Ross procedure in an infant weighing 4.5 kg

A 6 month-old male infant (weight: 4.5 kg) with congenital aortic stenosis underwent aortic valve replacement with a pulmonary autograft (Ross procedure). The right ventricular outflow tract (RVOT) was reconstructed with a polytetrafluoroethylene (PTFE)-valved equine pericardial conduit. At the age of 5, re-RVOT reconstruction with an equine pericardial patch bearing a PTFE monocusp was required because of severe pulmonary stenosis resistant to 2 attempts of percutaneous transluminal pulmonary valvotomy. Currently, at the age of 8, the degree of aortic regurgitation is trivial and the pulmonary autograft is free of functional deterioration despite somatic growth.     

Severe pulmonary artery stenosis by a calcified pericardial ring.

We present a rare case of a 44-year-old man with acquired pulmonary stenosis caused by a calcified pericardial ring. Chest computer tomography and cardiac angiography showed external compression of the main pulmonary artery by a calcified pericardial ring. A calcified pericardial ring was removed and the pulmonary artery angioplasty was performed for the stenotic pulmonary artery. The patient's condition improved dramatically thereafter.     

Tracheal surgery in children: an 18-year review of four techniques

Objective: Review the short- and long-term outcomes of a single institution experience in infants with congenital tracheal stenosis, comparing four different operative techniques used from 1982 through 2000. Methods: Hospital and clinic records of 50 infants and children who had surgical repair of congenital tracheal stenosis secondary to complete tracheal rings were reviewed. Age at surgery ranged from 7 days to 72 months (median, 5 months, mean 7.8±12 months). Techniques included pericardial patch tracheoplasty (n=28), tracheal autograft (n=12), tracheal resection (n=8), and slide tracheoplasty (n=2). All procedures were done through a median sternotomy with cardiopulmonary bypass. Seventeen patients had a pulmonary artery sling (35%), and 11 had an intracardiac anomaly (22%). Results: There were three early deaths (6% early mortality), two after pericardial tracheoplasty and one after autograft. There were six late deaths (12% late mortality), five after pericardial tracheoplasty and one after slide tracheoplasty. Length of stay (median) was 60 days (pericardial tracheoplasty), 28 days (autograft), 14 days (resection), and 18 days (slide). Reoperation and/or stent placement was required in seven patients (25%) after pericardial tracheoplasty, in two patients (17%) after autograft, in no patients after resection, and in one patient (50%) after slide tracheoplasty. Conclusions: Our current procedures of choice for infants with congenital tracheal stenosis are resection with end-to-end anastomosis for short-segment stenoses (up to eight rings) and the autograft technique for long-segment stenoses. Associated pulmonary artery sling and intracardiac anomalies should be repaired simultaneously.     

Mid-term results of the arterial switch operation for transposition of the great arteries: effect of fresh autologous pericardial patch in preventing postoperative pulmonary stenosis

To evaluate the differences in patch-materials used to reconstruct the pulmonary artery in arterial switch operation for transposition of the great arteries, we compared mid-term results in 50 consecutive survivors who underwent arterial switch operation. In 35 patients (XP-group), the pulmonary artery was reconstructed using a glutaraldehyde-treated heterologous pericardial patch, while in 15 patients (AP-group) it was reconstructed using a fresh autologous pericardial patch. A W-shaped patch was used in 14 patients of the XP-group. In 21 patients of the XP-group and all those of the AP-group, a square patch was used. The mean length of follow-up has been 94.1 +/- 38.1 months after surgery in XP-group, and 16.7 +/- 11.8 months in AP-group, respectively. Four patients in XP-group required balloon angioplasty for pulmonary stenosis and 5 patients in XP-group underwent reoperation, but no patients in AP-group required balloon angioplasty or reoperation for pulmonary stenosis. The risk factors influencing postoperative pulmonary stenosis (sex, age at surgery, preliminary pulmonary artery banding, patch shape and material) were analyzed by multiple regression analysis. The patch material (heterologous patch) was the only identifiable risk factor for pulmonary stenosis. These data suggest that pulmonary artery reconstruction with an autologous pericardial patch may be effective to prevent postoperative pulmonary stenosis, although the long-term prognosis remains unknown.     

Thoracoabdominal ectopia cordis with single ventricle and pulmonary stenosis. A case report of successful surgical repair

A case of thoracoabdominal ectopia cordis with single ventricle and pulmonary stenosis is reported. A cyanotic boy with omphalocele was brought to our hospital soon after his birth and was diagnosed as thoracoabdominal ectopia cordis with single ventricle and pulmonary stenosis. A conservative treatment of omphalocele was performed successfully and a plastic chest shield had been made for him which protected the anterior surface of his chest. He continued to develop in a fairly satisfactory condition and operation was delayed until he was 8 years old when he had severe cyanosis and frequent episodes of headache. The operative procedures were; 1) ascending aorta to main pulmonary artery shunt with EPTFE tube; 2) to bring the heart into the thoracic and abdominal cavity by developing widely the pericardial and diaphragmatic defect behind the heart's preoperative position; 3) to reconstruct the new pericardial sac lying from thoracic to abdominal cavity by covering the heart using EPTFE sheet. This trial of making a new pericardial sac for thoracoabdominal ectopia cordis is not reported so far in the literature. It is expected that the heart has being raised to the thoracic cavity with patient's physical growth after this operation.     

Surgical management of progressive pulmonary venous obstruction after repair of total anomalous pulmonary venous connection

BACKGROUND: The occurrence of a progressive pulmonary venous obstruction after the repair of the total anomalous pulmonary venous connection is a severe complication. OBJECTIVES: The objectives of this study were to retrospectively review the patients with this condition and to report our experience with a new surgical technique with a sutureless in situ pericardium repair. METHODS: Of 178 patients who underwent correction of total anomalous pulmonary venous connection, 16 patients (9%) experienced the development of a progressive pulmonary venous obstruction in a median interval of 4 months (5 weeks-12 years). Three patients had isolated anastomotic stenosis, 4 patients had isolated pulmonary venous ostial stenosis, and 9 patients had both. Pulmonary venous obstruction was bilateral in 7 patients. The surgical procedures used at reoperation included 8 patch enlargements, 5 ostial endarterectomies, 1 intraoperative stenting, and 7 sutureless in situ pericardium repairs. RESULTS: There were 4 deaths after reoperation (4 of 15 patients; 27%). The only significant mortality risk factor was the bilateral location of the pulmonary venous obstruction (P =.045). In patients with isolated anastomotic stenosis or with only 1 pulmonary venous ostial stenosis (n = 5), there was no death, except the patient presenting with a single ventricle. In patients with 2 or more pulmonary venous ostial stenoses (n = 10), there were 3 deaths; 5 of the 7 survivors were successfully treated with the in situ pericardial technique, with normalized pulmonary artery pressure at a mean follow-up of 26 months. CONCLUSION: Progressive pulmonary venous stenosis after repair of total anomalous pulmonary venous connection remains a severe complication when bilateral. The sutureless in situ pericardial repair offers a satisfactory solution, particularly on the right side.     

Endarterectomy of the left main coronary artery stenosis by a ‘transpulmonary artery approach’

For better visualization of the left main coronary artery, a new technique involving transection of the main pulmonary artery is described. With this new method it was possible to perform endarterectomy of the left main coronary artery in 35 patients from February 1981 to July 1987. The endarterectomy incision was closed with a pericardial or venous patch. We had no mortality, and 91% are free from angina at a mean follow-up of 31 months. Angiographic evaluation was performed in 19 patients revealing good patency of the left main artery. This procedure is safe, and we recommend it in isolated left main coronary artery stenosis without distal involvement and with good left ventricular function.     

Bilateral partial anomalous pulmonary venous connection; report of a case

We have experienced a case of bilateral partial anomalous pulmonary venous connection with a fossa ovalis type of atrial septal defect and pulmonary stenosis. The right upper pulmonary vein returned to the superior vena cava and the left upper pulmonary vein returned to the left innominate vein via the vertical vein. The atrial septal defect was enlarged and the right upper pulmonary vein was baffled into the left atrium with an equine pericardial patch. The left upper pulmonary vein was divided and anastomosed to the left atrial appendage. Pulmonary commissurotomy was also done for concomitant pulmonary stenosis. Postoperative course of the patient was excellent with constantly normal sinus rhythm. Angiography 2 weeks after operation showed no evidence of pulmonary venous obstructions on both sides.     

Acute coronary syndrome due to abnormal fibrous tissue growth after Aubert-Imai modification for transposition of the great arteries

We report a female infant with acute coronary syndrome after Aubert-Imai modification for transposition of the great arteries. Two months postoperatively, she visited the emergency room because of perspiration and tachypnea. She was diagnosed with acute coronary syndrome by blood chemistry examination. Cardiac catheterization revealed Aubert route stenosis, and emergency operation was performed. The lumen around the aortopulmonary window was almost totally occluded by fibrous tissue extending from the equine pericardial patch. This fibrous tissue was completely resected and the aortopulmonary window was deepened to enlarge the coronary ostium. We recommend a close follow-up including angiography after these procedures.     

Histopathology of anastomotic stenosis after total anomalous pulmonary vein connection

We report a case of a 10-month-old girl who was diagnosed with pulmonary vein stenosis after total anomalous pulmonary vein connection repair and underwent release of an anastomotic stenosis. Histopathological examinations of the resected anastomotic tissue revealed intimal hyperplasia at the anastomotic site. Predominant lesion cells were identified as myofibroblasts and had the characteristics of fibroblasts and synthetic smooth muscle cells. These cells could be a useful target for preventing anastomotic stenosis after total anomalous pulmonary vein connection repair.     

自体心包片下腔静脉重建

目的 探讨自体心包片腔静脉成形(APPC)或下腔静脉重建(RIVC)的治疗方法、适应症、临床价值和注意事项。方法 自1986年5月至1998年6月我们完成了APPC治疗下腔静脉(IVC)—肝静脉(HV)狭窄39例和自体心包管代血管IVC移植(VTIVC)治疗IVC闭塞或缺损3例，同时施行直视根治术切除梗阻病灶。结果 手术死亡2例(死亡率4．76％)，1例死于肝肾综合征，另1例死于呼吸道出血性窒息。40例痊愈出院(治愈率95.24％)。术后随访13—96个月，37例典型症状体征消失，B超和IVC造影证实IVC-HV通畅良好者37例，术后1．5年显示IVC狭窄1例，2例于术后2—4个月发现IVC血栓形成。结论 APPC是治疗IVC-HV狭窄或闭塞的直接有效的外科疗法，常使病人迅速康复。     

婴幼儿室间隔完整的重度肺动脉瓣狭窄手术方案探讨

目的　探讨婴幼儿室间隔完整的重度肺动脉瓣狭窄 (PS)的手术指征和手术方法。方法　1999年 6月至 2 0 0 4年 3月 ,手术治疗室间隔完整的重度PS婴幼儿 2 8例 ,年龄 1 3～ 2 9 0个月 ,平均( 11 3± 2 0 )个月。体重 3 5～ 12 5kg ,平均 ( 8 5± 1 2 )kg。据不同的手术方法分 3组 ,第 1组 18例 ,三尖瓣Z值 - 1 0～ - 1 6 ,11例经肺动脉切口行肺动脉瓣膜交界切开 ,7例因瓣环小而采用自体心包补片进行右心室流出道至肺动脉的补片扩大 ;9例因术后低氧血症而加作体肺分流术。第 2组 7例 ,Z值- 1 5～ - 4 8,行 1 心室修补 ,即右心室流出道至肺动脉的补片扩大 上腔静脉与右肺动脉的腔肺血管吻合 (BDG) ;第 3组 3例 ,Z值 - 4 5～ - 6 7,行肺总动脉横断同时行BDG。结果　手术死亡 1例。余2 7例生存 ,术后血流动力学稳定 ,经皮氧饱和度平均 0 95。随访 3～ 2 4个月疗效满意。结论　术前判断右心室发育不良的程度是手术成功的关键 ,手术方式除选择单心室和双心室修补外 ,1 心室修补手术是一种安全、可靠、有效的手术方法     

不同类型退变性腰椎管狭窄症的手术治疗

目的 通过对不同类型退变性腰椎管狭窄症手术方法的选择，提高手术治疗的疗效。方法回顾性分析2001年9月～2004年1月收治退变性腰椎管狭窄症患者96例，其中男85例，女11例。年龄39～71岁，平均54岁。病程3个月～7年。根据患者临床症状、体征及脊髓造影检查，分为5组，A组：1个节段椎间管狭窄，39例，行椎板间开窗椎间管（侧隐窝、神经根管）潜行扩大术；B组：1个节段中央椎管狭窄，21例，行椎板间开窗椎间盘摘除，椎间管潜行扩大术；C组：1个节段退行性脊柱滑脱，18例，行两侧椎板间开窗减压潜行扩大椎管后椎弓根钉系统内固定（AF、RF等）并横突间、小关节间植骨；D组：2个以上节段混合型椎管狭窄，ll例，行病变节段两侧开窗潜行扩大椎管，切除黄韧带，摘除椎间盘，松解神经根；E组：退行性脊柱侧突，7例，综合以上减压措施行椎弓根钉棒系统矫形内固定后外侧植骨。随访并评价其疗效。结果96例患者获随访6～36个月，平均12．2个月，未出现手术并发症。JOA评分优85例、良9例、中1例、差1例；X线片复查无椎弓根钉误置、断钉、拔出等。结论退变性腰椎管狭窄症的治疗采取有限化手术、有效化减压原则可减少并发症，提高疗效。脊髓造影对退变性腰椎管狭窄症的手术方式选择有重要价值。     

Ketamine anesthesia for pericardial window in a patient with pericardial tamponade and severe COPD

PURPOSE: To describe the use and concerns of ketamine anesthesia for pericardial window in a patient with pericardial tamponade and severe chronic obstructive pulmonary disease (COPD) with CO(2) retention. CLINICAL FEATURES: A 73-yr-old woman with long-standing COPD and cor pulmonale admitted with pericardial effusion and tamponade had surgery for a pericardial window receiving a total of ketamine 450 mg iv. Arterial pCO(2) increased from 71.8 mmHg preoperatively to 96 mmHg intraoperatively postdrainage of 1000 mL of effusion. Hemodynamic stability and SpO(2) >93% were maintained. Intubation was avoided and concerns of increased pulmonary vascular resistance and potential for right ventricular failure in an already compromised right ventricle were not observed clinically. CONCLUSION: In this patient with pericardial tamponade, COPD and CO(2) retention, the advantages of ketamine included maintaining spontaneous ventilation, avoiding institution and weaning of mechanical ventilation, bronchodilation and relative preservation of the CO(2) response curve. Deleterious effects on right ventricular afterload were not observed.     

Experimental model of laryngotracheal stenosis in infants: effects of different high-frequency jet ventilation patterns on pulmonary parameters

Background: Supraglottic high‐frequency jet ventilation (HFJV) in laryngotracheal surgery in infants with modified jet laryngoscopes offers the surgeon an unimpaired operating field. However, supraglottic HFJV is associated with the development of high airway pressures, inadvertent positive end‐expiratory pressure (PEEP) levels, and barotrauma. Methods: We investigated the total lung volumes (TLV) and tidal volume variations at peak inspiratory pressure levels (PIP) and at PEEP levels along with the pulmonary pressures (PIP and PEEP) during two conventional methods of supraglottic HFJV in an infant trachea–lung model without stenosis and with different degrees of stenosis. Results: With augmentation of the driving pressure in the experiment without stenosis, the TLV plus the pulmonary pressures increased. With narrowing of the stenosis, TLV reduced at PIP level and increased at PEEP level. Volume shifts were significantly higher during superimposed HFJV compared with monofrequent HFJV at equivalent stenosis diameter (P < 0.05) except for the setting with 0.3 bar driving pressure (P > 0.05). The pulmonary PIP was in none of the test series higher than 20 mbar, and the pulmonary PEEP did not exceed 14 mbar. Conclusions: The results from our experimental model support the safe and effective clinical use of supraglottic HFJV in infants with tracheal stenosis. Moderate driving pressures provide acceptable pulmonary pressures in normal compliant lungs.     

Staged repair of supravalvular aortic stenosis associated with severe multiple peripheral pulmonary stenoses: report of extended peripheral pulmonary arterioplasty

This paper describes surgical experience in supravalvular aortic stenosis associated with severe multiple peripheral pulmonary stenoses treated by a staged approach: initial staged repair of the bilateral pulmonary stenoses by arterioplasty through a thoracotomy and later definitive intracardiac repair of supra-valvular aortic stenosis. Our experience in two cases proved that the peripheral pulmonary arteries could be exposed up to the segmental branches by dissection from the pulmonary hilum through a lateral thoracotomy without damaging the lung parenchyma. The stenotic areas could then be repaired with either a bifurcated or trifurcated pericardial patch.     

Definite improvement in left ventricular function at six years after the Takeuchi procedure.

We report a case of a six-year-old girl who underwent the Takeuchi procedure for anomalous origin of the left coronary artery from the pulmonary artery at the age of 4 months. The left ventricular function was severely deteriorated before the initial operation and at 6 years after the procedure showed a remarkable improvement. Mitral regurgitation disappeared during the 6 years. The intrapulmonary tunnel was sufficiently patent to provide adequate blood flow for the anomalous coronary artery. This patient showed supravalvular stenosis due to shrinkage and thickening in the equine pericardium used for reconstruction of the pulmonary artery, and this stenosis was successfully released by autologous pericardial patch angioplasty.     

Pediatric laryngotracheal stenosis

Severe laryngotracheal stenosis (LTS) in children is a problem of increasing incidence in the past 15 years, following the widespread adoption of prolonged endotracheal intubation for respiratory support. Rarer cases of stenosis secondary to external trauma, high tracheotomy, thermal and chemical burns, and dystrophic cartilage are seen. In contrast to congenital subglottic stenosis, where conservative therapy is generally indicated, severe, mature LTS often requires surgical correction--either endoscopic or external reconstruction. The prevailing attitude has been to perform a tracheotomy and hope for decannulation after 1 or 2 years, due to the expected growth of the larynx. This attitude developed from experience with congenital subglottic stenosis. Unfortunately, acquired LTS tends to be a much more severe problem than congenital subglottic stenosis; the degree of obstruction is usually greater and loss of cartilaginous support of the airway commonly occurs. Some of the acquired lesions are so severe that often no lumen is demonstrable. In such cases no amount of growth will allow extubation. A variety of endoscopic methods such as dilation, with or without resection using diathermy, cryotherapy, or laser, or steroid injection are certainly helpful in the early phases of wound healing while granulation tissue is still present or while the scar tissue is still soft and pliable. To deal with the mature, hard, fibrous unresponsive scar, various authors have proposed different approaches both endoscopic and external reconstruction. The present study discusses a unique experience of external laryngotracheal reconstruction (LTR) in 100 children. In the evaluation of LTS, a thorough endoscopic evaluation is required using both flexible and rigid endoscopic techniques.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pericardial window procedures: Implications on left ventricular function

INTRODUCTIONPericardial window procedures are generally designed to relieve pericardial fluid pressure on the heart, in cases of cardiac tamponade, and to restore the hemodynamic stability of the patient. Rarely, however, may acute left ventricular failure develop after creation of a pericardial window.PRESENTATION OF CASEWe describe a patient in whom that complication developed. We are trying to give an insight to the pathophysiology, existence of potential predisposing factors, as well as to propose therapeutic measures.DISCUSSIONAcute heart failure, developing after pericardiocentesis or surgical creation of a pericardial window is an unusual complication, with several theories developed to explain that paradox.CONCLUSIONTreatment is supportive, but that complication of pericardial window procedures may carry a high mortality rate.