From January 1981 to December 1990, intracardiac repair of tetralogy of Fallot in 148 pediatric patients, with one surgical death, was directed toward preservation of the native pulmonary valve. Using the accepted preoperative angiographic criterion for the pulmonary valve annulus area (PVA) of 1.8 cm2/m2, 85 patients were candidates for transannular right ventricular outflow patch (TAP). However, in 54 patients with a mean PVA of 1.5 cm2/m2 (range 1.06-1.76), the valve was preserved without using TAP because the morphological changes (cusp thickening and annular distensibility) seemed acceptable for preservation in view of its probable hemodynamic efficiency and growth potential. A morphological classification of pulmonary valve changes has evolved. Retrospectively, 24 (77%) of the 31 patients with TAP had moderate to severe cusp thickening and ring rigidity; this incidence was significantly higher (p < 0.001) than that in preserved patients (18 of 54 or 33%). The incidence of morphological changes increased with operative age; that is, 2 of 13 (15%) patients younger than 1 year versus 23 of 40 (58%) patients older than 4 years (p < 0.01). All 54 patients with preserved pulmonary valves were catheterized one month postoperatively. The intraoperative right to left ventricular systolic pressure ratio (RVP/LVP) decreased significantly (p < 0.005) in one month, from a mean of 0.79 (range 0.44-1.36) to 0.57 (range 0.36-0.97). The PVA increased from a mean of 1.5 to 1.9 cm2/m2 (range 1.20-2.65), and the rate of its increase was significantly larger (p < 0.005) as operative age decreased. Pulmonary valve regurgitation of greater than mild degree occurred in 8 of 54 (15%) patients with the valve preserved.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗

PubMedDate not supplied

Arterial switch operation for transposition of the great arteries: surgical techniques to avoid complications.

From June 1984 to November 1990, 109 patients with transposition of the great arteries underwent arterial switch operation. There were 5 deaths, yielding a mortality rate of 4.6%. During this period, modifications of the surgical technique were devised to minimize intra- and postoperative problems, such as bleeding, kinking of the coronary arteries, aortic regurgitation and pulmonary stenosis. The surgical refinements that evolved include (1) a more distal division of the ascending aorta, (2) a punch technique for reimplantation of the coronary arteries in a medially rotated position, approximating the commissure, and superior to the upper border of the sinus of Valsalva, and (3) removal of left coronary ostia by incision down from the transected site to include a button of aortic wall, avoiding the free margin of the aorta and patch enlargement of the neopulmonary artery. Since instituting these refinements: (1) the time consumed for hemostasis after termination of the bypass considerably decreased from 111 +/- 59 to 87 +/- 51 minutes (p less than 0.05), (2) the incidence of kinking of the coronary arteries decreased from 29% (4/14) to 7% (6/88) (p less than 0.05), and (3) the occurrence of aortic insufficiency 1 year after correction was reduced from 36% (5/14) to 8% (5/66) (p less than 0.02). However, the occurrence of pulmonary stenosis with a pressure gradient greater than 30 mmHg did not decrease significantly despite aggressive modifications of surgical techniques, and its incidence in the most recent series of 32 patients was still a high 19%.

Aortic Valve Insufficiency↗

PubMedDate not supplied

Primary repair for complete atrioventricular canal: recommendation for early primary repair.

Forty patients with complete atrioventricular canal (CAVC) underwent primary repair at Fukuoka Children's Hospital in Fukuoka, Japan, between August 1, 1981 and July 31, 1989. The age at repair ranged from 2 months to 6 years (mean 19 months); weight ranged from 2.3 to 22 kg. The surgical mortality was 2.5%. Justification for early primary repair was examined. Eleven patients underwent repair before 6 months of age (Group 1), 12 patients, between 7 and 11 months of age (Group 2), and 17 patients, after 12 months of age (Group 3). Degenerative changes in the atrioventricular valve increased significantly as age at repair increased (p less than 0.05 Group 1 versus Group 3). The incidence of residual mitral regurgitation tended to increase in the order of Group 1, 2 and 3, though the degree ranged from trivial to mild. Study of the left atrium/aorta ratio by echocardiography revealed that stable values of around 1.1 in Groups 1 and 2 and around 1.3 in Group 3 continued during the follow-up period of 3 years. Assessment of the diameter of the repaired mitral valve in the mean interval of 26 months in groups 1 and 2 revealed normal growth of the mitral valve annulus. The angle between the repaired mitral valve and ventricular septum, which can be affected by the growth of the ventricular septum, converged to normal range in the mean interval of 26 months. Postoperative pulmonary vascular resistance in Groups 2 and 3 was higher at 4.4 +/- 2.3 and 6.3 +/- 2.2, respectively, than in Group 1 at 3.3 +/- 2.2 (p less than 0.01 versus Group 3).(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗

PubMedDate not supplied

Open-heart surgery in infants using pulsatile high-flow cardiopulmonary bypass.

Pulsatile high-flow cardiopulmonary bypass (2.5 l/m2/min with a rectal temperature of 28 degrees C) combined with the Pulsatile Bypass Pump (Kontron Instrument) has been used at Fukuoka Children's Hospital in 259 cases of open-heart surgery in patients less than 1 year of age for a period of 5 years beginning July 1982. The overall results were satisfactory with a surgical mortality of 6.2% (VSD: 96 cases/2 deaths, TGA: 48/1, TAPVD: 34/3, Complete ECD: 15/1, IAA: 10/1, DORV: 10/1, HLHS: 7/4, TOF: 6/0, Truncus Art: 5/0, Others 28/3). The mean duration of cardiopulmonary bypass was 123 +/- 50 minutes during which time the patients had a positive water balance of only 28 +/- 38 ml per kg of body weight. The lowest positive water balance was noted in the patient group with 60-75 mmHg in peak systolic pressure and 30-45 mmHg pulse pressure divided by the pulsatile wave form. This value was significantly lower than other groups of patients with lower or higher peak systolic and pulse pressures. Urinary output during the first 24 hours after operation was 4.1 +/- 1.3 ml/kg/hour. Weight gain on the first postoperative day was 10 +/- 43 g per kg of body weight, and the duration of postoperative respiratory support was 4 +/- 5 days. In conclusion, pulsatile high-flow cardiopulmonary bypass is useful in infant open-heart surgery in light of operative techniques, water balance and postoperative recovery.

Cardiopulmonary Bypass↗