[Myocardial revascularization. Central problem of cardiosurgery in the 1980's].
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Coronary Disease↗
Biomedical subjects
O Alfieri
Publications and source records attributed to O Alfieri.
Surgical repair of persistent truncus arteriosus in infancy.
Fourteen patients younger than two years of age with persistent truncus arteriosus underwent primary repair. Twelve of them were less than 1 year and 4 less than 3 months of age. Intractable heart failure was the indication for surgery in all patients but one who had increased pulmonary vascular resistance. There were 5 hospital and 2 late deaths. Six out of the 7 survivors (median follow-up: 29 months) were symptom-free. The remaining infant who preoperatively had significant truncal valve regurgitation was doing fairly well 2 1/2 years after repair. Our experience suggests that, although the mortality remains high, primary repair for infants with persistent truncus arteriosus is feasible and offers better overall results than does pulmonary artery banding followed by later intracardiac repair. We advise primary repair for all infants with intractable heart failure or increasing pulmonary vascular resistance with or without truncal valve regurgitation. Elective repair is recommended before the age of 2 years to minimize the risk of pulmonary vascular disease.
Follow-Up Studies↗
Extensive myocardial revascularization--influence of cardioplegia on operative results.
Experience with extensive myocardial revascularization (5 or more distal anastomoses) during a one-year period is reviewed. Intermittent hypothermic aortic occlusion was used in 68 patients (non-cardioplegia group), and cold cardioplegia in 70 patients. The 2 groups were similar in regard to age, sex, extension of coronary artery disease, number of previous myocardial infarctions, preoperative diagnosis of impending myocardial infarction and preoperative left ventricular function. Five patients in the non-cardioplegia group died early postoperatively, while no cardiac death occurred in the cardioplegia group (p = 0.02). The incidence of perioperative infarction and postoperative catecholamine requirement was lower in the cardioplegia group (p-values 0.04 and < 0.01 respectively). The major determinant of the postoperative catecholamine requirement in the non-cardioplegia group was the total aortic cross-clamp time, while in the cardioplegia group it was the preoperative left ventricular end-diastolic pressure. A policy of "complete revascularization" in diffuse coronary artery disease seems to be justified only if cold cardioplegia is used for myocardial preservation.
Cardiopulmonary Bypass↗
Complete atrioventricular canal associated with tetralogy of Fallot. Successful repair using a new surgical technique. A case report.
A modified Mayo technique was successfully employed to correct a case of complete atrioventricular (a-v) canal associated with tetralogy of Fallot. The technique included: 1) separated patch closure of the atrial and ventricular septal defects, 2) attachment of the a-v valves between the two prosthetic septa without suturing the clefts, 3) mitral valve commissuroplasty, 4) relief of the right ventricular outflow obstruction. Postoperative catheterisation revealed normal haemodynamic findings. The child is asymptomatic two years after the operation.
Abnormalities, Multiple↗
[Surgical treatment of truncus arteriosus in the 1st year of life].
80% of patients with Truncus arteriosus died in the first year of life by cardiac insufficiency from left to right shunt, high level of pulmonary vascular disease, truncal valve insufficiency. The palliative procedure, banding of the pulmonary arteries, is technically difficult, with high hospital mortality (50%) and increases the risk of the second stage repair (70%). Eight infants (1 to 9 months) have been corrected with 3 operative deaths and two late deaths. Three patients are doing well 12, 12 and 36 months post-operatively. Two technical problems are of concern: 1: The size of the valved extracardiac conduit comparing with the size of the infants thorax and the long term follow-up of such conduit. 2: The management of the truncal valve insufficiency: no plasty or replacement have be done, but in three cases of truncal insufficiency one pericardial patch has been used to double the VSD's dacron patch to avoid hemolysis. The one-stage repair of truncus arteriosus in infancy is one acceptable approach.
Humans↗
Atrio-ventricular canal malformations. Recent surgical techniques.
Twenty patients with atrio-ventricular canal malformations (5 complete and 15 partial forms) were operated upon during the last two years, using new surgical techniques. The repair of the complete form based on a three-leaflet three-commissure mitral valve concept, was accomplished by: a) Two separate partitioning patches (one ventricular, one atrial), b) mitral and tricuspid valve attachment in between, c) no cleft sutures, d) correction of subvalvular apparatus abnormalities, e) commissuroplasty. The repair of the partial form was obtained by: a) Valvular and subvalvular repair of the lesions when present, b) patch closure of the ostium primum defect suturing on the tricuspid side. All patients survived operation and exhibited normal sinus rhythm. Residual mitral incompetence proved to be less frequent as compared to previous techniques.
Adolescent↗
Results of systemic-to-pulmonary artery anastomosis for tricuspid atresia with reduced pulmonary blood flow.
Fifty-six patients with tricuspid atresia and decreased pulmonary blood flow received a systemic-to-pulmonary artery anastomosis as a preliminary operation. Thirty-five had a Waterston shunt, 12 a Blalock-Taussig anastomosis, and nine various other procedures. The age at operation ranged from 2 days to 10 years (median 4.5 months). Pulmonary atresia was present in eight newborn infants. Four patients (7%), all less than 3 months old, died in hospital from persistent servere hypoxia despite the palliative procedure. By actuarial methods, 93% of the survivors were alive at and after one year (longest follow-up:9.8 years), while 83% had not required further palliation at and after four years from the first operation. None of the patients subsequently restudied had raised pulmonary pressure or resistances, and in most of them the pulmonary arterial tree was deemed adequate for the Fontan operation.
Age Factors↗
[On the possibility of determining preoperatively the real diameter of aortic annulus (author's transl)].
The possibility of determining the real size of the aortic annulus on the basis of adequate angiocardiographic measurements has been retrospectively verified in a group of 10 patients who underwent aortic valve replacement. A good correlation (r = 0.99) was found between the predicted diameter of the aortic annulus and the size of the valve inserted at operation. The useful implications associated with prediction of the diameter of the aortic annulus are discussed.
Angiocardiography↗
Repair of tetralogy of Fallot after Waterston anastomosis.
Sixty-three corrective operations have been performed in patients with Tetralogy of Fallot and a previously constructed Waterston shunt. The patients were from 1.4 to 8 years of age (median 4.3 years), and the mean interval between the Waterston shunt and the repair was 39.3 +/- 16.05 months. Three patients developed pulmonary atresia and six required a second anastomosis prior to intracardiac repair. Kinking and stenosis of the right pulmonary artery at the site of the Waterston anastomosis occurred in 12 (19 percent; 70 percent confidence limits 14 to 26 percent) patients who required patch enlargement of the right pulmonary artery at repair. Seven (11 percent; 70 percent confidence limits 7 to 17 percent) patients died in the hospital and three (5 percent; 70 percent confidence limits 2 to 11 percent) during the period of late follow-up. None of the early or late deaths was specifically related to the presence of the previously performed Waterston anastomosis.
Age Factors↗
Growth of the pulmonary anulus and pulmonary arteries after the Waterston anastomosis.
Twenty-six patients with tetralogy of Fallot underwent angiocardiography before a Waterston shunt and again several years later, prior to complete repair (mean interval 40 +/- 15.6 [SD] months). The ratio between the diameter of the pulmonary valve anulus (PVA) and that of the descending thoracic aorta (Ao) increased by 0.32 +/- 0.233, significantly more than is reported to occur after a Blalock-Taussig anastomosis (p = 0.0001). This increase had some relation to the interval between the two angiographic studies (r = 0.34, p = 0.08) and to the mean pressure in the main pulmonary artery (MPA) at the time of the second study (r = 0.35, p = 0.08). The ratio of diameter of the right (RPA) and left pulmonary arteries (LPA) and that of the Ao also increased by 0.24 +/- 0.226 and 0.20 +/- 0.201, respectively. These data suggest that an initial large aortopulmonary shunt may result in less need for transannular patching at complete repair.
Angiocardiography↗
[Chylorthorax following heart surgery].
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Child↗
[The predictability of the degree of right ventricular hypertension after correction of the tetralogy of Fallot].
The validity of an equation which, on the basis of various angiocardiographic measurements allows prediction of the post-repair ratio between the systolic pressures in the right and the left ventricle is retrospectively tested in a series of 46 patients with the "classical" form of tetralogy of Fallot. If the right and left pulmonary arteries are "restrictive", the equation was found to be reliable in such a prediction, provided a negligible gradient is left at the pulmonary anulus level. The implications of the use of this equation on surgical management of patients with tetralogy of Fallot are discussed.
Angiocardiography↗
[Ventricular septal defect associated with aortic regurgitation. Results and surgical considerations in pediatric age group (author's transl)].
The Authors report their experience on the surgical treatment of ventricular septal defect and aortic regurgitation. Out of 13 patients operated upon, four required aortic valve replacement; five patients were treated with plasty of the aortic leaflets and four with the only patch closure of the V.S.D. There have not been reported hospital or late deaths. In one case, after the aortic plasty, the aortic regurgitation became severe; this patient had shown clinical signs of aortic regurgitation for more than five years before the operation. The Authors emphasize the surgical aggressiveness in this lesion when the aortic regurgitation has recently showed, whereas it is preferable to delay the operation when the aortic regurgitation has been present for more than five years.
Aortic Valve Insufficiency↗
[Autoptic findings and anatomo-clinical correlations in subjects who died after repair of tetralogy of Fallot (author's transl)].
The postoperative course and the post-mortem findings of a group of 30 patients who died after repair of tetralogy of Fallot were reviewed. A residual ventricular septal defect was the most common finding at the autopsy (13 patients = 43%) while a severe residual obstruction to the right ventricular outflow was found in 5 patients (17%), miscellaneous lesions in 3 (10%) and no intracardiac defects in 9 (30%). Since a residual anatomic defect is frequently responsible for the hospital mortality, prompts hemodynamic evaluation and reoperation is recommended when the postoperative course is deteriorating.
Autopsy↗
[Early and late results in palliative surgery for complete transposition of great arteries (author's transl)].
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Follow-Up Studies↗
Successful surgical repair of double outlet right ventricle with situs inversus, l-loop, l-malposition and subaortic VSD in a 16-month-old patient.
The case of a 16-mth-old patient who had double outlet right ventricle, l-loop and l-malposition in the presence of dextrocardia and situs inversus is presented. A successful repair was performed using an internal conduit to divert the blood from the left ventricle to the aorta. The outflow tract of the right ventricle was then enlarged with a dacron patch. The anatomic variations of double outlet right ventricle surgically corrected are reviewed.
Aorta↗
The Senning operation for transposition of the great arteries.
The original Senning technique of interatrial transposition of venous return was selectively employed for physiological correction in 24 patients with transposition of the great arteries (TGA) ranging in age from 74 days to 26 months (median 7 months). Twenty-three had intact ventricular septum and one had a large ventricular septal defect and diaphragmatic subpulmonary stenosis. There were no hospital or late deaths, and at follow-up examination 1.5 to 12 months postoperatively, each patient was asymptomatic, in normal sinus rhythm, and had no clinical evidence of caval or pulmonary venous obstruction. Nine patients underwent cardiac catheterization and angiocardiographic studies between 1.3 and 9 months postoperatively which demonstrated widely patent venous pathways and effective "left" and "right" atrial contraction. This experience lends support to the continued use of the Senning technique for interatrial transposition of venous return.
Angiocardiography↗
Surgical treatment of tetralogy of Fallot with pulmonary atresia.
Thirteen (16 percent) of 80 patients with tetralogy of Fallot and pulmonary atresia undergoing corrective operations between Jan. 1, 1967, and Jan. 1, 1978, died in the hospital. The hospital mortality rate was 13 percent (10 deaths) among the 77 patients with confluent right and left pulmonary arteries. The risk of operation was not significantly affected by age at operation or by use of a valved external conduit versus a transannular outflow patch. It was affected (p = 0.008) by the ratio of peak right ventricular to left ventricular pressure (PRV/LV) immediately after repair. This (PRV/LV) was determined primarily by size of left and right pulmonary arteries. An equation was developed relating postrepair PRV/LV to diameter of right and left pulmonary artery (normalized by dividing by size of descending thoracic aorta), body surface area, and possible arborization abnormalities and stenoses of the right and left pulmonary arteries. Cardiac performance after repair was better in those in whom a transannular patch was used rather than a valved external conduit. Important pulmonary dysfunction postoperatively occurred more often in patients with large "bronchial" arteries than in those without them, but was less when these were not ligated. Four (8 percent) of 48 traced hospital survivors died late postoperatively. Reoperations late postoperatively were required only in patients receiving valved external conduits. Forty (91 percent) of 44 living traced patients are asymptomatic.
Angiocardiography↗