Experimental use of intercostal muscle flaps for repair of induced cardiac defects

Intercostal muscle flaps were successfully used to repair 3 cm defects of the ventricular myocardium in the mongrel dog. Early and late healing of all flaps was uncomplicated and there were no late complications related to aneurysmal formation or electrical abnormalities of the heart. The existing blood supply of the heart was unaffected. The intercostal muscle is suggested as an alternative muscle flap for use in myocardial wall reconstruction.     

Transcatheter repair of recurrent postinfarct ventricular septal defects

Surgical repair of recurrent postmyocardial infarction septal defect is associated with a high mortality rate. We present 2 patients whose recurrent defects were closed percutaneously using an Amplatzer device.     

Successful repair of multiple muscular ventricular septal defects using a unique hybrid procedure

The surgical management of multiple muscular ventricular septal defects (mVSDs) in the infant remains a challenging problem because of the presence of residual shunts and postoperative myocardial dysfunction. We present a case of successful repair of multiple mVSDs with a unique hybrid procedure combining both the perventricular closure and open surgical repair.     

Apical right ventriculotomy for closure of apical ventricular septal defects

Background

Apical ventricular septal defects (VSDs) are difficult to visualize through a transatrial approach, while the use of a left ventriculotomy may result in progressive ventricular dysfunction. Transcatheter closure has not been reliable, especially in small infants. Apical right ventriculotomy provides good exposure, preserves left ventricular function, and allows secure closure of apical VSDs.

Methods

From November 1994 through April 2002, nine children, median age 8 months (range, 74 days to 2.5 years) underwent 10 operations for VSD closure via apical right ventriculotomy (one patient with a residual defect underwent successful VSD closure via a second apical right ventriculotomy). Two patients were status post pulmonary artery banding and two patients had previous unsuccessful attempts at closure via a transatrial approach.

Results

There was no hospital mortality; there were 2 late deaths (78% survival; 95% confidence interval [CI], 45% to 94%), 3 months and 4 years postoperatively. Postoperative echocardiography demonstrated no residual VSDs in 3 and insignificant residual VSDs in 4 of the survivors. All survivors currently exhibit normal biventricular function during a median follow-up of 25 months (range, 11 to 104 months).

Conclusions

Apical right ventriculotomy provides excellent exposure allowing safe and effective closure of apical VSDs. The observed late morbidity and mortality reflects the complexity that often exists in these cases due to additional irreparable lesions.     

Internal right ventricular band for multiple ventricular septal defects in a neonate undergoing arterial switch and aortic arch repair

A neonate presented with d-transposition of the great arteries, aortic arch hypoplasia, aortic coarctation, and multiple ventricular septal defects. During the arterial switch procedure and the aortic arch repair, a fenestrated Gore-Tex disk (W.L. Gore & Assoc, Flagstaff, AZ) was sewn into the right ventricular outflow tract to restrict pulmonary blood flow. The internal right ventricular band successfully controlled the pulmonary blood flow, maintaining a systemic oxygen saturation of 88% to 92%, and allowing growth from 3.5 to 10.5 kg. At 8 months of age, the internal band in the patient was removed, and the ventricular septal defects were successfully closed.     

Experience with repair of muscular trabecular ventricular septal defects]

We reviewed the records of 9 pediatric patients with muscular trabecular ventricular septal defects undergoing repair between April 1994 and June 1998 (mean age 2.6 +/- 3.1 years, mean weight 9.0 +/- 5.2 kg). The prevalence rate for muscular trabecular defects in the patients undergoing open-heart surgery for congenital heart disease was 2.0%. Although only 6 of the 9 patients were diagnosed as having muscular trabecular defects preoperatively, 60 degrees left anterior oblique and 30 cranially tilted projections of left ventricular cineangiocardiogram were useful to detect these defects. The technique of filling the left heart with blood by stopping to vent the left heart and inflating the lungs during the last one or two ligatures in closure of the defects was also useful to detect these defects intraoperatively. In closure of muscular trabecular defects, division of some trabeculations including a moderator band enabled complete repair through a right atriotomy. The nearer the inferior border of the ventricular septal defects were to the heart apex, the more postoperative residual shunts were left. We consider that apical left ventriculotomy may be needed in apical defects, although the right atrial approach is satisfactory for most muscular trabecular defects.     

Surgical closure of apical ventricular septal defects through a right ventricular apical infundibulotomy

BACKGROUND: We present a new understanding of the anatomic position of apical ventricular septal defects and its surgical relevance. These defects occur between the left ventricular apex and the infundibular apex, rather than between the left and right ventricular apices. Often a sizable apical recess, the infundibular apex lies anteriorly and inferiorly to the moderator band and is the most leftward part of the right ventricle. METHODS: Four patients (2 boys and 2 girls) with a mean age of 109 days (range, 48 to 217 days) underwent patch closure through an apical infundibulotomy, which allowed complete visualization of the muscular apical ventricular septal defect. RESULTS: There were no early or late deaths at operation. No significant residual shunt at ventricular level was detected by postoperative two-dimensional and Doppler echocardiography. Intraoperative comparison of right atrial and pulmonary arterial blood samples showed a difference of less than 5%. At a mean follow-up of 18 months, all the patients are asymptomatic and growing well. CONCLUSIONS: The successful outcome of these 4 patients indicates that surgical closure of apical ventricular septal defects can be achieved safely and completely in early infancy through a limited right ventricular apical infundibulotomy. Long-term follow-up of these and similar patients is needed to provide further evaluation of this approach.     

The use of muscle flaps in the repair of aortic defects

The successful repair of an infected arterial anastomosis is often hampered by the need to leave prosthetic material at the site of infection. To determine whether an aortic defect could be repaired by direct closure with a muscle flap, thereby eliminating the need for prosthetic material, we subjected 33 young pigs weighing 17 to 19 kg to a left lateral thoracotomy under sterile conditions. An aortic defect 2 cm in diameter was created in the descending thoracic aorta just distal to the origin of the left subclavian artery. In one group (n = 11), this defect was patched with a freshly harvested but devascularized segment of chest wall muscle. In another group (n = 22), the aortic defect was patched with a vascularized chest wall muscle flap. Pigs were followed for up to 12 weeks and evaluated by arteriography and postmortem examination. There were no deaths or vascular complications attributable to the muscle flap repair in any pig. Pseudointimal formation began within 24 hours postoperatively and was of comparable thickness to the original arterial wall by 12 weeks. No aneurysmal changes were noted in any animal, and normal aortic luminal dimensions were preserved despite a tripling in mean body weight over the 12 week period. The loss of flap viability appeared to offer no threat to vascular integrity, as the free muscle patches, although undergoing cell necrosis and substantial remodeling, remained intact. These results demonstrate the short-term feasibility of using viable muscle flaps to patch aortic defects in situations wherein the use of prosthetic material would be undesirable.     

Surgical repair of post infarction ventricular septal defects: a national experience.

OBJECTIVES: Ventricular septal rupture is a rare but feared complication after acute myocardial infarction. Most reports about outcome after surgical treatment are single center experiences. We investigated the results after surgical repair in all patients in Sweden during a 7-year period. METHODS: All patients undergoing surgical repair 1992-1998 were identified with the aid of the Swedish Heart Surgery Registry. The patients (n=189, 63% men, mean age 69+/-8 years) were operated at 10 different centers. Pre-and peri-operative variables were collected from the Registry and individual patient charts. Mortality was calculated and a Cox proportional hazards regression model was used to identify independent predictors for early and late mortality. Mean follow-up was 2.4 years. RESULTS: Seventy-seven of the 189 patients died within 30 days (41%). Urgent repair (Risk Ratio 4.2 (2.0-8.9), P<0.001) and posterior rupture (RR 2.1 (1.3-3.4), P=0.002) were independent predictors of 30-day mortality. Total cumulative survival (Kaplan-Meyer) was 38% at 5 years. For patients that survived the first 30 days (n=112), 5 year cumulative survival was 67%. Independent predictors for mortality after 30 days were number of concomitant coronary anastomoses (RR 1.5 (1.2-2.0), P=0.001), residual postoperative shunt (RR 2.7 (1.4-5.4), P=0.004) and postoperative dialysis (RR 3.4 (1.5-7.5), P=0.003). CONCLUSIONS: Early mortality after surgical repair of post infarction septal rupture is still considerable. Early repair and posterior rupture are predictors of early mortality. Long-term survival in patients surviving the immediate postoperative period is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt.     

Closure of defects of the dura mater using flaps of autologous periosteum

The author has used for closure of the defects of dura mater the periosteal flaps on a pedicle. Such a flap is mobilized in the operative wound, its careful sewing to the dura mater provides hermetization of the subdural space, its size is not limited, it can stretch, providing in necessity brain decompression. The tender adhesions are forming between the periosteal flap and underlying brain. The method was successfully used in 49 patients. No complications were noted. A shortcoming of the method consists in the fact that it can be used only in resective cranial trepanation.     

Repair of ventricular septal defects

Primary closure of large ventricular septal defects was performed in 57 patients ranging in age from 1 to 24 months during an 11-year period. Weight of patients ranged from 2.5 to 12.2 kg (mean, 6.6±0.9 kg). Shunt flow was large with mean Qp/Qs, 3.5±0.5. It was possible to close the defect by the transatrial approach in 86% of patients using a prosthetic patch attached to the ventricular septum by continuous polypropylene suture (89%). Early mortality of 5% and late mortality of 2% and excellent functional results in 93% suggest that this approach is appropriate.

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Resumen El cierre primario de defectos septales ventriculares mayores fué realizado en 57 pacientes con edades entre 1 y 24 meses en el curso de un período de 11 años. El peso de los pacientes varió entre 2.5 y 12.2 kg (promedio 6.6±0.9 kg). El flujo a través del defecto (shunt) fué considerable, con promedio Qp/Qs 3.5±0.5.Fue posible cerrar el defecto por vía transatrial en 86% de los pacientes usando un parche prostético fijado al septo ventricular con sutura continua de polipropileno (89%). La mortalidad temprana de 5% y la mortalidad tardía de 2%, junto con resultados funcionales excelentes en el 93% de los casos, sugiere que este enfoque es apropiado.

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Résumé Au cours d'une période de 11 ans, 57 sujets âgés de 1 à 24 mois ont bénéficié de la correction d'une large communication interventriculaire. Leur poids variait de 2.5 à 12.2 kg (moyenne 6.6.±0.9). Le débit du shunt était important avec une moyenne Q.P./Q.S. de 3.5±0.5. Dans 89% des cas il fut possible par voie transauriculaire de mettre en place un patch fixé au septum interventriculaire par un surjet continu de polypropylène. La mortalité précoce fut de 5% et la mortalité tardive fut de 2%, les résultats fonctionnels étant excellents dans 93% des cas. Ces faits plaident en faveur de l'intervention.