Prosthesis endocarditis: treatment of a case occurring five years after a Rastelli-Ross operation.

A severe staphylococcal septicemia originating from an unknown focus occurred in a 17-year-old patient who had undergone a Rastelli-Ross operation 5 years earlier. The clinical course was complicated by extensive bilateral pneumonia, diffuse intravascular coagulation, and glomerulonephritis. After 4 weeks of intensive conservative treatment, including a daily regimen of 16 Gm. of cloxacillin, the patient was operated upon for a rapidly progressive false aneurysm, which had resulted from dehiscence of the anastomosis between the prosthesis and ventricle. The excised prosthesis proved to be sterile. The postoperative course was uneventful. Cloxacillin treatment was continued for 6 months, initially parenterally and later orally. After discontinuation of therapy, no signs of infection have occurred. Right-sided intracardiac or intravascular prosthetic material may be particularly susceptible to infections originating from the body surface.

Ventricular septal defect associated with left ventricular outlfow tract obstruction below the defect.

Muscular subaortic stenosis associated with ventricular septal defect (VSD) is a rare but important anomaly. Two types of left ventricular outflow tract (LVOT) obstruction should be distinguished on the basis of morphologic as well as hemodynamic differences, depending on whether the stenosis is localized above (Type I) or below (Type II) the defect. The five cases presented are all in the latter category. In the first two cases the correct diagnosis was not made until after repair of the VSD. Two patients had previously undergone banding of the pulmonary artery (PAB). Marked carotid shudder and a vertical QRS axis in the frontal plane were presented in all cases. For the diagnosis to be established by catheterization, the catheter tip must be maneuvered into the apical part of the left ventricular cavity in order to detect the stenosis on the withdrawal curve. It is difficult to visualize the stenosis by angiography. The surgical approach through the VSD via a right atriotomy is highly recommended for Type II subaortic stenosis.

Long-term results of atrial correction for transposition of the great arteries. Comparison of Mustard and Senning operations.

Few data exists on the differences in long-term outcome between Mustard and Senning operations. We reviewed available data of all hospital survivors of these operations and assessed risk factors for late death and sinus node dysfunction. Of those patients undergoing the Mustard operation, 60 were hospital survivors (46 simple transposition, 14 complex); of those patients undergoing the Senning operation, 62 were hospital survivors (43 simple, 19 complex). Median duration of follow-up was 16 years (maximum 25 years) for Mustard operation, 11 years (maximum 20 years) for Senning operation. No reoperations were done, except for pacemaker implantation. No differences were found between the two groups with regard to baffle-associated problems, right ventricular failure, sudden death (6% in both groups), and functional status at final follow-up (New York Heart Association class I or II, except for four patients). For patients undergoing the Mustard operation, survival at 16-year follow-up was 91% with simple transposition and 60% with complex transposition (p = 0.027); for both groups of patients undergoing the Senning operation, survival at 16-year follow-up was 78%. Survival in the absence of rhythm disturbance at 16-year follow-up was 18% for Mustard operation and 53% for Senning operation (p < 0.001). In multivariate analysis, significant independent risk factors for late death turned out to be complex transposition (versus simple) and active arrhythmias. The only significant risk factor for the occurrence of sinus node dysfunction was the Mustard operation. We conclude that apart from the difference in the loss of sinus rhythm, no differences were found in the long-term clinical results of the two types of operations.

The arterial switch operation. An eight-year experience.

Sixty-six patients (23 neonates with transposition of the great arteries and intact ventricular septum, 33 infants and children with transposition and a large ventricular septal defect, and 10 with double-outlet right ventricle with a subpulmonary ventricular septal defect have received an arterial switch repair since 1977. Eight (one with transposition and intact ventricular septum, six with transposition and ventricular septal defect, and one with double-outlet right ventricle with subpulmonary ventricular septal defect) died in the hospital. All other patients have had follow-up as of June, 1985. Including the hospital deaths, the 11 month actuarial survival rate for the entire group was 81%, and no deaths have occurred among the 33 patients alive at that time and traced as long as 8 years. The hazard function for death has only a single early phase, and its 70% confidence limits overlap the hazard function of a matched general population by 12 months after the operation. Incremental risk factors for death included low birth weight (but not weight or age at operation), transposition of the great arteries with large ventricular septal defect, double-outlet right ventricle with subpulmonary ventricular septal defect, and presence of a patent ductus arteriosus. Coronary artery morphology and position of the great arteries were not risk factors. Long aortic cross-clamp time was possibly (p = 0.11) a risk factor. Early date of operation was a risk factor (p = 0.004); thus, predicted 1 year survival rate, including hospital deaths, after the arterial switch operation in 1985 is 99.9% (70% confidence limits 99.0%-100%) for neonates with transposition and intact ventricular septum and 99.7% (98.4%-99.9%) for those with transposition and a large ventricular septal defect or double-outlet right ventricle. The late functional status was excellent, and the rhythm was sinus in 96% of the 55 surviving patients. A formal comparison with the results of the atrial switch repair indicates that the arterial switch repair is superior.

Growth of an aorta-coronary anastomosis. An experimental study in pigs.

The influence of growth of an aorta-coronary anastomosis, comparable to the coronary translocation anastomosis during the arterial switch operation, was studied in pigs. The anastomosis between the right coronary artery and the aorta did not grow, and this lack of growth may result in stenosis. With another technique, by which the coronary artery was excised with a cuff of aortic wall, the effects caused by absence of growth were circumvented and a normal-sized coronary ostium was present after growth. However, when no cuff was used, stenosis occurred at the suture line and caused growth retardation of the animal as well as histologic damage to the right ventricle.

Tricuspid atresia. Morphology of the outlet chamber with special emphasis on surgical implications.

An anatomic study of 28 heart specimens with tricuspid atresia showed 15 hearts with ventriculoarterial concordance and a right-sided anterior outlet chamber. Of these 15 hearts, 12 showed evidence of restricted pulmonary blood flow. In eight of these 12 specimens, an anterior deviation of the outlet septum, relative to the primary septum, was present. This deviation caused a narrowing inside the outlet chamber and functioned as infundibular pulmonary stenosis. The outlet chambers of the 15 hearts with ventriculoarterial concordance were compared with those of 13 hearts with tricuspid atresia and ventriculoarterial discordance and also a right-sided anterior outlet chamber. In the latter group of 13 hearts, five showed evidence of restricted pulmonary blood flow, at least partially caused by posterior deviation of the outlet septum relative to the primary septum. A clear difference in outlet chamber morphology was found without exception between specimens with and without ventriculoarterial concordance. Clinical data in three long-term survivors of the Fontan procedure demonstrate that the special morphology of the outlet chamber can pose surgical problems. Especially in patients with ventriculoarterial concordance, when the outlet chamber is incorporated into the pulmonary circuit, the surgeon must give special attention to the specific morphology to prevent undesirable sequelae.

The trousers-shaped baffle for use in the Mustard operation.

The trousers-shaped baffle has been found very useful in intraatrial correction of transposition of the great arteries. Reasons are given to explain the particular form of the patch, and details of the operative technique are described.

Horizontal submammary skin incision for median sternotomy.

Usual techniques in open-heart operations leave a vertical median skin scar. Especially for women this is rather embarassing since it looks ugly. The use of horizontal submammary skin incision for access to the heart is described here. Although obtaining the usual midsternal exposure takes some extra time, long-term results have shown the value of this approach and its benefit to the patient. The surgical technique is simple, and wound healing, in the long run, is unimpaired.

Surgical correction of unusual double-outlet right ventricle.

This paper presents the case history of an 8-year-old girl who had total situs inversus and double-outlet right ventricle with pulmonary stenosis and severe tricuspid insufficiency in the presence of dextrocardia with ventricular discordance. A successful repair was performed using the Rastelli technique in conjunction with replacement of the tricuspid valve with a Bjork-Shiley prosthesis. The postoperative course was uneventful, and follow-up catheterization revealed a good operative result. However, the patient died suddenly during an emotionally upsetting period about two months after the operation. Postmortem examination revealed only signs of moderately severe cardiac decompensation. Some anatomical and embryological comments are made.

Developmental considerations of mitral valve anomalies.

Atrioventricular valve development is described as following the general principle of junctional invagination and myocardial undermining. We have added considerations of the topographic relations of the developing mitral valve to these principles. Two groups of malformations are then distinguished: the first comprises disturbances of the general principle, the second is related to topographic abnormalities. It is shown that the atrioventricular septal defect, the straddling mitral valve and the isolated mitral cleft all have their own specific developmental backgrounds.

[Congenital aortic arch anomalies and vascular rings (author's transl)]. / Congenitale vasculaire ringen door aortabooganomalieën

The anomalies of the aortic arch are consequences of malformations in the first twelve weeks of the intrauterine life. Embryologically it is possible to explain and classify all of them. Most remain asymptomatic and do not need treatment. About one third of all anomalies are causing tracheo-esophageal compression with consequent complaints. In most cases the symptomatology starts in the first days of life. Some of them can be temporarily treated conservatively. The prognosis of patients, who need surgery is good, even in small infants. Surgery consists mainly in section of the atretic or hypoplastic part of the double aortic arch, section of the aberrant subclavian artery, section of the Botal ligament or duct and liberation of the trachea and esophagus. A normal configuration of trachea and esophagus is reached after several months or even more than a year. There are no reports on reoperations for secondary strictures. In the University Hospital of Nijmegen and Leiden we operated on 17 patients. There were 8 patients of group I A --- Edwards classification -- double aortic arch with both aortic arches open and left Botal duct or ligament; 4 patients of group I B, double aortic arch with one atretic aortic arch with a left Botal ligament; 3 patients of group II B, with a left aortic arch and aberrant right subclavian artery and a left Botal ligament; 2 patients of group III B with a right aortic arch and an aberrant left subclavian artery and a left Botal duct or ligament. Of our 17 patients one died during the operation because of a haemorrhage and overtransfusion; an other one died three weeks postoperatively from an endotracheal bleeding. All the other patients are without complaints and remained so.

Posttraumatic bronchial stenosis.

Bronchial rupture and its sequelae are discussed with reference to data from the literature. Special attention focuses on the pathophysiology and treatment of post-traumatic bronchial stenosis, and in particular on restoration of the ventilation even at operations performed long after the original injury. Two cases are described: one in which the stenosis was abolished a year after the injury, after an unsuccessful primary operation performed elsewhere, and one in which the stenosis was successfully abolished five years after the original injury.