A new instrument for surgical exposure of subaortic and subpulmonic stenosis.

An instrument for providing adequate visualization of the subvalvular area during repair of intracardiac defects is described. Essentially a type of modified nasal speculum, the instrument has proved helpful in performing resections in both subaortic and subpulmonic stenoses by exposing a wider surgical field.     

Corrective treatment of isolated ventricular septal defect in infancy.

Intracardiac correction of VSD in infants should be indicated if the mortality and morbidity of the operation at this age group is lower than cumulative mortality of pulmonary artery banding plus second-staged procedure mortality. Experience with closure of VSD in 23 patients under 1 yr of age with 4% mortality and low morbidity is presented. Indications for operation are: (1) intractable heart failure; (2) persistence or progression of pulmonary hypertension; and (3) failure of banding procedure. Deep hypothermia and circulatory arrest facilitated the intracardiac repair in all patients. Mortality and morbidity related to the banding procedure are emphasized, and it is suggested that banding be restricted only to patients with associated coarctation of the aorta or to patients with multiple muscular ventricular septal defects in whom left ventriculotomy can be safely performed at an older age.     

Thermodilution cardiac output measurement in infants and small children following intracardiac surgery

A modified catheter has been used in conjunction with a thermodilution cardiac output computer for postoperative assessment of cardiac function in infants and children.Because of the small amount of fluid required for each determination and the simplicity of the technique, serial measurements can be done safely.Its use has a contributed to the early detection of low output states. It has also proven to be a useful tool for estimating the optimal heart rate in each patient and for assessing the effectiveness of therapeutic measures.     

Sinus Venosus Atrial Septal Defect Associated with Partial Anomalous Pulmonary Venous Drainage: Surgical Repair

This report describes a new technique for the repair of sinus venosus atrial septal defect associated with partial anomalous pulmonary venous drainage. A right atrial wall flap is used both to deflect the anomalous venous blood into the left atrium and to close the atrial septal defect. Then an atrioplasty is performed. This method does not employ any foreign materials, avoids injury to the sinoatrial node and internodal tracts, and minimizes the risk of obstruction of the ostia of the anomalous pulmonary veins and superior vena cava.     

Intracardiac repair of tetralogy of Fallot in patients under 5 years of age

Thirty-six infants and small children less than 5 years of age with severe symptoms underwent intracardiac repair for tetralogy of Fallot between January, 1969, and June, 1973, at the Children's Hospital of Buffalo. Of the 36, 24 had primary correction and 12 had a secondary correction after an initial palliative procedure. Since February, 1970, only 5 infants have undergone palliation, the contraindication for total repair being hypoplasia of the distal pulmonary arteries and anomalies of the right coronary arterial system which precluded outflow patching. Three patients who were first seen with clinical, hemodynamic, and angiographic characteristics of pulmonary atresia with ventricular septal defect (Group B) have been included because of demonstrable but rudimentary anatomical continuity between the right ventricle and pulmonary artery. Of the remaining 33 patients (Group A), 22 underwent primary repair without mortality, and 11 had secondary correction with 1 death. Eight infants under 2 in Group A underwent primary correction; the youngest was 5 weeks old. An outflow patch of pericardium was employed in 13 of the 33 children in Group A and in all 3 in Group B. It was observed that the major determinant of successful repair was an annulus diameter larger than 12 mm. Deep hypothermia and circulatory arrest were employed in 20 children under 15 kg. in weight. Heart block was not encountered, and an outflow tract aneurysm was seen in 1 patient who had no patch. It is concluded that primary intracardiac repair is advisable for patients in those centers prepared for infant intracardiac surgery.     

Anomalous origin of the left coronary artery from the pulmonary artery. Definitive surgical treatment by saphenous vein interposition in a 17-month-old child.

A 17-month-old child underwent successful operative correction of anomalous origin of the left coronary artery from the pulmonary artery by saphenous vein interposition. The clinical, hemodynamic, and angiographic features of the anomaly are presented. Three months after the operation, cardiac catheterization and angiography revealed a patent graft with good antegrade flow and improvement in left ventricular function.     

Successful Repair of Complete Atrioventricular Canal with Undivided Anterior Common Leaflet in a 6-Month-Old Infant

Complete atrioventricular canal with undivided free-floating anterior common leaflet was corrected in a 6-month-old infant with uncontrollable congestive heart failure. At follow-up two months after operation the patient was in excellent clinical condition.This report illustrates the surgical technique of successful intracardiac repair of this anatomical type of atrioventricular canal.Corrective rather than palliative operation is recommended for infants with uncontrollable heart failure due to complete atrioventricular canal.     

Cardiac Output Determination in Infants and Small Children After Open Intracardiac Operations

Simple postoperative clinical observations of infants and small children are not truly objective or reliable. Direct measurement of cardiac output by means of a thermodilution catheter inserted at the time of operation has been used in conjunction with a computer in infants and small children. The technique is simple and can be done rapidly and repeatedly. The effects of various modes of cardiac stimulation can be assessed and the optimal method of treatment employed.     

Critical Pulmonary Stenosis in Infants Less than Three Months of Age: A Reappraisal of Closed Transventricular Pulmonary Valvotomy

Sixteen patients less than 3 months of age underwent closed transventricular pulmonary valvotomy for critical pulmonary stenosis with intact ventricular septum. There were 14 survivors; the 2 deaths were unrelated to the technique. Early and late results reveal good hemodynamics in all but 1 patient who underwent open valvotomy four years later for restenosis. We have used this technique exclusively, as it is safe, requires little preparation for operative relief in the very sick infant, and the early and late results are excellent.     

Surface-induced Profound Hypothermia in Infant Cardiac Operations: A New System

A new system of surface-induced profound hypothermia for infant cardiac operations has been developed in order to overcome problems inherent in the current techniques using crushed ice, water baths, and similar methods. The hypothermic chamber consists of two parts: a lower part, containing a refrigeration unit and a blower fan capable of lowering the air temperature in the chamber to ?6°GC, and an upper part made of Plexiglas that has a completely detachable end to allow easy access to cannulas, the anesthesia hose, and the infant. A temperature panel recorder to monitor the infant's esophageal and rectal temperatures and the ambient chamber temperature is incorporated into the unit.Following evaluation in the animal laboratory, the hypothermic chamber has been successfully used in 10 infants without any complications attributable to the technique. This method provides a rapid and uniform drop of the body temperature and even skin cooling, eliminates the possibility of contact skin lesions, saves medical and paramedical personnel time in preparation of the infant and equipment, and allows observation of the child during the cooling phase. This hypothermic chamber has facilitated infant hypothermic operations.     

Electroencephalographic and Neurological Correlates of Deep Hypothermia and Circulatory Arrest in Infants

At present there is much interest in the use of surface-induced deep hypothermia with circulatory arrest in infants undergoing an open-heart procedure for repair of congenital defects. This paper presents our experience with infants who have been monitored by preoperative, intraoperative, and postoperative electroencephalograms as well as by preoperative and postoperative neurological assessments. Our results indicate that young infants tolerate deep hypothermia with circulatory arrest quite well, and we therefore continue to advocate use of this procedure in operations for congenital cardiac disease.     

Mustard procedure after Baffes operation.

Patients in whom Baffes' procedure has been done for palliative treatment of transposition of the great arteries may develop symptom recurrence later in life that deserves further treatment. A modified Mustard procedure is suitable for this purpose; the main difficulty in performing a formal Mustard operation is the proximity of the superior vena cava and of the inferior vena caval graft openings that enable the left pulmonary veins to drain without obstruction into the new atrium. This report deals with a 15-year-old patient in whom a modified Mustard technique was employed as a palliative method.     

Aorta-pulmonary artery shunts with expanded polytetrafluoroethylene (PTFE) tube.

Ten patients underwent an aortapulmonary artery shunt with a polytetrafluoroethylene (PTFE) tube between December, 1976, and October, 1977. Five of them were less than 1 month old. The diameter of the PTFE tube was 5 mm in 9 patients and 4 mm in 1 patient. Seven patients survived the operation. One of them had a clotted shunt, which was reoperated on successfully. Three patients died in the postoperative period, and all had a patent shunt. Overall patency was 90% (9/10). Congestive heart failure refractory to medical treatment developed in 1 patient with a patent Blalock-Taussig and PTFE shunt. In our institution, the Blalock-Taussig shunt is the procedure of choice. The PTFE shunt is used when the anatomy of a patient is unsuitable for a Blalock-Taussig shunt. A tube diameter of 5 mm is optimal for infants when further growth is considered, even if digitalization is necessary to control congestive heart failure.     

Aortic Origin of the Right Pulmonary Artery

A seven-week-old infant with aortic origin of the right pulmonary artery and patent ductus arteriosus is reported. During preoperative studies, a balloon catheter was used to occlude the ductus arteriosus in order to define the status of the pulmonary vascular bed. Corrective operation was performed by anastomosis of the anomalous right pulmonary artery to the main pulmonary trunk and ligation of the ductus arteriosus. Preoperative assessment of the presence of pulmonary vascular obstructive disease is discussed.     

Correction of transposition of the great arteries in infants under surface-induced deep hypothermia

Thirty-five infants with transposition of the great arteries underwent primary surgical repair. There were 2 deaths in the 20 infants with uncomplicated transposition of the great arteries and 5 deaths among the 15 infants with complex transposition. Patients with pulmonary vascular disease and an intact ventricular septum present a higher risk, but it is our policy to repair the defect in these patients since normal hemodynamics and full oxygen saturations following correction protect them against cerebrovascular accidents.     

Peptic ulcer in children with gastric tube interposition.

An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary.     

Prophylactic Antibiotics in Pediatric Cardiovascular Surgery: Current Practices

A survey of 23 pediatric cardiovascular surgery programs demonstrated uniform use of prophylactic antibiotics for open-heart operations. Only 65% of the programs used prophylaxis for repair of patent ductus arteriosus. Cephalosporins were the most frequently used antibiotics, but aminoglycosides in combination with penicillins were used in approximately 25% of the operations. Antibiotics were most often started prior to operation (89.7%) and continued for less than five days. These data demonstrate that the use of prophylaxis in pediatric cardiovascular operations conforms to current guidelines.     

Aeromedical transportation for infants and children.

Transfer of a critically ill child to a pediatric center is indicated when patient needs have exceeded local expertise or facilities. It is illogical to impose on the referring hospital the added burden of transporting such a patient. The receiving hospital is better equipped to extend its specialized services by assuming responsibility for interim management and transfer of the patient. An aeromedical transport system capable of quick response was built around National Guard helicopters. In 21 cases, doctors, nurses, and equipment were flown to children in community hospitals, and urgent treatment was begun in half the time formerly possible. Only after the patients were stabilized were they returned safely under continuing appropriate management. The helicopter is a versatile and speedy tool to deliver expertise and equipment when and where needed. Timely arrival of specialty services can be expected to improve patient care and salvage.     

Mortality from neonatal diaphragmatic hernia

The ability of the newborn to reestablish a fetal-type eirculation is potentially lethal in infants with diaphragmatic hernia operated upon on the first day of life. The responses of their pulmonary vasculature to all stimuli are exaggerated. Our efforts to treat them will continue to be in the direction of pharmacologic manipulation of pulmonary arterial pressure and the rate of ductal closure. To do so, it is necessary to have direct measurements of PaO₂ above and below the ductus, so that changes in shunt can be interpreted.