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1.
OBJECTIVES: This study was undertaken to compare the outcomes of the Lecompte procedure and Rastelli repair in the transposition of the great arteries (TGA) with ventricular septal defect (VSD) and left ventricular outflow tract obstruction (LVOTO) and to determine the risk factors associated with unfavorable events. METHODS: Over a 12-year period (April 1990-October 2002), 35 patients underwent complete repair for TGA, VSD, and LVOTO. Twenty-five patients (71%) underwent the Lecompte modification, and mean age and weight were 23.4+/-18.2 months and 10.2+/-3.0 kg. Ten patients (29%) underwent the Rastelli operation, and mean age and weight were 39.1+/-36.1 months and 13.8+/-6.8 kg. RESULTS: One early death (3%) occurred after the Lecompte procedure and no late death. The mean follow-up was 5.9+/-3.8 years. Eight patients in the Rastelli group (80%) underwent a late reoperation for obstruction of the extracardiac conduit, and in four of these patients, a reoperation for LVOTO was concomitantly required. Reoperation was also required in six patients of the Lecompte group (25%); five for right ventricular outflow tract obstruction (RVOTO) including one for LVOTO and two for VSD leakage, and one for mitral regurgitation and left pulmonary artery stenosis. The interval prior to reoperation ranged from 1.6 to 11.1 years, with a mean of 5.7+/-3.1 years. The actuarial figures for freedom from reoperation at 5 and 10 years were 40.0+/-15.5 and 26.7+/-15.0% after the Rastelli operation and 95.7+/-4.3 and 63.5+/-12.6% after the Lecompte procedure (P = 0.02). Multivariate analysis by Cox regression analysis revealed that the risk factors of RVOTO were a younger age at operation, the Rastelli operation, and ductus ligation during the operation. CONCLUSIONS: The Lecompte procedure and Rastelli repair provide satisfactory early and late results. However, substantial late morbidity is more associated with conduit obstruction, and LVOTO in Rastelli repair rather than Lecompte procedure.  相似文献   

2.
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.  相似文献   

3.
Between January, 1976, and June, 1983, 16 patients with transposition of the great arteries and fixed subpulmonary obstruction underwent repair by means of a combined Mustard procedure and placement of a conduit between the left ventricle and main pulmonary artery. Their mean age and weight were 5.3 years and 19 kg. Ten patients had an intact ventricular septum and six had a ventricular septal defect, which because of its size or location precluded a Rastelli repair. A fibromuscular tunnel was the most common type of subpulmonary obstruction (10/16, 62%). There were three early deaths and one late death. Early cardiac catheterization (mean interval from operation, 45 days), performed in 10 of 13 survivors, showed a significant decrease in the mean left ventricular-pulmonary arterial gradient from 66 to 8.5 mm Hg. Late cardiac catheterization (mean interval from operation, 4 years) showed continuing relief of the subpulmonary obstruction with a mean increase in peak systolic transconduit pressure gradient of 6.4 mm Hg. This procedure is an option to direct relief in the management of severe fixed subpulmonary obstruction in patients with transposition and intact ventricular septum or in the presence of a ventricular septal defect when a Rastelli repair is precluded.  相似文献   

4.
The relationship of the conduit to the sternum is crucial in the Rastelli operation. Right-sided conduits are more greatly affected by sternal compression than left, since the position of the right ventricular infundibulum is more anterior. A 37-year-old woman developed right ventricular outflow tract obstruction, left ventricular outflow tract obstruction, and aortic valve regurgitation secondary to infective endocarditis 15 years after Rastelli repair for double-outlet right ventricle (SDL). We enlarged the ventricular septal defect, performed intraventricular rerouting and aortic valve replacement, and reconstructed the valved conduit using a Carpentier-Edwards conduit. The old conduit was densely adherent to the sternum. Subaortic stenosis was caused by a narrow fibromuscular ridge associated with a bulge of the underlying septal muscle. The patient's recovery was uneventful. She is alive and well without any complaints 1 year after surgery.  相似文献   

5.
A bstract Twenty patients had a repair of an atrioventricular septal defect with tetralogy of Fallot (n = 13) or double outlet right ventricle (n = 7). Mean age was 3.5 years. Surgical technique included transatrial-transpulmonary resection of right ventricular outflow tract obstruction and transatrial two patch repair of the atrioventricular septal defect. Ten patients required a transannular patch and one patient had a right ventricle-pulmonary artery conduit placed. There was no hospital mortality, and mean hospital stay was 15 days. One patient had late sudden death of unknown cause. Six patients have required reoperation because of residual ventricular septal defect (VSD), mitral incompetence, residual right ventricular outflow tract obstruction, and/or conduit stenosis. No patient was reoperated on because of left ventricular outflow tract obstruction. Fifteen patients are asymptomatic, one has exertional dyspnea, and two have intermittent occasional bronchospasm. The transatrial-transpulmonary two patch repair and extensive relief of right ventricular outflow tract obstruction have given good immediate results. Reoperation rate has been high mainly due to residual VSD and mitral incompetence. ( J Card Surg 1993; 8:622–627 )  相似文献   

6.
From November 1980 to November 1985, 50 patients underwent anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction. The technique used was one that we have previously described, which we call REV. The principles of this technique are resection of the infundibular septum, construction of a tunnel connecting the left ventricle to the aorta, and direct anastomosis, without a prosthetic conduit, of the pulmonary arterial trunk with the right ventricle. The tunnel is situated beneath the aortic valve and occupies very little space in the right ventricular cavity. Age at operation ranged from 4 months to 13 years (mean 3.5 years). Twenty-six patients had a classic type of transposition of the great arteries; all other patients had various types of anomalies of ventriculoarterial connection in which it was impossible, after the intraventricular connection of the left ventricle to the aorta, to use the natural pulmonary orifice for the pulmonary outflow tract reconstruction. There were nine hospital deaths (18%) and one late death. Twenty-six of 29 patients whose follow-up time exceeded 1 year had an excellent clinical result. No stenosis of the aortic outflow tract was found. Four patients had significant pressure gradients on the pulmonary outflow tract. Our present experience with REV suggests that this technique allows anatomic repair in a wide variety of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction, even in infants, with an acceptable rate of mortality and morbidity.  相似文献   

7.
Surgical management of patients with complete transposition and intact ventricular septum may become difficult in the presence of left ventricular outflow tract obstruction. A Mustard operation and direct resection of the obstruction through the pulmonary artery has been the treatment of choice for this combination. Our study of the structure of the left ventricular outflow tract in four specimens with the anatomic findings of complete transposition, intact ventricular septum, and subpulmonary stenosis suggests that direct resection of the stenosis through the pulmonary artery can seldom be adequate without major risk of damaging either the mitral valve or the conduction tissue. An alternative procedure, namely, a combined Mustard operation and insertion of an external conduit from the left ventricle to the main pulmonary artery, has been employed in the management of six patients with this combination of lesions. One early and one late death occurred. Postoperative cardiac catheterization performed in all of the survivors before discharge from the hospital showed good relief of the stenosis and no significant gradient across the conduit.  相似文献   

8.
OBJECTIVE: Evaluate long-term results of autologous pericardial valved conduits in the pulmonary outflow. METHODS: Between June 1983 and October 1993, 82 conduits were placed in the outflow of the venous ventricle. Patients who received homografts (n = 2 patients), heterografts (n = 3 patients), and valveless conduits (n = 19 patients) and those patients who died within 90 days after the operation were excluded. Fifty-four survivors of pulmonary outflow reconstruction with fresh autologous pericardial valved conduits were followed up from 5 to 15 years (mean, 7.47 +/- 2.8 years). Diagnosis include d -transposition of great arteries (n = 16 patients), L -transposition of great arteries (n = 14 patients), tetralogy of Fallot, pulmonary atresia with ventricular septal defect (n = 11 patients), truncus arteriosus (n = 10 patients), and double-outlet ventricle (n = 3 patients). Implantation age ranged from 0.25 to 24 years (mean, 5.2 +/- 4.2 years). Median conduit diameter was 16 mm. Two-dimensional echocardiographic Doppler evaluations were made yearly; 9 patients underwent cardiac catheterization. Reintervention for stenosis was indicated when the pressure gradient exceeded 50 mm Hg. RESULTS: Three late deaths were unrelated to the conduit. Thirty-five autologous pericardial valved conduits increased in diameter (1-7 mm), remained unchanged in 15 patients, and reduced 1 to 2 mm in 4 patients. The median diameter was 18 mm at the last evaluation (P =.0001). Eight patients required conduit-related reoperation 3 to 8 years after the implantation. Two patients underwent balloon dilation of the autologous pericardial valved conduit. No conduit had to be replaced. Freedom from reintervention at 5 and 10 years was 92% and 76%, being 100% at 10 years for conduits larger than 16 mm at time of implantation. CONCLUSIONS: Autologous pericardial valved conduits show excellent long-term results and compare favorably with other conduits.  相似文献   

9.
右心室双出口的手术治疗   总被引:1,自引:0,他引:1  
目的 总结右心室双出口手术治疗的早期和远期结果及经验。 方法  1985年 5月~ 2 0 0 1年 12月 4 1例右心室双出口患者接受了外科治疗 ,其中男 2 6例、女 15例 ,年龄 10个月~ 2 1岁 ,平均 (10± 6 )岁 ,体重 6 5~ 6 5 0kg ,平均 (2 6± 16 )kg。 4 1例中 ,14例行经典的Rastelli手术 (内隧道外管道手术 ) ;11例行经内隧道成形左心室流出道、右心室流出道直接疏通或用心包片加宽 ;11例行改良Rastelli手术 ;2例行全腔静脉肺动脉吻合术 ;2例行双向格林手术 ;1例行大动脉调转术。结果 早期 (术后 1个月 )死亡 1例 ,出院 4 0例。随访 36例 ,随访 5个月~ 17年 ,中位数为 7年 ,无死亡 ,二次手术 3例。所有患者紫绀消失 ,症状明显改善 ,心功能Ⅰ级 34例 ,心功能Ⅱ级 2例 ,能够进行正常的生活、学习和工作。 结论 绝大多数右心室双出口患者经双心室矫治可以取得很好的早期及远期结果 ;对于合并其他严重畸形的患者可行右心室旁路手术。  相似文献   

10.
Left ventricular outflow enlargement by the Konno procedure   总被引:1,自引:0,他引:1  
The optimal management of patients with small aortic anulus or left ventricular outflow tract obstruction remains unclear. Between 1976 and March, 1982; 18 patients have undergone enlargement of their left ventricular outflow tract by means of the Konno or a modification of the Konno procedure. Fourteen of these 18 patients had previous operations for aortic stenosis or tunnel left ventricular outflow tract, and two patients had undergone three previous operations. All 18 patients had symptoms of either heart failure of chest pain, or had electrocardiographic evidence of strain. They ranged in age from 4 years to 58 years, with 13 of the 18 patients being less than 20 years of age. A Dacron patch was used to enlarge the left ventricular outflow tract after incising down the ventricular septum. In all patients, at least a 21 mm valve could be placed, with between 50% and 65% of the valve anulus being made up of natural tissue. The remaining portion of the valve anulus was constructed from the Dacron patch. The patch was extended up to enlarge the ascending aorta, and a pericardial patch was used to close the defect in the right ventricular outflow tract. In all 18 patients the gradient was obliterated at the time of operation. There was one early death in a patient who had previous insertion of a left ventricular apical-aortic conduit in which the heterograft valve had degenerated. There has been one late death because of bacterial endocarditis in a child who also had a parachute mitral valve and evidence of pulmonary hypertension. The remaining 16 patients are functioning well after the Konno procedure. Three are receiving warfarin sodium, and 13 are receiving aspirin. These results suggest that this is an acceptable method of treating patients with small aortic anulus or left ventricular outflow tract obstructions and would appear to have advantages over a left ventricular apical-aortic conduit.  相似文献   

11.
Repair of complete atrioventricular canal with tetralogy of Fallot was performed in 9 patients. Ventricular septal defect was closed through the right atrium using a single polytetrafluoroethylene patch with ample anterior extension to avoid subaortic obstruction. The atrial septal defect was closed with a separate patch. Undivided atrioventricular valve leaflets were sandwiched between the two patches. Right ventricular outflow tract stenosis was relieved by pulmonary valvotomy and an infundibular patch in 7, a supravalvar patch (none transannular) in 6, and right ventricle-to-pulmonary artery conduit in 2. There was one hospital death (1/9, 11%) in a patient with persistent clinically significant postoperative pulmonary stenosis and low cardiac output requiring reoperation and right ventricle-to-pulmonary artery conduit insertion. There was no late mortality. All patients are asymptomatic 0.3 to 5.6 years after operation. Follow-up right ventricular outflow tract gradient ranged from 11 to 43 mm Hg and was 70 mm Hg in 1 patient who later had successful relief of obstruction. Three patients had mitral valve insufficiency; 1 needed reoperation. Aggressive relief of right ventricular outflow tract stenosis with maintenance of pulmonary valve competence and use of two separate patches for closure of the septal defects contribute to optimum immediate and long-term results after repair of this lesion.  相似文献   

12.
The surgical considerations, clinical follow-up, and hemodynamic data for 23 patients (age range, 4 months to 80 years) who underwent insertion of a porcinevalved apicoaortic conduit between December, 1976, and June, 1983, are reviewed. All patients had complex forms of left ventricular outflow obstruction. All were symptomatic, and 18 had had 23 prior attempts at surgical relief of the obstruction. There was a total of 6 deaths (26%); 2 were in small children with other complex cardiac malformations, and 2 others in patients who required emergency operation for acute cardiac decompensation.Sixteen patients have had cardiac catheterization 1 to 1.5 years postoperatively, and a reduction in the resting left ventricular–aortic gradient from 91 ± 30 to 13 ± 8 mm Hg was demonstrated (p < 0.001). None of the patients is taking anticoagulants, and no thromboembolic events have occurred. Four of the 17 survivors have undergone a subsequent operation 1.5 to 4.0 years postoperatively with conduit removal, aortoventriculoplasty, and conduit valve replacement in 1, 1, and 2 patients, respectively. These data demonstrate that the apicoaortic conduit is effective in relieving complex left ventricular outflow obstruction and improving left ventricular performance with acceptable long-term results. Increasing the durability of the conduit valve will greatly improve the late results with this technique.  相似文献   

13.
Long-term results after early primary repair of tetralogy of Fallot.   总被引:14,自引:0,他引:14  
OBJECTIVE: Early primary repair of tetralogy of Fallot has been routinely performed at Children's Hospital, Boston, since 1972. We evaluated the long-term outcome of this treatment strategy including the influence of a transannular patch. METHODS: Fifty-seven patients less than 24 months of age (median 8 months) underwent primary repair of tetralogy of Fallot between January 1972 and December 1977. Thirty-one patients had a transannular patch. Survival and freedom from reintervention were determined by the Kaplan-Meier method with 95% confidence intervals. RESULTS: There were 8 early deaths, and 1 patient died 24 years after initial repair. Recent follow-up was obtained for 45 of the 49 long-term survivors (92%). Median follow-up was 23.5 years. Ten patients underwent reintervention, 8 of whom underwent relief of right ventricular outflow tract obstruction. Right ventricular outflow tract obstruction occurred in 6 patients without a transannular patch and 2 with a transannular patch (33% vs 6%, P =.04). One pulmonary valve replacement was performed at another institution 20 years after the repair. Forty-one long-term survivors were in New York Heart Association class I and 4 were in class II. Actuarial survival was 86% at 20 years (95% confidence intervals = 80%-92%). Freedom from reintervention was 93% at 5 years (95% confidence intervals = 87%-99%) and 79% at 20 years (95% confidence intervals = 70%-86%). No significant differences were found between patients with and without a transannular patch (survival, P =.34; freedom from reintervention, P =.09, log-rank tests). CONCLUSIONS: Long-term survival is excellent and the freedom from reintervention is satisfactory after early primary repair of tetralogy of Fallot in the 1970s. Use of a transannular patch does not reduce late survival and is associated with a lower incidence of right ventricular outflow tract obstruction.  相似文献   

14.
Aeba R  Katogi T  Koizumi K  Iino Y  Mori M  Yozu R 《The Annals of thoracic surgery》2003,76(5):1383-7; discussion 1387-8
BACKGROUND: In conventional repair of the congenitally corrected transpositions of the great arteries associated with ventricular septal defect and pulmonary outflow tract obstruction, the placement of the left ventricle-pulmonary artery conduit is at risk owing to probable compression by the sternum, heart block, or injury to the mitral anterior papillary muscle. Apical placement of the left ventriculotomy for the inflow conduit rather than in the midportion or base placement may avoid these complications, although this results in a long and winding extracardiac conduit that may be short-lived because of the proliferation of pseudointima. METHODS: Between 1985 and 1990, a nonvalved Dacron woven-fabric graft conduit was placed between the left ventricular apex and pulmonary artery in 5 patients (mean age, 6.2 +/- 1.7 years) who were then followed for at least 10 years. RESULTS: No iatrogenic heart blocks or mitral regurgitation developed. All patients were complaint-free during the follow-up period, although 1 patient who was clinically well died suddenly in the 10th follow-up year. Cardiac catheterization in the 10th follow-up year indicated a pressure gradient of 21 +/- 6 mm Hg across the conduit, and angiography revealed that the conduit diameter was 91% +/- 6% of the original conduit diameter. CONCLUSIONS: The reportedly poor early and late outcomes that occur after a conventional repair of congenitally corrected transpositions of the great arteries associated with ventricular septal defect and pulmonary outflow tract obstruction, which places an extracardiac conduit between the left ventricle and the pulmonary artery, may be partially neutralized by relocating the inflow position to the apex.  相似文献   

15.
目的总结单中心双心室矫治室间隔缺损远离型右室双出口的15年经验,探讨双心室矫治的合适方法,分析再手术的危险因素。方法回顾性分析2005~2019年于我院连续入组162例接受双心室矫治的室间隔缺损远离型右室双出口患儿的临床资料。根据内隧道建立的路径将患儿分为两组:110例患儿术中行室间隔缺损连接至主动脉内隧道[A组,男75例、女35例,平均年龄(3.6±3.2)岁];52例患儿行室间隔缺损连接至肺动脉内隧道[B组,男30例、女22例,平均年龄(2.8±2.7)岁]。为了建立通畅的心室内隧道,同期进行的操作包括室间隔缺损扩大、圆锥肌肉切除、三尖瓣腱索或乳头肌转移等。结果全组行双心室矫治的患儿早期死亡9例(5.6%),早期心室内隧道梗阻6例(3.7%)。经过(7.5±7.0)年的随访,8例(4.9%)患儿发生晚期死亡,A组的1年、5年、10年、15年生存率分别为92.7%、91.1%、91.1%、85.4%,B组分别为92.2%、85.2%、85.2%、85.2%,两组差异无统计学意义(P=0.560)。随访发现10例(6.2%)迟发性心室内隧道梗阻,8例接受了再次手术。两组比较A组患儿有更多的迟发性心室内隧道梗阻(A组9例vs.B组1例,P=0.017)及总体心室内隧道梗阻(A组15例vs.B组1例,P=0.001)。两组患儿的早期死亡率和晚期死亡率差异无统计学意义(P=0.386、0.223)。A组中同期进行三尖瓣操作46例,其中1例发生左室流出道梗阻,是否同期行三尖瓣操作的术后左室流出道梗阻发生率差异具有统计学意义(1/46 vs.15/64,P=0.004),并不会造成三尖瓣反流或狭窄。Rastelli术后患儿因右室流出道病变再手术率明显高于REV手术和双根部调转术,两者差异具有统计学意义(5/14 vs.0/38,P<0.001)。结论双心室矫治室间隔缺损远离型右室双出口可以取得令人满意的远期结果。室间隔缺损连接至主动脉内隧道较室间隔缺损连接至肺动脉内隧道左室流出道梗阻发生率更高。同期进行三尖瓣处理可降低内隧道梗阻发生率。  相似文献   

16.
BACKGROUND: The straddling mitral valve in the biventricular heart is a rare condition that may complicate biventricular repair. METHODS: Treatment and outcomes in 5 consecutive patients who underwent primary repair between 1992 and 1997 were reviewed. Their ages at repair ranged from 2 months to 8 years. Three patients had a double-outlet right ventricle with a subaortic (n = 2) or subpulmonary (n = 1) ventricular septal defect. Two patients had transposition of the great arteries (S,D,D), a ventricular septal defect, and left ventricular outflow tract obstruction. The attachments of the papillary muscles of the straddling mitral valves were located on the right ventricular aspect of the ventricular septum. Four patients underwent baffle partitioning of the ventricular cavity. The baffle suture line was used to secure the chordae tendineae crossing the ventricular septal defect, or was intentionally omitted at the papillary muscle. The right ventricular outflow tract was reconstructed with patch augmentation, an extracardiac conduit, or an arterial switch operation. One patient with transposition who had a giant papillary muscle to the straddling mitral valve associated with abnormal insertion of the tricuspid valve on the conal septum underwent univentricular repair. RESULTS: There were no early or late postoperative deaths. There was no mitral valve dysfunction, left ventricular outflow tract obstruction, or heart block in the 4 patients who underwent biventricular repair. CONCLUSIONS: Although there are several exceptional situations in which ventricular partitioning may result in early and late complications, a straddling mitral valve does not preclude biventricular repair.  相似文献   

17.
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.  相似文献   

18.
OBJECTIVE: To review more than a decade of experience with complete repair of tetralogy of Fallot (TOF) in neonates at the University of Michigan; to assess early and late survival, perioperative complications, and the incidence of reoperation; and to analyze patient, procedural, and morphologic risk factors to determine their effects on outcome. SUMMARY BACKGROUND DATA: Palliation of TOF with systemic-to-pulmonary artery shunts has been the accepted standard for symptomatic neonates and infants. Complete repair has traditionally been reserved for infants older than 6 months of age because of the perception that younger and smaller infants face an unacceptably high surgical risk. RESULTS: A retrospective review from August 1988 to November 1999 consisted of 61 consecutive symptomatic neonates with TOF who underwent complete repair. Thirty-one patients had TOF with pulmonary stenosis, 24 had TOF with pulmonary atresia, and 6 had TOF with nonconfluent pulmonary arteries. The mean age at repair was 16 +/- 13 days, and the mean weight was 3.2 +/- 0.7 kg. Before surgery, 36 patients were receiving an infusion of prostaglandin, 26 were mechanically ventilated, and 11 required inotropic support. Right ventricular outflow tract obstruction was managed with a transannular patch in 49 patients and a right ventricle-to-pulmonary artery conduit in 12. Cardiopulmonary bypass time averaged 71 +/- 26 minutes. Hypothermic circulatory arrest was used in 52 patients (mean 38 +/- 12 minutes). After cardiopulmonary bypass, the average intraoperative right/left ventricular pressure ratio was 55% +/- 13%. There were no new clinically apparent neurologic sequelae after repair. The postoperative intensive care unit stay was 9.1 +/- 8 days, with 6.8 +/- 7 days of mechanical ventilation. There was one hospital death from postoperative necrotizing enterocolitis on postoperative day 71 and four late deaths, only one of which was cardiac-related. Actuarial survival was 93% at 5 years. Follow-up was available for all 60 hospital survivors and averaged 62 months (range 1-141 months). Twenty-two patients required a total of 24 reoperations at an average interval of 26 months after repair. Indications for reoperation included right ventricular outflow tract obstruction (19), branch pulmonary artery stenosis (11), severe pulmonary insufficiency (4), and residual ventricular septal defect (1). The 1-month, 1-year, and 5-year freedom from reoperation rates were 100%, 89%, and 58%, respectively. CONCLUSIONS: Complete repair of TOF in the neonate is associated with excellent intermediate-term survival. Although the reoperation rate is significant, this is to be expected with the complex right ventricular outflow tract and pulmonary artery anatomy seen in symptomatic neonates and the need for conduit replacement in patients with TOF with pulmonary atresia.  相似文献   

19.
On the basis of experience with older children, creation of a double-outlet ventricle by interposition of a valved conduit between the apex of the left ventricle and the thoracic aorta appeared to be an option for treating life-threatening left ventricular outflow tract obstruction even in the small heart of the infant. Over the recent 3 year period, nine infants ranging in age from 3 days to 13 months with various forms of left ventricular outflow tract obstruction underwent placement of an apical-aortic conduit to decompress the hypertensive left ventricle. There were two early and two late deaths. Five patients are clinically well and developing normally 5 to 23 months following the operation. This series demonstrates that this operation permits normal growth and development in infants previously failing to thrive. Echocardiographic and cardiac catheterization data suggest that left ventricular function need not be adversely affected by placement of a stent in the small infant ventricle; rather, ventricular function can be markedly improved. Although the mortality in this series is appreciable, it appears that apical-aortic conduit interposition can provide significant palliation for infants with otherwise lethal left ventricular outflow tract obstruction.  相似文献   

20.
Forty-four patients, with a mean age at surgery of 10 years, were followed for 5 to 16 years (mean 9.7 years) after relief of left ventricular outflow tract obstruction. There were no early deaths, but 5 late deaths occurred, 3 following reoperation. Twenty-five patients were recatheterized from 1 to 16 years later (mean 6.6 years). In 21 of 32 patients (66 per cent), a new diastolic murmur followed relief of valvular stenosis; 25 (78 per cent) of these patients had a postoperative diastolic murmur. Seventeen of these 25 (68 per cent) were recatheterized, and 11 of the 17 (65 per cent) had moderate-to-severe aortic incompetence on angiography. Eight patients (18 per cent) have undergone reoperation and 9 more (20 per cent) will have to be reoperated upon soon. Although the aortic valve gradient and left ventricular stroke pressure were reduced in all obstructive types after surgery, left ventricular end-diastolic pressure significantly increased and cardiac index decreased after valvotomy. Cardiomegaly and electrocardiographic (ECG) abnormalities were present in 45 and 66 per cent, respectively, of all postoperative patients. Although 93 per cent of patients may be expected to survive and 82 per cent be reoperation free at 10 years, further surgery thereafter becomes increasingly common. Timely relief of obstruction prevents sudden death and produces excellent symptomatic improvement, but the operation is only palliative. Development of a reliable pediatric valve and ventriculo-aortic conduit may encourage earlier and more aggressive therapy.  相似文献   

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