[Current peroperative mortality in valve replacements. Study of modalities and causes of death].
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Biomedical subjects
Publications and source records attributed to J Y Neveux.
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This study presents a new technique for correction of tricuspid atresia. All 13 patients operated upon had the same form of the anomaly, with the great arteries normally related. The principle is to conserve the pulmonary valve and anulus of the patient in its anatomic position and to exclude the hypoplastic right ventricle. Because there is no need for closing the ventricular septal defect, the risk of heart block and residual left-to-right shunts is avoided. Deaths are related to questionable indications for two patients and to a bilateral pneumothorax for the third one. The long-term follow-up (5 years for the first patient) shows good results for the 10 survivors. Six of them are in Class 1 of the New York Heart Association and four are in Class II.
A new technique of anatomic correction of transposition of the great arteries with ventricular septal defect is presented. The procedure described, which avoids the use of a prosthetic conduit in the reconstruction of the pulmonary outflow tract, has been used in nine consecutive patients. Six remain alive and well 4 to 24 months postoperatively. Details and illustrations of the technique utilized are presented. Avoiding the use of a prosthetic conduit in the procedure re-established the basic appeal of arterial correction of transposition of the great arteries with ventricular septal defect.
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Immediate and late postoperative results in 70 patients undergoing resection of a true left ventricular aneurysm (50 patients) and of an asynergic area (20 patients) are presented. The operative mortality was 14 per cent. Predicted survival by actuarial methods was 80 per cent at one year after operation and 65 per cent at six years. Functional improvement was obvious with most of the survivors falling in NYHA class I or II. Factors influencing operative mortality were the clinical indication for operation and the anatomical lesion. Late postoperative results were better for true aneurysms than for asynergic areas. An asynergic area was usually associated with multiple coronary vessel lesions and a diffusely ischaemic myocardium. An aneurysm was often associated with a single coronary vessel disease and with good function of the non-infarcted myocardiun.
Right bundle branch block (RBBB) is usually considered almost unaviodable after repair of teralogy of Fallot (TOF). By modifications of the standard technique, its frequency has been decreased to 32% in a series of 1000 consecutive patients. These modifications are: (1) a very short right ventricular incision avoiding the ventriculotomy-induced RBBB pattern; (2) an infundibular resection limited to the septal attachment of the infundibular septum; and (3) closure of the ventricular septal defect with a patch sutured to the very edge of the muscular septum, avoiding injury to the right bundle along the right aspect of the septum. No patient in this series sustained permanent complete atrioventricular heart block. Among patients with RBBB, five had a left anterior hemiblock. Postoperative intraventricular conduction was related to age at operation: The incidence of RBBB was significatively higher in infants. The beneficial effects of a low incidence of postoperative RBBB after repair of TOF are not known.
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Complete repair was undertaken in 28 infants with severe forms of tetralogy of Fallot because severe cyanosis or anoxic spells. Age at operation ranged from 8 days to 11 months (mean: 4,4 months). Among the 24 cases without any other intracardiac defect, there were 6 early deaths related in 4 cases to a wrong indication or a technical error. Re-investigation was performed in 14 out of the 18 survivors from 3 weeks to 6 months post-operatively: the result is good in 10 cases, fair in 1 case, and poor in 3 cases requiring twice a reoperation with 1 further death and 1 good final result. More accuracy in selecting the surgical patients and improvement in operative techniques should result in a further decrease of our early mortality rate. Primary complete repair should therefore become a substantial alternative to the palliative shunts which results seem to be hazardous in the more severe types of the defect.
The malformations requiring valve fitted prosthetic tubes in the pulmonary outflow tract were mainly persistent truncus arteriosus and pulmonary atresia with ventricular septal defect in this series. The surgical mortality before 18 months was 75% and 19% after this age. The long-term clinical result (average follow up period: 2,5 years) was good or acceptable in 20 of the 32 survivors. There were 5 late deaths and 6 reoperations. The main causes of long-term failures were progressive pulmonary hypertension without shunt, acquired stenoses on the prosthesis and late infection. It is important to assess poor results by catheterisation as reoperation is frequently possible with a relatively low mortality rate (1/6) and encouraging results.
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The au;hors report 12 cases of Fallot' tetralogy with stenosis or obstruction of one of the two branches of the pulmonary artery following palliative anterior anastomosis. The complications of correction by open heart surgery include the frequent incidence of pulmonary hypertension, which was responsible for 4 deaths. No satisfactory explanation could be found for these poor results. It is desirable to avoid the creation of asymetry in pulmonary blood supply in Fallot's tetralogy and, if such should be found, suggestions are made for its correction by open heart surgery in order to improve the prognosis.