Ventricular septal defect closure in tetralogy of Fallot: the aortic rule

Ventricular septal defect (VSD) closure is an important part of the surgical repair of tetralogy of Fallot and related anomalies. Visual appreciation of the VSD size (either transinfundibular or transatrial) can be misleading. My colleagues and I describe a simple and precise way to predict the size and shape of the VSD patch before extracorporeal circulation: the patch should be circular with a diameter identical to that of the mid ascending aorta.     

Arterial patch angioplasty for reconstruction of proximal coronary artery stenosis

Background. Ostium patch angioplasty and reconstruction with an onlay patch consisting of pericardium or the saphenous vein is an alternative surgical technique for patients with proximal coronary artery stenosis. Previously described surgical techniques comprise anterior or posterior approaches. In this article we report our experience of using a segment of the proximal right internal mammary artery as an onlay patch for surgical angioplasty.

Methods. Between June 1997 and April 1999, 18 patients (9 men and 9 women) were subjected to surgical patch angioplasty of the left main coronary artery, 3 patients had an additional angioplasty performed on the proximal right coronary artery. The first 12 patients were operated with a posterior incision technique, and six subsequent patients by a new technique performed through an oblique incision into the left main stem after transsection of the ascending aorta.

Results. All patients had an uneventful postoperative course, and were fully rehabilitated without clinical symptoms of ischemic heart disease at mean follow-up of 10 months (range 1–23 months). Postoperative catheterization after six days showed excellent results with a widely open and funnel-shaped neoostium.

Conclusions. The use of a proximal segment of the right internal mammary artery as an onlay patch for reconstructing proximal coronary artery lesions is safe with no complications. Although the posterior approach may be used to obtain excellent results, transsection of the ascending aorta gives an optimal visualization and mobilization of the left main coronary artery when performing surgical angioplasty.     

Surgical Complications in Children with CDH: A Multivariate Analysis

Introduction

Several medical and surgical improvements in the treatment of congenital diaphragmatic hernia (CDH) patients have led to a higher survival rate. However, some of these improvements also lead to an increased morbidity rate. This study aims to determine the contribution different medical and surgical treatments have had on the development of surgical complications.

Method

All CDH patients treated in a single centre between 2000 and 2015 were retrospectively evaluated. Multivariate logistic regression was used to estimate the independent effects of several treatment options that could influence the surgical outcome by adjustment for multiple risk factors.

Results

Sixty of the 197 surgically repaired CDH patients had surgical complications. There were more haemorrhagic complications in the ECMO compared to non-ECMO group (27% vs. 2%, p < 0.001). The use of inhaled nitric oxide was also significantly related to haemorrhage (OR = 13.0 (95% CI 1.1–159)). After adjustment for other risk factors, chylothorax was neither significantly associated with ECMO treatment (OR = 1.6 (95% CI 0.5–5.2) nor with patch repair (OR = 2.1: 95% CI 0.7–6.1). A recurrence occurred more often in patients with pulmonary hypertension (OR = 10.0 (95% CI 1.5–65.8) and after treatment with an abdominal patch (OR = 11.3: 95% CI 1.5–84.4).

Conclusion

ECMO treatment and the inhalation of nitric oxide are used in the most severe CDH patients but are associated with a higher risk on surgical haemorrhage. The recurrence rate is associated with both the use of an abdominal patch and the presence of pulmonary hypertension, regardless of medical treatment.

     

Surgical strategy for left ventricular free wall rupture after acute myocardial infarction

BACKGROUND: Left ventricular free wall rupture is usually fatal without surgical intervention. However, the most appropriate surgical procedure remains controversial. METHODS: Seventeen patients (14 men, 3 women) who developed left ventricular free wall rupture after acute myocardial infarction were treated surgically. Their mean age was 65.4 years (range, 55 to 79 years). The following surgical procedures were performed: infarctectomy and patch reconstruction in 1 patient, direct closure with or without patch covering in 4 patients, simple patch covering anchored by running suture in 4 patients, and a sutureless technique in 7 patients. Endventricular patch closure was performed in 1 patient with ventricular septal perforation. RESULTS: One of 3 patients with a blow-out type rupture and 1 of 13 patients with an oozing type rupture died shortly after operation. The overall surgical mortality rate was 11.8%. CONCLUSIONS: Selection of the optimal procedure for each cardiac condition is important for obtaining good results. For patients with ongoing squirting bleeding, patch covering is the technique of choice. For oozing, the sutureless technique is preferable.     

Surgical treatment of right ventricular outflow tract obstruction after Tetralogy of Fallot {S,D,I} repair

Situs solitus of viscera and atria, D-looped ventricle with atrioventricular concordance, and inverted normally related great arteries with ventriculoarterial concordance characterize the segmental anatomy of an extremely rare {S,D,I} variant of Tetralogy of Fallot. The main pulmonary artery is rightward of the aorta and the right coronary artery crosses over the right ventricular outflow tract from left to right to reach the right atrioventricular groove. Our patient had undergone a neonatal repair due to persistent cyanosis with the implantation of a pericardial infundibular patch after the diagnosis of Tetralogy of Fallot {S,D,I}. He presented with an annular right ventricular outflow tract obstruction at 19 months of age. We describe the surgical approach employing a transannular patch implantation for the relief of the annular right ventricular outflow tract obstruction.     

Pseudoaneurysm formation in a subset of patients with small intestinal submucosa biologic patches after carotid endarterectomy

BACKGROUND: The carotid artery is frequently patched after carotid endarterectomy (CEA) to minimize the risks of early postoperative thrombosis and late recurrent stenosis. The small intestinal submucosa (SIS) patch is a biologic vascular patch derived from porcine small intestine. It is composed primarily of cell-free collagen and other extracellular matrix constituents that act as a scaffold for host cell deposition. METHODS: In May 2001, we began an investigational trial of SIS patches in 76 patients undergoing patch angioplasty of the carotid artery after CEA. RESULTS: No adverse events related to the patches were observed in the first 69 patients implanted with an SIS patch. However, in late 2002, seven patients were found to have asymptomatic pseudoaneurysms (PSA) by duplex imaging < or =10 weeks after their CEAs. The trial was immediately suspended. The PSAs were treated by surgical resection with vein grafting in two patients and placement of covered endoluminal stents in four patients. One patient is being followed as the PSA is small and has remained stable. Histopathologic examination of the SIS patch explanted from one of the surgically treated patients demonstrated the presence of actin-positive myofibroblasts or smooth muscle cells. Extensive mechanical testing of the SIS material from the two material lots associated with PSAs demonstrated thinner and more variable physical characteristics compared with control device lots. CONCLUSIONS: Biologic patches that undergo active remodeling in the carotid artery require greater thickness than was anticipated to decrease wall stress and suture hole elongation. Patches exceeding this minimum thickness will be required to ensure the safety of new SIS patch designs for vascular operations.     

Current usage and future directions for the bovine pericardial patch

Bovine pericardium (BP) is widely used in surgery and is commonly used as a patch after arteriotomy in cardiovascular surgery. BP patches have several advantages compared with prosthetic patches, including superior biocompatability, easy handling, less suture line bleeding, and possibly reduced rates of infection. These advantages of BP have led to its common use during carotid endarterectomy (CEA). However, long-term clinical results reported after CEA have suggested several issues that may be related to the patch, including restenosis, pseudoaneurysm formation, infection, fibrosis, calcification, and thrombosis. These complications may diminish the long-term efficacy of CEA and suggest potential areas for improvement of surgical patches. Understanding the mechanisms by which BP heals after patch angioplasty may lead to next generation tissue-engineered patches.     

The use of pulmonary autograft patch for type A aortic interruption and Swiss-cheese ventricular septal defect (VSD)

The surgical management of the aortic arch pathologies is controversial. Primary anastomosis and patch aortoplasties combined with end-to-end anastomosis have some complications like recurrence and aneurysm formation. Surgical repair of apical muscular (Swiss-cheese) defects is also still under debate. A 6-year-old patient with diagnosis of type A aortic arch interruption and Swiss-cheese ventricular septal defect (VSD) underwent successful intracardiac repair and aortic arch reconstruction. Aortic arch reconstruction was done by end-to-side anastomosis of distal aortic archus and thoracic aorta without cardiopulmonary bypass. The anterior side of the anastomosis was augmented by using pulmonary autograft patch and this patch was extended to the inferior surface of the archus aorta. Swiss-cheese VSD was repaired with a single patch using septal obliteration technique via transatrial approach. Pulmonary autograft patch aortoplasty and end-to-side anastomosis may be an alternative surgical management for surgical repair and it may be done without the need for cardiopulmonary bypass. In these patients associated multiple apical muscular VSDs can be repaired with a single patch, septal obliteration technique.     

Management of recurrent leaks following postinfarction ventricular septal defect repairs

Abstract Ventricular septal rupture (VSR) complicates acute myocardial infarction (AMI) in less than 0.2% of cases and is usually surgically managed by endocardial patch repair with infarct exclusion. Although successful in 80% of cases, failure of patch repair (often because of patch dehiscence) results in attempts at percutaneous closure as reoperative mortality can be as high as 40%. We describe a case of an AMI in a 63-year-old male with resultant VSR that required repeat surgical patch repair secondary to recurrent leak. We discuss the management of recurrent leaks and surgical techniques aimed at decreasing residual defects. (J Card Surg 2012;27:576-580).     

Double patch technique for closing acute ventricular septal perforation

Purpose  

Ventricular septal perforation (VSP) is a rare but life-threatening complication of acute myocardial infarction (AMI). Even with assisted circulation heart failure often progresses quickly, and urgent surgical intervention is required to close the VSP. For several years, we have been performing a double patch closure technique using an equine pericardial patch. In this report, we present details of our patch closure technique and the VSP surgical results; we also examine the problems we encountered.     

左冠状动脉主干血管成形术

目的介绍单一性左冠状动脉主干狭窄的外科手术方法.方法回顾性总结采用血管补片成形术治疗单一性左冠状动脉主干病变的手术结果.结果本组8例患者均存活,无围手术期心肌梗死等严重并发症发生,平均随访时间5年4个月;其中1例患者于术后6个月因心绞痛复发而行冠状动脉旁路移植术,术后无并发症发生;其余患者心绞痛症状均完全消失,并参与正常活动.结论冠状动脉主干血管成形术可作为单一性左冠状动脉主干狭窄的外科手术方式之一,但不宜用于病变血管处有管壁严重钙化的患者.     

Arterial reconstruction with detubulated aortic patch in simultaneous kidney-pancreas transplantation

Simultaneous pancreas kidney transplantation has become an accepted therapy for the treatment of patients with insulino-dependant diabetes and renal chronic failure. The arterial arrangement of the pancreatic graft is necessary in order to avoid surgical complications of vascular thrombosis. We reported three cases of simultaneous pancreas kidney, a simple procedure using aortic arterial patch preleved with the superior mesenteric artery and detubulated, than the splenic artery is directly anastomosed to the patch.     

生物型硬脑膜补片修补大鼠全层腹壁缺损

目的 探讨运用生物型硬脑膜补片修补大鼠全层腹壁缺损的可行性,并与涤纶布补片修补比较.方法 分别采用脑膜建补片和涤纶布修补12对大鼠全层腹壁缺损,术后2、8、16周分批处死大鼠采集标本,观察创面感染情况、缺损愈合速度、缺损愈合组织的厚度、镜下病理情况.结果 脑膜建补片组大鼠无死亡,12例缺损全部修复成功.涤纶组大鼠死亡2例,10例缺损修复愈合.脑膜建补片组织愈合较快,镜下炎症反应较轻,但愈合组织厚度差异无统计学意义.结论 脑膜建补片能很好地诱导结缔组织增生,修复腹壁缺损.     

Epidural blood patch as treatment for a surgical durocutaneous fistula.

We describe the first case report of an epidural autologous blood patch used for the treatment of a durocutaneous fistula caused by a surgical dural tear. The epidural blood patch cured the patient's headache and was followed by a sequelae of back pain that responded to conservative therapy.     

Reverse subclavian flap and aorto-pulmonary window technique for repair of interrupted aortic arch and truncus arteriosus

We report a surgical strategy for repairing an interrupted aortic arch (IAA) with truncus arteriosus (TA) by using a reverse subclavian flap and an aorto-pulmonary (A-P) window technique for preserving the pulmonary artery architecture. A 10-day-old neonate with type B IAA and type I TA with echocardiographic evidence of a significant distance between the ascending and descending aorta underwent surgical repair at the Bristol Royal Hospital for Children. The superior part of the arch was reconstructed using a reverse subclavian flap and the undersurface with a pulmonary homograft patch. The ascending aorta was separated from the pulmonary arteries using a Gore-Tex patch (A-P window type of repair) without disconnecting the branch pulmonary arteries, in order to preserve their architecture. The continuity between the right ventricle and the pulmonary artery bifurcation was established using a 12 mm Contegra conduit. The postoperative course was uneventful, and the neonate was discharged after 12 days. At follow-up, the patient remains well, gaining weight, with no echocardiographic evidences of obstruction. Reverse subclavian flap with homograft patch combined with and 'A-P window' technique for preservation of the pulmonary artery architecture is a useful and effective surgical strategy for neonates presenting with IAA associated with TA.     

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.     

A comparison of patch angioplasty and stenting for axillary venous stenoses of thrombosed hemodialysis grafts

The efficacy of balloon angioplasty with stent placement is compared to surgical patch angioplasty for thrombosed upper arm hemodialysis grafts with stenotic lesions at the venous anastomosis. Patients with thrombosed hemodialysis grafts terminating at the axillary vein were reviewed. Thirty-eight stents were placed after thrombectomy and venous balloon angioplasty in 26 patients. Fifteen case-matched controls underwent 23 polytetrafluoroethylene patch angioplasties for similar lesions. Kaplan-Meier survival analysis was used for statistical comparison. Primary patency for stent placement compared with patch angioplasty was not statistically different at any time through 1-year follow-up (37% vs 55% at 3 months, 25% vs 45% at 6 months, and 25% vs 15% at 12 months, respectively; p = 0.37). Secondary patency rates were slightly better for patch angioplasty compared with stent placement (78% vs 59% at 3 months, 78% vs 48% at 6 months, and 54% vs 32% at 12 months, respectively) however these differences were not statistically significant (p = 0.13). There was no difference in complication rates between groups. Sustained patency is poor for both angioplasty with stent placement and surgical patch angioplasty when revising thrombosed dialysis grafts with anastomotic axillary vein stenosis. These data suggest slightly better patency for the routine use of patch angioplasty for these lesions. However, the endovascular approach appears to be a reasonable alternative when surgical exposure is difficult.     

Complete atrioventricular canal. Anatomic study and presentation of a new technique for total correction

A new surgical technique for total correction of complete common atrioventricular canal was evolved from study of 34 specimens from affected infants who had died in the first year of life. An interventricular patch was fashioned to reconstruct the interventricular septum and the atrioventricular valves. The patch had two distinct components, one superior or atrial and the other inferior or ventricular. The division was made by inserting a lateral support at different levels on either face of the patch, to which the anterior and posterior atrioventricular cusps were sutured. The interatrial defect was closed with a patch that, together with the atrial component of the interventricular patch, produced a foramen ovale type closure mechanism. The authors present the pathologic observations which served as a basis for development of the surgical technique.     

Comparison between Gallbladder Serosal and Mucosal Patch in Duodenal Injuries Repair in Dogs

Background: One of the most challenging problems in clinical surgery is management of an extensive duodenal injury. In its management, there are limitations in using jejunal serosal patch and other conventional methods in specific conditions. This study was performed to compare treatment of large duodenal defects by a gallbladder serosal patch and the gallbladder mucosal patch in a dog as an animal model. Methods: A duodenal defect (2 cm, about 50% of the total circumference) was created in the second portion of the duodenum in eight dogs. The animals were divided into two equal groups, with group 1 undergoing serosal patch repair and group 2 undergoing mucosal patch repair. The macroscopic and microscopic healing features of the gallbladder serosal and mucosal patch were compared. Results: None of the dogs died due to surgical complications. The whole grafted area was covered by neomucosa at the end of the third week in all animals with the gallbladder serosal patch (group 1). In this group, the scar was small; no significant narrowing of lumen was noted and serosal healing was uniformly complete. In histological examination, a complete coverage of the gallbladder serosal patch by neomucosa consisting of columnar epithelium with short villous formations was observed. In mucosal patch models (group 2), complete epitheliazation, mild fibrosis, and incomplete repair were visible. In histological examination, severe inflammation was noticed too. Conclusion: In patients with multiple trauma affecting upper gastrointestinal tracts, use of the gallbladder serosal patch method is easy and reliable. So it may be considered in the surgical management of large duodenal defects, which cannot be repaired by available conventional methods.     

Repair of recurrent visceral aortic patch aneurysm after thoracoabdominal aortic aneurysm repair with a branched endovascular stent graft

Aneurysmal degeneration of the visceral aortic patch is an uncommon late complication of surgical replacement of the thoracoabdominal aorta. We report on a 70-year-old woman who had undergone previous open thoracoabdominal aortic aneurysm repair and subsequent revision surgery for a visceral aortic patch aneurysm. The patient presented with a recurrent asymptomatic 60-mm-diameter visceral aortic patch aneurysm involving the celiac axis and superior mesenteric artery. The lesion was successfully treated with a custom-designed Zenith branched endovascular stent graft. The patient remains well at 12 months.