Management of symptomatic tetralogy of Fallot in the first year of life.

The surgical management of symptomatic tetralogy of Fallot in infants is debatable. The question of total correction versus palliation and the type of palliative procedure remain controversial. During the past 4 years, 30 infants, aged 1 day to 12 months (mean 5.6 months) with symptomatic tetralogy of Fallot underwent either total correction (21 infants) or palliation by relieving the pulmonary stenosis with a right ventricular outflow tract patch (nine infants). The ratio of diameter of the right pulmonary artery to diameter of the ascending aorta (PA/Ao ratio) was calculated from the anteroposterior cineangiogram of all patients. There were three operative deaths in the total correction group; two of these occurred in infants with PA/Ao ratios less than 0.3. One death occurred in the 19 patients undergoing total correction with PA/Ao ratios greater than 0.3 (mortality rate 5.3%). All nine infants undergoing right ventricular outflow tract patching had PA/Ao ratios less than 0.3, and one operative death occurred in this group. Four patients who had right ventricular outflow tract patching have had repeat cardiac catheterization 2 to 15 months postoperatively. All four have shown symmetrical enlargement of the pulmonary arterial tree and significant increases in their PA/Ao ratios.     

Diameters of the Pulmonary Arteries and Veins as an Indicator of Bilateral and Unilateral Pulmonary Blood Flow in Patients With Congenital Heart Disease

Abstract Objectives: This study was done to clarify which diameter, that of the pulmonary arteries (PAs) or that of the pulmonary veins (PVs), more precisely reflects pulmonary blood flow (PBF) bilaterally and unilaterally. Methods: To evaluate bilateral PBF, we studied 15 consecutive patients with Kawasaki disease as normal patients and 30 patients with tetralogy of Fallot who received cardiac catheterization. To evaluate unilateral PBF, 20 patients with various congenital heart diseases undergoing cineangiography and lung perfusion scintigraphy were studied. The diameter of PA was measured immediately proximal to the origin of the first lobar branches bilaterally, and right PA area, left PA area, PA area (mm²), and PA index (mm²/m²) were calculated. The diameter of PV was also measured distal to the junction with the left atrium. Right PV area, left PV area, PV area (mm²), and PV index (mm²/m²) were calculated from these diameters. Pulmonary blood flow (PBF) was obtained by the Fick method during catheterization. To evaluate unilateral PBF, PBF was divided into right and left PBF according to the right/left perfusion ratio measured by lung perufusion scintigraphy. Results: Evaluation of bilateral PBF was as follows: in normal patients, PA and PV areas were correlated with body surface area (r = 0.88, p = 0.0001 and r = 0.93, p = 0.0001); PA index and PV index ranged from 248 to 436 (mean = 343) mm²/m² and from 346 to 595 (mean = 466) mm²/m², respectively, and were constant irrespective of body surface area; PA and PV areas were correlated with PBF in normal patients, as well as in patients with tetralogy of Fallot. There was a better correlation between PV area and PBF than between PA area and PBF in normal patients, as well as a significantly better correlation in patients with tetralogy of Fallot. Evaluation of unilateral PBF was as follows: right PV area was correlated with right PBF (p = 0.0002), while right PA area was not; left PV area and left PA area were correlated with left PBF; right/left PV area ratio was correlated with the right/left perfusion ratio with better agreement than right/left PA area ratio. Conclusion: Our data suggest that the size of PVs in patients with congenital heart disease may be more useful than the size of PAs to indicate bilateral and unilateral PBF than the size of PAs. Differences in PV area of each lung may be a suitable indicator of discrepancy in blood flow to each lung.     

肺动脉及分支量化分析在法洛四联症根治术中的意义

目的：对法洛四联症患者的肺动脉（PA）,左肺动脉（LPA）和右肺动脉（RPA）分支进行量化分析,探讨其临床意义。方法：术前测量236例法洛四联症患者PA及其分支直径,计算PA与主动脉（AO）直径比值（PA／AO＿,PA与体表面积（BSA）比值（PA／BSA）,PA与正常肺动脉面积（NPA）比值（PA／NPA）,（LPA＋RPA）／AO,（LPA＋＿RPA）／PA,（LPA＋RPA）／BSA等,测量术后右心室与左心室收缩压比值（PRV／LV）,分析存活者与死亡者这些指标判别意义。结果（LPA＋RPA）／AO＜0．5时,手术危险性显著增加,PA／BSA大于等于2．0时,（LPA＋RPA）／BSA大于等于2．4及PA／NPA大于等于0．6时,其手术安全性是显著增加,是否需跨肺动脉瓣环补片主要与PA／SBA,PVA／BSA,PA／NPA有关;术后PRV／LV比值与PA及其分支发育情况无关,而主要受术中右心室流出道和PA疏通情况的影响。结论：PA及其分支发育情况虽然对手术结果有影响,但更重要的是手术过程对右心室流出道及肺动脉狭窄的纠正情况／     

Total cavopulmonary connection for grown diminutive pulmonary artery after staged Blalock-Taussig shunt

We report a two-year-old girl with asplenia, {A, L, L} DORV, pulmonary atresia, common AV valve, PDA, and TAPVC, who successfully underwent total cavo pulmonary connection (TCPC). Deep cyanosis was pointed out since birth. Cardiac catheterization performed on the sixth day after birth revealed a diminutive pulmonary artery tree of which PA index was 41 mm²/m². Left modified Blalock-Taussig shunt was created at 27 days of age. The PA index increased to 282 mm²/mm², but disparity in diameter between the left and the right pulmonary artery was yielded by PDA subsidence. Therefore additional contralateral B-T shunt was made at one year of age. Follow-up cardiac catheterization at 28 months of age showed well developed pulmonary artery; PA index of 460 mm²/m², right pulmonary resistance (Rp) of 3.49 units, left Rp of 2.33 units, and estimated total Rp was 1.39. According to study, bidirectional Glenn procedure or TCPC was indicated. Considering neccesity of urgent repair of common pulmonary vein obstruction, regurgitation of the common atrio-ventricular valve and pulmonary artery stenosis, TCPC was performed with concomitant repair of the associated lesions. Severe butterfly-figure stenosis of the central PA was augmented by anastomosing both the left SVC and the left-sided atrium. In conclusion, diminutive pulmonary artery could be adequately grown by phase-in Blalock-Taussig shunts. Pulmonary blood flow scintigraphy was thought to be useful for estimation of pulmonary resistance in such cases with different pulmonary resistance between right and left PA.     

Follow-up study of pulmonary artery configuration in hypoplastic left heart syndrome

Objective. Pulmonary artery (PA) distortion significantly compromises the outcome of the staged approach to the Fontan operation in patients with hypoplastic left heart syndrome (HLHS). This retrospective study was designed to investigate the influence of the initial operation on postoperative PA anatomy. Methods. Forty-nine patients with HLHS and its variant were enrolled in this study. As an initial palliation, the Norwood operation with a modified Blalock-Taussig (BT) shunt was performed in 12, the Norwood operation with a right ventricle to pulmonary artery (RV-PA) shunt in 31, and bilateral PA banding in 6. The incidence and risk factors of postoperative central pulmonary artery stenosis (PS) were investigated, and the PA configuration was followed up until post-Fontan status. Results. Twenty-two patients (51.2%) had developed central PS after the Norwood operation (33.3% with a BT shunt vs. 58.1% with a RV-PA shunt). The RV-PA shunt with a polytetrafluoroethylene (PTFE) patch at the distal pulmonary stump significantly decreased the central PS (P = 0.035). The PA index after the Norwood operation was not statistically different between the BT and RV-PA shunt groups, although in the RV-PA group it was significantly higher in patients with a PTFE patch on the distal PA stump. PA plasty was performed in 16 patients in the second-stage palliation and in 15 with the Fontan completion. Freedom from PA plasty was significantly lower in the RV-PA shunt group than in the BT shunt group (63.5% vs. 31.1% at 5 years, P = 0.034). Six patients initially palliated with bilateral PA banding had no stenosis at the banding site in the Norwood + Glenn operation, and one patient required stent placement for left PS in the Fontan completion. Post-Fontan catheterization (n = 31) showed central venous pressure of 11.5 ± 2.6 mmHg, cardiac index of 3.6 ± 0.8 l/kg/min, and PA index of 194.0 ± 58.4 mm²/m²; there was no difference between the groups. Conclusion. The incidence of central PS after the Norwood operation was significant, and the shunt type and procedure for the distal PA stump influenced the postoperative configuration of the central PA. With an aggressive surgical approach to central PS, PA anatomy was satisfactory with good hemodynamic variables after Fontan completion. Bilateral PA banding did not cause later vascular deformity. Presented at the 59th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery, held in Tokyo, Japan, October 1–4, 2006     

Hemodynamic evaluations of patients with small aortic annulus with St. Jude Medical prosthetic heart valve

As the elderly population in Japan increases, senile degenerative aortic valvular disease also tends to increase. These patients often have a small aortic annulus. The problem of “valve-patient-mismatch” occurs when a small prosthesis is inserted into a patient with a small aortic annulus. To avoid annular enlargement after aortic valve replacement (AVR), we tried to use a small-sized St. Jude Medical (SJM) valve. From September 1988 through November 1996, 110 AVR were performed in our institution. In these cases, 30 underwent AVR with a small sized SJM valve (male ≦21 mm, female ≦19 mm). Dobutamine stress echocardiography was performed in 19 patients who had undergone AVR with a small-sized SJM valve. Surgical results were also compared between patients with small aortic annulus and those with normal-sized aortic annulus. Using Doppler echocardiography, pressure gradients (PG), cardiac index (CI), effective orifice area (EOA), and performance index (PI) were calculated at rest and during stress. The mean body surface area (BSA) of patient who had undergone AVR with SJM19A, 19HP and 21A was 1.40, 1.42 and 1.56 m², respectively. With dobutamine stress, heart rates, PG and CI increased significantly. Mean and maximum PG of patients with 19HP (8.0 and 15.4 mmHg at rest, 12.9 and 28.0 mmHg under stress, respectively) and 21A (9.5 and 19.1 mmHg at rest, 16.5 and 35.3 mmHg under stress, respectively) were relatively low. EOA index (EOAI) of patient with 19HP showed the highest values mean 0.93 cm²/m². Pis tended to be higher with HP models than with standard models. The tests were completed without significant side effects such as frequent ventricular arrhythmias. Among the cases with small aortic annulus, there were no operative deaths or hospital deaths. There were also no late deaths, episodes of hemorrhage or thrombosis. Conclusions. In our institution, AVR was peformed safely without any aortic annular enlargement with a small aortic anulus in small BSA patients. Postoperative hemodynamic data obtained by echocardiography were satisfactory for all patients at rest and even during maximum dobutamine stress test.     

Indicators of surgical treatment of patent ductus arteriosus in preterm neonates in the first week of life

Objective

To identify clinical and echocardiographic indicators of the necessity for early surgical closure of patent ductus arteriosus in preterm neonates.

Methods

The prospective study was conducted at the Neonatal Unit of Hospital Municipal Odilon Behrens between 2006 and 2010. The study population comprised 115 preterm neonates diagnosed with patent ductus arteriosus in the first week after birth, of whom 55 (group S) were submitted to clinical and or surgical closure and 60 (group NS) received non-surgical treatment. The parameters analyzed were birth weight, diameter of the ductus arteriosus (DAD), left atrial-to-aortic root diameter ratio (LA:Ao), the quotient of DAD² and birth weight (mm²/kg), and ductal shunting.

Results

The study population comprised 58 males and 57 females. The average birth weight of group S (924 ± 224.3 g) was significantly (P=0.049) lower than that of group NS (1012.3 ± 242.8 g). The probability of the preterm neonates being submitted to surgical closure was 62.1% (P=0.006) when the DAD2/birth weight index was > 5 mm²/kg, 72.2% (P=0.001) when the LA:Ao ratio was > 1.5, and 61.2% when ductal shunting was high (P=0.025).

Conclusion

The parameters DAD²/birth weight index > 5 mm²/kg, LA:Ao ratio > 1.5 and high ductal shunting were statistically significant indicators (P<0.05) of the need for surgical closure of patent ductus arteriosus in low birth weight preterm neonates. Moreover, when an LA:Ao ratio > 1.5 was associated with the occurrence of shock, the probability of surgical closure increased to 78.4%.     

Evaluation of the technical difficulty performing laparoscopic resection of a rectosigmoid carcinoma: visceral fat reflects technical difficulty more accurately than body mass index

Background In general, visceral fat and adhesion greatly influence the technical difficulty in performing abdominal surgery. Body mass index (BMI) has been widely used to express the degree of obesity, but it does not always properly reflect the degree of visceral fat. This retrospective study investigated the impact of visceral fat on the operation time to examine whether a quantified visceral fat area (VFA) could be used as a sensitive predictor of technical difficulty in performing a laparoscopic resection of rectosigmoid carcinoma. Methods Between February 1999 and April 2004, 58 consecutive patients underwent a laparoscopically assisted sigmoidectomy or anterior resection. After a review of the medical charts, the relationship between the operation time and the following variables was analyzed: sex, depth of invasion, approach (medial-to-lateral, lateral-to-medial), subjectively graded degree of visceral fat and adhesion, history of previous abdominal surgery, and BMI. The correlations between VFA, VFA/body surface area (BSA) measured by the “FatScan,” software package for quantifying the VFA from the preoperative CT images, and operation time were investigated. Next, the impact of the VFA amount on the early surgical outcome was examined. Results According to the intraoperative findings, two patients with a severe adhesion required a significantly longer operation time. A history of previous abdominal surgery was not a significant factor in the operation time. Instead, the VFA/BSA had a stronger correlation with the operation time than the BMI. A significantly longer operation time (209 ± 42 vs 179 ± 37 min; p = 0.031) was observed for the patients in the high VFA/BSA group (≥85 cm²/m²) group than in the normal VFA/BSA group (<85 cm²/m²). Conclusion For predicting the technical difficulty of performing a laparoscopic resection of rectosigmoid carcinoma, VFA/BSA may be a more useful index than BMI.     

Long-term result of total correction of tetralogy of Fallot

Long-term result of total correction of tetralogy of Fallot was investigated in 51 patients who underwent operation at least 10 years previously. Ninety percent of the patients who responded to the questionnaires expressed his daily life as satisfactory and 4% of the patients had no exercise limitation even in strenuous sports like swimming and running. It was disclosed that the exercise capacity in long-term period was thought to be prescribed by the developmental state of the pulmonary vascular bed at the time of operation which was expressed by the preoperative hemoglobin level and the PA/Ao diameter ratio and no correlation was found with the RV/LV pressure ratio recorded immediately after correction. Three patients died after discharge, 2 years, 2 years and 6 months and 21 years after operations respectively and the cause of death was supposed to be arrhythmia. In case of postoperative complete right bundle block associated with an extreme right axis deviation or left axis deviation, prophylactic pacemaker implantation was recommended.     

The Benefits of High‐flow Management in Children With Pulmonary Atresia

The high‐flow management of cardiopulmonary bypass (CPB; ≥2.4 L/min/m²) is a standard strategy used at this institute for children with pulmonary atresia (PA) due to a fear that the blood flow may be diverted by the major/minor aortopulmonary‐collateral‐arteries and hypervascularization due to long‐term hypoxia. The purpose of this study was to describe the validity of high‐flow management in children with PA. The CPB records of 23 children with PA who underwent a definitive biventricular repair between Feb 2006 and Nov 2008 were retrospectively reviewed. The mean age at the operation was 33 ± 22 months. The blood‐pressure during bypass was controlled with the same protocol. The mean cooling‐temperature was 28.4 ± 3.7°C. The mean minimum hematocrit was 25.0 ± 3.4%. The mean maximum bypass flow index at the initiation, the mean maximum flow index during aortic cross‐clamping, the mean minimum flow index during aortic cross‐clamping, and the mean maximum flow index after rewarming were 3.1 ± 0.5, 3.1 ± 0.5, 2.6 ± 0.4, and 3.2 ± 0.4 L/min/m², respectively. The higher bypass flow indexes significantly correlated with the lower serum lactate levels. The lowest oxygen delivery during CPB had significant influences on the urine output during bypass (R = 0.547, P = 0.007), the serum lactate levels at the end of CPB (R = ?0.442, P = 0.035), and the postoperative thoracic effusion (R = ?0.459, P = 0.028). A bypass flow index of 2.4 L/min/m² may not be sufficient and the maximum requirement of bypass flow index may be 3.2 L/min/m² or more in this patient population.     

Evidence for palliative enlargement of the right ventricular outflow tract in severe tetralogy of Fallot

Objective: If the pulmonary artery (PA) tree in patients with Fallot's tetralogy (TOF) is extremely hypoplastic, a shunt procedure may be difficult and not desirable because of side-effects. Moreover, the failing catch-up growth of the pulmonary annulus is well known. In patients with a severe form of TOF, we performed palliative transannular patching of the right ventricular outflow tract. The early and long-term follow-up was evaluated. Methods: Eleven patients (93 days (10–245 days); 3.5±0.7 kg (2.5–4.3 kg)) had highly symptomatic TOF (Hb: 18±2 g/dl, SO₂: 68±11%); angiographic diameters: RPA: 4.1 mm (2.5–6.4 mm), LPA: 3.4 mm (1.6–7.0 mm), PA trunc: 4.4 mm (2.5–7.0 mm). All 11 underwent transannular enlargement of the right ventricular outflow tract without closure of the ventricular septum defect. A PA index (cross-sectional area of the pulmonary arteries to BSA) was used to compare pre- and postoperative data. For follow-up, the patients were repetitively examined clinically and echocardiographically. Results: Preoperative PA index was 87±40 mm²/m² (normal: 330±35 mm²/m²). Postpalliation angiograms (age: 10–14 months) demonstrated a significant catch-up growth in nine patients (PA index from 99±40 to 310±54 mm²/m²) and inadequate growth in two patients (PA index 63 and 115 mm²/m²). Perioperative mortality was zero. Ten patients (43 months; 6–105 months) underwent elective repair. Six patients received pulmonary homograft valves (6–15 years after repair) because of severe pulmonary valve insufficiency and severe RV dilation. Complications: One patient died 10 months postpalliation due to pneumonia, one patient received a pacemaker after repair and died (2 months post-repair) due to pacemaker failure, a 5-year-old patient died 1 month after repair due to sepsis. All eight long-term survivors (12–17years) are in excellent clinical condition. Echocardiography revealed good RV function and near normal diameters at peak systolic pressures between 25 and 50 mmHg. Only one patient developed brady-arrhythmia; a pacemaker was implanted 8 years after repair and 2 years after homograft implantation. Conclusions: In a very severe form of TOF, palliative right ventricular outflow tract construction may provide the potential for complete repair. In the presented high-risk patient group, mortality was not related to the hypoplastic pulmonary arteries. Obviously, all patients need pulmonary valve implantation in the long run.     

婴儿早期法洛四联症的外科治疗

目的总结婴儿早期法洛四联症（TOF）外科治疗经验,探讨TOF早期根治术的相关问题。方法回顾性分析上海市儿童医院2008年6月至2010年8月收治21例婴儿早期（〈6个月）TOF患者的临床资料,其中男14例,女7例;年龄4.86±1.15个月;体重6.84±1.33 kg。均经心脏彩色超声心动图确诊,有4例行CT或磁共振成像（MRI）或右心导管造影术。McGoon比值1.86±0.41,肺动脉指数（PAI）142.54±59.46 mm2/m2。经右心房（19例）或右心室（2例）自体心包补片连续缝合修补室间隔缺损;对肺动脉瓣环Z值〈-1者采用心包补片跨瓣扩大成形（18例）;对接近或基本达到正常Z值者保留瓣环,用心包补片分别扩大右心室流出道（RVOT）和肺总动脉（3例）。结果术后第15 d因心力衰竭死亡1例;1例术后第2 d拔除气管内插管后出现喉头水肿,再插管辅助通气,3 d后顺利撤机;其余患者术后均顺利恢复。18例获得随访,随访9.89±6.47个月,心功能改善（Ross分级Ⅰ~Ⅱ级）;随访心脏超声心动图提示：RVOT压差为21.20±12.27 mm Hg（8.10~45.14 mm Hg）;肺动脉瓣反流（PI）轻度10例,中度5例,无重度患者;2例早期残余室间隔缺损已闭合。与术后早期相比,RVOT压差和PI程度差异均无统计学意义（P〉0.05）,右心功能良好。结论婴儿早期行TOF根治术可取得良好的手术效果;经右心房矫正心内畸形,并保留肺动脉瓣环有利于术后心功能保护。     

Factors affecting a dilated ascending aorta in patients with bicuspid aortic valve: the relevance of valve anatomy,body size and age

Purpose

Information regarding the appropriate management of patients with moderately dilated ascending aortas is limited. We investigated factors affecting ascending aortic dilatation in BAV patients, such as anatomy, body size and age.

Methods

We evaluated 130 patients with BAV (age, 59.9 ± 16.1 years; body surface area (BSA), 1.58 ± 0.20 m²) who underwent aortic valve surgery. The cusp configuration was determined according to the presence and location of the raphe and the cusp direction. The ascending aortic diameter index (AADI) was calculated using computed tomography and the BSA.

Results

Sixty-four patients had A-P-type BAV, while 66 had R-L-type BAV. The mean ascending aorta diameter was 42.6 ± 6.7 mm, and the mean AADI was 27.1 ± 5.6 mm/m². Based on the AADI, cusp configuration (R-L-BAV: 28.3 ± 6.0 mm/m² vs. A-P-BAV: 25.8 ± 4.9 mm/m², P < 0.05), a female gender, age and the presence of aortic stenosis were found to be related to ascending aortic dilatation, while the mean ascending aortic diameter did not differ between the groups. Among the elderly patients, an AADI greater than 28 mm/m² was more frequently observed in the R-L-BAV group than in the A-P-BAV group. Ascending aortic replacement was required after 10 years in two patients with R-L-BAV and no patients with A-P-BAV.

Conclusions

The relative ascending aortic diameter helped to identify patients with BAV with a risk of dilatation, indicating that the use of ascending aortic replacement should be considered more frequently in patients with R-L-type BAV, while the procedure is avoidable in elderly patients with A-P-type BAV.     

The association of echocardiographic parameters on renal outcomes in chronic kidney disease

BackgroundPatients with chronic kidney disease (CKD) often have structural abnormalities of the heart due to pressure and volume overload. The aim of this study was to evaluate associations between echocardiographic parameters and renal outcomes (estimated glomerular filtration rate [eGFR] slope and progression to dialysis) in patients with stage 3–5 CKD.MethodsThis longitudinal study enrolled 419 patients. Changes in renal function were assessed using the eGFR slope. Rapid renal progression was defined as an eGFR slope < −3 mL/min/1.73 m²/year, and the renal endpoint was defined as commencing dialysis.ResultsIncreased left atrial diameter (LAD), ratio of left ventricular mass to body surface area (LVM/BSA), ratio of LVM to height^2.7 (LVM/ht^2.7), and ratio of observed to predicted LVM (o/p LVM) were associated with eGFR slope in an adjusted model, but left ventricular ejection fraction (LVEF) was not. Furthermore, LAD ≥ 4.7 cm, LVM/BSA > 115 g/m² in males and > 95 g/m² in females, and LVM/ht^2.7 > 48 g/ht^2.7 in males and > 44 g/ht^2.7 in females were correlated with progression to dialysis, but o/p LVM and LVEF were not. The maximum change in χ² change to predict renal outcomes was observed for LAD, followed by LVM/BSA and LVM/ht^2.7.ConclusionsA large LAD and increased LVM, regardless of how it was measured (LVM/BSA, LVM/ht^2.7 and o/p LVM), were correlated with adverse renal outcomes in patients with CKD stage 3–5. LAD had superior prognostic value to LVM and LVEF.     

Repair of tricuspid valve with pulmonary valve replacement in repaired tetralogy of fallot

Objectives: We aimed to investigate the outcome of tricuspid valve repair (TVR) performed concomitantly with pulmonary valve replacement in repaired tetralogy of Fallot (TOF) patients. Design: This retrospective study included all patients who underwent pulmonary vale replacement from 2000 to 2016 after TOF correction. TVR patient data were compared to those of patients who underwent pulmonary vale replacement alone. Results: Thirty-eight patients were enrolled. The degree of tricuspid regurgitation was significantly decreased after operation in the TVR group. Tricuspid valve annulus and annuloectasia before operation did not vary between groups (21.1?±?6.3 and 41.4% in no TVR vs. 21.3?±?4.8 and 52.6% in TVR). However pre-operative right ventricular volumes were larger in the TVR group. Normal tricuspid valve coaptation (body to body) was observed less frequently in the TVR group than in the other group (52.6% vs. 93.1%, p < .001). Pre-operative tricuspid regurgitation had a linear correlation with right ventricular volume, but not with tricuspid annulus size. Conclusion: Tricuspid annulus diameter decreased significantly regardless of TVR. Abnormal coaptations were observed more in patients group and the degree of pre-operative tricuspid regurgitation was linearly correlated with right ventricular volume rather than tricuspid annulus size.     

Medtronic Freestyle valve for right ventricular reconstruction in pediatric Ross operations

BACKGROUND: The use of homograft conduits to reconstruct right ventricle (RV) to pulmonary artery (PA) connections is an essential component of the Ross operation. Homograft availability and cost may be problematic when considering the Ross operation. We elected in January 1998 to utilize commercially available xenografts as an alternative to homografts for RV/PA reconstruction in the pediatric Ross operation. Our early results using the Medtronic Freestyle valve (Medtronic, Minneapolis, MN) for RV/PA reconstruction are presented. METHODS: We reviewed our database for all Ross operations performed on children since January 1998. A total of 16 patients were identified. Eleven children received a Medtronic Freestyle valve, 2 children received a homograft, and 3 children received another type of xenograft. Echocardiographic evaluation of all children who received the Medtronic Freestyle valve was performed at hospital discharge and at two subsequent outpatient evaluations. RESULTS: The median peak instantaneous pressure gradient across the xenograft was 16 +/- 9 mm Hg (immediately after surgery before hospital discharge); 22 +/- 20 mm Hg at 23 +/- 11 months (first postdischarge follow-up); and 27 +/- 20 mm Hg at 35 +/- 9 months (second postdischarge follow-up). Linear regression analysis revealed an increasing pressure gradient with time (R(2)-adjusted = 0.44, p < 0.0001). At the same three observation points, the xenograft annulus diameter decreased: 25 +/- 1.2 mm; 19 +/- 4.3 mm; and 20 +/- 1.8 mm. Linear regression analysis revealed a decreasing annulus diameter with time (R(2)-adjusted = 0.41, p < 0.0001). CONCLUSIONS: The Medtronic Freestyle valve provides a possible alternative to homografts for the reconstruction of the RV/PA connection in the pediatric Ross operation. Long-term follow-up is necessary to evaluate this xenograft as an alternative to the homograft.     

Impact of the HeartMate 3 continuous-flow left ventricular assist device in patients with small body size

Open in a separate window OBJECTIVESLimited data are available for use of the HeartMate 3 (HM 3) left ventricular assist device in patients with a small body surface area (BSA). Because the HM 3 is currently the sole device available worldwide, we conducted a single-centre retrospective study of patients with a small BSA (<1.5 m²) who underwent HM 3 implantation to better understand the operative and postoperative management.METHODSThis study enrolled 64 consecutive patients who had undergone HM 3 implantation from August 2018 to July 2021. The patients were divided into 2 groups based on their BSA before the operation: BSA of <1.5 m² (small BSA group, n = 18) and BSA of ≥1.5 m² (regular BSA group, n = 46). The primary study endpoint was survival free of events such as disabling stroke and pump failure. The secondary endpoint was the frequency of adverse events.RESULTSThe average BSA was 1.38 m² in the small BSA group. The overall event-free survival rate at 12 months was 100% and 86.7% in the small BSA group and regular BSA group, respectively, and no significant difference was found between the 2 groups (log-rank P = 0.2). The number of cumulative adverse events of death, stroke of any severity, driveline infection, pump infection, ventricular arrhythmia, gastrointestinal Haemorrhage and pump failure was similar between the 2 groups.CONCLUSIONSThe HM 3 was safely implanted in patients with a small BSA, and postoperative outcomes were acceptable regardless of BSA. However, further research is needed to confirm the indications for HM 3 implantation in even smaller patients.     

Vertical Banded Gastroplasty at More than 5 Years

Background: Optimal evaluation of the results of surgery for morbid obesity requires a long-term follow-up for at least 5 years. Methods: One hundred patients were operated by vertical banded gastroplasty (VBG) and revised with a follow-up of no less than 5 years. Sixty patients were morbidly obese with a body mass index (BMI) of between 40 and 50 kg/m², and 40 were superobese with a BMI of >50 kg/m². Follow-up included 93 patients (93%). Results: Initial surgical mortality was nil. Twenty-five patients required surgery for complications related to the technique (25%) and one patient died due to pulmonary embolism after a re-stapling operation. The percentage excess weight loss was 54.3%, and the BMI was 33 kg/m² for the 84 patients followed to 5 years post VBG. Only 40 out of 92 patients (43.5%), obtained the weight loss benefit due to the operation. None of them is able to eat a regular diet, and the quality of food intake has been severely affected in some of them. Conclusions: VBG is, in our experience, a safe and technically simple operation, but the long-term results are questionable. The reoperation rate was high, and weight loss and quality of life are superior with other operations.     

Continuous Hydralazine Infusion for Afterload Reduction

Impedance reduction with a continuous infusion of hydralazine was evaluated in 20 patients following cardiopulmonary bypass. Patients were selected for therapy when the cardiac index (CI) was less than 2.2 L/m²/min, when the systemic vascular resistance index (SVRI) was greater than 2,500 dyne sec cm^?5, or when both conditions were present. No other vasoactive or cardiotonic drugs were used intraoperatively or postoperatively. Responses were measured at 15, 30, 60, 120, 180, and 240 minutes and compared with control measurements. Significant responses appeared by 15 minutes in the mean arterial pressure, CI, and SVRI, which were maximal by 2 hours. At 4 hours, the SVRI was 1,520 ± 276 dyne sec cm^?5 (control, 3,235 ± 222) and pulmonary vascular resistance index, 365 ± 102 dyne sec cm^?5 (control, 592 ± 71). The CI was 3.20 ± 0.29 L/m²/min (control, 1.96 ± 0.16) and mean arterial pressure, 75 ± 2.3 mm Hg (control, 92 ± 2.4). Left atrial, pulmonary artery diastolic, and right atrial pressures increased from control but not significantly: 11.4 ± 0.8 to 13.3 ± 1.2 mm Hg, 13.6 ± 1.6 to 17.2 ± 1.5 mm Hg, and 6 ± 1.6 to 9.4 ± 1.7 mm Hg, respectively. In 16 patients, hydralazine was continued for 24 hours and in 11, the transition to oral therapy was made. Hydralazine by infusion effectively reduces after-load, avoids the fluctuations of bolus therapy, and allows the transition to oral therapy if needed.     

Long-or short-limb gastric bypass?

The aim of this study was to determine whether longer limb length improved results of gastric bypass in patients who were morbidly obese (body mass index <50 kg/m²) or superobese (body mass index >50 kg/m²). A total of 242 patients were followed for a mean of 5.5 years. The standard operation was a Roux-en-Y gastric bypass with a 40 cm Roux limb and a 10 cm afferent limb. The long-limb operation had a 100 cm Roux limb and a 100 cm afferent limb. Morbidly obese patients did not benefit from a long-limb bypass. The final body mass index was 28.6 ±4.7 kg/m² in the short-limb group and 28.5 ± 3.8 kg/m² in the long-limb group. The superobese patients did benefit from a long-limb bypass. Final body mass index was 35.8 ±6.7 kg/m² in the short-limb patients and 32.7 ±5.1 in the long-limb patients (P = 0.049). A subgroup of 20 patients, all of whom had a body mass index greater than 60 kg/m², benefited the most from long-limb bypass. No macronutritional side effects unique to the long-limb bypass were encountered.