Mustard takedown and arterial switch in a patient with transposition of the great vessels.
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Child, Preschool↗
Biomedical subjects
F S Idriss
Publications and source records attributed to F S Idriss.
Vascular anomalies causing tracheoesophageal compression. Review of experience in children.
Two hundred four infants and children (mean age 13 months) have undergone operation for the relief of tracheoesophageal obstruction resulting from vascular anomalies. One hundred thirteen patients had complete vascular rings (group I), 61 with double aortic arch and 52 with right aortic arch with a left ligamentum. Nine patients had a pulmonary artery sling (group II), 71 had innominate artery compression (group III), and 11 had miscellaneous anomalies (group IV). Patients were admitted with respiratory distress, stridor, apnea, dysphagia, or recurrent respiratory infections. Diagnosis was established by barium esophagogram in group I; barium esophagogram, bronchoscopy, and computed tomography or angiography in group II; bronchoscopy in group III; and barium esophagogram or angiography in group IV. The operative approach was through a left thoracotomy in group I, II and IV (93% of these patients) and through a right thoracotomy for group III (96% of these patients). The operative mortality rate was 4.9% and there were seven late deaths (3.4%). There have been no operative deaths in patients with isolated vascular anomalies in the past 28 years. Follow-up data from 1 month to 20 years (mean 8.5 months) were available on 159 patients; 141 (92%) were essentially free of symptoms, and 12 (8%) had residual respiratory problems. Five of six patients in group II having a lung scan postoperatively had a patent left pulmonary artery. A strong index of suspicion is necessary to avoid the complications of vascular rings in children. Barium swallow is the best single diagnostic technique for patients with complete vascular rings. A bronchoscopic study is required to diagnose innominate artery compression. Angiograms or computed tomographic scans are used to confirm the diagnosis of pulmonary artery sling. Left thoracotomy provides excellent exposure for all vascular rings except the displaced innominate artery, for which a right thoracotomy is the best approach.
Aorta, Thoracic↗
Surgical management of patients with interrupted aortic arch and severe subaortic stenosis.
Ten patients underwent palliative surgery for interrupted aortic arch and severe subaortic obstruction due to posterior displacement of the conal septum. Their ages ranged between 4 and 28 days (mean, 11.0 +/- 7.7 days) and their weights, between 2.1 and 4.2 kg (mean, 2.85 +/- 0.6 kg). Preoperative echocardiography and cardiac catheterization were performed on all patients. The ratios of the left ventricular outflow tract diameters and the ascending aortic diameters to the descending aortic diameters were 0.56 +/- 0.03 and 0.56 +/- 0.06, respectively, compared with 0.81 +/- 0.12 and 0.95 +/- 0.17, respectively, in 20 patients with interrupted aortic arch but without obstruction (p less than 0.001). Four of the 10 patients underwent pulmonary artery banding and insertion of a bypass graft between the ascending and the descending aorta. All 4 died of low cardiac output soon after operation (100% operative mortality). The remaining 6 patients underwent banding and insertion of a graft between the main pulmonary artery proximal to the band, and the descending aorta. All of these patients survived, and all except 1 are doing well 3 months to 4 years postoperatively. The use of a pulmonary artery-descending aorta conduit and of distal pulmonary artery banding provides good palliation for patients with interrupted aortic arch and major subaortic stenosis.
Aorta, Thoracic↗
Comparison of single versus multidose blood cardioplegia in arterial switch procedures.
Fifty-three patients with transposition of the great arteries and Taussig-Bing anomaly undergoing an arterial switch procedure were divided into two groups. Group 1 (N = 32) received multidose cardioplegia injected initially into the aortic root and subsequently into the coronary artery orifices and Group 2 (N = 21), single-dose cardioplegia injected into the aortic root. The mean aortic cross-clamp and bypass times were generally longer in Group 1 compared with Group 2. Group 1 patients with simple transposition undergoing primary repair (N = 15) had an aortic cross-clamp time of 80 +/- 8 minutes and a bypass time of 203 +/- 27 minutes versus 64 +/- 6 minutes (p less than 0.001) and 170 +/- 15 minutes (p less than 0.01), respectively, for similar patients in Group 2 (N = 10). Group 1 patients with simple transposition undergoing staged repair (N = 7) had an aortic cross-clamp time of 71 +/- 6 minutes and a bypass time of 201 +/- 24 minutes versus 66 +/- 4 minutes (p = not significant [NS]) and 226 +/- 25 minutes (p = NS), respectively, for Group 2 (N = 6). In Group 1 patients with complex transposition (N = 10), the aortic bypass time was 79 +/- 12 minutes and the bypass time was 261 +/- 40 minutes versus 64 +/- 11 minutes (p less than 0.05) and 225 +/- 16 minutes (p less than 0.1), respectively, for Group 2 (N = 5). Early mortality was 16% (5/32) in Group 1; there were no early deaths in Group 2.(ABSTRACT TRUNCATED AT 250 WORDS)
Aorta↗
Transposition of the great arteries with intact ventricular septum. Arterial switch in the first month of life.
Twenty-three infants with simple transposition of the great arteries and intact ventricular septum were operated on from October 1983 to October 1986. The age at operation in 22 infants ranged from 2 to 21 days and in one was 35 days (mean 9.82 +/- 6.86 days). The infants were evaluated with cardiac catheterization at 1 to 27 days of age. Twenty-two infants had balloon atrial septostomy, and 22 received prostaglandin E1 infusion. The left ventricular diastolic wall thickness, assessed by M-mode echocardiograms, varied between 2.8 and 4 mm. There were two hospital deaths in this group of 23 infants (mortality 8.6%), and there were no late deaths. All surviving patients are doing well clinically. One patient had asymptomatic nonsustained ventricular tachycardia necessitating phenytoin. Postoperative echocardiographic assessment performed on 15 patients at 0.93 +/- 0.61 years of age and cardiac catheterization and angiographic studies on seven patients at 1.07 +/- 0.13 years after operation revealed excellent ventricular performance, good semilunar valve function, and mild gradient at the right ventricular outflow with a mean right ventricular pressure of 37.4 +/- 4.1 torr.
Aorta↗
Arterial switch in simple and complex transposition of the great arteries.
Arterial switch for repair of transposition of the great arteries was performed on 53 patients since October 1983. These patients were divided into three groups: group I, 25 infants with an intact ventricular septum who had primary repair in the first month of life (2 to 34 days of age, mean 9.7 +/- 6.6); group II, 13 patients with an intact ventricular septum who had anatomic repair after a preliminary procedure (pulmonary artery banding in 13, shunt in 10, atrial septectomy in 1); and group III, 15 infants with transposition of the great arteries and ventricular septal defect. In group III, six patients had Taussig-Bing abnormality, nine had previous pulmonary artery banding, three had coarctation of the aorta repaired earlier in life, and four were less than 2 weeks old. Overall early mortality was 9.4% (5/53: group I 8%, group II 7.6%, group III 13.3%). Two late deaths occurred in group II 10 and 12 weeks postoperatively after infection and high fever. A third late death 18 weeks postoperatively was due to aspiration in an infant with Goldenhar's syndrome. Mortality and morbidity decreased significantly after an initial learning period (no deaths from July 1985 to March 1987 overall, and none in the last 15 infants operated on in group I). The surviving 45 patients are doing well. All have normal sinus rhythm. Two had transient asymptomatic arrhythmias. Left and right ventricular function assessed by echocardiogram and postoperative cardiac catheterization were within normal ranges in all but two patients, one with pulmonary artery stenosis and one (Taussig-Bing abnormality with two large ventricular septal defects) with severe pulmonary vascular disease (9.6 units) observed before anatomic repair. The right ventricular pressure at catheterization ranged from 27 to 42 mm Hg in 12 patients and was 55 mm Hg in two. There was no aortic stenosis. Aortic insufficiency was trivial in three patients and mild in one. We conclude that excellent results can be obtained with arterial switch for transposition of the great arteries with or without ventricular septal defect, especially in neonates.
Cardiac Catheterization↗
Factors influencing coronary vascular resistance during hypothermia.
Factors influencing total coronary vascular resistance (CVR) during hypothermia were studied in 30 mongrel dogs. Complete isolation of the heart in situ was achieved by transection of all cardiac neural and vascular connections in 15 dogs (denervated, Group I). Cardiac innervation was maintained in the other 15 dogs using systemic normothermic cardiopulmonary bypass (innervated, Group II). The aortic root was perfused with heparinized oxygenated blood at a constant flow rate at variable myocardial temperatures. Electromechanical arrest was achieved using potassium chloride (KCl) (25 meq/liter) added to the coronary perfusate. In each group, 5 dogs were maintained at a flow rate of 10 cc/kg/min without KCl and allowed to beat spontaneously, another 5 at a flow rate of 10 cc/kg/min and arrested with KCl, and the remaining 5 at a flow rate of 5 cc/kg/min with KCl. Total coronary vascular resistance was calculated from aortic root pressure, right atrial pressure, and flow rate and expressed in units per 100 grams of cardiac tissue. At 37 degrees C, resistance was lower in the denervated arrested (1.3 +/- 0.2) than in the innervated arrested hearts (2.1 +/- 0.2) (P less than 0.001). Preservation of spontaneous electromechanical activity in the innervated hearts resulted in a lower resistance (0.4 +/- 0.1) (P less than 0.001). A progressive decrease in myocardial temperature to 15 degrees C resulted in a corresponding decrease in coronary vascular resistance to a plateau value (0.5 to 0.7 U) in all arrested groups. The data suggest that at normothermia, innervation increases vascular tone in the coronary vascular bed, while electromechanical activity decreases it.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Surgical management of infants with complex cardiac anomalies associated with reduced pulmonary blood flow and total anomalous pulmonary venous drainage.
Eight infants with complex cardiac anomalies and pulmonary stenosis or atresia were noted to have obstructed total anomalous pulmonary venous drainage (TAPVD) either at the initial cardiac catheterization (Group 1; n = 2) or after creation of systemic-pulmonary artery shunts (Group 2; n = 6). The 2 patients in Group 1 underwent early repair of TAPVD (1 at 7 days, the other at 1 1/2 months of age) before any subsequent operation and are now doing well at 18 months of age. The 6 patients in Group 2 underwent repeat cardiac catheterization because of persistent severe cyanosis with faint or absent continuous murmur and were found to have patent shunts and obstructed TAPVD (1 mild, 5 severe). One patient who underwent repair of TAPVD at 2 1/2 months of age survived and is well at 2 years of age, whereas 4 patients who underwent repair at an average age of 6 months (age range, 3-16 months) subsequently died. The sixth patient, who did not undergo repair, remained severely cyanotic with hypoplastic pulmonary arteries in spite of repeated shunts. We feel that increased awareness of the possible association of TAPVD and reduced pulmonary blood flow in infants with complex cardiac defects, in combination with echocardiography, oxygen saturation studies, and angiography with prostaglandin E1 challenge, should lead to early diagnosis, avoidance of unnecessary systemic-pulmonary artery shunts, and increased survival rates in these infants.
Constriction, Pathologic↗
Management of recurrent coarctation of the aorta: a new experimental technique.
A new technique is described for the management of recurrent coarctation of the aorta. It involves enlarging the narrowed segment by an onlay patch sutured to the adventitia and outer media of the aortic wall. The procedure was used in 6 mongrel dogs with preexisting surgically created coarctation. Aortic cross-clamping time ranged between 7.5 and 11 minutes (mean, 8.8 +/- 1.3 minutes). There were no operative deaths or complications. Gross and microscopic examination of the aorta 6 to 12 months (mean, 9 +/- 2.2 months) postoperatively revealed a 290 to 380% (mean, 350 +/- 30%) increase in the diameter of the repaired area and no evidence of thrombosis or pseudoaneurysm formation. The need for minimal dissection and the brief period of aortic cross-clamping make this approach an attractive alternative in the surgical treatment of patients with difficult cases of recoarctation.
Animals↗
Valve replacement in children: guidelines for selection of prosthesis and timing of surgical intervention.
One hundred fifty-nine patients ranging from 3 months to 18 years old (mean, 8.1 +/- 3.7 years) underwent 162 primary valve implantations. A porcine valve was used in 104 patients, a St. Jude Medical valve in 40, and a Björk-Shiley valve in 18. The valve replaced was the aortic in 25 patients, the mitral (systemic atrioventricular [AV] valve) in 43, the pulmonary in 71, and the tricuspid (pulmonary AV valve) in 23. Hospital mortality was 6%. Patients with a Björk-Shiley valve received warfarin sodium anticoagulation, and those with a St. Jude Medical valve were given salicylates and dipyridamole. Follow-up is available on all patients 0.6 to 12 years postoperatively (mean, 6.3 +/- 2.6 years). New York Heart Association Functional Class improved in 62% and remained unchanged in 38% of the patients. Thromboembolic complications occurred in only 8 (57%) of 14 patients with a St. Jude Medical valve in the right (pulmonary) side and in 3 (12%) of 26 with the valve in the left (systemic) side of the circulation. Bacterial endocarditis developed in 3 patients, all with porcine valves. Early valve replacement, less than 2 years after detection of hemodynamic deterioration, resulted in improvement in the ventricular ejection fraction in 25 of 29 patients (from 81 +/- 14% to 90 +/- 12% of normal; p less than 0.05). In contrast, the ejection fraction remained abnormal in all 22 patients with delayed valve insertion (more than 2 years) (81 +/- 16% of normal preoperatively and 80 +/- 10% of normal following operation; p = not significant).
Adolescent↗
Preparation of the left ventricle for anatomical correction in patients with simple transposition of the great arteries. Surgical guidelines.
Pulmonary artery banding in combination with an aortopulmonary shunt was performed on 16 patients with simple transposition of the great arteries to prepare the left ventricle for anatomical correction. Three groups were identified after operation: Group I (four patients) had increased pulmonary blood flow and tight pulmonary artery banding; Group II (four patients) had increased pulmonary blood flow and moderate pulmonary artery banding; Group III (eight patients) had normal pulmonary blood flow and moderate pulmonary artery banding. Postoperative low cardiac output was present in all patients in Group I, whereas mild heart failure was present in two patients in Group II and in two in Group III. There was one hospital death (6%). The follow-up period was 125 patient-months. Left ventricular systolic pressure rose from 63 +/- 11 torr before the operation to 101 +/- 35 torr after the procedure in Group I (p less than 0.05), from 59 +/- 10 to 93 +/- 33 torr in Group II (p less than 0.05), and from 55 +/- 10 to 84 +/- 16 torr in Group III (p less than 0.005). The increase in left ventricular muscle mass was from 44 +/- 2 gm/m2 preoperatively to 108 +/- 12 gm/m2 after operation in Group I (p less than 0.01), from 43 +/- 3 to 93 +/- 8 gm/m2 in Group II (p less than 0.02), and from 46 +/- 3 to 55 +/- 14 gm/m2 in Group III (p = no statistically significant difference). The postoperative change in left ventricular end-diastolic volume was from 100% +/- 17% to 133% +/- 23% of normal in Groups I and II (p less than 0.05) and from 123% +/- 29% to 107% +/- 36% of normal in Group III (p = no statistically significant difference). In preparing the left ventricle for anatomical correction, avoidance of severe pulmonary artery banding decreases the incidence of postoperative myocardial dysfunction, a moderate degree of volume overload and pulmonary artery banding provides the most effective stimulus for ventricular growth, and a small to moderate atrial septal defect is advantageous because it ensures the volume preload necessary for the development of the left ventricle.
Arteriovenous Shunt, Surgical↗
Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair. Surgical implications.
Postoperative cardiac catheterization data of 74 patients with pulmonary insufficiency after tetralogy repair were analyzed. Two groups were identified: Group A, 26 patients with normal right ventricular function (ejection fraction 95% +/- 5.5%, end-systolic volume 110% +/- 17% of predicted normal) and Group B, 48 patients with right ventricular dysfunction (ejection fraction 80% +/- 18% [p less than 0.001], and end-systolic volume 218% +/- 75% of predicted normal [p less than 0.001]). There was no significant difference between the two groups with respect to frequency of previous palliative procedures, age at operative repair, operative techniques, methods of myocardial protection, and follow-up period. Right ventricular dysfunction in Group B was associated with significant distal pulmonary stenosis (right ventricle-pulmonary artery pressure gradient 28 +/- 13 torr in Group A versus 55 +/- 20 torr in Group B, p less than 0.001), moderate pulmonary regurgitation (regurgitant fraction 18% +/- 11% in Group A versus 32% +/- 10% in Group B, p less than 0.001), and large transannular outflow patch (ratio of patch diameter to descending aorta diameter 1.31 +/- 0.16 in Group A versus 2.50 +/- 0.28 in Group B, p less than 0.001). Pulmonary valve insertion was performed in 42 patients in Group B. Eighteen had subsequent cardiac catheterization. Right ventricular function recovered completely (end-systolic volume 122% +/- 24%, and ejection fraction 92% +/- 7% of predicted) in five of six patients (83%) who had valve insertion within the first 2 years after tetralogy repair. In contrast, right ventricular function remained abnormal in all 12 patients who had valve insertion later than 2 years after tetralogy repair (p less than 0.05). Patients with residual pulmonary stenosis and/or a large transannular outflow patch are at risk for the development of right ventricular dysfunction from pulmonary insufficiency after tetralogy repair. Early correction of these residual lesions and control of pulmonary insufficiency may prevent long-term deterioration in right ventricular function.
Adolescent↗
Experience with St. Jude Medical valve prosthesis in children. A word of caution regarding right-sided placement.
Thirty-six children aged 6 months to 18 years, underwent insertion of 37 St. Jude Medical cardiac prostheses. In 20, the valve was placed in the aortic or mitral position, and in 16 in the pulmonary or tricuspid position. There was one (2.8%) hospital death. All patients received maintenance doses of salicylates and dipyridamole after the operation. Follow-up data are available for all patients for 12 to 24 postoperative months. There was no incidence of valve dysfunction or thromboembolic complication in any of the 20 patients with valves in the systemic (left) side of the circulation, and all manifested improvement in their functional class. In contrast, six (37%) of the 16 patients with valves in the pulmonary (right) side of the circulation developed dysfunction of the prosthesis 1 to 6 months after insertion. Prosthesis failure was associated with fibrous tissue growing into the struts, leading to leaflet immobilization. At 2 years, the actuarial functional life was 100% for mitral and aortic valves and 70% for pulmonary and tricuspid valves. The data illustrate the excellent hemodynamic function of the St. Jude Medical valve in children. The absence of thromboembolic complications warrant continued implantation of the prosthesis in the left side without warfarin anticoagulation therapy, but the high incidence of valve dysfunction in the pulmonary position does not justify its continued use in the right side.
Adolescent↗
Development of neo-coarctation in patients with transposed great arteries and hypoplastic aortic arch after Lecompte modification of anatomical correction.
We report on three patients with kinking in the proximal aortic arch that developed after Lecompte modification of the arterial switch operation. Two patients had a previous subclavian patch repair of coarctation of the aorta and had an associated hypoplasia of the transverse aortic arch, and one patient had hemodynamically mild coarctation at the anatomical repair. A severe pressure gradient across the kinked area ("neo-coarctation") necessitating reoperation developed in one patient. The acute arch angulation appears to be due to an excessive posterior displacement of the ascending aorta by the anterior relocation of either the right or left main pulmonary artery branch from underneath the aortic arch. A foreshortened and frequently hypoplastic transverse aortic arch, a common association with coarctation of the aorta, appears to be especially vulnerable to the development of "neo-coarctation" after the Lecompte modification of the anatomical repair of transposed great arteries.
Aorta, Thoracic↗
Repeat median sternotomy in pediatrics: experience in 164 consecutive cases.
One hundred thirty-eight children underwent 164 operations through repeat median sternotomy. Ages ranged from 4 months to 21 years (mean, 8.6 +/- 5.0 years). The technique consisted of opening the sternum with chisel and mallet, avoidance of sudden separation of sternal edges and blunt dissection, elimination of the electrocautery during lysis of adhesions, and judicious use of fresh blood and components. Several variables were analyzed comparing the initial and repeat procedures on each patient. Time from incision to bypass was an hour longer with the repeat procedure (174 +/- 45 minutes versus 96 +/- 37 minutes). Operative transfusions and postoperative bleeding (first 48 hours) were not significantly different between the two procedures. Cyanosis, however, significantly increased bleeding in both groups. There were eight injuries (5%) at reoperation. During sternal reentry in 2 patients, a tear occurred in a valved conduit coursing underneath the sternum. A right ventricular tear occurred in 1 patient while the sternal edges were being separated. Ventricular fibrillation was noted in 2 patients during lysis of adhesions with the electrocautery used early in the series. Intimal disruption occurred in two valved conduits during intraoperative manipulations. An aortic tear occurred and was repaired without cardiopulmonary bypass. There were 13 (8%) hospital deaths, all unrelated to the technique. We believe that the current approach can be a valuable alternative for surgeons dealing with repeat median sternotomy in children.
Adolescent↗
Long-term results of porcine valve insertion for pulmonary regurgitation following repair of tetralogy of Fallot.
Between January 1975 and January 1985, 49 patients, aged 2 to 20 years, underwent porcine valve insertion for control of pulmonary regurgitation following repair of tetralogy of Fallot. In 9 patients the valve was placed at the time of the repair; in the remaining 40, valve insertion was performed 2 to 5 years postoperatively. The primary indications for valve implantation included progressive cardiomegaly and evidence of right ventricular (RV) dilatation or dysfunction. Operative technique emphasized ample enlargement of the RV outflow tract and main pulmonary artery to allow for insertion of a large valve and prevention of turbulence or stenosis. There was 1 hospital death (2%). Follow-up is available on remaining patients 1 to 10 years postoperatively. Considerable prosthetic valvar stenosis or regurgitation occurred in 7 patients (14%) 3 to 8 years following insertion, including one after subacute bacterial endocarditis. The complication-free actuarial life was 82%, and the functional actuarial life was 84% at 10 years for the prosthesis. The data suggest that the porcine valve has a good long-term durability when inserted in the pulmonary position in pediatric patients.
Adolescent↗
Use of a counterpulsation balloon as a substitute for the pulmonic valve: a new application.
An inflatable, 3-ml balloon positioned within the distal right ventricular outflow tract was used to restore pulmonic valve function in 8 dogs that had undergone open-chest valvectomy. Balloon inflation and deflation were accomplished with a counterpulsation console. Valvectomy produced loss of the pulmonic incisura, a decrease in pulmonary artery diastolic pressure (PADP; mean +/- standard error) (9.5 +/- 1.3 versus 4.4 +/- 0.6 mm Hg, p less than 0.01), and an increase in pulmonary artery pulse pressure (PAPP) (8.6 +/- 0.7 versus 19.1 +/- 1.9 mm Hg, p less than 0.01) without significantly affecting forward cardiac output (CO) (1,750 +/- 110 versus 1,880 +/- 230 ml/min, p is not significant). Properly timed counterpulsation restored the pulmonic incisura, raised the PADP from 6.1 +/- 0.8 to 9.5 +/- 0.8 mm Hg (p less than 0.01), lowered the PAPP from 15.1 +/- 1.4 to 10.6 +/- 1.0 mm Hg (p less than 0.01), and raised the forward CO from 1,850 +/- 260 to 1,920 +/- 260 ml/min (p less than 0.01). The injection of glass beads, 40 to 150 microns in diameter, into the right ventricular outflow tract increased pulmonary vascular resistance from 383 +/- 87 to 730 +/- 150 dyne . sec cm-5 (p less than 0.05) and decreased forward CO from 1,850 +/- 260 to 1,570 +/- 230 ml/min (p less than 0.05). Following this injection, counterpulsation again restored the pulmonic incisura, raised the PADP from 9.3 +/- 1.4 to 16.0 +/- 1.8 mm Hg (p less than 0.01), lowered the PAPP from 25.0 +/- 2.5 to 18.2 +/- 2.5 mm Hg (p less than 0.01), and raised the forward CO from 1,570 +/- 230 to 1,720 +/- 220 ml/min (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Fontan type operation for complex lesions. Surgical considerations to improve survival.
Twenty-five of 49 patients who underwent a Fontan type operation had complex lesions other than tricuspid atresia with ventriculoarterial concordance. Three patients had significant subaortic stenosis. Thirty-four palliative operations, including nine Glenn shunts, were performed before the Fontan operation. Direct atriopulmonary anastomosis was performed in 21 patients. In four, valved conduits were used. Twelve patients had right atrioventricular valve patch closure (three had running and nine had interrupted suture technique). On the basis of the presence of increased or decreased pulmonary blood flow before any surgical intervention, patients were divided into Group 1 (previous pulmonary artery banding, N = 8) and Group II (pulmonic stenosis, N = 17). Postoperatively, in Group I, 87% had significant effusions, mean right atrial pressure was higher (20.6 +/- 6.5 torr), and hospital stay longer (31 days). In Group II, 40% had significant effusions, mean right atrial pressure was lower (16.5 +/- 4.3 torr), and hospital stay shorter (15 days). Significant atrioventricular valve patch disruption occurred in three patients (two had running suture technique), and conduit occlusion occurred in two. Four patients (three with subaortic stenosis and pulmonary artery banding) without an established Glenn shunt required Fontan takedown for persistent low cardiac output, two of whom died (2/25 or 8%). There were three late deaths (3/23 or 13%). Nineteen of 20 surviving patients observed from 2 months to 6 years are doing well. We believe that early Fontan takedown in patients with persistent low cardiac output, interrupted suture technique for atrioventricular valve closure, avoidance of valved conduits, and a preliminary Glenn shunt in patients with pulmonary artery banding and/or subaortic stenosis can further improve the results with the Fontan operation for complex lesions.
Adolescent↗