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Biomedical subjects

A R Castaneda

Publications and source records attributed to A R Castaneda.

At least 19 recordsLinked to original sources
PubMed1997

Perioperative effects of alpha-stat versus pH-stat strategies for deep hypothermic cardiopulmonary bypass in infants.

OBJECTIVES: In a randomized, single-center trial, we compared perioperative outcomes in infants undergoing cardiac operations after use of the alpha-stat versus pH-stat strategy during deep hypothermic cardiopulmonary bypass. METHODS: Admission criteria included reparative cardiac surgery, age less than 9 months, birth weight 2.25 kg or more, and absence of associated congenital or acquired extracardiac disorders. RESULTS: Among the 182 infants in the study, diagnoses included D-transposition of the great arteries (n = 92), tetralogy of Fallot (n = 50), tetralogy of Fallot with pulmonary atresia (n = 6), ventricular septal defect (n = 20), truncus arteriosus (n = 8), complete atrioventricular canal (n = 4), and total anomalous pulmonary venous return (n = 2). Ninety patients were assigned to alpha-stat and 92 to pH-stat strategy. Early death occurred in four infants (2%), all in the alpha-stat group (p = 0.058). Postoperative electroencephalographic seizures occurred in five of 57 patients (9%) assigned to alpha-stat and one of 59 patients (2%) assigned to pH-stat strategy (p = 0.11). Clinical seizures occurred in four infants in the alpha-stat group (4%) and two infants in the pH-stat group (2%) (p = 0.44). First electroencephalographic activity returned sooner among infants randomized to pH-stat strategy (p = 0.03). Within the homogeneous D-transposition subgroup, those assigned to pH-stat tended to have a higher cardiac index despite a lower requirement for inotropic agents; less frequent postoperative acidosis (p = 0.02) and hypotension (p = 0.05); and shorter duration of mechanical ventilation (p = 0.01) and intensive care unit stay (p = 0.01). CONCLUSIONS: Use of the pH-stat strategy in infants undergoing deep hypothermic cardiopulmonary bypass was associated with lower postoperative morbidity, shorter recovery time to first electroencephalographic activity, and, in patients with D-transposition, shorter duration of intubation and intensive care unit stay. These data challenge the notion that alpha-stat management is a superior strategy for organ protection during reparative operations in infants using deep hypothermic cardiopulmonary bypass.

Acid-Base Equilibrium↗
PubMed1995

Sternotomy approach for the modified Blalock-Taussig shunt.

BACKGROUND: Since 1990, sternotomy has been the preferred approach for construction of a modified Blalock-Taussig shunt (MBTS) at Children's Hospital, Boston, Mass. In retrospect, we sought to test the hypothesis that this approach yields less mortality and morbidity than the traditional thoracotomy approach. METHODS AND RESULTS: One hundred four primary MBTSs with polytetrafluoroethylene grafts were constructed in patients from January 1988 through December 1992. Fifty-two shunts were constructed by thoracotomy approach and 52 by sternotomy approach. Fifteen of the thoracotomy patients were less than one month of age (8 less than 7 days), while 36 of the sternotomy patients were less than 1 month of age (20 less than 7 days). There were 10 shunt failures and 3 hospital deaths in the thoracotomy group and 4 shunt failures with 6 hospital deaths in the sternotomy group. The overall hospital mortality rate for the group was 8.7% (9 of 104). The operative route was not a significant predictor of hospital mortality (P = .30). However, there was a significant difference between the two operative approaches in shunt failure, with shunts that were created by thoracotomy four times more likely to fail than those created by the sternotomy route (odds ratio, OR, 3.88; 95% CI, 1.01 to 15.03; P = .049). The side of the shunt was also a significant predictor of failure with left-side MBTSs foru times more prone to failure (OR, 4.02; 95% CI, 1.19 to 15.25; P = .025). CONCLUSIONS: The sternotomy route is technically less challenging and is associated with fewer shunt failures than the classic thoracotomy approach. The potential theoretical disadvantages of this method for future sternal reentry for subsequent procedures was not apparent but requires prospective analysis.

Adolescent↗
PubMed1995

Cardiac catheterization and test occlusion of the interatrial communication after the fenestrated Fontan operation.

OBJECTIVES: Our objective was to determine whether catheterization data obtained after a fenestrated Fontan operation influenced patient management or predicted functional status. BACKGROUND: Cardiac catheterization after a fenestrated Fontan operation is undertaken to identify residual lesions and to observe the patient's response to test occlusion of the baffle fenestration. METHODS: Sixty patients undergoing both a fenestrated Fontan operation before July 1991 and a postoperative catheterization before March 1992 were included in the study. Catheterization data were collected according to a test occlusion protocol; these data were reviewed, and the patient's clinical status at follow-up was ascertained. RESULTS: Test occlusion resulted in a significant increase in systemic venous pressure, arterial oxygen saturation and arteriovenous difference in oxygen content (p < 0.0001). After test occlusion, systemic venous pressure was 40% higher and systemic venous saturation 23% lower among patients with an unfavorable versus a favorable response to test occlusion, although differences between the two groups were subtle or inapparent in the baseline state. Branch pulmonary artery stenosis (identified and balloon dilated in 6 patients) and grade 2 or 3 aortopulmonary collateral vessels (identified and coil embolized in 20) were associated with elevation in systemic venous pressure (p < 0.01). After an average of 2 years of follow-up, there were no deaths, and 50 (83%) of 60 patients were in New York Heart Association functional class I. The only postoperative characteristic significantly associated with being in functional class I at follow-up was a systemic venous pressure < 17 mm Hg. CONCLUSIONS: Cardiac catheterization with test occlusion of the interatrial communication provides useful information after a fenestrated Fontan operation. Conditions associated with elevated systemic venous pressure should be sought and treated, and the response of systemic venous pressure to test occlusion should be considered when deciding whether to close an interatrial communication.

Cardiac Catheterization↗
PubMed1995

Video-assisted thoracoscopic surgery for congenital heart disease.

Video-assisted endoscopic techniques have reduced operative trauma in adult thoracic and general surgery, but applications in children with congenital heart disease have been limited. We report the development of video-assisted thoracic surgery procedures for neonates and infants with cardiovascular disease. Endoscopic instruments and techniques for pediatric cardiovascular procedures were designed and tested in the animal laboratory. Forty-eight operations were subsequently performed in 46 pediatric patients ranging in age from 2 hours to 14 years (median 9 months), weighing from 575 grams to 54 kg (median 8.5 kg). Clinical applications included seven different surgical procedures: patent ductus arteriosus interruption in infants (n = 26) and premature neonates (n = 5), vascular ring division (n = 8), pericardial drainage and resection (n = 3), arterial and venous collateral interruption (n = 2), thoracic duct ligation (n = 2), epicardial pacemaker lead insertion (n = 1), and diagnostic thoracoscopy (n = 1). There was no operative mortality. Technical success, defined as a video-assisted procedure completed without incising chest wall muscle or spreading the ribs, was achieved in 39 of 48 procedures (82%), with thoracotomy required to complete nine procedures. Most patients (22/25, 88%) undergoing elective ductus ligation were extubated in the operating room and discharged from the hospital within 48 hours of the operation. Eight of the last 10 patients having ductus ligation were discharged on the first postoperative day. Residual ductal flow was assessed by (1) transesophageal echocardiography in the operating room (incidence: 0/25, 0%, 70% CL 0% to 7.3%); (2) discharge auscultation (incidence: 1/30, 3%, 70% CL 0.5% to 10.8%); and (3) follow-up Doppler echocardiography (incidence: 3/25, 12%, 70% CL 5.4% to 22.6%). Video-assisted thoracoscopic techniques can be safely applied to pediatric patients with patent ductus arteriosus and vascular rings and may become an effective addition to the staged management of more complex forms of congenital heart disease.

Adolescent↗
PubMed1995

Transformation of the cardiovascular program. Leadership and organization.

The development of this organizational innovation continues to provide many challenges and opportunities for all involved. The authors emphasize that although cost containment is perhaps the most noticeable effect thus far, it is not the central goal of this endeavor. Obviously, it is important to be conscious of reducing costs in this very competitive health-care environment where quality of care is in danger of being substituted for lower-priced care. The challenge before all of us is to maintain excellence and efficiency less expensively within a collegial and risk-willing environment, as external forces seem to be countercurrent to these efforts. We hope that this new model for providing cardiovascular services within the institution will allow us to continue to improve our tradition of excellence in clinical care and will help us in retaining an environment and spirit conducive to the generation of new knowledge. The more long-lasting result achieved to date is the level of creativity and commitment demonstrated by all staff toward our common vision. The other articles in this issue of Nursing Clinics exemplify the collaborative spirit of our CVP and offer some initial evidence about the early effects of these changes.

Cardiac Surgical Procedures↗
PubMed1994

Maturational and hemodynamic factors predictive of increased cyanosis after bidirectional cavopulmonary anastomosis.

Bidirectional cavopulmonary anastomosis (BCA) is thought to be beneficial in the palliation of patients with univentricular congenital heart disease considered at high risk for Fontan repair. Experience with patients undergoing BCA suggested that those who were older or larger at the time of surgery tended to be more cyanotic postoperatively than their younger and smaller counterparts. This study was designed to identify correlates of systemic arterial oxygen saturation after BCA. Specifically, it was postulated that maturational changes in blood flow distribution might be associated with decreasing arterial oxygen saturation. Database records of all 110 patients undergoing BCA at our institution from June 1988 until the end of 1991 were reviewed. Postoperative catheterization data were available for 66 patients. Twenty-one patients were excluded because they had potentially reversible causes of cyanosis yielding inestimable degrees of error in hemodynamic calculations. In the remaining 45 patients, univariate and multivariate regression analyses were used to identify correlates of systemic arterial oxygen saturation. Growth and maturation as represented by body surface area exhibited a highly significant inverse correlation with arterial oxygen saturation (p = 0.005), as did pulmonary vascular resistance (p = 0.003). Patients who underwent BCA when > 3.9 years of age or with body surface area > 0.65 m2 were at significantly increased risk for excessive postoperative cyanosis, defined as systemic arterial oxygen saturation < or = 75% (p < 0.005). The interval between surgery and catheterization correlated directly with arterial oxygen saturation (p = 0.002), indicating a tendency toward earlier study of more cyanotic patients. None of the other variables examined correlated significantly with arterial oxygen saturation.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Total anomalous pulmonary venous drainage in newborns with visceral heterotaxy.

Children with visceral heterotaxy often present with total anomalous pulmonary venous drainage (TAPVD) associated with univentricular congenital heart disease. We reviewed our experience with the primary surgical management of this lesion under these circumstances. Over a recent 10-year span, 38 patients within the first 3 days of life were admitted to our institution and underwent primary palliation. Twenty-one of them had TAPVD, 18 to a systemic vein. Twelve (67%) of these 18 were seen with obstruction of the anomalous connection and underwent emergency operation. In 7 patients, repair of TAPVD was combined with a systemic-pulmonary artery shunt because of additional obstruction of the pulmonary blood supply, with two deaths. One patient had primary shunting and then repair of TAPVD. Four patients underwent repair of TAPVD alone. Two of them then showed signs of insufficient pulmonary blood flow, received a shunt in a second procedure, and subsequently died. Early mortality in the group with obstructed TAPVD was thus 4 (33%) of 12 patients. Statistical analysis of all 38 patients (univariate analysis, chi 2 testing) showed that neither the presence of TAPVD (p = 0.7) nor TAPVD repair alone (p = 0.8) or with shunting (p = 0.8) was a definite risk factor for early death. The performance of a shunt during the first operation, however, was associated with lower early mortality (p = 0.03). Total anomalous pulmonary venous drainage is a common finding in newborns with visceral heterotaxy. Its presence and its subsequent early repair (requiring cardiopulmonary bypass) do not increase the mortality risk. The need of a concomitant shunt in obstructed TAPVD can initially be underestimated.

Heart Defects, Congenital↗
PubMed1994

Management and outcome of low birth weight neonates with congenital heart disease.

In 100 consecutive neonates with birth weights < or = 2500 gm (range, 540 to 2500 gm; median, 2200 gm), major congenital heart disease (excluding patent ductus arteriosus, isolated atrial septal defect, and ventricular septal defect) was diagnosed between January 1987 and January 1991; 46 had ductus-dependent lesions. Of the 100 neonates, 30 had genetic aberrations or significant associated congenital anomalies. The four most common cardiac diagnoses were tetralogy of Fallot with or without pulmonary atresia (n = 16); coarctation of the aorta (n = 12); transposition of the great arteries (n = 11); and common atrioventricular canal (n = 11). The hospital survival rate for the entire group of 100 neonates was 70%. The patients were separated into three groups on the basis of the time of intervention. Group 1 (early intervention) included 62 infants. These neonates (including 31 with ductus-dependent lesions) had surgical or catheter intervention during the initial hospitalization (median age, 9 days), all at weights < or = 2500 gm. The hospital survival rate was 81% (50/62); survival rates for palliation (78%, 18/23) and for correction (82%, 32/39) were similar. There were 26 neonates in group 2 (late intervention). These neonates did not have surgical intervention during the initial hospitalization. All were managed medically; survivors were discharged and had surgical procedures later (at a median age of 4.3 months). Six neonates (23%) died during medical management; all 20 survivors returned and had surgical procedures, with 90% survival. Overall survival rate for this group was 69% (18/26). The remaining 12 patients (group 3) had complicating features that precluded intervention; none survived. On the basis of these results, we conclude that early intervention, even with corrective surgery, can be performed in low birth weight neonates with an acceptable mortality rate. Prolonged medical therapy to achieve further weight gain did not appear to improve the survival rate.

Cardiac Catheterization↗
PubMed1994

Severe congenital mitral stenosis in infants.

BACKGROUND: Despite current medical and surgical therapy, infants with symptomatic congenital mitral stenosis (CMS) continue to have high rates of morbidity and mortality. Catheter balloon dilation has been successful in relieving symptoms in a few older children with CMS but has not been evaluated in infants. METHODS AND RESULTS: We reviewed the records of 85 infants with CMS to assess severity of CMS, associated cardiac lesions, echocardiographic morphological appearance of the mitral valve, treatment, and outcome. There were five valve morphologies identified: "typical" hypoplastic mitral valve with symmetric papillary muscles (SYMM, 52%), supravalvar mitral ring (SVMR, 20%), double-orifice mitral valve (DOMV, 11%), hypoplastic mitral valve with asymmetric papillary muscles (ASYMM, 8%), and parachute mitral valve (PARA, 8%). Of the 85 infants, 31 (36%) were severely symptomatic, requiring intervention within the first 2 years. Balloon dilation was performed in 18 infants (age, 8.7 +/- 5.7 months; weight, 5.9 +/- 1.9 kg) and valve surgery in 13 (age, 10.9 +/- 5.9 months; weight, 6.7 +/- 2.1 kg). Balloon dilation decreased the peak transmitral gradient (LAa-LVED) > 30% in 15 of 18 initial attempts, from 20.3 +/- 8.2 to 10.9 +/- 4.9 mm Hg (P < .001), and the mitral valve area increased from 0.7 +/- 0.3 to 1.0 +/- 0.5 cm2/M2 (n = 10, P = .01). No infants died during the initial balloon dilation, although 2 of 3 died during a repeat procedure for restenosis. Other complications included significant mitral regurgitation in 7 of 18 patients (39%), 4 of whom had SVMR. Of the 18 infants, 8 (44%) had persistent symptomatic improvement at a mean follow-up of 14 months (range, 2 to 32 months). The 2-year survival after balloon dilation was 70%; 40% remained free of repeat intervention. Mitral valve surgery in 13 infants consisted of SVMR resections in 7, mitral valve replacements in 4, and LA-to-LV aortic valved homografts in 2. The operative mortality was 30%. Sustained improvement occurred in 8 (6 with SVMR) at 11 to 62 months of follow-up (mean, 30 months), with a 2-year survival of 60%. CONCLUSIONS: Infants with severe CMS have 2-year mortality rates approaching 40% regardless of treatment modality. Balloon dilation significantly reduces the transmitral gradient in the majority, but symptomatic improvement persists in only 40%. Procedure-related mortality was associated with repeat balloon dilation in patients with left ventricular hypoplasia. Balloon dilation of "typical" CMS can provide symptomatic relief in many infants, allowing postponement of valve replacement, although infants with SVMR do better with surgical management.

Cardiac Catheterization↗
PubMed1994

Rapid two-stage arterial switch operation. Evaluation of left ventricular systolic mechanics late after an acute pressure overload stimulus in infancy.

BACKGROUND: Banding of the pulmonary artery to induce left ventricular (LV) hypertrophy followed by arterial switch operation (ASO) within 2 weeks has been performed when a primary ASO was considered high risk because of inadequate LV hypertrophy. METHODS AND RESULTS: Potential adverse myocardial effects of the two-stage procedure were examined by comparing outcome in 18 patients after a rapid two-stage ASO with 33 patients after a primary ASO. Regional wall motion was assessed. Echocardiographic and noninvasive pressure data were combined to obtain LV dimension, wall thickness, mass, fractional shortening, rate-corrected mean velocity of shortening, and end-systolic wall stress. Afterload-adjusted velocity of shortening was obtained as a load-independent index of contractility. In the two-stage ASO group, the magnitude and rate of hypertrophy after pulmonary artery banding were measured serially. No wall motion abnormalities were seen in either group. Systolic dysfunction due to higher afterload and lower contractility was observed in the two-stage ASO group. Contractility below the limits of normal was seen in 25% of two-stage ASO compared with 3% of primary ASO; however, symptomatic or progressive LV dysfunction was not observed. There was a significant inverse relation between the peak rate of hypertrophy immediately after banding and contractility at late exam. Lower ejection fraction before and early after pulmonary artery banding correlated with depressed contractility on late examination. CONCLUSIONS: Myocardial contractility is lower after the two-stage ASO than after a primary repair. Severe or progressive dysfunction was not seen. A very high peak rate of hypertrophy and severe LV dysfunction after banding predict a greater reduction in late contractility.

Acute Disease↗
PubMed1994

Regional cerebral perfusion abnormalities after cardiac operations. Single photon emission computed tomography (SPECT) findings in children with postoperative movement disorders.

Despite the clinical and pathologic indicators implicating injury to the basal ganglia in children with hyperkinetic movement disorders, we were previously unable to identify lesions in these structures by means of cranial computed tomography or magnetic resonance imaging. We evaluated regional cerebral perfusion measured by single photon emission computed tomography (SPECT) with technetium 99m hexamethyl propylene amine oxime as a technique to localize functional cerebral abnormalities in eleven children who had a movement disorder after hypothermic cardiac surgery. Perfusion defects of the deep gray matter were noted in six of these eleven patients and cortical perfusion defects in nine. For both cortical and subcortical defects a strong right-sided predilection was present. Our findings suggest functional brain injury not detectable by conventional cranial computed tomography and magnetic resonance imaging in these patients. We speculate that these perfusion defects might relate to the behavioral and developmental sequelae in survivors of this syndrome. SPECT may identify subclinical injury in patients at risk for future neurodevelopmental problems and contribute to our understanding of the mechanisms of cerebral injury in the patient operated on for cardiac disease.

Brain↗
PubMed1994

Result of biventricular repair for double-outlet right ventricle.

The choice of optimal repair for many patients with double-outlet right ventricle continues to challenge the heart surgeon. We present the results of a 10-year surgical experience with the biventricular repair for double-outlet right ventricle with situs solitus and atrioventricular concordance. Preoperative anatomic findings within this population of 73 patients are detailed. These morphologic features are correlated with type of anatomic repair and clinical outcome. Patients were classified by ventricular septal defect location. Normal coronary anatomy was found in the majority of patients with subaortic and doubly-committed ventricular septal defects. Patients with subpulmonary and noncommitted ventricular septal defects had a wide variety of coronary anatomy. Patients with subpulmonary and noncommitted ventricular septal defects also had a considerably higher prevalence of aortic arch obstruction. A tricuspid-to-pulmonary annular distance equal to or greater than the diameter of the aortic annulus was found to indicate the possibility of achieving a conventional ventricular septal defect-to-aorta intraventricular tunnel repair. Tricuspid-to-pulmonary annular distance sufficient for intraventricular tunnel repair predominates in those patients with a right posterior or right side-by-side aorta. Five types of repair were used during the study period: intraventricular tunnel repair, arterial switch with ventricular septal defect-to-pulmonary artery baffle, Rastelli-type extracardiac conduit repair, Damus-Kaye-Stansel repair, and atrial inversion with ventricular septal defect-to-pulmonary artery baffle. Overall actuarial survival estimate at 8 years is 81%. The presence of multiple ventricular septal defects and patient weight lower than the median were nearly significant risk factors for early mortality (p < 0.06). Nineteen patients (26%) required 24 reoperations. Patients with subaortic ventricular septal defects were significantly reoperation free (p < 0.05). Patients with noncommitted ventricular septal defects were at significantly higher risk for reoperation during the study period (p < 0.05). The prevalence of late right or left ventricular outflow obstruction in the nonsubaortic groups is concerning. The median age at repair in this series was 0.76 years, and there was a nonsignificant trend (p = 0.13) for early mortality in patients younger than 1 year of age. These patients tended to have other serious cardiac anomalies associated with double-outlet right ventricle that necessitated early operation. On the basis of these data, we favor early repair for double-outlet right ventricle if possible.

Abnormalities, Multiple↗
PubMed1993

Reparative cardiac surgery in the very young.

In addition to primary circulatory disturbance, the presence of congenital heart disease may compromise the development of organ systems including the myocardium, the pulmonary vasculature and the central nervous system. Therefore, early elective repair of complex congenital heart defects is desirable. Today repair of complex congenital heart defects in the neonate can be achieved at low early and late mortality and morbidity with favorable long-term functional results. However, much remains to be learnt about the cellular and molecular effects of open heart surgery and hypothermia on the neonate.

Brain↗
PubMed1993

Fate of small homograft conduits after early repair of truncus arteriosus.

Neonatal repair of truncus arteriosus is being performed in a number of centers, often with the use of small homograft conduits. The fate of the homograft and the risk of replacement were the subjects of this study. Between January 1987 and October 1991, 43 infants aged less than 3 months (range, 3 to 90 days) underwent primary repair of truncus arteriosus including implantation of a valved homograft conduit (diameter, 7 to 12 mm). Twenty-nine had follow-up of more than 6 months (range, 6 to 65 months; mean, 21.9 months). After a mean period of 31 months (range, 8 to 65 months), 7 patients showed obstruction with right ventricular pressures at least 75% systemic and underwent either a conduit change (n = 5) or a patch augmentation (n = 2). Mean cardiopulmonary bypass time at reoperation was 99 minutes; mortality was zero. Five other children are known to have a right ventricular pressure of 50% to 60% systemic, 2 having undergone balloon dilation. Statistical comparison of the patients with conduit reoperation or high right ventricular pressure (n = 12) with the rest of the population (n = 17) revealed an elevated pulmonary artery to right ventricular pullback gradient on postoperative day 1 after the repair (7.7 versus 1.3 mm Hg; p = 0.001) and choice of an aortic over a pulmonary homograft (100% versus 64.7%; p = 0.065) as significant risk factors. Age and weight at repair, postoperative pulmonary artery pressure, length of follow-up, and size of the homograft showed no significant differences between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Aorta↗
PubMed1993

Tetralogy of Fallot with pulmonary atresia. Rehabilitation of diminutive pulmonary arteries.

BACKGROUND: Patients with tetralogy of Fallot, pulmonary atresia, and diminutive pulmonary arteries are a high-risk group for whom there is no consensus on the correct approach to medical management. The purpose of this report is to review a 14-year experience in the treatment of these patients comparing management schemes. METHODS AND RESULTS: Between January 1978 and August 1988, 91 patients with tetralogy of Fallot and pulmonary atresia had an adequate evaluation of their pulmonary artery anatomy before any surgical management. Forty-eight of these patients had diminutive pulmonary arteries (38 to 104 mm2/m2) supplied by aortopulmonary collaterals and were managed in four different fashions. Of the 9 patients repaired primarily, 7 died early and the two survivors had poor hemodynamic outcome. Of the 9 patients conservatively managed with no intervention before 5 years of age, 4 died and only 1 had a satisfactory hemodynamic result after repair. Of 10 shunted patients, 3 died and 3 had satisfactory repairs. Since 1984, we have rehabilitated pulmonary arteries with (1) right ventricle to pulmonary artery surgical graft, (2) balloon dilation of residual pulmonary artery stenoses and embolization of collaterals, and (3) surgical closure of ventricular septal defect and repair of remaining obstructions. Of 20 patients so managed, 7 died after various stages, but 10 of 20 had complete repairs. All repaired patients with subsystemic right ventricular pressures had at least one successful pulmonary artery dilation. CONCLUSIONS: A combined catheter-surgery approach begun at an early age in patients with tetralogy of Fallot and pulmonary atresia with diminutive pulmonary arteries appears to enhance the chances of satisfactory complete repair.

Angioplasty, Balloon↗
PubMed1993

Surgical repair of complete atrioventricular canal defects in infancy. Twenty-year trends.

Case histories of 301 patients with complete atrioventricular canal defect presenting to our institution in infancy between January 1972 and January 1992 were reviewed with the purpose of identifying the factors responsible for the observed improvement in perioperative mortality over this time period. A retrospective analysis of hospital records examined 46 patient-related, morphologic, procedure-related, and postoperative variables for associations with perioperative death and reoperation. Operative mortality decreased significantly over the period of the study from 25% before 1976 to 3% after 1987 (p < 0.0001). A number of the 46 variables examined showed trends over time that were similar to that for mortality. Palliative procedures decreased over time. Reoperation for most residual lesions also decreased to the degree that they were essentially eliminated in recent years. The exception to this was reoperation for postoperative left atrioventricular valve regurgitation, which also decreased but remained at 7% in recent years. Both technical and support-related procedural variables showed no trends over time, with the exception of the performance of left atrioventricular valve annuloplasty, which increased over time. Closure of the left-sided cleft was performed in 61% of the patients, with no trend over time. Annuloplasty and cleft closure were not associated with less postoperative left atrioventricular valve regurgitation, fewer reoperations, or lower mortality. Multivariate logistic regression analysis identified only earlier year of operation, the presence of double-orifice left atrioventricular valve, and postoperative residual regurgitation of the left atrioventricular valve as risk factors for death. Experience-related improvements in technical precision achieved over time best account for the reduction in the rate of reoperation for most types of residual lesions and also for the reduction in mortality. The only residual lesion that has not been essentially completely eliminated is left atrioventricular valve regurgitation, with reoperation for this lesion having been reduced in recent years, but not eliminated. Improved understanding of the structural and functional variability of the atrioventricular valve in this lesion may be necessary before postoperative dysfunction of this valve can be completely eliminated.

Child↗