分期双调转解剖矫治术治疗左心室退化的矫正型大动脉转位的临床疗效分析

目的评价分期双调转解剖矫治术治疗先天性左心室退化矫正型大动脉转位（CCTGA）的临床疗效。方法回顾性分析2005年5月至2011年5月北京阜外心血管病医院14例左心室退化CCTGA患儿经手术治疗的临床资料,男8例,女6例;年龄2．5～72．0（34．4-24．0）个月;体重5．1～23．0（12．7±4．9）kg。术前经超声心动图、心血管造影或心导管检查确诊。主要合并畸形：三尖瓣关闭不全13例,限制型室间隔缺损10例,房间隔缺损或卵圆孔未闭7例,动脉导管未闭4例,肺动脉瓣轻度狭窄4例,Ⅲ度房室传导阻滞1例。在全身麻醉下完成一期左心室训练术,在体外循环下完成二期心房大动脉双调转术,平均间隔时间0．67～34．0（10．23±9．47）个月。结果一期左心室训练术后无住院死亡,随访结束时形态左心室舒张期末内径（mLVEDd）及形态左心室（mLV）后壁厚度均较术前显著增加（P〈0．05）,室间隔位置较术前略向形态学有心室侧（mRV）移位,三尖瓣关闭不会（TR）较术前减轻,跨肺动脉环缩带压差显著增加（P〈0．05）,左心室射血分数（LVEF）无显著变化;形态左心室压力与形态右心室压力比值（PmLV／PmRV）显著增大（P〈0．05）。二期心房大动脉双调转术住院死亡2例,死亡率14．3％（2／14）;死亡原因：严重心律失常、循环衰竭、猝死。术后早期并发症：肺部感染6例,房性心律失常2例,胸腔积液2例,气胸、膈肌麻痹行膈肌折叠术、气道出血、主动脉瓣轻度关闭不全、腹膜透析、体外膜肺氧合辅助、二次气管内插管各l例。生存患者均痊愈出院。术后随访12例,随访时间2～8年。随访期间死亡1例,死亡率8．33％（1／12）,死亡原因：严重心律失常、循环衰竭。心功能I级8例,Ⅱ级3例。主要晚期并发症：左心功能不全3例,主动脉瓣中度关闭不全3例,二尖瓣中度关闭不全1例。结论分期双凋转解剖矫治术治疗左心室退化CCTGA早期临床疗效满意,中远期疗效尚需进一步随访观察,但术后左心功能不良和新出现的主动脉瓣关闭不全应值得关注。     

主动脉瓣置换术后室间隔厚度对主动脉瓣跨瓣压差的影响

目的 探讨主动脉瓣置换术后室间隔厚度对主动脉瓣跨瓣压差的影响.方法 2005年1月至2010年12月,接受主动脉瓣置换术患者273例,全部为单纯主动脉瓣狭窄.根据手术时使用的主动脉瓣不同品牌,将患者分为3组:Regent组、On-x组、其他品牌组.定义术后跨瓣压差大小为:轻度(0～30 mm Hg,1 mm Hg=0.133 kPa)、中度(30 ～60 mm Hg)及重度(大于60 mm Hg).分别比较术前、术后测量的左心室收缩期末径、左心室舒张期末径、左心室射血分数(EF值)和室间隔厚度.结果 3组患者术前的左心室收缩期末径、左心室舒张期末径及EF值差异无统计学意义(P＞0.05).Regent组患者,术后跨瓣压差为重度的患者术前室间隔厚度明显多于轻、中度(P＜0.05).使用On-x组患者,术后跨瓣压差为重度与中度的患者术前室间隔厚度者明显多于轻度组(P＜0.05).其他品牌组患者,术后跨瓣压差为重度的患者术前室间隔厚度明显多于中、轻度组(P＜0.05).结论 行主动脉瓣置换术后,术前室间隔厚度大于13.6 mm的患者其主动脉瓣跨瓣压差较厚度小于13.6 mm的患者显著增高.室间隔厚度大于15.3 mm的患者,应同期行室间隔部分切除或替换无支架瓣膜以减少主动脉瓣替换后的跨瓣压差.     

梗阻性肥厚型心肌病的外科治疗

目的 总结肥厚室间隔切除联合二尖瓣置换术治疗梗阻性肥厚型心肌病的手术效果和经验体会.方法 2000年1月至2007年6月,共对22例合并有中度以上二尖瓣反流的OHCM患者实施肥厚室间隔切除联合二尖瓣置换术.其中男性20例,女性2例;年龄28～51岁,平均(36±5)岁.左心室流出道压差55～120 mm Hg(1 mm Hg=0.133 kPa),平均(88.0±15.8)mm Hg.分析比较患者术前超声心动图,术中经食管心脏超声,以及术后10 d,6个月、1年超声心动图的结果 .结果 术后因顽固性室性心律失常死亡1例.术中经食管超声示所有患者二尖瓣前叶收缩期前向运动现象消失.存活的21例患者均获随访,术后各时间点左心室流出道压差和室间隔厚度均较术前下降(P<0.01).结论 肥厚室间隔切除联合二尖瓣置换术治疗合并中度以上二尖瓣反流的梗阻性肥厚型心肌病,近中期手术效果可靠,并发症少.     

右胸微创手术治疗肥厚型梗阻性心肌病合并中度以上二尖瓣反流

目的探讨经右胸微创切口采用改良扩大Morrow手术及"缘对缘"二尖瓣成形术治疗肥厚型梗阻性心肌病(HOCM)合并二尖瓣反流(MR)的疗效及安全性。方法 2008年1月至2018年6月,我科经右胸微创切口采用改良扩大Morrow手术及"缘对缘"二尖瓣成形术治疗HOCM合并中度以上MR 54例,其中男31例、女23例,年龄(47.1±12.6)岁。患者术前均合并二尖瓣收缩期前向运动(SAM)现象。术前平均左心室流出道峰值压差(93.6±32.8)mm Hg,平均室间隔厚度(24.8±2.8)mm。结果全组患者均顺利完成手术。围术期无死亡病例,无转为胸部正中切口手术,无室间隔穿孔发生。1例(1.9%)患者因完全性房室传导阻滞安装心脏永久起搏器。出院前复查经胸超声心动图,平均左心室流出道峰值压差(18.1±6.2)mm Hg,平均室间隔厚度(14.5±2.1)mm,均较术前明显改善(P0.05);二尖瓣关闭良好,无二尖瓣狭窄发生,无SAM现象。术后随访6～132个月,无死亡病例,无晚期永久起搏器植入,复查经胸超声心动图,平均左心室流出道峰值压差(19.4±5.7)mm Hg,平均室间隔厚度(14.2±1.5)mm,无SAM现象。结论经右胸微创切口采用改良扩大Morrow手术及"缘对缘"二尖瓣成形术治疗HOCM合并MR安全、有效,不仅可有效解除左心室流出道梗阻,而且可有效消除MR及SAM现象,早、中期治疗效果满意。     

改良Morrow手术治疗肥厚型梗阻性心肌病的疗效分析

目的比较采用经典Morow术与改良Morrow术治疗肥厚型梗阻性心肌病的疗效。方法选取2005年1月至2011年7月在北京安贞医院接受手术治疗的42例肥厚型梗阻性心肌病患者。根据手术方式不同将患者分为两组。传统Morrow组16例,男13例、女3例,年龄（49±15）岁;改良Morrow组26例,男14例、女12例,年龄（40±18）岁。改良Morrow术是在经典Morrow手术的基础上,扩大室间隔的切除范围,切除范围由经典的2～3cm扩大达到5～6cm,向下切除范围由经典的单纯室间隔基底部扩大到心尖部;同时根据二尖瓣的结构情况,进行二尖瓣乳头肌松解、二尖瓣前叶横向折叠成形、“缘对缘”二尖瓣成形或瓣膜置换。术前术后均进行超声心动图检查,比较两组室间隔厚度、左心室流出道流速及左心室流出道压差的差异。结果肥厚型梗阻性心肌病患者通过经典Morrow术与改良Morrow术治疗后,室间隔厚度、左心室流出道流速及左心室流出道压差均较术前显著降低。经典Morrow术患者的室间隔厚度[（23．10±3．64）mm vs．（17．38±4．39）mm]、左心室流出道流速[（433．08±101．68）mm／s vs．（248．46±101．88）mm／s]、左心室流出道压差[（78．57±40．16）mmHg vs．（4．29±21．52）mmHg]术前和术后差异均有统计学意义（P〈0．05）。改良Morrow术患者的室间隔厚度[（25．04±7．05）mm vs．（18．38±6．55）mm,P〈0．05]、左心室流出道流速[（414．83±83．33）mm／s vs．（159．72±60．84）mm／s,P〈0．05]、左心室流出道压差[（77．94±29．16）mmHg vs．（17．56±9．39）mmHg,P〈0．05]术前和术后差异均有统计学意义（P〈0．05）。改良Morrow手术患者手术前后左心室流出道压差的变化程度较经典Morrow患者更明显[（74．25±27．91）mmHg vs．（34．63±30．66）mmHg,P〈0．05]。结论改良Morrow术可明显减低肥厚型梗阻性心肌病患者左心室流出道压差,效果优于经典Morrow术。     

肺动脉环缩术在矫正型大动脉转位形态学左心室功能锻炼中的应用

目的探讨肺动脉环缩术在矫正型大动脉转位形态学左心室功能锻炼的临床应用效果。方法回顾性分析2007年1月至2011年12月上海交通大学医学院附属上海儿童医学中心手术治疗矫正型大动脉转位患者89例中行肺动脉环缩术11例的临床资料,其中男9例,女2例;年龄除1例12岁外,其余为3～42(16.40±11.67)个月;体重6～32(11.70±7.20)kg。所有患者均经超声心动图和心血管造影检查确诊。结果 11例行肺动脉环缩术患者无死亡,术前肺循环与体循环压力比(Pp/Ps)值0.3～0.6(0.44±0.09),术后为0.6～0.8(0.70±0.04),差异有统计学意义(P<0.01)。术前三尖瓣反流轻度2例(18.2%),中度5例(45.4%),重度4例(36.4%);术后无反流2例(18.2%),轻度反流7例(63.6%),轻-中度反流2例(18.2%)。11例中5例术后(15.20±8.31)个月行二期双心室解剖纠治术,其中1例死亡;余6例行单纯肺动脉环缩术后随访(18.83±3.43)个月,超声心动图检查提示:三尖瓣反流轻微2例(33.3%),轻度3例(50.0%),中度1例(16.7%)。结论矫正型大动脉转位通过肺动脉环缩术可减轻三尖瓣反流,锻炼形态学左心室功能,为二期解剖纠治做好准备,手术效果较好。但术后必须定期随访,观察术后形态学左心室功能和三尖瓣反流情况。     

快速二期大动脉转位术的左心室功能判断

目的 总结完全性大动脉转位行快速二期大动脉转位术的左心室功能锻炼结果,探讨判断左心功能锻炼效果的指标和二期大动脉转位术的最佳手术时机.方法 2002年9月至2007年9月21例患者接受快速二期大动脉转位术.其中男性13例,女性8例;手术年龄29～250 d,中位数75 d,平均(103±69)d;体质量3.5～7.0 kg,中位数5.0 kg,平均(5.0±1.2)kg.所有患者先行一期左心功能锻炼术,术后常规隔天复查床旁超声心动图.测量左心室舒张末期内径、左心室后壁舒张期厚度和舒张期室间隔厚度,根据公式计算左心室质量和左心室质量指数.结果 两次手术平均间隔(9±5)d.一期术后,左右心室压力比从术前的0.47±0.15上升至0.91±0.20(P＜0.01).左心室质量指数从(30±11)g/m2上升至(63±20)g/m2(P＜0.01).一期术前与二期大动脉转位术前的左心室舒张末期内径、左心室舒张末期容积、左心室后壁舒张期厚度以及舒张期室间隔厚度,差异有统计学意义(P＜0.05).结论 左心功能退化的完全性大动脉转位患者,经左心室锻炼术后左心功能可得到锻炼恢复.左心功能锻炼期的时间为7～10 d.左右心室压力比大于0.65,左心室质量指数50g/m2是判断左心功能锻炼结果的主要指标.

Abstract：

Objectives To Summarize the results of left ventricle retraining in rapid two-stage switch operation and to determine the estimating index of left ventricle retraining and the best time of the second stage operation. Methods From September 2002 to September 2007, 21 patients underwent rapid two stage switch operation. There were 13 male and 8 female patients, ageing from 29 to 250 d [mean ( 103±69) d, median 75 d], weighting from 3.5 to 7.0kg [mean (5.0 + 1. 2) kg, median 5.0 kg]. After pulmonary band, bedside echocardiography was regularly done every other day. Paired t-test was used to analyze the changes of left ventricular end-diastolic dimension ( LVDd ), left ventricular posterior wall dimensions ( LVPWd), diastolic intra-ventricular septal dimensions ( IVSd), left ventricular (LV) mass and LV mass indexed for body surface area. Results The mean interval was ( 9 + 5 ) d. After the left ventricle preparative operation, the left ventricular to right ventricular pressure ratio (pLV/RV) raised from 0.47 +0. 15 to 0.91 ±0.20 (P＜0.01). LV mass indexed for body surface area raised from (30+11) g/m2 to (60±20) g/m2(P＜0.01). Extremely significant difference of LV mass existed between pre-arterial switch operation and pre-left ventride preparative operation, and significant difference existed in LVDd,LVDd3, LVPWd and IVSd between the two operative timing points. Conclusions The left ventricular function of the transposition of the great arteries can be retraining by the left ventride preparative operation. The interval of left ventricle retraining should be controlled in 7 to 10 d, and the pLV/RV reach 0. 65 and the LV mass index over 50 g/m2 are two important indicators of the second stage operation of arterial switch operation.     

三尖瓣瓣环扩张伴轻度反流的二尖瓣置换术患者同期行三尖瓣成形术的随机对照试验

目的分析三尖瓣瓣环扩张伴轻度三尖瓣反流(TR)的二尖瓣置换术(MVR)患者同期行三尖瓣成形术对患者心功能及TR程度的影响,为临床决定是否为二尖瓣置换术(MVR)患者同期处理三尖瓣瓣环扩张伴轻度三尖瓣反流(TR)提供客观依据。方法纳入2013年4~10月四川大学华西医院心脏大血管外科36例需施行MVR的患者,术前超声心动图提示全组患者轻度TR、且三尖瓣瓣环舒张期末内径/体表面积21 mm/m2。36例患者被随机分为三尖瓣成形组(TAPG组,n=18,其中男7例、女11例)和非三尖瓣成形组(NTAPG组,n=18,其中男6例、女12例),术后1周、半年复查超声心动图。结果两组患者的年龄、性别、心律、体表面积、术前心功能分级(NYHA)、左心房径(LAD)、左心室径(LVD)、右心房最大长轴径(RAmla)、右心房中部短轴径(RAmmd)、心尖四腔心中部的右心室径(RVD2)、左心室射血分数(LVEF)、左心室短轴缩短分数(LVFS)之间的差异无统计学意义(P0.05)。两组患者术后半年左心房室径较术前减小(P0.05)。TAPG组患者术后半年左心室长轴切面的右心室径(RVD1)、舒张期右心室游离壁厚度(RVWT)、三尖瓣瓣环舒张期末内径(TVAEDD)、三尖瓣瓣环收缩期末内径(TVAESD)较术前减小(P0.05),三尖瓣环缩短分数(PSTVA)较术前差异无统计学意义(P0.05),TR程度较术前减轻(P0.05),右心室面积变化分数(RVFAC)、右心室射血分数(RVEF)较术前增加(P0.05);NTAPG组患者术后半年RVD1、RVWT较术前增加,TVAEDD、TVAESD、PSTVA较术前差异无统计学意义(P0.05),3D RVEF较术前减小(P0.05),RVFAC增加但小于同期TAPG组患者,TR程度构成比改变(P0.05),但术后出现6例中度及中度以上TR。结论三尖瓣瓣环扩张伴轻度TR的MVR患者同期行三尖瓣成形术将更有利于患者RVD1、RVWT及TVAEDD、TVAESD的减小,TR程度构成比的改善,RVFAC及RVEF的升高。     

外科治疗肥厚型梗阻性心肌病的近中期疗效评价

目的探讨肥厚型梗阻性心肌病(HOCM)的外科治疗以及手术近中期疗效。方法回顾性分析2010年6月至2013年12月于武汉亚洲心脏病医院心外科行改良扩大Morrow手术治疗65例HOCM患者的临床资料,其中男40例、女25例,年龄18~70(48.4±11.5)岁。结果全组无住院死亡,手术无瓣叶损伤及室间隔穿孔发生。手术后LVOTG、室间隔厚度(IVS)、左心室射血分数(LVEF)、左心室舒张期末内径(LVEDD)以及二尖瓣反流(MI)程度均较术前降低,差异有统计学意义(P0.05)。术后发生完全性房室传导阻滞3例,完全性左束支传导阻滞7例,左前分支传导阻滞3例。术后所有患者均随访,随访时间6~35个月,55例(84.6%)患者临床症状消失,其余10例患者症状较术前明显减轻。随访期患者纽约心功能分级(NYHA)为Ⅰ~Ⅱ级。结论室间隔心肌切除术可以解除左心室流出道梗阻,消除或明显改善患者临床症状,具有满意的近中期疗效。     

左室训练术在婴幼儿大动脉转位分期手术中的应用

目的总结左室训练术在婴幼儿大动脉转位分期手术中的经验。方法2001年1月至2011年12月北京阜外心血管病医院对38例室间隔完整的大动脉转位及合并限制性小室间隔缺损的大动脉转位患儿施行了左室训练手术,其中男26例、女12例,年龄（19．1±7．7）个月,体重（7．6±4．7）埏。术前动脉血氧饱和度72．6％±9．1％。左室训练术包括体动脉肺动脉分流术和肺动脉环缩术。3例需要同期行房间隔开窗术。术后对患儿进行随访观察。结果本组患儿术后动脉血氧饱和度从术前72．6％4±9．1％上升至83．9％±8．1％,左右心室压力比从术前的0．364±O．04上升至0．75±0．09。全组死亡3例,死亡率7．89％。随访35例,随访时间2～11年,随访期间行二期动脉调转手术23例。结论对于超过新生儿期已经发生左心室退化的大动脉转位患儿,左室训练术可以安全有效的施行,为二期做动脉调转手术提供必要的条件。     

Left ventricular reconditioning and anatomical correction for systemic right ventricular dysfunction

The morphologically right ventricle (mRV) fails after managing systemic workload for a variable period of time in some patients with transposition of the great arteries (TGA) who have undergone an atrial switch operation and in patients with congenitally corrected transposition of the great arteries (cc-TGA). Conventional therapy for progressive mRV failure, including tricuspid valve replacement and cardiac transplantation, has been disappointing. Anatomical correction, reincorporating the morphologically left ventricle (mLV) into systemic circulation, was performed in a total of 84 patients (39 TGA, 45 cc-TGA) in 2 institutions (Royal Children Hospital 1981-1993; Cleveland Clinic Foundation 1993-1999). The mVL was retrained to generate systemic pressure by means of pulmonary artery band in 43 patients. The overall mortality for patients entering this program is 15.4% (8 early and 5 late operative deaths). All of the operative deaths were patients with TGA and a prior atrial switch operation. Four patients (5%) have been transplanted or are on a transplantation waiting list. In patients with TGA and previous atrial switch operation, older age and abnormal coronary anatomy was associated with a higher operative mortality. None of the measured parameters of the mLV and mRV were predictors of failure of mLV reconditioning. Follow-up echocardiographic evaluations of the 46 survivors of anatomical correction showed normal mRV function in 41 (89%) and normal mLV function in 42 patients (91%). mLV retraining and anatomical correction produces good results in prepubescent patients. The response of older patients is less predictable and associated with a higher early and late mortality. Copyright © 2000 by W.B. Saunders Company     

Blood pressure independent effects of nitrendipine on cardiac structure in patients after renal transplantation

Left ventricular hypertrophy is well established as a blood pressure independent cardiovascular risk factor in patients on renal replacement therapy. The effects of antihypertensive treatment on myocardial structure and function in renal transplant recipients have been so far only rarely investigated. In a double-blind, placebo-controlled study patients were randomized to the calcium channel blocker nitrendipine or placebo if the transplanted kidney had developed a stable phase. Normotensive patients received nitrendipine 2 x 5 mg daily or placebo, hypertensive patients received 2 x 10 mg up to 2 x 20 mg nitrendipine daily or placebo. To achieve adequate blood pressure control, all patients with still elevated blood pressure on study medication received antihypertensive drugs other than calcium channels blockers. Ambulatory blood pressure recording and 2D-guided M-mode echocardiography were performed at baseline and upon completion of the study. In addition, laboratory workup (including serum creatinine and lipids) was done, and serum aldosterone, plasma renin activity, plasma angiotensin II and blood glucose levels were measured in all patients at baseline and after at least 12 months of therapy. Ambulatory blood pressure was almost identical between both groups at study baseline and follow-up. In renal transplant patients on nitrendipine, posterior wall thickness (-0.10 +/- 1.77 mm) and septal wall thickness (-0.83 +/- 2.23 mm) did not change significantly from baseline. In contrast, posterior wall thickness (0.71 +/- 0.92 mm, P < 0.01) and septal wall thickness (0.97 +/- 2.20 mm, P < 0.05) increased in patients on placebo, which differed from the observed changes on nitrendipine (ANOVA: P = 0.093 and P = 0.048, respectively). Relative wall thickness, a parameter for concentric left ventricular hypertrophy, became numerically smaller on nitrendipine therapy from 0.46 +/- 0.07 to 0.44 +/- 0.09 (-0.02 +/- 0.09, NS) but increased from 0.42 +/- 0.08 to 0.48 +/- 0.08 in the placebo arm (+0.04 +/- 0.08, P < 0.02), which was also significant between the two groups (ANOVA: P = 0.036). Endocrine parameters, lipids and blood glucose were not different between the two groups. We conclude from these data that the calcium channel blocker nitrendipine exerted beneficial effects on cardiac structure in patients after renal transplantation independent of blood pressure.      

成人Ebstein’s畸形的临床特征及外科治疗策略

目的探讨成人Ebstein’s畸形的临床特征及外科治疗策略。方法 2008年1月至2011年12月阜外心血管病医院手术治疗成人Ebstein’s畸形78例,其中男24例,女54例;年龄18~54（33.0±9.5）岁。术前心功能分级（NYHA）Ⅰ~Ⅱ级72例,Ⅲ级以上6例。临床表现主要为运动耐力下降和活动后心累。术前二维超声心动图示三尖瓣隔瓣下移20~60（34.8±12.7）mm,隔瓣严重发育不良或缺如3例;后瓣下移20~70（46.8±11.6）mm,后瓣缺如1例;三尖瓣瓣环明显扩大为37~70（60±10）mm;平均房化心室占右心室约40%;三尖瓣中量反流18例,中大量反流60例。75例行三尖瓣成形术。除2例未处理房化心室外,余均进行了房化心室折叠（56例）或房化心室去除（20例）。32例应用了人工三尖瓣瓣环。3例行三尖瓣置换术。结果术后死亡2例,死亡率2.5%。患者术后恢复尚可,无严重房室传导阻滞等其他并发症。出院前常规检查提示三尖瓣功能良好,无三尖瓣中度以上反流。平均随访时间26个月,无1例需要再次手术。结论成人Ebstein’s畸形患者急性心功能衰竭发生率低。外科治疗以成形为主,术后可达到外科治疗的主要目的,即改善心功能、增加患者的远端耐力和改善生活质量。     

Regional differences in myocardial work of the left ventricle in patients with idiopathic dilated cardiomyopathy: Implications for the surgical technique used for left ventriculoplasty

OBJECTIVES: In this study we measured regional myocardial work of the left ventricle in patients with dilated cardiomyopathy and examined the existence of regional differences in myocardial work. BACKGROUND: Left ventriculoplasty aims to improve the ejection fraction by excluding a region with decreased wall motion and decreasing wall tension. If regional differences in myocardial work are present, left ventriculoplasty will be more effective when a region with decreased myocardial work is excluded. METHODS: The study group consisted of 10 patients with idiopathic dilated cardiomyopathy. Regional work of the ventricle normalized to a unit volume of myocardium (RWM) is given as follows: RWM = -integral sigma(d)[ln(1/H)], where sigma is mean wall stress, and H is wall thickness of the region. After right-sided catheterization, left ventricular pressure was measured with a 3F micromanometer catheter. Echocardiography was performed simultaneously, and a short-axis view of the left ventricle at the level of the papillary muscles was obtained. The derived M-mode image was recorded with left ventricular pressure. sigma-ln(1/H) relations for the ventricle were delineated, and regional work of the interventricular septum and posteroinferior wall were determined. Relationships between regional work of the myocardium and wall thickness, interventricular septal regional work of the myocardium and right ventricular systolic pressure, and right ventricular ejection fraction were also studied. RESULTS: Interventricular septal regional work ranged from -0.84 to 3.34 mJ/cm3 (0.74 +/- 1.51 mJ/cm3). Posteroinferior wall regional work ranged from 1.59 to 4.29 mJ/cm3 (2.77 +/- 0.86 mJ/cm3). In the study group, interventricular septal regional work was lower than posteroinferior wall regional work (P <.05). In 8 of these 10 patients, interventricular septal regional work was lower than posteroinferior wall regional work. In the other 2 patients, conversely, interventricular septal regional work was higher than posteroinferior wall regional work. CONCLUSIONS: The existence of differences in regional work between the interventricular septum and the posteroinferior wall suggests the importance of the evaluation of regional work in the selection of an effective treatment for dilated cardiomyopathy.     

Midterm results of surgical treatment of systemic ventricular outflow obstruction in Fontan patients

BACKGROUND: Achieving unobstructed blood flow from the systemic ventricle to the aorta is important during the Fontan procedure for complex cyanotic congenital heart disease when there is systemic ventricular outflow obstruction (SVOO). Because SVOO can progress after the Fontan procedure if there is morphologic obstruction, we have adopted a policy of relieving obstructions to systemic blood flow. METHODS: Twenty-five patients were treated by the Fontan procedure with SVOO. Twenty-one patients had undergone prior pulmonary artery banding and 10 patients had undergone prior arch repair. Systemic ventricular outflow obstruction progressed in 5 patients after the Fontan procedure. Main diagnosis was single ventricle in 12, tricuspid atresia in 5, transposition of the great arteries in 4, double-outlet right ventricle in 3, and common atrioventricular canal in 1. Mean age at operation was 6.5 years (range 1 to 15 years) and the average preoperative pressure gradient across the ascending aorta and systemic ventricle was 29 mm Hg (range 0 to 100 mm Hg). The Damus-Kaye-Stansel procedure was performed in 18 patients (double-barrel anastomosis in 13, end to side anastomosis in 5), and subaortic resection or ventricular septal defect or bulboventricular foramen enlargement was performed in 7. Double-barrel anastomosis has been our first choice since 1994, if the pulmonary valve is intact. Follow-up has ranged from 4 months to 14 years (average 5.0 years). Twenty-three of the 25 patients have undergone recatheterization (average 21.4 months later). RESULTS: No early deaths were found; one late death was reported of a patient with single right ventricle (4.0%). The postoperative average pressure gradient was 1.1 mm Hg (0 to 10 mm Hg), and the average right atrial pressure was 14 mm Hg (9 to 20 mm Hg). In all patients who underwent ventricular septal defect or bulboventricular foramen enlargement, regular sinus rhythm was maintained postoperatively. Regarding the Damus-Kaye-Stansel procedure, there was minimal progression of semilunar valve insufficiency except in 1 patient who underwent end-to-side anastomosis with moderate pulmonary regurgitation postoperatively. CONCLUSIONS: The midterm results of the Fontan procedure with SVOO have been satisfactory. Because SVOO might progress after the Fontan procedure if there is morphologic obstruction, an appropriate strategy to relieve obstruction to systemic blood flow should therefore be performed concomitantly with the Fontan procedure.     

Left ventricular wall stress and thickness in complete transposition of the great arteries. Implications for surgical intervention

The effects of volume and pressure loading of the left ventricle on posterior wall thickness and left ventricular wall stress in transposition of the great arteries were studied by combining echocardiographic and cardiac catheterization data. Pure volume loading with low left ventricular pressure resulted in little or no thickening of the left ventricular posterior wall (0.52 mm/log month). Pressure loading to levels above half of the right ventricular pressure was associated with thickening (2.80 to 3.89 mm/log month); however, further increase in pressure or volume load did not significantly alter the rate of thickening. Estimates of ventricular wall stress using a simple radius/wall thickness ratio may be misleading. However, if allowance is made for variable ventricular geometry and pressure, estimated wall stress is constant in transposition and is approximately equal to that reported previously in patients with normally related great arteries. The walls of low-pressure left ventricles in patients with transposition are demonstrably thinner than those of high-pressure left ventricles by age 1 to 3 months (2.67 versus 3.52 mm). Surgical procedures to use the left ventricle for systemic work, such as the arterial switch operation, should be performed in the first month of extrauterine life. Preparatory operations, if necessary prior to arterial switch, should load the left ventricle to greater than half systemic pressure.     

Two-stage Jatene procedure after Mustard or Senning operation]

We have successfully performed a two-stage Jatene procedure in four patients who showed severe anatomical right ventricular dysfunction after atrial switch (Mustard or Senning) operation for transposition of the great arteries. All four patients developed an adequate left ventricular pressure for the arterial switch operation by one or two-stage pulmonary artery banding. Left ventricular posterior wall thickness increased sufficiently enough after the banding although left ventricular ejection fraction showed significant decrease. After Jatene procedure left ventricular ejection fraction recovered, and RV end-diastolic volume which had been prominently enlarged preoperatively was dramatically normalized. Cardiac index increased from 3.6 +/- 1.6 l/min/m2 preoperatively to 5.3 +/- 6.1 l/min/m2 postoperatively with the decrease in left atrial pressure. Postoperative electrophysiological study revealed the recovery of sinus node function and atrial conduction by means of the take-down of atrial switch operation previously performed. We conclude that the Jatene procedure should be an ideal alternative in patients with right ventricular dysfunction after atrial switch operation. The left ventricle could be prepared by an effective pulmonary artery banding in most instances.     

Remote control of pulmonary blood flow: initial clinical experience

OBJECTIVE: After positive experimental results were obtained with the FloWatch-R-PAB (EndoArt S.A., Lausanne, Switzerland), an implantable device for pulmonary artery banding with telemetric control, it was tested in a prospective, multicenter clinical trial. METHODS: From June to September 2002, 6 patients with a mean age of 10.6 months (1-31 months) and a mean weight of 6.5 kg (3.5-11 kg) underwent pulmonary artery banding with the implantation of the FloWatch-R-PAB device through median sternotomy (4 patients) or left thoracotomy (2 patients). The diagnoses were the following: univentricular heart (2 patients), complete atrioventricular septal defect (2 patients), ventricular septal defect (1 patient), and multiple ventricular septal defects with double aortic arch (1 patient). The associated procedures were atrioseptostomy with cardiopulmonary bypass (2 patients), closure of patent ductus arteriosus (2 patients), and division of double aortic arch (1 patient). RESULTS: In a mean follow-up of 7 months (6-9 months), there were no early or late deaths, reoperations, or device-related complications. A mean of 5 regulations per patient (range 2-14) were required to adjust the tightening of the pulmonary artery banding, 50% (15/30) within the first postoperative week, 20% (6/30) during the second week, and 30% (9/30) within 8 months after surgery. In 70% (21/30) of the cases, the regulation was required to further narrow the pulmonary artery, and in 30% (9/30) of the cases, the regulation was required to release the pulmonary artery. CONCLUSIONS: The initial trial confirmed the adequate functioning of the FloWatch-R-PAB device as telemetrically adjustable pulmonary artery banding. Repeated pulmonary artery banding adjustments, dictated by the clinical need in all patients even weeks after surgery, were accomplished without need for reoperation or invasive procedures. In children requiring pulmonary artery banding, the therapeutic strategies can be expanded by this promising technology. This device should be particularly indicated in patients with transposition of the great arteries requiring left ventricular retraining.