Additional pulmonary blood flow has no adverse effect on outcome after TCPC.

BACKGROUND: Use of additional sources of pulmonary blood flow (APBF) with bidirectional cavopulmonary anastomosis (BDG) and total cavopulmonary connection (TCPC) remains controversial. We have therefore assessed the effects of APBF on BDG and TCPC outcome. METHODS: From 1996 to 2000, 106 patients underwent BDG, either isolated (group 1, n = 54), or with APBF via pulmonary artery (PA) (group 2, n = 30), or Blalock-Taussig shunt (BTS) (group 3, n = 22) with 28 patients completed by TCPC. RESULTS: After BDG low output syndrome was more frequent in group 2 and less in 3 ( p = 0.01), whereas superior cava syndrome was again more common in group 2 and less in groups 1 and 3 ( p < 0.05) than expected. Mortality and complications were similar after TCPC in all groups. Oxygen saturation (SaO (2)) was lower without than with APBF ( p < 0.002) after BDG and in group 3 than in group 2 after TCPC ( p < 0.05). Repeated measures ANOVA showed no effect of APBF on SaO (2), PA pressures, fractional shortening, end-diastolic pressure and AV-valve function. CONCLUSIONS: Early after BDG, APBF via PA presents different difficulties than APBF via BTS. However, BDG and TCPC outcomes are not affected by the presence or absence of APBF.

Impaired poststenotic aortic pulsatility after hemodynamically ideal coarctation repair in children.

Using echocardiographic quantification of aortic pulsatility distal to the site of the surgical anastomosis, we evaluated whether the preoperatively impaired poststenotic aortic pulsatility returned to normal after repair of coarctation with a hemodynamically ideal result. Patients who underwent repair of aortic coarctation without residual obstruction were compared to a matched group of normal children. A standardized M-mode echocardiographic evaluation of the aorta at the diaphragmatic level was performed for all patients. Measurements consisted of maximum and minimum aortic diameters, time intervals, and a calculated pulsatility index. Compared to normal children (n = 19), 20 children with operated coarctation and with a hemodynamically ideal result showed a significantly smaller increase in aortic diameter in systole (mean of 29 +/- 7% in patients versus 37 +/- 7% in normals; p < 0.01). In contrast to patients with coarctation in whom the maximum aortic distension is reached much later during the cardiac cycle, hemodynamically normalized, operated patients in our study had no such delay (maximum aortic pulsation at 28% of cardiac cycle time compared to 27% in normals; p = not significant). The pulsatility index of the poststenotic aorta was clearly lower in operated children (mean, 130 +/- 50%/sec) compared to a normal mean value of 202 +/- 33%/sec but was still significantly higher than that in patients with unoperated coarctation, who showed a low mean value of 51 +/- 24%/sec (p < 0.01). After correction of aortic coarctation with a hemodynamically ideal result, the pulsatility of the poststenotic aorta, severely impaired prior to repair, did not return to normal during the observation period in the patients studied.

[The Sorin pericardial bioprosthesis--a stentless aortic valve with very good hemodynamic performance]. / Die Sorin Perikard-Bioprothese--eine Stentless Aortenklappe mit sehr guter hämodynamischer Leistung.

BACKGROUND: The Sorin Pericarbon Freedom Stentless aortic valve has the potential to provide superior hemodynamic function and durability. In this study we assessed the hemodynamic performance of this valve and its impact on LV-mass regression after aortic valve replacement. METHODS: 31 consecutive patients who received a Sorin Pericarbon Freedom Stentless aortic valve were analysed. Mean age of the patients (16 female and 15 male) was 64 +/- 17 years. Five patients had isolated aortic stenosis, three isolated aortic regurgitation and one combined aortic valve disease. Three patients had combined aortic and mitral valve disease, 14 patients concomitant coronary artery disease, one congenital aortic coarctation. Three patients had an acute aortic valve endocarditis. 18 patients were classified as high-risk patients (mean EuroSCORE 9 +/- 2). Mean left ventricular ejection fraction was 52.5 +/- 15.0%. RESULTS: Valve sizes from 21 mm to 29 mm were implanted. The valves were oversized by 2 mm compared to measurement. 16 patients received isolated aortic valve replacement, Three patients aortic valve replacement and mitral valve reconstruction. 12 patients had concomitant CABG. Three procedures were reoperations. Hospital mortality was 6.4% (two patients). Both deaths occurred in high-risk patients and were not valve-related. Four patients had perioperative low-output-syndrome and needed IABP. After six months a follow up echocardiography was performed. Mean and peak gradients were 9.6 +/- 4.4 and 20.6 +/- 5.9 mmHg, respectively. Significant reduction of left ventricular hypertrophy (LV mass index 126.5 +/- 27.3 vs. 189.6 +/- 45.3 g/m2, p = 0.0313) and improvement of the ejection fraction (58 +/- 9.8 vs. 52.5 +/- 15.0%, p = 0.9749) as compared with preoperative valve. CONCLUSIONS: The hemodynamic performance of the Sorin Pericarbon Freedom Stentless aortic valve is excellent and the patient outcome is satisfying. However the implantation technique requires longer ischemic time, the prosthesis offers very satisfying hemodynamic function and accelerates probably the LV-mass regression in the mid term follow-up. Late performance and durability of the valve have to be assessed.

Aprotinin reduces blood loss in off-pump coronary artery bypass (OPCAB) surgery.

OBJECTIVE: Effects of aprotinin in off-pump coronary artery bypass (OPCAB) surgery have not yet been described. This study analyses hemostasiologic changes and potential benefit in OPCAB patients treated with aprotinin. METHODS: In a prospective, double-blind, randomized study 47 patients undergoing OPCAB surgery were investigated. Patients received either aprotinin (2 x 10(6) KIU loading dose and 0.5 x 10(6) KIU/h during surgery, n=22) or saline solution (control, n=25). Activated clotting time was adjusted to a target of 250 s intraoperatively. Blood samples were taken up to 18h postoperatively: complete hematologic and hemostasiologic parameters including fibrinopeptide A (FPA) and D-dimer in a subgroup of 31 patients were analyzed. Blood loss, blood transfusion and other clinical data were collected. RESULTS: Both groups showed comparable demographic and intraoperative variables. Forty-one (87%) patients of the whole study group received aspirin within 7 days prior to surgery. Number of grafts per patient were comparable (2.9+/-1.0 [mean+/-SD] in the aprotinin group and 2.8+/-1.2 in control, P=0.83). Blood loss during the first 18 h in intensive care unit was significantly reduced in patients treated with aprotinin (median [25th-75th percentiles]: 500 [395-755] ml vs. 930 [800-1170] ml, P<0.001). Postoperatively only two patients (10%) in the aprotinin group received packed red blood cells, whereas eight (35%) in the control group (P=0.07). Perioperatively FPA levels reflecting thrombin generation were elevated in both groups. The increase in D-dimer levels after surgery was significantly inhibited in the aprotinin group (P<0.001). Early clinical outcome was similar in both groups. CONCLUSIONS: Aprotinin significantly reduces blood loss in patients undergoing OPCAB surgery. Inhibition of enhanced fibrinolysis can be observed. FPA generation during and after OPCAB surgery seems not to be influenced by aprotinin.

Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis.

OBJECTIVE: Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. METHODS: Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies). RESULTS: Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups. CONCLUSION: We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.

The reversed and bidirectional elephant trunk technique in the treatment of complex aortic aneurysms.

BACKGROUND: The elephant trunk technique with a free-floating vascular prosthesis was originally developed to facilitate a subsequent operation on the downstream aorta. We present here our experience with further developments of this technique, which we call the reversed elephant trunk and bidirectional elephant trunk. METHODS: Between January 1, 1995, and December 31, 2000, 505 adult and adolescent patients underwent operations of the thoracic aorta. A reversed elephant trunk procedure in 13 patients and a bidirectional elephant trunk procedure in 4 patients was performed to facilitate either subsequent proximal or proximal and distal aortic replacement. Nine patients underwent subsequent aortic arch replacement with the reversed prosthetic portion after a mean interval of 8 +/- 5.5 months, and 2 patients received distal extension by use of the distal portion of the free-floating graft. RESULTS: There was no hospital mortality (30 days) in this small group of patients, and no patient had aortic rupture, malperfusion caused by the technique itself, or thromboembolic complications during the waiting interval between the first and the second operations. Five patients are still being observed until the contiguous aortic size is large enough to require an operation, and one 74-year-old patient declined a second-stage operation. CONCLUSION: The reversed and bidirectional elephant trunk techniques are interesting options that may be suitable for patients having complex abnormalities of the thoracic aorta and thoracoabdominal aorta when the proximal portion of the descending aorta has to be replaced before the aortic arch with or without the ascending aorta or the distal descending aorta with or without the thoracoabdominal aorta.

Short- and long-term mechanical cardiac assistance.

With the increase in high risk patients undergoing cardiac surgery and the substantial mortality among patients waiting for cardiac transplantation, the need for mechanical circulatory support is growing. Several devices are currently available, ranging from the intra-aortic balloon pump to fully implantable ventricular assist devices. Each system has its own features, and proper patient selection as well as the timing of implantation is sometimes difficult. Algorithms for stepwise management in subgroups of patients remain controversial and the concepts of weaning patients after myocardial recovery during mechanical circulatory support need further evaluation for their long-term effects. Future identification of valuable prognostic and risk factors may help in decision-making and allow for improved survival of these often very ill patients. In this report we review the concepts of mechanical circulatory support at our institution with emphasis on a detailed overview of technical features of extracorporeal life support.

[Challenging perioperative anticoagulation in a patient with Budd-Chiari syndrome and heparin-induced thrombocytopenia]. / Erschwerte perioperative Antikoagulation bei einem Patienten mit Budd-Chiari Syndrom und Heparin induzierter Thrombozytopenie.

We report on a patient suffering from Budd-Chiari disease who developed heparin-induced thrombocytopenia preoperatively. Dorsocranial liver resection and hepatoatrial anastomosis were performed with the extracorporeal circulation and perioperative anticoagulation was achieved with r-hirudin. Surprisingly, thrombus formation was observed in the venous reservoir although intraoperative anticoagulation values were within the targeted level. An additional bolus of hirudin and rinsing the reservoir allowed unproblematic discontinuation of the cardiopulmonary bypass.

Dilation of the ascending aorta in childhood: 4 cases without obvious predisposing disease.

Dilation of the ascending aorta is rare in childhood. When seen, it is usually associated with some form of connective tissue disease or predisposing cardiac malformations, especially an aortic valve with two leaflets. We describe four children in whom significant dilation of the ascending aorta was encountered as an incidental finding. No patient had any sign of an associated connective tissue disease, nor did we detect any predisposing cardiac anomalies. One patient had undergone surgical ligation of the arterial duct in infancy, whilst another had undergone repair of aortic coarctation, also in infancy. A third child has had repair of an atrioventricular septal defect with exclusively atrial shunting, whereas the fourth patient had a structurally normal heart. The aortic valve had three leaflets, and was functionally normal in all. The dilation of the ascending aorta was progressive in all patients, and finally surgical treatment was recommended, relying on the guidelines established for the management of patients affected with the Marfan syndrome.

Budd--Chiari syndrome and heparin-induced thrombocytopenia.

We report on a patient suffering from Budd--Chiari disease who developed heparin-induced thrombocytopenia preoperatively. Dorsocranial liver resection and hepatoatrial anastomosis were performed with the extracorporeal circulation and perioperative anticoagulation was achieved with r-hirudin. Surprisingly, thrombus formation was observed in the venous reservoir although ACT was 590 s and aPTT 55 s. An additional bolus of hirudin and rinsing the reservoir allowed unproblematic discontinuation of the cardiopulmonary bypass.

[New approaches in cardiac surgery for the therapy of congenital heart disease]. / Neue kardiochirurgische Aspekte bei der Therapie kongenitaler Herzfehler.

Recent developments in the field of pediatric cardiac surgery and pediatric cardiology have led to significant changes in the surgical approach to the various cardiac malformations. There is a clear trend towards surgical treatment at a younger age of the patient, towards complete correction of malformations instead of staged procedures with initial palliation and delayed correction. Perioperative cardioprotection has improved significantly as has postoperative management in specialized pediatric cardiac intensive care units. As a result of this, mortality and morbidity of pediatric cardiac surgery have been in steady decline, although complexity of cardiac surgery in even smaller children has increased. Preoperative diagnostic work-up of the cardiac malformation can nowadays be achieved in an always increasing number of patients without invasive cardiac catheterization and based exclusively on ultrasound findings alone. A new element comes from the possibilities of therapeutic cardiac catheterization, which now allows for a combined therapeutic approach using therapeutic catheter procedures either to perform preparatory interventions prior to surgery or to treat surgical complications in the postoperative course. Refinements in the use of surgical implants have led to new possibilities of correction of complex malformations early in life, especially with regard to the use of biological prosthesis for valvar or outflow tract replacement.

Modified repair of mixed total anomalous pulmonary venous connection.

Mixed total anomalous pulmonary venous connection (TAPVC) is a rare condition, accounting for only 5% of diagnosed TAPVC. It is associated with a poor prognosis unless surgically corrected by connecting the pulmonary venous sinus to the left atrium and optionally dividing the abnormal connection to the systemic venous system. We report a modified technique of complete intracardiac repair of mixed supracardiac and cardiac TAPVC in a 3-year-old child without pulmonary venous sinus-to-left atrium anastomosis.

Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale.

OBJECTIVE: During recent years, transcatheter closure has become an alternative to operations for the treatment of atrial septal defects and patent foramen ovale. However, this procedure may be unsuccessful or complicated and requires surgical treatment. METHODS: We retrospectively analyzed the outcomes of patients who needed surgical treatment after failed or complicated transcatheter closure of an atrial septal defect or a patent foramen ovale. RESULTS: Between April 1994 and March 1999, 124 patients were treated with transcatheter closure of an atrial septal defect or a patent foramen ovale at our institution. We report the results of 10 (8%) patients of this series who required operations after transcatheter closure attempts. In 8 of these 10 patients a significant shunt caused by malposition or dislocation of the device persisted, leading to surgical closure of the defect. In 2 patients injury of the femoral artery at the puncture site required surgical repair. In one patient the device had to be removed surgically from the iliac vein after retraction. One patient died of left ventricular perforation after dislocation of the device and several surgical attempts to close the left ventricular rupture. All other patients recovered well. CONCLUSION: An operation was required after transcatheter closure of an atrial septal defect or a patent foramen ovale in 8% of patients. After device complications, the atrial septal defect and the patent foramen ovale can still successfully be closed surgically with good results and low morbidity. However, serious complications like cardiac perforation may have a fatal outcome. Residual shunt, dislocation, or vascular complications are the most frequent problems that require surgical interventions.

Pediatric cardiac surgery after exclusively echocardiography-based diagnostic work-up.

This study was performed to evaluate the accuracy of exclusively non-invasive preoperative diagnostic work-up based on echocardiography and to assess the safety of cardiac surgery using this diagnostic approach in children with heart disease. During a 3. 5-year period, accuracy of preoperative (invasive and non-invasive) diagnostic work-up was prospectively tested by comparison with the intraoperative findings obtained by surgical inspection and transoesophageal echocardiography. Included were all consecutive 358 children undergoing cardiac surgery (except pulmonary artery bandings and ductus ligations) during the study period at our institution. Of the patients, 44% were operated on in infancy, 84% of procedures were on cardiopulmonary bypass. Echocardiography as the only preoperative imaging modality was used in 231 patients (65%), in the other children, a diagnostic catheter was done. Diagnostic errors occurred in 3.9% (n=5) of patients after diagnostic catheter and in 6.9% (n=16) of patients with echocardiography only. Major diagnostic errors (resulting in prolongation of cardiac bypass time) were observed at equal frequency in both groups (1.7% or four children in the echo-only group and 1.6% or two patients in the catheter group). In no case was the outcome affected by the previously unrecognized findings. It was shown that diagnostic cardiac catheterization could be avoided in a majority of pediatric patients prior to surgical palliation or correction of cardiac defects, without increasing the risk of complications or the overall outcome.

Cardiovascular interventions during oncologic surgery: technical principles and mid-term survival.

BACKGROUND: While the veins are primarily affected by compressing or invasive tumors, the arteries usually undergo only a less pronounced stenosis, due to the higher internal pressure. However, some tumors infiltrate the arterial adventitia which should be resected or might be injured in cases where radical surgery is attempted. PATIENTS AND METHODS: We report some technical principles utilized in various vascular localizations and mid-term survival observed in a group of 35 patients in whom a vascular reconstruction was performed during the surgical treatment of a malignant tumor. The following vessels were involved: carotid artery (n = 5), superior vena cava (n = 9), aortic arch (n = 1), subclavian artery (n = 1), right atrium +/- inferior vena cava (n = 6), abdominal aorta (n = 3) and finally iliac artery and/or vein (n = 10). The following surgical techniques were employed: extra-anatomic bypass (n = 3), in situ reconstruction (n = 23) using either prosthetic graft or saphenous vein interposition, patch angioplasty with autologous vein or xenopericardium and ligature of the involved artery or vein (n = 4). In 5 patients suffering from hypernephroma with a tumor thrombus, cardiopulmonary bypass was used to allow radical intracardiac excision. RESULTS: There was no intraoperative mortality despite the fact that a majority of these vascular procedures was performed after incidental and unexpected finding during surgery. Two patients died before hospital discharge (one from pneumonia, the second one from sepsis). Mid-term survival was satisfactory with 45% of the patients still alive after a mean follow-up of 4.5 years--all tumor types confounded. CONCLUSIONS: This series demonstrates that an aggressive approach might be justified in appropriate patients who otherwise might not be considered as operative candidates.

Outcome of thoracoabdominal aortic operations using deep hypothermia and distal exsanguination.

BACKGROUND: Operation of the descending and thoracoabdominal aorta may be affected by a significant perioperative morbidity, mainly because of ischemic damage of the spinal cord and malperfusion of the abdominal organs. METHODS: A comparative analysis was performed on two consecutive series of patients operated between 1982 and 1998. Group 1 consisted of 90 patients operated with moderate hypothermic left heart bypass. Group 2 included 38 patients operated using deep hypothermic cardiopulmonary bypass and a period of circulatory arrest while performing the proximal anastomosis and distal exsanguination during confection of the distal anastomosis. RESULTS: Main demographic factors and causes of the aortic disease were similar in both groups. Early mortality was significantly higher in the group of patients with aortic cross-clamping (15 of 90, 16%) than in those operated with circulatory arrest (2 of 38, 5.2%), p < 0.001. Paraplegia occurred in 8 patients in the group operated with mild hypothermia (8.8%) but in only 1 patient (2.6%) when deep hypothermia had been used. CONCLUSIONS: In our experience, deep hypothermia combined with distal exsanguination significantly improved the early postoperative outcome after operation of the descending and thoracoabdominal aorta. This technique allowed easy confection of proximal and distal anastomoses, and the duration of the operation was not prolonged significantly through this approach.

Surgery of the complete atrioventricular canal: relationship between age at operation, mitral regurgitation, size of the ventricular septum defect, additional malformations and early postoperative outcome.

The perioperative risk after repair of the complete atrioventricular canal is reported to be low provided there is a balanced relationship of both ventricles, and elevated pulmonary vascular resistance has been demonstrated to be reversible. However, some pre- and perioperative conditions may adversely affect early postoperative outcome. A consecutive series of 42 patients (mean age 8.5 months, 34/42, 81%, with trisomy 21) operated between 1994 and 1998 was analyzed prospectively for pre- and perioperative risk factors. Echocardiography alone was performed in 35 patients whereas cardiac catheterization was performed in 7 patients aged more than 18 months to confirm operability. Additional malformations were found in 20 patients. Early mortality was 2.3% (1/42), and postoperatively a low cardiac output was observed in 25 patients (59%); NO inhalation was used in 12 patients. Only the size of the ventricular septal defect (> than the diameter of the aortic annulus) could be identified as a predictor of adverse postoperative outcome in multivariate analysis. The presence of associated intracardiac malformations showed a trend to increased perioperative risk in multivariate analysis. Early results after repair of the complete atrioventricular canal are excellent. Survival, postoperative morbidity and normalization of pulmonary artery pressure can be related to the size of the ventricular septal defect. Continuous monitoring of the pulmonary artery pressure (with consequent NO application when indicated) is probably responsible for the low perioperative risk encountered in this series, despite the high incidence of postoperative pulmonary artery hypertension.

Pediatric open heart operations without diagnostic cardiac catheterization.

BACKGROUND: Echocardiography allows for an adequate noninvasive preoperative evaluation in an increasing proportion of pediatric patients before open heart operations. The present study assessed the diagnostic accuracy of both invasive and noninvasive preoperative evaluation in children with congenital heart disease. METHODS: We prospectively evaluated the accuracy of preoperative noninvasive or invasive diagnostic methods. Preoperatively established diagnosis was compared with the intraoperative diagnosis made by surgical inspection and routine perioperative transesophageal echocardiography. RESULTS: During the study period of 30 months (ending in December 1997) 209 open-heart procedures were performed. Eighty-one patients (39%) were in the first year of life at the time of surgery, and 43% of all patients had symptoms. Noninvasive preoperative diagnosis using echocardiography was done exclusively in 142 patients (68%). Of the 67 children who had preoperative catheterization, 4 (6%) showed an additional intraoperative finding that modified the surgical approach in 2 of them. In the 142 patients who had echocardiographic preoperative assessment, the surgeons were confronted with a previously undiagnosed finding in 12 patients (8.5%). The finding was considered significant (prolongation of cardiopulmonary bypass time) in 2 patients and might have affected the outcome in 1 of them, a neonate with transposition of the great arteries and a preoperatively undiagnosed intramural coronary artery, who died postoperatively despite a technically adequate repair. CONCLUSIONS: In many infants and children, diagnostic work-up before open heart operations could be adequately based on an exclusively noninvasive basis by relying on echocardiography alone.