cardiovascular ring were operated with extracorporeal surgery. Three of them with pulmonary sling had a tracheobroncoplasty with costal cartilage, one with xiphoides appendix and another with pericardio. One girl 2 years old was operated resecting three tracheal rings and anastomosis end to end. The child that was operated with pericardio died with infection and sepsis three months after the operation. The other five are well five, four and two years after plasty.

[Surgical treatment of Fallot's tetralogy with hyperplasia or agenesis of the conal septum]

INTRODUCTION

The clinical evolution, anatomosurgical aspects, and postoperative evolution of a specific group of Fallot's tetralogy with hipoplasic or agenesic of the conal septum (representing a 7% of our Fallot's tetralogy cases) is presented.

METHODS

A total of 41 patients surgically corrected in our Service between February 1973 and December 1995 has been retrospectively studied. Ages ranged between 13 months and 13 year. Clinically all cases developed moderate or severe hypoxemia. In 43.9% of cases it was necessary to perform a palliative surgery at an age between 15 days and 4 years.

RESULTS

There was no hypoxemics spells. In the ECG we have found a QS in the aVR in 40% of cases. There was 7 deaths (17% of mortality rate). Four cases required reoperation. The clinical evolution, ECG, EKO, and hemodynamics findings are commented.

CONCLUSIONS

In this type of Fallot's tetralogy, specifically in those cases with a pulmonary artery ring of normal size, it is necessary to have a good preoperative diagnoses in order to perform a longitudinal ventriculotomy with right ventricular outflow tract enlargement. Also, it is important to be meticulous with the stitches in the closure of the ventricular septal defect with a patch in order to avoid the potential lesion of the aortic valve.

[Tetralogy of Fallot: total repair in the first year of life]

OBJECTIVE

Since the first correction of tetralogy of Fallot in 1955, the optimal age for total correction has been in continuous debate and remains a controversy.

PATIENTS AND METHODS

Here we present our experience with 44 patients with tetralogy of Fallot which was surgically corrected in the first year of life. In 37 cases total correction was achieved with the first operation. In the remaining 7 cases previous palliative surgery was performed. Details of surgical decision making, hemodynamic data and surgical procedure are described in detail.

RESULTS

There were 8 deaths (18.1% mortality rate). There were no deaths in the last 24 consecutive cases. Complications, need for reoperation and long-term follow-up of the 36 survivors are discussed.

CONCLUSIONS

After a detailed analysis of both results and follow-up, our surgical criteria is described, with the intention of performing palliative surgery in only a restricted number of cases of tetralogy of Fallot where the anatomy is unfavorable for total correction with a single intervention.

[Technical innovations in total extracardiac cavo-pulmonary connection in Fontan-type operation. An experimental study and first 2 operated clinical cases with excellent immediate results]

INTRODUCTION

Three technical modalities are presented with total extracardiac cava-pulmonary connection, with bidirectional Glenn, as coverage of this type of extracardiac connection for all types of cardiopathies suitable for Fontan type correction.

METHODS

Development of an experimental protocol for the perfecting of the three technical variants tested: "Tunnel from inferior cava to right pulmonary artery by means of right atrial wall and vascularized pericardium", "Tunnel from inferior cava to the trunk of the pulmonary artery with or without pulmonary valve with P.T.F.E. hemiconduit" and "Tunnel from inferior cava to the pulmonary graft as a artery with P.T.F.E. graft as a hemiconduit".

RESULTS

The first two clinical cases operated on using the third technical variant are presented. Both cases evolved during immediate postoperative period with a very favourable hemodynamic response, with pressures at conduit and P.A. level of 10-12 mmHg, normal cardiac output and sinus rhythm. The later clinical evolution in both cases is very satisfactory. The five cases published by Laschinger with this same technique showed a very favourable evolution during the immediate postoperative period and later.

CONCLUSION

The technical facility of its performance, the slight traumatism of this surgery, the important technical advantages with respect to the total cava-pulmonary intraauricular connection and the good initial hemodynamic results make us consider the total extracardiac cava-pulmonary connection as an important contribution in this type of surgery. It is clear that time and greater clinical experience with this type of connection is required for the correct evaluation of all and each one of the numerous theoretical advantages shown and in order to detect possible disadvantages.

[Vascular rings of aortic origin: the surgical experience in 43 cases]

INTRODUCTION AND OBJECTIVES

Aortic vascular rings can produce compression and obstruction in the airway and/or esophagus early surgical treatment in the first days or months of life. The reported incidence range between 0.3-0.6% with an 0.5% in our series. The following is a retrospective analysis with clinical, radiological and angiocardiographic study of the patients operated on in our service with the diagnosis of aortic vascular ring focused on the surgical results.

METHODS

A total of 43 children with ages ranging between 21 days and 10 years (mean age 17 months) underwent surgical treatment for aortic vascular ring, during the period between january 68 and january 94. Clinically, 74% had stridor, 27.4% gastroesophageal reflux, 34% pulmonary infection, 14% respiratory insufficiency with mechanical ventilation, 12% heart failure, 9% dysphagia, 2% crisis of bronchospasm and 2% tracheomalacia that require tracheotomy prior to surgical correction. Diagnosis was made by esophagogram 86% of the cases. Aortography as the late diagnosis method or for election to surgical approach was made in 85% of the cases. In 42% were double aortic arch, 32% anomalous right subclavian artery and 25% right aortic arch with left ductal ligamentum.

RESULTS

Reoperation was performed in 4 cases. Two early (1 case for hemorrhage, 1 case for phrenic paralysis requiring diaphragmatic plication), and two late reoperations (1 aortopexy, 1 tracheal termino-terminal anastomosis) at 2 and 13 months respectively. Hospital mortality was 1 case (2%) with 1 additional late death (2%). Follow-up was performed in the remaining 39 cases with a mean of 11 years (ranging between 1 and 25 years. Thirty seven of 41 patients alive asymptomatic (90%).

CONCLUSIONS

Due to a low mortality rate (2.3%) not related with the age of the patient at the moment of the surgical procedure based in our experience, we conclude that it is very important to perform both, early diagnosis and surgical treatment in order to avoid the potential residual lesion on the airway caused by tracheo-broncho malacia, in order to avoid the deleterious effect on the results both at early and later follow-up.

[Long-term results of surgical management of congenital aortic stenosis]

This retrospective study and review of the literature was undertaken to assess the long term results of valvotomy in congenital aortic stenosis (AS). One hundred and seven patients, aged between 14 days and 15 years (mean: 6.2 years), were operated on between 1966 and 1989. Thirty-three cases had valvular AS, 48 discrete subvalvular AS, 10 supravalvular AS and 16 combined AS. Thirty-three patients had associated cardiac anomalies. The surgical mortality was 6.5% (3.5% in children over 2 years of age). Three patients were lost. Ninety-seven patients had a follow-up period between 6 months and 16 years (mean: 5.4 years) with an actuarial survival of 95% at the age of 15 years. There were adverse events in 39 patients: AS, aortic regurgitation, bacterial endocarditis, third-degree heart block. Thirteen patients required re-operation and 4 balloon valvuloplasty; the late mortality was 5%. We conclude that this surgery has a low surgical mortality, but must be considered as palliative in most cases.

[Left subclavian-pulmonary trunk fistula with a vascular prosthesis as palliative treatment in Fallot conditions]

In this paper, our experience with a new systemic-to-pulmonary artery shunt: subclavian-pulmonary artery trunk shunt with PTFE (central shunt) is presented. Between November 1985 and March 1990 this central shunt was employed in 8 children with ages ranged between 4 days and 3 years, and weights between 2 and 12 kg. Diagnosis were Fallot's tetralogy in three; pulmonary atresia with intact septum in three; complete AV canal and Fallot's tetralogy in one, and univentricular heart and pulmonary atresia in 1 patient. There were no surgical deaths. Hospital mortality was present in 1 case (AV canal and Fallotś tetralogy) at the moment of reoperation 1 month later. Follow-up ranged between 2 and 46 months. One case, pulmonary atresia with intact septum, has undergone total correction. The remainder 6 cases are in good situation with O2 saturation above 70%. This central shunt has the advantages to provide a bidirectional blood flow to both pulmonary branches avoiding the risk of direct damage in the pulmonary arteries found with the conventional aorto-pulmonary shunts.

[Anatomy and surgical implications of incomplete forms of atrioventricular septal defects]

We present an anatomic intraoperative study of 93 consecutive operated cases with an ostium primum defect. The type of the ostium primum, size of interauricular defect, position of the coronary sinus, tricuspid valve, mitral valve and subvalvular apparatus, are analyzed. Inside the mitral valve apparatus, the size, form, type and number of clefts are described as well as septal valve anomalies. We point out the importance of performing a detailed and fast anatomic study within a surgical protocol to obtain the optimal anatomic correction of the cardiopathy.

[Surgery of symptomatic interauricular communication in the first year of life]

Symptomatic atrial septal defect (ASD) is rare in infancy and even more is symptomatic ASD requiring surgery at that age (13.7% and 3.7% respectively in our series). Our experience on surgery for symptomatic ASD in infancy with 6 cases out of 161 consecutive ASD surgically corrected during an experience of 17 years is presented. Ages ranged between 5 and 11 months (9.5 +/- 2.5 months) and weight between 4 and 6.400 kg (5.3 +/- 0.8 kg). In all cardiomegally was present with cardiothoracic ratio between 0.6 and 0.7 in 4 and over 0.7 in the remainder two cases. Isolated ASD was present in 3 cases, associated partial anomalous pulmonary venous drainage ein 3 and additional ventricular septal defect in one. Mortality was present in one case due to hypoplasia of the left ventricular cavity. Follow up ranged between 30 and 156 months with a cumulative follow up of 442 months, mean 88.4 +/- 50.8 months/patient. Clinically all are asymptomatic without medication. Clinical and hemodynamic data file, surgery complications and possible risk factors for development symptomatology in the ASD in infancy are widely commented.

[Vascular rings]

30 patients with vascular rings operated between 1966 and 1985 are described. Age, sex and symptomatology are studied. Nineteen had a double aortic arch, 9 cases had anomalous subclavian artery, 6 patients had right aortic arch with ductus or ligamentum arteriosum, 1 patient had pulmonary artery sling and 1 patient had right aortic arch and ductus arteriosus and anomalous subclavian artery. Associated congenital malformations were seen in 8 (27%) patients. Basic surgical procedures include a left thoracotomy, identification of the aortic arch anatomy and division of anomalous ring. The aortic arch malformations have a good prognosis with early diagnosis ans surgical treatment.

[Cardiac surgery in the neonatal period. 17 years' experience]

Although the mortality rate with cardiac surgery in the neonatal period has decreased in the last years, due to the development of the neonatal intensive care units and the routinary use of prostaglandins, it remains higher than in whatever other ages. Since october 1967 to may 1984, 321 consecutive cases were operated on. Ages ranged between 12 hours and 31 days. In 301 cases closed cardiac surgery was performed, and cardiopulmonary bypass was employed in the remaining 20 cases. Taking off the mortality rate by periods of time, first (1968-1974), second (1975-1979), third (1980-1984), and by surgical groups (closed and open heart surgery) we found a statistically significant decrease in the mortality rate comparing the results over the time with the current period (1980-1984) having 114 cases of closed surgery and a 27% of mortality rate and 11 cases of open heart surgery with 2 deaths, 18% of mortality rate. Follow up was possible in 184 out of the 203 survivors, representing a 91% with a range between 3 month a 15 years. Medical and surgical management and long term follow up is described.

A new surgical technique for orthoterminal correction: experimental development

A new technique is presented for surgical correction of tricuspid atresia, univentricular heart, pulmonary atresia with intact ventricular septum and hypoplastic ventricle, and hypoplastic left heart syndrome. The procedure consists of an angled right atriotomy, creation of an interatrial septal defect and a right neoatrium that is anastomosed to the pulmonary artery, and creation of a left neoatrium communicating with the left atrium through the interatrial septal defect. The technique was evaluated in 28 mongrel dogs. In 15 of these experimental procedures, the objective was to acquire skill in performing the technique. In the remaining 13, the procedure was executed with cardiopulmonary bypass. Hemodynamic studies were made at 30, 60, 120, and 180 minutes after operation. The results and advantages of the procedure are discussed. We consider it feasible for clinical application.

[Surgical treatment of congenital cardiopathies in the 1st year of life: experience in 893 treated cases]

We present a study of 893 infants treated surgically, of ages from 30 hours to 12 months old, with a global mortality rate of 23.1%. In 37.6% of the cases, a total correction of cardiopathy was reached, using closed techniques in 25.9% and open-heart surgery in 11.7%. Palliative techniques wer chosen in 62.3% of the patients. The highest mortality corresponds to those patients under one month old (40%), decreasing to 14% in the 7-12 month old group. Surgical indications and techniques used are commented in each group of cardiopathies, making special reference to post surgical care.

[Aortic coarctation in childhood. Surgical experience in 120 cases]

112 cases of coarctation of the aorta and 8 cases of tubular hypoplasia of the aortic isthmus operated upon in the Children's Hospital "La Paz" from Madrid, are reviewed. All children were under 7 years of age. 64.2% of the cases of aortic coarctation were in the first year of life, 47.3% of them had associated lesions, being the most frequently present persistent ductus arteriosus and ventricular septal defect. Hospital mortality was 14.2%, what is considered as very acceptable. All the children operated upon for the correction of tubular hypoplasia of the aortic isthmus were in the first year of age. 75% of them had associated ductus arteriosus and ventricular septal defect, being hospital mortality of 62.5%. Most frequent postoperative complications and cause of death were due to broncopulmonary disorders secondary to the existence of a previous pulmonary hypertension.

[Pulmonary atresia with intact interventricular septum. Study of 28 cases]

The present report is based on the study of 28 cases of pulmonary atresia with intact ventricular septum, all of them necropsically and/or angiographically verified. A microscopic study of the wall of both ventricles was performed in the 20 necropsy cases. The size of the right ventricular cavity, a fact of great surgical significance, did not correlate with the electrocardiogram and varied from diminute to very large. In two cases necropsically proved there was as associated atresia of the infundibular, in one of them existing additionally an Ebstein malformation of the tricuspid valve, which could be angiocardiographically diagnosed. The surgical mortality, in our hands, is 64.3%. All survivors have a small right ventricle.

[Surgical management of Fallot's syndrome in young children (author's transl)]

The authors report the results in the surgical management of 232 children under two years of age suffering from syndrome of Fallot. Surgical techniques are described, and Waterston's right pulmonary artery to ascending aorta anastomosis advised. The problem of right lung overflow after this operation, its causes and prevention are commented upon. Analysis is made of indications for complete correction under extracorporeal circulation with and without deep hypothermia.