Repair of double-chambered right ventricle: surgical results and long-term follow-up.

BACKGROUND: We reviewed the outcomes of double-chambered right ventricle repair. METHODS: Between 1969 and 1998, 40 patients underwent surgical repair of a double-chamber right ventricle. The patients ranged in age from 3 months to 52 years (mean, 12.8 +/- 11.6 years). Right ventricular outflow tract pressure gradients were from 20 to 170 mm Hg (mean, 65.0 +/- 38.5 mm Hg) An associated ventricular septal defect was present in 27 patients (67.5%). Four patients were older than 30 years of age. RESULTS: There were no hospital or late deaths. Mean postsurgical follow-up was 16.5 +/- 8.9 years (range, 2.5 to 31 years). No patient required further surgery to relieve obstruction of right ventricular outflow tract. CONCLUSIONS: Surgical repair of a double-chambered right ventricle yields excellent hemodynamic and functional results over both the short and long term.     

Inadvertent implantable cardioverter defibrillator lead placement in the left ventricle: long-term follow-up at nine years and management by minimally-invasive surgery

We describe the case history of a 43-year-old male with type 1 Brugada syndrome. He was fitted with an implantable cardioverter defibrillator (ICD) for primary prevention nine years ago. After admission for inappropriate shocks, an abnormal position of the lead was discovered. Further investigations (chest X-ray and transesophageal echocardiography) showed that the ICD lead was in fact in the left ventricle. The ICD lead was removed successfully using video-assisted thoracoscopic surgery.     

Coronary artery bypass grafting in patients with depressed left ventricular function: Operative results and long-term follow-up

Nine consecutive patients with coronary artery disease who had a left ventricular ejection fraction (LVEF) of less than 0.4 and underwent coronary artery bypass grafting (CABG) at our institution were studied. All patients had angina pectoris and six of the nine patients (67%) had a history of congestive heart failure. The mean EF was 0.37±0.03 and the mean LV end-diastolic pressure was 10.1±4.9 mm Hg. An average of 1.56±0.50 grafts per patient were placed and there was no operative death. The graft patency rate was 92.9% and the mean EF rose significantly from 0.37 to 0.53 after surgery (P<0.05). There was one late death, the 4-year actuarial survival rate being 88.9%. Of the eight long-term survivors, six (75%) were totally asymptomatic and only two had mild angina on exertion. This study confirmed that CABG for patients with depressed LV dysfunction can be performed safely with an acceptably low operative mortality, a significant improvement of LV function, and excellent long-term results.     

Borderline left ventricle.

The first problem to solve when dealing with the topic 'borderline left ventricle' is to find the appropriate definition. Several parameters have been taken into consideration, either morphometric (diameter of the mitral valve, indexed mitral valve area, left ventricular inflow dimension, left ventricular cross-sectional area, ratio between the apex-to-base left ventricular dimension and right ventricular dimension, left ventricular long axis to heart long axis ratio, left ventricular end diastolic volume, left ventricular mass index, ratio of the right/left ventricular wall thickness, presence of endocardial fibroelastosis, cardiac apex not formed by the left ventricle, diameter of the ventriculo-aortic junction, diameter of the aortic valve annulus and indexed aortic root diameter) as well as functional (left ventricular ejection fraction, left ventricular end diastolic pressure, mean pulmonary artery pressure, direction of the blood flow in the ascending aorta and at the level of the patent ductus arteriosus). Pre-operative determination whether the left ventricle is adequate to sustain the systemic circulation, or it may became adequate with the available surgical approaches, and therefore a bi-ventricular type of repair is feasible, can be extremely difficult, particularly in the presence of a 'borderline left ventricle'. In the clinical practice pediatric cardiologists and cardiac surgeons are faced with the problem of the 'borderline left ventricle' in four different groups of congenital heart defects: (a) aortic valve stenosis, (b) aortic coarctation, with or without hypoplastic aortic arch, (c) hypoplastic left heart complex, (d) right ventricular pressure and/or volume overload. In all the above situations in the presence of a left ventricle smaller than normal a very exhaustive approach has been reviewed in the decision making process, taking in account the literature reports as well as the personal experience. In each patient with 'borderline left ventricle' the elements to be considered for the decision making process between uni- and bi-ventricular type of repair, or for less ideal options of management, are the following: morphometric and functional parameters, hemodynamic data, available surgical options, results of the personal and institutional experience.     

Adenoidectomy: long-term follow-up.

OBJECTIVE: To assess the long-term (3-5 years) success of adenoidectomy and reasons for unsatisfactory results. STUDY DESIGN AND SETTING: The parents of all children who underwent adenoidectomy alone at a major tertiary center from 1998 to 2000 were asked to complete a questionnaire assessing their child's well-being and symptomatology 3-5 years after surgery; some were invited for follow-up. Symptom improvement, persistent symptoms, and adenoid regrowth were evaluated. RESULTS: Among the 206 parents who complied, 74%-87% reported improvement in all main symptoms: nasal obstruction, snoring, chronic rhinorrhea, hyponasal speech, and obstructive sleep disorder. At follow-up (n = 36), the symptomatic patients had significantly more anatomic nasal abnormalities (P = 0.01) and a higher rate of significant adenoid enlargement (P = 0.08), 3 patients (19%) vs none (0%). CONCLUSIONS AND SIGNIFICANCE: Adenoidectomy alone is satisfactory treatment for nasal obstruction and obstructive sleep apnea in selected children. Though some adenoid regrowth is not rare, clinically significant adenoid regrowth is infrequent. Persistent or recurrent symptoms are attributable mainly to nasal pathology.     

Aortoventriculoplasty: a new technique for the treatment of left ventricular outflow tract obstruction.

Aortoventriculoplasty is a new method of treatment for left ventricular outflow tract obstructions. The concept is based on creating a surgical defect which is patched in such a way as to provide the largest possible outflow to the left ventricle. The incision of the aorta continues down as far as necessary, with the right ventricular wall, the aortic ring, and the septum being cut. Reconstruction with an inner Dacron patch on the septum is completed by replacing the aortic valve with an adequate prosthesis, covering the aortic incision with the same patch, and patching the right venticular opening with an outer patch. This method was used in 4 children with tunnel-like subaortic stenosis, 3 of whom had had unsuccessful previous surgical attempts. Other associated lesions including parachute mitral valve were also corrected during aortoventriculoplasty. Hemodynamic results were excellent following this operation. Two patients died postoperatively, one from advanced myocardial damage and progressive failure and the other from cerebral ischemia caused by insufficient retrograde perfusion through an aortic coarctation that was not repaired earlier. No arrhythmias were observed following the procedure. The other 2 patients are well 7 and 5 months postoperatively with excellent hemodynamic function.     

Vascular rings and slings: long-term follow-up of pulmonary function

Between 1968 and 1983, 54 patients underwent surgery for symptomatic aortic arch and pulmonary artery anomalies at St Christopher's Hospital for Children. Presenting symptoms included stridor, wheeze, apnea, recurrent pulmonary infections, or dysphagia. Diagnosis was established with chest roentgenogram, bronchoscopy, barium esophagram, and arteriography. Four types of vascular anomalies were encountered; double aortic arch (24 patients), right aortic arch with left ligamentum arteriosum (17 patients), anomalous innominate artery (10 patients), and pulmonary artery sling (three patients). There were no intraoperative deaths and only one postoperative death. All surviving patients had immediate relief of their severe respiratory or swallowing symptoms. Mild respiratory symptoms persisted postoperatively from 3 months to 4 years and included frequent or severe upper respiratory infections, persistent cough, stridor and pneumonia. Five of the 53 surviving patients were lost to follow up. The remaining 48 patients were followed from 6 months to 14 years and all but one patient noted complete resolution of all respiratory symptoms. Twenty-nine patients at follow up were old enough to undergo pulmonary function testing including vital capacity, functional residual capacity, and inspiratory and expiratory flow volume loops. Seventeen of these 29 asymptomatic patients consented to these studies, and nine of these patients had abnormal flow volume loops indicative of significant central airway obstruction; the other eight studies were normal. We conclude that surgical repair for vascular rings and slings is safe and symptomatically efficacious. However, anatomic tracheal or bronchial distortion persists in a significant number of these patients as evaluated by pulmonary function studies.     

Systolic long axis function of the left ventricle. Global and regional information

Objective—To compare global systolic measurements of mitral annular motion by M‐mode and tissue velocity time integral, and annular velocity by pulsed and colour Doppler for precision and bias. Secondly, to compare the ability of annular motion to identify regional dysfunction with segmental analysis by strain rate imaging.

Design—Nineteen normal subjects and 19 patients with myocardial infarction were studied with echocardiography.

Results—There were significant correlations between ejection fraction (EF) and annular motion/velocity by all methods, ranging from 60 to 80%. Measurements had 95% limits of agreement intervals between 7.7 and 15.6?mm for annulus excursion and 8.8?cm/s for annulus velocities with biases between methods of 0.7–1.9?mm and 2.6?cm/s. Annular motion and velocity were reduced in the patients compared with the control group, but were depressed at all points so the infarcted region could not be identified. Only segmental analysis could identify the region of dyssynergy.

Conclusion—Annular motion and velocity measure global function, but have high variability and measurements are method dependent. Only segmental analysis can identify regional dyssynergy. This is possible with strain rate imaging, but the precision is still too low for clinical use.     

Systolic long axis function of the left ventricle. Global and regional information

OBJECTIVE: To compare global systolic measurements of mitral annular motion by M-mode and tissue velocity time integral, and annular velocity by pulsed and colour Doppler for precision and bias. Secondly, to compare the ability of annular motion to identify regional dysfunction with segmental analysis by strain rate imaging. DESIGN: Nineteen normal subjects and 19 patients with myocardial infarction were studied with echocardiography. RESULTS: There were significant correlations between ejection fraction (EF) and annular motion/velocity by all methods, ranging from 60 to 80%. Measurements had 95% limits of agreement intervals between 7.7 and 15.6 mm for annulus excursion and 8.8 cm/s for annulus velocities with biases between methods of 0.7-1.9 mm and 2.6 cm/s. Annular motion and velocity were reduced in the patients compared with the control group, but were depressed at all points so the infarcted region could not be identified. Only segmental analysis could identify the region of dyssynergy. CONCLUSION: Annular motion and velocity measure global function, but have high variability and measurements are method dependent. Only segmental analysis can identify regional dyssynergy. This is possible with strain rate imaging, but the precision is still too low for clinical use.     

Scheuermann kyphosis: long-term follow-up.

BACKGROUND CONTEXT: There is considerable controversy as to the optimal treatment of Scheuermann kyphosis. Proposed modalities have included exercise, bracing and surgery. PURPOSE: The purpose of this study was to document the functional capacity and radiographic findings in adults who have been previously treated for Scheuermann kyphosis. STUDY DESIGN: A cohort study of all patients with Scheuermann kyphosis treated in a single institution using three different treatment modalities: exercise and observation, Milwaukee bracing and surgical fusion using the Harrington Compression System. PATIENT SAMPLE: Sixty-three patients were evaluated at a mean of 14 years after treatment (10 to 28 years). OUTCOME MEASURES: Two different functional evaluation instruments were used. Radiographic evaluation was carried out in 38 patients (60%). METHODS: Patient interviews were conducted using a specially designed questionnaire. Patients were then asked to undergo standing radiographs. Patients were divided into groups depending on the location of their kyphosis and the manner in which they had been treated. Standard statistical analysis was then carried out. RESULTS: At time of follow-up evaluation there were no differences in marital status, general health, education level, work status, degree of pain and functional capacity between the various curve types, treatment modality and degree of curve. Patients treated by bracing or surgery did have improved self-image, which they attributed to their treatment. Patients with kyphotic curves exceeding 70 degrees at follow-up had an inferior functional result. At time of final follow-up there were no statistical differences in degree of kyphosis and mode of treatment. CONCLUSIONS: By carefully selecting the appropriate treatment for patients with Scheuermann kyphosis on the basis of the patient's age, spinal deformity and the severity of back pain, it is possible to achieve a similar functional result at long-term follow-up. Despite different treatment protocols, patients with Scheuermann kyphosis tend to achieve a similar functional result at long-term follow-up.     

Aortoventriculoplasty for different types of left ventricular outflow tract obstructions

Since the first clinical application of aortoventriculoplasty for tunnel subaortic stenosis in 1974 the indication for this method was extended to other types of left ventricular outflow tract stenoses (LVOTO). The operative technique consists of enlarging both the left and right ventricular outflow tracts and inserting an aortic prosthetic valve. 47 operations have been performed in patients with various types of LVOTO: 8 narrow annulus, 23 diffuse subaortic stenosis (multiple level stenosis), 9 complex forms of tunnel subaortic stenosis (Shone complex) 3 outgrown prosthesis, 4 obstructive idiopathic hypertrophic subaortic stenosis. Patients ages ranged from 4 to 35 years. Overall mortality was 13%, there were no late deaths, in the last 34 patients there was no death. In 25 patients there had been 1, and in 13 patients 2 previous procedures. As a result of the operation 9 patients developed complete right bundle branch block or left anterior hemi-block; 2 patients developed total a-v block with the need of a permanent pacemaker 25 patients had catheterization postoperatively. The mean gradient across the left ventricular outflow tract was significantly reduced from 91.5 +/- 21 mm Hg to 13.1 +/- 15 mm Hg. According to our experience aortoventriculoplasty can be used routinely in all forms of diffuse subaortic stenosis, narrow aortic annulus, reoperation in HOCM, multiple level stenosis and outgrown aortic prosthesis.     

Global and regional left ventricular function in heart transplant patients: an angiographic follow-up study.

We studied the global and regional left ventricular function, its determinants and its modification with time, in orthotopic heart transplant recipients. We reviewed the left ventricular cineangiography performed 1 (50 patients), 2 (33 patients), 3 (18 patients), and 4 (seven patients) years after operation. Regional wall motion was quantitatively evaluated by the area method. All patients had angiographically normal coronary arteries and no evidence of acute rejection at the time of the study. One year after heart transplantation, cardiac index and left ventricular ejection fraction were mildly but significantly lower than normal. Cardiac index was more than 2.5 L/min/m2 in all but one patient, and ejection fraction was more than 50% in all patients. Only previous acute cardiac rejection necessitating therapy and arterial hypertension showed some influence on the left ventricular function. Two years after operation, the left ventricular end-diastolic volume was increased, and left ventricular mass-volume ratio decreased compared with year 1. Three years after operation, an increase of left ventricular end-diastolic pressure and of left ventricular ejection fraction was also evident. Four years after operation, the heart rate was higher, compared with previous years. Even if the changes in the parameters of left ventricular function were significant, they were small in terms of absolute value. Regional hypokinesia was detected 1 year after heart transplantation in eight patients, involving one segment in six patients and two segments in two patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Decreased lung function and exercise capacity in Fontan patients. A long-term follow-up

OBJECTIVE: The haemodynamic situation for patients with Fontan circulation is characterized by a reduced, non-pulsatile pulmonary blood flow. To evaluate if this has any impact on lung function and exercise capacity, we studied the surviving 20 patients operated upon at our institution between 1980 and 1991. The median age was 17.5 years, the median follow-up time was 11.5 years. DESIGN: Lung volumes, flow-volume curves, the ventilatory distribution and the diffusion capacity for carbon monoxide were obtained using routine methods. The exercise tests were performed on a bicycle ergometer with determination of ventilation, oxygen uptake, carbon dioxide production, respiratory rate and heart rate. RESULTS: The lung volumes, maximal expiratory flows and diffusion capacity were significantly lower than expected. The median maximal oxygen uptake was 1.39 for the females and 1.63 l/min for the males, corresponding to 25.1 and 25.2 ml/kg/min, respectively. The maximal heart rates varied from 104 to 177 beats/min. All patients reached a respiratory exchange ratio above 1.0. CONCLUSION: Fontan patients have small lungs. They have a markedly reduced exercise capacity and a low maximal heart rate.     

Pulmonary function for pectus excavatum at long-term follow-up

PURPOSE: The aim of this article was to assess whether and to what extent pulmonary function recovered to normal degree postoperatively and to investigate the changes in pulmonary function after surgical correction and the value of surgical correction. METHODS: A total of 27 patients who could be questioned and examined in person at the outpatient department of our hospital were included in this study. Of these patents, 24 were boys and 3 were girls. Their ages ranged from 3 to 16 years (mean, 8.67) at follow-up. The mean age at surgery was 4 years, and mean years of follow-up was 6.8. Pulmonary functional measurements included in vital capacity (VC), total lung capacity (TLC), residual volume (RV), functional residual capacity (FRC), RV-TLC ratio, maximal voluntary ventilation (MVV), force ventilatory capacity (FVC), forced expiratory volume in one second (FEV1), maximal midexpiratory flow curve (MMEF), maximal expiratory flow in 75% vital capacity (V75), maximal expiratory flow in 50% vital capacity (V50), maximal expiratory flow in 25% vital capacity (V25), and breathing reserve ratio (BR). RESULTS: TLC, FRC, MVV, MMEF, V75, and V50 values were not different from the normal values. IVC, FVC, FEV1, and V25 values were decreased significantly compared with the normal values. The RV and RV-TLC were high in 87.5% cases. CONCLUSIONS: Preoperative symptoms obviously improved after operation. There was little airway obstruction in the patients postoperatively. The patients with pectus excavatum should be operated on as soon as possible.     

Propofol reduces tissue-Doppler markers of left ventricle function: a transthoracic echocardiographic study

BACKGROUND: Propofol is thought to minimally depress myocardial function,but mainly to reduce blood pressure by vasodilation. Transthoracictissue-Doppler echocardiography (TDE) is a novel, validatedmethod of quantifying myocardial function. It provides new insightinto myocardial function by measuring myocardial motion. Weexamined the effects of propofol upon myocardial function bymeasuring changes in left ventricle function by TDE. METHODS: We assessed change in myocardial function in propofol anaesthetizedASA I patients tissue tracking displacement (TTD) before anaesthesiaonset and repeated measurements after a single propofol bolusdose. Tissue tracking score (TTS), a marker of ejection fraction,was also used (n = 10). RESULTS: Propofol 1.5–2 mg kg^–1 significantly attenuatedPSV from 5.64 (1.17) to 4.66 (0.55) cm s^–1 (P< 0.0001) and TTD from 10.2 (2.1) to 8.5 (1.4) mm (P= 0.0091), whereas TTP was unchanged [all data: mean (SD)].TTS declined from 7.2 (1.3) to 6.1 (0.6) mm (P < 0.01).Non-invasive mean blood pressure declined 17% (P < 0.0001). CONCLUSIONS: The results indicate that myocardial contractile function iscompromised concomitantly with reduced cyclic displacement afterpropofol dosing. Blood pressure declined accordingly. From theseresults, it is impossible to ascertain whether this was secondaryto reduced cardiac filling or a consequence of a direct negativeinotropic action of propofol, but it represents a left-shiftof the Starling curve. The novel TDE yields new informationon myocardial velocities and motion.     

Recovery of parathyroid function after total thyroidectomy: long-term follow-up study

BACKGROUND: To prevent postoperative hypoparathyroidism following total thyroidectomy, the parathyroid glands are preserved in situ and/or resected or devascularized parathyroid glands are autotransplanted. A retrospective investigation was conducted utilizing biochemical and specific endocrine assessments to evaluate the difference in recovery of parathyroid function in the long term. METHODS: A total of 103 patients underwent total thyroidectomy at Second Department of Surgery, School of Medicine, Kagawa University between 1990 and 1998. These patients were divided into a preservation group (n = 17), with only preserved glands in situ; a combination group (n = 72), consisting of patients with one or more parathyroid glands preserved in situ and one or more autotransplanted parathyroid glands; and an autotransplantation group (n = 14), with only transplanted glands. RESULTS: The overall incidence of permanent hypoparathyroidism in the preservation group, the combination group, and the autotransplantation group was 0%, 1.4%, and 21.4%, respectively. The mean levels of intact parathyroid hormone in the preservation group, the combination group, and the autotransplantation group recovered to 102%, 107%, and 50% of the preoperative levels at 5-year follow up. CONCLUSION: The results of the present study suggest that parathyroid glands should be preserved in situ whenever possible, to promote better recovery of postoperative function, and that only autotransplantation produces inadequate recovery of long-term function.     

Double-outlet right ventricle with tunnel from left ventricle to aorta.

The successful surgical correction of an unusual form of double-outlet right ventricle (DORV) in a 4-year-old boy is described. A long tunnel-like structure was present between the left ventricle and the aorta and also communicated with the right ventricle. hemodynamic and angiographic evaluation demonstrated restrictive communications between the tunnel, the aorta, and each of the ventricles. A pathological concept explaining the anatomic abnormality seen in this patient is discussed.     

Double-outlet left ventricle

Origin of both great vessels from the left ventricle is an uncommon congenital cardiac anomaly. When there is an associated ventricular septal defect and pulmonary stenosis, the preoperative diagnosis has usually been that of tetralogy of Fallot. Operative repair was accomplished successfully in a 12-year-old boy with such a combination of defects. This involved patch closure of the ventricular septal defect, interruption of blood flow from the left ventricle to the pulmonary artery by suture closure of the pulmonary valve and annulus, and restoration of blood flow to the lung by using a Dacron tube conduit between the right ventricle and the distal main pulmonary artery. This represents the third successful operative repair of double-outlet left ventricle.