Biomedical subjects

F J Puga

Publications and source records attributed to F J Puga.

At least 109 records · Page 6Linked to original sources

PubMed1988

The modified Fontan operation for asplenia and polysplenia syndromes.

From 1975 through 1986, 49 patients with asplenia (23 patients) or polysplenia (26 patients) syndromes underwent a modified Fontan operation. All patients had anomalous systemic venous return, and 43 (88%) had anomalous pulmonary venous return. The atrioventricular valve anatomy varied: 36 patients had a common atrial chamber and common atrioventricular valve, eight had mitral valve atresia, and five had severe mitral valve hypoplasia. Redirection of systemic venous return was accomplished by (1) atrial baffle (29 patients), (2) intraatrial conduit (19 patients), and (3) extraatrial conduit (one patient). There were 21 (43%) hospital deaths overall. However, since 1985, six of 22 patients (27%) have died. Increased mortality was seen in patients requiring atrioventricular valve repair or replacement (8/11, 73%) and in patients with asplenia (65%). Lower mortality was seen in patients with polysplenia (24%) and those receiving an intraatrial conduit (26%), although this decrease also represents the more recent experience. We conclude: (1) The Fontan operation for patients with asplenia or polysplenia syndromes has resulted in a significant (although recently declining) mortality; (2) mortality is higher in patients with asplenia; (3) patients with atrioventricular valve insufficiency requiring repair or replacement are at higher risk; and (4) intraatrial conduits seem to offer promise for successfully accomplishing this repair.

Abnormalities, Multiple↗

PubMed1987

Cardiorespiratory response to exercise after definitive repair of univentricular atrioventricular connection.

To characterize the exercise hemodynamic responses after definitive operation for patients with univentricular atrioventricular connection, we compared the cardiorespiratory response to exercise of 4 patients who had undergone the ventricular septation procedure and 9 patients who had undergone the Fontan operation with that of 38 patients who had univentricular atrioventricular connection but had not undergone definitive operation. Exercise duration and total work increased significantly after the Fontan procedure but not after the septation operation. Rest or exercise (or both) ventilation improved significantly after the septation operation but less so after the Fontan operation. Blood oxygen saturation (rest and exercise) improved significantly after either procedure. Cardiac output and stroke-volume response to exercise remained abnormal in both groups of patients after operation. Although definitive operation for univentricular atrioventricular connection results in improved cardiorespiratory function at rest and exercise, these variables remain abnormal when compared with those of normal subjects.

Adolescent↗

PubMed1987

Drapanas shunt using a spiral saphenous vein graft.

An alternative technique for creation of a Drapanas shunt was used in a 12-year-old boy with upper gastrointestinal bleeding. Dissatisfaction with available prosthetic grafts and the inherent limitations of other autogenous materials led to the use of a spiral saphenous vein graft to bridge the superior mesenteric vein and the inferior vena cava. Patency of the graft was demonstrated 1 year postoperatively, and the patient has not had further bleeding episodes for 2 years postoperatively. Continued use of this operation is necessary to determine its usefulness.

Gastrointestinal Hemorrhage↗

PubMed1987

Definitive operation for pulmonary atresia with intact ventricular septum. Results in twenty patients.

Definitive operation was performed on 20 patients (aged 25 to 178 months) with pulmonary atresia and intact ventricular septum. All patients had one or more prior preliminary palliative procedures. Right ventricular outflow tract reconstruction with atrial septal defect closure and shunt removal was done on 10 patients. Tricuspid annular circumference was at least 70% of normal in seven patients and between 55% and 70% in three patients. Two patients died during hospitalization. The eight surviving patients were asymptomatic 3 to 145 months after operation. The modified Fontan operation was performed on 10 patients. None of these patients had a tricuspid annular circumference greater than 70% of normal; the circumference was less than 55% in nine patients and between 55% and 70% in one patient. One patient died during hospitalization and one died later. Follow-up 6 to 48 months after operation showed that six patients were in the New York Heart Association Class I and two were in Class II. After effective preliminary palliation of pulmonary atresia with intact ventricular septum, definitive operation can be done with an operative risk of 15% (three of 20 patients) and excellent late results. Right ventricular outflow tract reconstruction can be done as a complete repair for patients who have adequate tricuspid annular size. The modified Fontan operation is the only option for definitive repair when the tricuspid anulus is severely hypoplastic.

Child↗

PubMed1987

Right ventricular outflow construction without cardiopulmonary bypass.

Establishment of right ventricular-pulmonary arterial continuity without the use of cardiopulmonary bypass was undertaken in 36 patients with different anomalies associated with pulmonary atresia or severe stenosis. Hospital mortality was 11% with no late death. Fourteen of the 27 individuals with pulmonary atresia, ventricular septal defect, and hypoplastic confluent pulmonary arteries had adequate angiographic follow-up, which demonstrated significant pulmonary artery enlargement. Five patients underwent total correction, two after unifocalization operations to establish lobar pulmonary arterial continuity. Symmetric growth of the left and right pulmonary artery was not achieved. However, the enlargement was adequate for potential final repair in all the patients with an unrestricted outflow tract.

Blood Vessel Prosthesis↗

PubMed1987

Modifications of the Fontan operation applicable to patients with left atrioventricular valve atresia or single atrioventricular valve.

Two modifications of the Fontan operation are proposed for prevention of pulmonary venous obstruction in patients with left atrioventricular valve atresia or single atrioventricular valve. In the first technique, a bipedicled flap of right atrial wall is used to separate systemic and pulmonary venous drainages; an atriopulmonary connection is constructed by use of the right atrial appendage, and the defect in the right atrial wall is repaired with a pericardial patch. In the second technique, the superior vena cava is transected and the cardiac and cephalad ends are anastomosed separately to the pulmonary arterial confluence. A patch is positioned inside the right atrium to separate the systemic from the pulmonary venous drainage. Both techniques achieve unrestricted systemic and pulmonary venous channels. Severe atrial arrhythmias, present in the four patients operated on with the first procedure, were not seen in 12 patients who had repair with the second procedure.

Heart Atria↗

PubMed1987

Intermediate follow-up and predicted survival after the modified Fontan procedure for tricuspid atresia and double-inlet ventricle.

We reviewed the records of 135 patients with tricuspid atresia and 120 patients with double-inlet ventricle who underwent modified Fontan procedure from 1973 to June 1985. This represents 67% of the total number of patients undergoing the procedure during this period. There were 32 (12%) in-hospital deaths (14 tricuspid atresia, 18 double-inlet ventricle) and 23 late deaths (13 tricuspid atresia, 10 double-inlet ventricle). For patients surviving to hospital dismissal, the 5 year survival was 87%. Follow-up data (mean 3.9 years) were obtained for 157 patients who survived at least 1 year after operation. At last follow-up, of the 157 patients, 92% were in NYHA class I or II, 92% claimed to be improved clinically by the operation, and 98% could work or attend school. Fifty percent were not taking medication at last follow-up. Some degree of edema or ascites was found in 16%. The study showed that (1) the modified Fontan procedure can be performed with low in-hospital mortality (12%) in patients with tricuspid atresia and double-inlet ventricle, (2) hospital survivors have an estimated 5 year survival of 87%, (3) subjectively, functional status is good for hospital survivors at intermediate follow-up, and (4) fluid retention continues to be a problem in a minority (16%) of patients.

Blood Vessel Prosthesis↗

PubMed1987

Replacement of obstructed extracardiac conduits with autogenous tissue reconstructions.

Tissue-valved prosthetic extracardiac conduits fail in 6% to 30% of patients within 5 years of implantation. Failure is caused both by valve degeneration and by conduit peel formation. This report describes a technique, performed in 16 children, in which an obstructed right ventricle-to-pulmonary artery valved conduit was removed and a new conduit constructed using the conduit bed as the posterior wall and a patch of xenograft pericardium (n = 10), homograft dura mater (n = 5), or Dacron (n = 1) as the roof of the conduit. One child with pulmonary hypertension required a Björk-Shiley pulmonary valve; in the others no valve was inserted. This technique simplifies conduit replacement, allows for a generous-sized outflow tract that may grow with patient growth, and uses material unlikely to become obstructed.

Adolescent↗

PubMed1987

Repair of tricuspid valve insufficiency in patients undergoing double (aortic and mitral) valve replacement. Perioperative mortality and long-term (1 to 20 years) follow-up in 109 patients.

Between 1965 and 1984, 109 patients underwent simultaneous aortic and mitral valve replacement and tricuspid valve repair at the Mayo Clinic, with a perioperative mortality of 21%. The only variable predictive of perioperative mortality on multiple regression analysis was New York Heart Association class IV disability. The median follow-up was 5.6 years (range 1 to 20 years). Cumulative 5-, 10-, and 15-year survival rates in patients discharged from the hospital were 70% +/- 5%, 42% +/- 6%, and 33% +/- 7%. Multivariate analysis identified advanced age and class IV disability as significant predictors of poor survival. Five-year survival rates were similar in patients undergoing operation between 1965 and 1974 and after 1975, despite an increase in age and in the severity of preoperative symptoms in the recent group. Late mortality was due to sudden death in 38% of the patients, heart failure in 21%, reoperation in 5%, endocarditis in 2%, and thromboembolism and bleeding in 4%. Late complications included systemic emboli in 22% (embolism rate 4.5 events/100 patient-years), bleeding in 17%, reoperation in 14%, myocardial infarction in 8%, permanent pacemaker implantation in 5%, and infective endocarditis in 3%. Of 43% of the patients still alive, 79% are in class I or II.

Aortic Valve↗

PubMed1987

Tetralogy of Fallot with anomalous origin of left anterior descending coronary artery. Surgical options.

Anomalous origin of the left anterior descending coronary artery from the right coronary artery can interfere with the location of the usual ventriculotomy during repair of tetralogy of Fallot. The purpose of this study was to compare the results of two operative techniques: (1) a "tailored" right ventricular incision and outflow patch reconstruction and (2) placement of a conduit from the right ventricle to the main pulmonary artery. We reviewed the records of 416 patients who had complete repair of tetralogy of Fallot at the Mayo Clinic from 1973 through 1984. Twenty (5%) (median age 6.5 years) had anomalous origin of the left anterior descending coronary artery from the right coronary artery. Twelve of these patients had right ventricular outflow patch reconstruction, and eight had placement of a conduit from the right ventricle to the pulmonary artery. Three deaths occurred, all during hospitalization, two in the patch reconstruction group and one in the conduit group. The average reduction in right ventricular pressure postoperatively was slightly but not significantly greater for the conduit group. These data indicate that correction of tetralogy of Fallot with anomalous origin of the left anterior descending coronary artery can be done with either patch reconstruction or conduit placement. Selection of the more appropriate procedure depends on the exact location and degree of tortuosity of the anomalous artery and the level and severity of right ventricular outflow obstruction.

Blood Vessel Prosthesis↗

PubMed1987

Repair of ascending aortic dissection. Influence of associated aortic valve insufficiency on early and late results.

Operative treatment of dissections of the ascending aorta differs from that for the descending aorta, not only because of the need for cardiopulmonary bypass, but also because of the frequent occurrence of aortic valve insufficiency. To determine the early and late results of operative repair, we have reviewed the case histories of 121 consecutive patients who underwent repair of ascending aortic dissections between 1962 and 1985. Ages ranged from 16 to 79 years (mean 56 +/- 14 years); 54 patients had operation within 2 weeks of onset of symptoms (acute), and the remainder had later repair (chronic). Seventy patients (58%) had clinical evidence of aortic insufficiency at the time of admission. During repair of acute dissection, 10 patients (19%) had aortic valve resuspension and 15 patients (28%) had aortic valve replacement. During repair of chronic dissection, eight patients (12%) had resuspension and 43 patients (64%) had replacement. Overall operative mortality was 22%, significantly higher for patients with acute than for those with chronic dissections (39% versus 9%, p less than 0.01). Operative risk was similar for patients who underwent repair of ascending aortic dissections without valve resuspension or replacement (31%) versus those who had repair with aortic valve resuspension (17%) or replacement (17%). During a follow-up period ranging from 1 to 208 months, aortic regurgitation developed in only two patients who did not have aortic insufficiency at the time of repair. Late aortic regurgitation necessitating reoperation developed in one of the 15 survivors who had aortic valve resuspension. Eight patients undergoing aortic valve replacement had complications of their prostheses, including one periprosthetic leak and four mechanical failures. We conclude that resuspension or replacement of the aortic valve does not increase the risk of repair of ascending aortic dissections. Selective management of aortic insufficiency (with valve repair whenever possible) yields satisfactory long-term results.

Aortic Dissection↗

PubMed1986

Patent ductus arteriosus in patients more than 50 years old.

At the Mayo Clinic, from 1945 through 1983, a definitive diagnosis of patent ductus arteriosus was first made in 38 patients when they were more than 50 years old. Of the 29 patients who had cardiac catheterization, 14 had a small left-to-right shunt, 7 had a moderate shunt, and 8 had a large shunt. Five patients, including 2 with right-to-left shunts through the ductus, had pulmonary systolic pressures greater than 75 mm Hg. Thirty procedures were done in 29 patients: ductal ligation in 7, division and suture in 13, transaortic patch closure in 3, and closure via median sternotomy with extracorporeal circulation in 7. There was one intraoperative death (operative mortality, 3.3%). Although technically more challenging, surgical repair is associated with low mortality and excellent follow-up survival. The patients who benefit most from surgical correction are those with Qp/Qs greater than 1.5 and pulmonary artery systolic pressure less than 75 mm Hg.

Aged↗

PubMed1986

Exercise tolerance and cardiorespiratory response to exercise after the Fontan operation for tricuspid atresia or functional single ventricle.

To determine the impact of the Fontan operation on exercise tolerance and on the cardiorespiratory response to exercise, we compared the results of graded exercise to maximal effort of 81 patients with tricuspid atresia or single functional ventricle studied preoperatively with those of 29 patients studied postoperatively. Postoperatively, the values for total work performed, duration of exercise and maximal oxygen uptake increased significantly. Regardless of operative status, the maximal heart rate during exercise was reduced. The cardiac output and stroke volume response to exercise were subnormal after operation. Systemic arterial blood oxygen saturation was reduced markedly preoperatively both at rest and during exercise; postoperatively, it was significantly greater than the preoperative value but it remained slightly abnormal. The ventilatory response to exercise (respiratory rate, minute ventilation and ventilatory equivalent for oxygen) decreased toward normal after operation. Exercise tolerance and the cardiorespiratory responses to exercise improve after the Fontan operation. Formal exercise testing is essential to quantitate the degree of improvement.

Adolescent↗

PubMed1986

Pulmonary atresia with ventricular septal defect: preoperative and postoperative responses to exercise.

Between April 1982 and June 1984, maximal exercise testing was performed 35 times in 34 consecutive patients with pulmonary atresia and ventricular septal defect (14 studies in patients without repair, 11 studies in patients with partial repair [insertion of a right ventricle to pulmonary artery conduit without ventricular septal defect closure] and 10 studies in patients with complete repair [insertion of a conduit with septal defect closure]). Total work performed, maximal power achieved, exercise time and maximal oxygen uptake were significantly greater in patients after partial or complete repair than in patients without repair. Systemic arterial blood oxygen saturations at rest and during exercise were directly related to the degree of repair. Although heart rate at rest in the three study groups was similar to that in a separate group of normal control subjects, patients in all three study groups had a blunted heart rate response to exercise. The ventilatory equivalent for oxygen was increased both at rest and during exercise for patients without conduit repair and those with a right ventricle to pulmonary artery conduit without ventricular septal defect closure but was similar to that of control subjects in the group with conduit insertion and septal defect closure. This study indicates that patients with pulmonary atresia and ventricular septal defect have decreased exercise tolerance both before and after corrective surgery. Exercise tolerance improves significantly after placement of a conduit from the right ventricle to the pulmonary artery with or without ventricular septal defect closure. Although no further improvement in exercise tolerance occurs with closure of the septal defect, ventilatory function and systemic arterial blood oxygen saturation are improved.

Adolescent↗

PubMed1986

Staged surgical repair of pulmonary atresia, ventricular septal defect, and hypoplastic, confluent pulmonary arteries.

In patients with pulmonary atresia and ventricular septal defect, hypoplasia of the central pulmonary arteries prevents single-stage complete repair. Over an interval of 8 1/2 years, 105 patients underwent establishment of continuity between the right ventricle and a hypoplastic central pulmonary arterial confluence (first stage). There were 12 hospital deaths (11%) and 11 late deaths before second-stage (complete) repair. Twenty-five patients await late evaluation. The remaining 57 individuals have had follow-up cardiac catheterization a mean of 33 months postoperatively. In 31 of these, final repair was deferred because of insufficient pulmonary arterial enlargement (14), restricted peripheral arborization (nine), or both (eight). The final 26 patients were accepted for second-stage repair, which has been performed in 24. Complete repair included ventricular septal defect closure (24), right ventricular outflow tract reconstruction (18), relief of central pulmonary arterial stenosis (14), and ligation of systemic-pulmonary collateral arteries (10). The mean postrepair peak systolic right ventricular-left ventricular pressure ratio was 0.67 (range 0.32 to 1.0). One of these patients (4%) died in the hospital and there was one late death (4%) from sepsis after tricuspid valve replacement. Three patients were lost to follow-up; the remaining 19 patients are in functional Class I or II. A two-stage surgical approach is highly successful in those patients whose pulmonary arteries are too hypoplastic to allow a single-stage repair.

Adolescent↗

PubMed1986

Comparison of atriopulmonary versus atrioventricular connections for modified Fontan/Kreutzer repair of tricuspid valve atresia.

This study compares the clinical results of two basic variations of the modified Fontan/Kreutzer operation, direct atriopulmonary connection without an interposed valve versus atrioventricular connection using the native pulmonary valve and the potential pumping capability of the subpulmonary ventricular chamber. From January 1979 through June 1985, 84 patients with tricuspid atresia and ventriculoarterial concordance underwent the modified Fontan/Kreutzer operation at the Mayo Clinic. Sixty patients had atriopulmonary connection and 24 patients had atrioventricular connections. Preoperative characteristics of the two patient groups were similar, but there was a greater frequency of Waterston shunts in the atriopulmonary group (38% versus 17%) and greater frequency of Glenn shunts in the atrioventricular group (46% versus 15%). Mean pulmonary arteriolar resistance was 1.9 +/- 0.7 units in the atriopulmonary group and 1.1 +/- 0.8 units in the atrioventricular group (p less than 0.01). Early postoperatively, mean right atrial pressure was slightly higher in the atriopulmonary group than in the atrioventricular group (18 +/- 3 versus 16 +/- 3 mm Hg, p less than 0.01), but this difference was not reflected in the early or late results. Operative mortality was 5% for patients with atriopulmonary connections and 4% for patients with atrioventricular connections. At 3.5 years postoperatively, the overall survival rate was 89% +/- 4% for patients with atriopulmonary connection and 88% +/- 7% for patients with atrioventricular connections. We conclude that there is no important difference in the clinical outcome of patients undergoing modified Fontan/Kreutzer repair for tricuspid atresia with atrioventricular concordance with either of the two operative methods. The choice of the connection should be dictated by the anatomy, such as presence of pulmonary valve or arterial stenoses, size of outlet chamber, and the presence of anomalous coronary arteries.

Adolescent↗

PubMed1986

Prognostic factors and surgical treatment of partial atrioventricular canal.

In this study we sought to determine the prognostic factors that influence early and late survival after repair of partial atrioventricular canal and the need for reoperation. From January 1962 to January 1984, 199 patients underwent correction of partial atrioventricular canal. There were 73 male and 126 female patients, ranging in age from 5 months to 71 years (mean 11.2 years). Total 30 day operative mortality was 5.5%. Since 1980, the mortality has declined to 3%. Significant determinants of operative mortality were congestive heart failure, cyanosis, failure to thrive, age less than 4 years, and moderate-to-severe mitral valve insufficiency (p less than .01). Sex, cardiomegaly, radiographically increased pulmonary vasculature, intraoperative postrepair right ventricular-to-left ventricular pressure ratio, and pulmonary-to-systemic flow ratio were not significant in determining early mortality. Follow-up ranged from 1 to 21.4 years (mean 15.2). There were seven late deaths, primarily in older patients from atherosclerotic disease or malignancy. Late survival was 98% at 1 year and 96% at 20 years. Reoperation was performed on 18 patients, 15 for mitral incompetence, and three for subaortic stenosis. The need for reoperation correlated with severity of postrepair mitral insufficiency. Longterm survival is excellent after repair of the partial form of atrioventricular canal.

Aged↗

PubMed1985

Straddling atrioventricular valve: two-dimensional echocardiographic diagnosis, classification and surgical implications.

The usefulness of subclassifying the anatomic variations of straddling and overriding atrioventricular (AV) valve by 2-dimensional echocardiographic observation were evaluated. Chordae straddling into a contralateral ventricle were subdivided into type A (chordae inserting into the contralateral ventricle near the crest of the ventricular septum), type B (chordae inserting along the contralateral ventricular septum) and type C (chordae inserting into the free wall or papillary muscles of the contralateral ventricle). Overriding AV valve anulus was described as minor (less than 50% of the anulus committed to the contralateral ventricle), major (about 50% of the anulus committed to each ventricle), and double-inlet ventricle (greater than 50% of both AV valves committed to a single ventricular chamber). In 52 patients straddling AV valve was diagnosed by echocardiography and confirmed by direct examination at surgery or autopsy. In 60 of 66 straddling AV valves (91%), the diagnosis and the degree of straddling (type A, B or C) were correctly identified by 2-D echocardiography. Major associated cardiac defects included double-outlet right ventricle (31%), complete transposition (23%), corrected transposition (19%), double-inlet ventricle (19%) and other complex defects (8%). Twenty-two patients (42%) had right-sided straddling, 21 (40%) had left-sided straddling and 9 (17%) had straddling of both AV valves. In 41% of the patients, straddling AV valve had a major impact on the type of surgery or the surgical outcome. Of these valves, 52% were type C (severe), 26% type B and 22% type A straddling.(ABSTRACT TRUNCATED AT 250 WORDS)

Chordae Tendineae↗