Neointimal Obstruction of Carpentier-Edwards Valved Conduit in Two Patients with Modified Fontan Procedure

In 2 patients (single ventricle and dextrotransposition of the great arteries with hypoplastic right ventricle) who underwent a modified Fontan procedure, significant disruption of the tricuspid patch developed. The valved conduits remained patent until reoperation at two and six months, respectively.At the time of reclosure of the tricuspid patch, unavoidable manipulation of the conduits from dissection of adhesions led to detachment and collapse of the neointima, thereby producing complete obstruction of the conduit. The problem was detected immediately in the first patient and prompted clearance of the conduit of the collapsed neointima. In the second patient, the diagnosis was made six months later and conduit replacement was required. Both patients did well following reoperation.We suggest that in patients with woven valved conduits inserted for a Fontan procedure who require reoperation and extensive manipulation of the conduit, removal of the neointima or conduit replacement should be considered.     

改良Fontan手术的疗效分析

目的探讨改良Fontan手术后的早期效果[以住院期间或1个月(住院超过1个月者)统计]及远期效果(以手术后5年统计),为其临床应用提供理论依据.方法1990年9月至1996年5月行改良Fontan手术病儿52例,年龄2.5～16岁,随访49例(93%),平均随访时间(5.2±0.4)年.分析包括死亡、手术失败、心律失常、血栓形成、胸腔渗液等参数.结果3例早期死亡,4例远期死亡;1例早期再次手术,1例远期再次手术.术后早期生存率94%,成功率(不包括术后疗效不佳且危及生命,需二次手术者)92%,室上性心动过速6%,心动过缓10%,胸腔渗液38%;术后远期生存率87%,成功率83%,室上性心动过速10%,心动过缓13%,胸水渗出6%.结论在复杂先天性心脏病的治疗中,即使应用于不同的解剖诊断病人,改良Fontan手术仍有良好的术后早期及远期效果.     

Long-Term Results of the Modified Thal Procedure in Patients with Chagasic Megaesophagus

Background

Chagas disease is a serious public health issue in South and Central America due to its high prevalence, morbidity, and mortality. The esophageal form of the disease leads to achalasia and consequent megaesophagus. In advanced or recurrent cases of megaesophagus, there is no consensus for which of three established techniques—the Serra-Dória procedure, subtotal esophagectomy, or Modified Thal cardioplasty—is best. Very few studies have investigated the average efficacy and long-term outcomes of the Thal procedure. The present study sought to bridge this gap.

Methods

The Modified Thal procedure was performed in 29 patients at Hospital Universitário de Brasília between 1998 and 2008. All underwent clinical and nutritional evaluation, upper gastrointestinal endoscopy (UDE) with chromoscopy, esophageal manometry, and 24-h pH monitoring.

Results

Overall, 86 % experienced resolution of all symptoms after surgery. Most patients were classified as Visick grade I, II, or III. The average body mass index was 22.7 kg/m². UDE showed normal mucosa in 76 % of patients, and 11 % had unstained areas on chromoscopy. Esophageal manometry demonstrated incomplete lower esophageal sphincter (LES) relaxation in 50 % of patients, complete LES relaxation in 21 %, and no LES relaxation in 29 %. All showed complete relaxation of the upper esophageal sphincter. On 24-h pH monitoring, reflux was pathological in 50 % of patients.

Conclusions

Overall, the modified Thal procedure improved symptoms—namely, dysphagia to liquids with resulting weight loss and malnutrition—in patients with megaesophagus. No correlations were found between clinical complaints, endoscopic findings, and degree of manometric abnormality in these patients.     

Reduction in Triiodothyronine Levels Following Modified Fontan Procedure

Diminished cardiac function is a common manifestation following the modified Fontan procedure. Since thyroid hormone has important effects on cardiovascular function, the present study was undertaken to evaluate changes in thyroid hormone levels following this operation. A control group consisting of children undergoing open heart procedures other than a Fontan procedure was also evaluated. Serum total and free triiodothyronine (T₃), total and free thyroxine (T₄), thyroid stimulating hormone (TSH), and thyroglobulin were measured by immunoassays. The Fontan group demonstrated an initial increase in free T₄, while free T₃, total T₃, total T₄, TSH, and thyroglobulin were reduced. Over the subsequent days, free T₄ decreased to below the preoperative value. By the fifth and eighth postoperative days, free T₃, total T₃, free T₄, and total T₄ remained reduced, while TSH and thyroglobulin began increasing toward the preoperative levels. The control group also demonstrated decreases in free T₃ and TSH. However, these values had returned to baseline by the fifth postoperative day. The results indicate that children undergoing open heart surgery have suppression of the pitultary-thyroid axis, and that this is prolonged in patients undergoing Fontan procedure. The decreased levels of T₃ following Fontan procedure may have adverse effects on the recovery of patients undergoing this operation. (J Card Surg 1994;9:322–331)     

Laparoscopic Sleeve Gastrectomy as an Initial Bariatric Operation for High-Risk Patients: Initial Results in 10 Patients

Background: The outcomes and initial results of laparoscopic sleeve gastrectomy were evaluated. Methods: A prospective study of the initial 10 patients who underwent laparoscopic sleeve gastrectomy (LSG) was performed. Study endpoints included operative time, complication rates, hospital length of stay and percentage of excess weight loss (%EWL). Results: There were 5 women and 5 men, with mean age 43 years (range 31 to 52). Mean preoperative weight was 182 kg (range 125-247 kg), with mean preoperative BMI 64 (range 61-80). Indication for LSG was related to BMI in all patients. 1 patient had previous restrictive bariatric surgery. Mean operative time was 2 hours (range 1.5-2.5). No patient required conversion. There were no postoperative complications nor mortality. Median hospital stay was 7.2 days. Average %EWL and BMI at 1 year were 51% and 23 kg/m², respectively. Conclusion: LSG can be safely integrated into a bariatric surgical program with good results in terms of weight loss and quality of life. LSG can be a firststage procedure before gastric bypass or duodenal switch or a one-stage restrictive procedure if longterm results are good. LSG should be considered as a surgical option in the bariatric field.     

Results of MRI Screening for Breast Cancer in High-Risk Patients with LCIS and Atypical Hyperplasia

Background Magnetic resonance imaging (MRI) can detect breast cancer in high-risk patients, but is associated with a significant false-positive rate resulting in unnecessary breast biopsies. More data are needed to define the role of MRI screening for specific high-risk groups. We describe our experience with MRI screening in patients with atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS). Methods We retrospectively reviewed data from our high-risk screening program prospective database for the period from April 1999 (when screening MRI was first performed at our institution) to July 2005. Patients with AH or LCIS demonstrated on previous surgical biopsy were identified. All patients underwent yearly mammography and twice yearly clinical breast examination. Additional screening MRI was performed at the discretion of the physician and patient. Results We identified 378 patients; 126 had AH and 252 had LCIS. Of these, 182 (48%) underwent one or more screening MRIs (mean, 2.6 MRIs; range, 1–8) during this period, whereas 196 (52%) did not. Those who had MRIs were younger (P < 0.001) with stronger family histories of breast cancer (P = 0.02). In MRI-screened patients, 55 biopsies were recommended in 46/182 (25%) patients, with 46/55 (84%) biopsies based on MRI findings alone. Cancer was detected in 6/46 (13%) MRI-generated biopsies. None of the six cancers detected on MRI were seen on recent mammogram. All six cancers were detected in five patients (one with bilateral breast cancer) with LCIS; none were detected by MRI in the AH group. Thus, cancer was detected in 5/135 (4%) of patients with LCIS undergoing MRI. The yield of MRI screening overall was cancer detection in 6/46 (13%) biopsies, 5/182 (3%) MRI-screened patients and 5/478 (1%) total MRIs done. In two additional MRI-screened patients, cancer was detected by a palpable mass in one, and on prophylactic surgery in the other and missed by all recent imaging studies. For 196 non-MRI-screened patients, 21 (11%) underwent 22 biopsies during the same period. Eight of 22 (36%) biopsies yielded cancer in seven patients. All MRI-detected cancers were stage 0–I, whereas all non-MRI cancers were stage I–II. Conclusion Patients with AH and LCIS selected to undergo MRI screening were younger with stronger family histories of breast cancer. MRI screening generated more biopsies for a large proportion of patients, and facilitated detection of cancer in only a small highly selected group of patients with LCIS.     

Surgical Therapy of Arrhythmias in Single-Ventricle Patients Undergoing Fontan or Fontan Conversion

Abstract Background: Arrhythmia is detrimental to Fontan hemodynamics. Clinical outcomes among Fontan patients who underwent antiarrhythmic treatment were retrospectively reviewed. Methods: From January 1996 to January 2007, 182 patients underwent a Fontan procedure, including Fontan conversion. Thirty‐nine of the 182 patients showed various arrhythmias pre‐ or post‐Fontan operations, and were treated surgically including Fontan conversion (18 patients) or medically. The authors analyzed the outcomes of arrhythmia treatments retrospectively. Results: Thirty‐nine patients (21.4%) showed various arrhythmias, such as atrial flutter, atrial fibrillation, junctional rhythm, sinus node dysfunction, or brady tachyarrhythmia pre‐ or post‐Fontan procedure. Follow‐up duration was 13.1 ± 8.7 years (11 months to 325 months). Atrial flutter and fibrillation only developed in 17 patients who received atriopulmonary connection Fontan, and who were treated by Fontan conversion with concomitant procedures such as Cox‐maze procedure (two patients), right‐side maze and pacemaker implantation (five patients), right atrial isthmus ablation (four patients), right atrial isthmus cryoablation and pacemaker implantation (five patients), and only pacemaker implantation (one patient). The 21 patients who showed arrhythmia at the time of the Fontan procedure underwent the following procedures concomitantly: right atrial isthmus cryoablation with pacemaker implantation (one patient), right atrial isthmus cryoablation (one patient), or pacemaker implantation (nine patients). The remaining 10 patients, who showed junctional rhythm, sinus bradycardia, or intermittent ectopic beats, were managed medically. There were two late mortalities due to protein‐losing enteropathy. As a result, 33 patients (89.2%) maintained atrioventricular synchrony, 19 in sinus rhythm and 14 supported by a DDD‐type pacemaker. The remaining four patients (10.8%) showed persistent junctional rhythm with a stable hemodynamic status. Conclusions: The various arrhythmias in Fontan patients were well controlled by aggressive surgical management.     

Myocardial Revascularization of the Beating Heart in High-Risk Patients

OBJECTIVE: Myocardial revascularization without cardiopulmonary bypass (CPB) has been proposed as an alternative technique in patients at high risk for conventional coronary artery bypass grafting (CABG). The purpose of this article is to evaluate the potential benefit of such an approach. METHODS: We retrospectively evaluated the perioperative results of off-pump CABG (OPCAB) performed from January 1995 to December 1999. Patients were divided into three groups on the basis of their preoperative risk factors: age greater than 80 years, reoperative CABG, and left ventricular ejection fraction percentage (LVEF%) less than 40%. The three subgroups were compared with patients operated on-CPB (ONCAB) during the same period of time. A total of 172 octogenarians had ONCAB versus 97 OPCAB, 307 reoperations were ONCAB versus 274 OPCAB, and 514 patients with LVEF% less than 40% were operated ONCAB versus 220 OPCAB. RESULTS: Preoperative comorbidities were homogeneously distributed in the OPCAB and ONCAB groups. More extensive coronary artery disease was found in the ONCAB groups. A trend for a lower number of perioperative complications was reported in the OPCAB groups. Freedom from overall complications was significantly higher (p < 0.005) in the OPCAB group. Actual mortality rates in the OPCAB and ONCAB groups were comparable (p = NS). CONCLUSIONS: CABG can be performed safely without CPB in patients with a high preoperative risk profile. Freedom from perioperative complications is markedly higher when the OPCAB approach is utilized.