Anomalous left coronary artery from pulmonary artery: autogenous arterial tube for aortic implantation

Many surgical procedures for the implantation of anomalous left coronary artery from pulmonary artery have been described. A dual coronary system offers most benefit and is most advantageous for the patient. Two autogenous flaps of the pulmonary trunk and ascending aorta, without mobilizing the coronary artery, were created for use in this procedure. This technique was successfully used in an 8 month-old patient with severe myocardial dysfunction and moderate mitral regurgitation. This procedure allows 2 coronary systems to be repaired for any anatomic change of the left coronary artery without the use of prosthetic material. There were no technical complications. During the postoperative course minimal inotropic support was used. The magnetic resonance study, 11 months postoperative, showed wood flow of the left coronary artery and mild mitral regurgitation. The operative technique was simple and its execution easy. The follow-up in the intermediate and late period showed the growth of this endothelized tube.

Assessment of splanchnic perfusion with gastric tonometry in the immediate postoperative period of cardiac surgery in children

OBJECTIVE - A prospective, nonrandomized clinical study to assess splanchnic perfusion based on intramucosal pH in the postoperative period of cardiac surgery and to check the evolution of patients during hospitalization. METHODS - We studied 10 children, during the immediate postoperative period after elective cardiac surgery. Sequential intramucosal pH measurements were taken, without dobutamine (T0) and with 5mcg/kg/min (T1) and 10 (T2) mcg/kg/min. In the pediatric intensive care unit, intramucosal pH measurements were made on admission and 4, 8, 12, and 24 hours thereafter. RESULTS - The patients had an increase in intramucosal pH values with dobutamine 10mcg/kg/min [7.19+/- 0.09 (T0), 7.16+/-0.13(T1), and 7.32+/-0.16(T2)], (p=0.103). During the hospitalization period, the intramucosal pH values were the following: 7.20+/-0.13 (upon admission), 7.27+/-0.16 (after 4 hours), 7.26+/-0.07 (after 8 hours), 7.32+/-0.12 (after 12 hours), and 7.38+/-0.08 (after 24 hours), (p=0.045). No deaths occurred, and none of the patients developed multiple organ and systems dysfunction. CONCLUSION - An increase in and normalization of intramucosal pH was observed after dobutamine use. Measurement of intramucosal pH is a type of monitoring that is easy to perform and free of complications in children during the postoperative period of cardiac surgery.

Conventional and conventional plus modified ultrafiltration during cardiac surgery in high-risk congenital heart disease

BACKGROUND

This prospective nonrandomized study is the critical assessment of conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) techniques and their efficiency in congenital heart disease surgeries. Use of cardiopulmonary bypass (CPB) in children is associated with body water retention as a consequence of prime volume and systemic inflammatory reaction. The CUF during CPB has reduced body water excess and the MUF after CPB, removes inflammatory mediators, improves hemodynamic performance, and decreases transfusion requirements.

METHODS

Forty-one patients, aged 9 to 36 months, submitted to surgical correction for cardiac defects, using CPB, were divided into 2 similar groups: CUF (21 patients) operated between 1996-1997 were ultrafiltered during CPB, and CUF+MUF, (20 patients) operated between 1997-1998 and ultrafiltered during and after CPB. Postoperative duration of ventilator support, pediatric intensive care unit stay (PICU), hospital stay of the groups with and without preoperative pulmonary hypertension (PH), as well as transfusion requirement, hematocrit and platelet counts were compared.

RESULTS

There were no technical complications and a significant ultrafiltrate in the CUF+MUF group was observed as compared to the CUF group. No significant differences were observed between the CUF and CUF+MUF groups regarding ventilatory support, PICU stay and hospital stay. Requirements for red cell transfusion, Ht and platelet counts were not statistically different.

CONCLUSIONS

CUF and CUF+MUF were safe and efficient methods for patient stabilization independent of diagnosis and complexity of surgery. Future clinical evaluation should address a larger population of patients to research the different variables.

Cytokines and pediatric open heart surgery with cardiopulmonary bypass

It is well known that, subsequent to cardiopulmonary bypass, and particularly in children, an inflammatory response within the body can often result in a characteristic syndrome. Recently, it has been suggested that this phenomenon is due to a systemic inflammatory response, with significant involvement of cytokines. With this in mind, we investigated the behavior of tumour necrosis factor-alpha and interleukin-6 during the operative and in the immediate postoperative period in a group of children submitted to open heart surgery. We investigated any possible relation between the levels of these cytokines in the serum and the length of cardiopulmonary bypass, with the serum levels of lactate, and with the extent of use of inotropic drugs in postoperative period. The cytokines were measured in samples withdrawn after induction of anesthesia, after 10 minutes of cardiopulmonary bypass, after re-establishment of circulation, and then 2 and 24 hours after the end of cardiopulmonary bypass. The levels of tumour necrosis factor-alpha and interleukin-6 increased between the beginning and at two hours of the end of cardiopulmonary bypass. There was no correlation between the levels of these cytokines in the serum and the length of cardiopulmonary bypass, although there was a positive relation between levels of interleukin-6 and lactate in samples withdrawn at two hours of the end of bypass, and the measured levels of the cytokines correlated with the extent of inotropic drugs employed in the postoperative period.

Reconstruction of the pulmonary valve and outflow tract with bicuspid prosthesis in tetralogy of Fallot

BACKGROUND

Right ventricular outflow tract and pulmonary valve implant in patients with tetralogy of Fallot may be required to avoid late postoperative right ventricular impairment. The use of porcine bicuspid prosthesis might be a technical alternative, although comprehensive studies on the long-term use of these prostheses are not available.

METHODS

Sixty-three patients (aged 5 months to 34 years; mean, 6 years) with tetralogy of Fallot and pulmonary hypoplasia underwent surgical repair and enlargement of the right ventricular outflow using preserved porcine pulmonary bicuspid prostheses. Fifty-two patients (82.5%) were followed and underwent clinical evaluation and serial Doppler echocardiography. The first 15 patients (29.4%), with ages ranging from 5 to 16 years (mean, 8.2 years) and postoperative follow-up of 48 to 87 months (mean, 65.1 months) underwent hemodynamic and cineangiographic evaluations.

RESULTS

There were 11 deaths (17.4%) in the early postoperative period. Of the 52 surviving patients (82.5%), 51 (80.9%) were followed for 1 to 87 months (mean, 42.0 months). Four patients (7.6%) had additional treatment. Of the 15 patients (29.1%) undergoing hemodynamic evaluation, 9 (60%), had mild valvular pulmonary insufficiency and 6 (40%) had moderate insufficiency. Only the right ventricle-to-pulmonary artery pressure gradients and the right ventricular ejection fraction showed statistically significant differences between groups. Right ventricular dimension, although increased in all patients, did not show statistically significant differences.

CONCLUSIONS

Right ventricular outflow tract and pulmonary valve repair in patients with tetralogy of Fallot using a bicuspid porcine pulmonary prosthesis is a simple, reliable procedure with good results in postoperative medium term follow-up.

[Anomalous origin of the right pulmonary artery from the ascending aorta (Hemitruncus)]

The origin of the right pulmonary artery from the ascending aorta is a rare cogenital anomaly, with very few reports in the literature. We describe two cases of this rare malformation, one of them, associated with interruption of the aortic arch (type B). In both cases, the diagnosis was made by two-dimensional echocardiography, with angiographic confirmation in one of them. The origin of the right pulmonary artery was close to the aortic valve, anomaly pathogenetically distinct from the type that arises close to the innominate artery.

[Heart surgery in Brazilian Indians]

PURPOSE

Our experience with surgical treatment of heart diseases in Indians living in the Amazon rain forest in primitive stages was reviewed.

METHODS

From 1988 to 1995, 18 patients underwent cardiovascular surgical procedures at the São Paulo Hospital of the Escola Paulista de Medicina. Seven patients had valvar disease, nine congenital heart defects, one submitral aneurysm and one arrhythmia. Thirteen Indians came from tribes of the Amazon rain forest area: three from the Xavante, two from Waiapi, two from Tucano, two from Macuxi, two from Mayoruna, and one of each tribe of Xikrin, Guajajara, Terena, Surui, Galibi, Cinta-Larga and Pataxó.

RESULTS

We performed 22 operations, with two hospital deaths. Follow-up was possible in 87.5% of cases, with one late death. The majority of cases were due to congenital heart defects and in this series it was noted the absence of operations to treat coronary artery disease. The incidence of valve disease was higher in accultured or semi-accultured Indians.

CONCLUSION

The surgical treatment of cardiovascular disease has made possible to the surviving indians to return to and be accepted by their fellow tribesmen.

Anomalous origin of the right coronary artery from the pulmonary artery in association with a ventricular septal defect

Origin of the right coronary artery from the pulmonary artery is a rare lesion occasionally found at angiography or autopsy. We report the rare preoperative diagnosis, in a child, of anomalous origin of the right coronary artery from the pulmonary artery, in association with a ventricular septal defect. The chest radiograph was normal, but auscultation revealed a continuous murmur at the left sternal border and electrocardiography showed right and left ventricular hypertrophy. A transthoracic echocardiogram depicted anomalous origin of the right coronary artery from the pulmonary artery. Color-flow Doppler echocardiography indicated possible right-coronary-artery-to-right-ventricle fistulae. Diagnosis was made by selective left coronary arteriography, which showed retrograde filling of the right coronary artery from collateral vessels. Selective left coronary arteriography depicted intercoronary flow, with no fistulae. Operative repair consisted of moving the proximal right coronary artery from its origin at the pulmonary trunk to the aorta. An associated procedure for correction of the ventricular septal defect was performed. The postoperative cardiac angiogram showed that the ventricular septal defect was closed and that flow through the right coronary artery was normal. Preoperative diagnosis of anomalous origin of the right coronary artery from the pulmonary artery is important, because this condition is surgically correctable.

Transaortic approach has a role in the surgical treatment of ventricular septal defects

A transaortic approach was used for surgical closure of ventricular septal defects (VSDs), sometimes as first choice and otherwise as an alternative approach. This paper presents the experience in a group of 124 patients who underwent VSD closure by a transaortic approach in an 18-year-period, between 1974 and 1992. Patients were divided in three groups: (I) Isolated VSD, 89 patients (mean age 7.6 years); (II) VSD associated with other malformations, 27 patients (mean age 10.8 years); and (III) recurrent VSD, eight patients (mean age 15.6 years). Two deaths occurred in the postoperative period (2/124), one after closure of VSD in a patient with severe pulmonary hypertension; another death was observed after transaortic closure of the VSD as part of the repair of a complex heart malformation. There were no instances of new right bundle branch block (RBBB) in the group operated on for isolated VSDs. Three cases of left bundle branch block (LBBB) (3.4%) occurred in the isolated VSD group. There were no cases of complete aortic valve (AV) block in the whole series and no instances of AV dysfunction. The transaortic approach is an alternative for the surgical treatment of ventricular septal defects. The ease of exposure and closure of defects suggest this technique to be a particularly attractive approach in the treatment of small to moderate-sized VSDs and also in recurrent VSDs.

[Myocardial revascularization without extracorporeal circulation. Surgical results in 1090 patients]

PURPOSE

To report our experience of 12 years of myocardial revascularization without cardiopulmonary bypass (CPB) and to discuss its expanding surgical indications.

METHODS

This technique was employed in 1090 patients, between September/81 and April/93, corresponding to 17.4% of all revascularized patients. Regarding gender, male patients were the majority (73.7%) and ages ranged from 28 to 86 year-old (mean 57). Chronic coronary insufficiency was the main indication (69.4%) and 18.9% of our global experience were operated on during acute ischemia. The average number of grafts per patient was 1.6 and internal mammary artery was utilized in 60.1% of patients. Left anterior descending coronary artery and right coronary artery were the coronary arteries most often treated.

RESULTS

Our hospital mortality rate was 2.5% (28/1090) although it was 7% for patients over 70 years. The most common cause of death was cardiogenic shock after failed angioplasty. Postoperative complications included AMI in 4.8%, arrhythmias in 5.5% and pulmonary in 3.2%. Mean of any type of blood derivate utilization was 0.28 units/patients.

CONCLUSION

Myocardial revascularization without CPB is a valid alternative in a selected cohort of patients and it is performed with low morbidity and mortality. Nowadays it represents an excellent tactical option for high-risk patients and in failed angioplasties.