Low Back Pain (LBP), work and absenteeism.

BACKGROUND: Occupational physical demands are commonly assumed the cause of work-related Low Back Pain (LBP) and absenteeism. OBJECTIVES: To analyse relationships between LBP at work, physical demands and absenteeism. METHODS: Workers filled out a questionnaire on socio-demographic and work-related factors, general health, LBP (number of episodes in a 12-month period, pain severity and intensity), and occupational hazards related with physical demands. RESULTS: 735 workers completed the questionnaire (male n = 359). A high proportion of workers n = 507 (69%), from different occupational backgrounds, reported at least one LBP episode in the previous 12-month period. The highest ratio of subjects with more than 6 episodes of LBP per year was found among public services employees (31.8%) and the lowest ratio among administrative workers (10.3%). The highest ratio of workers (39%) were classified as sedentary workers, 34% of workers having a low or moderate level of physical demands in their work, and 27% reported high levels of physical demands in their work. There was a 4 % absenteeism rate in a 12-month period, which was significantly higher in the group with physically demanding work. Those subjects with higher physical requirements at work have increased odds of having more than 3 episodes of LBP during the previous year (p < 0.05) in comparison with subjects with more sedentary jobs and those with low or moderate physical demands. High intensity work, compared to sedentary work, is associated with an increased probability of being absent of work because of LBP in a previous 12-month period (OR = 3.12; CI 1.23-7.89; p = 0.016). CONCLUSIONS: Our findings suggest there is an association between highly physically demanding jobs, LBP and absenteeism. These results may contribute to the improvement of LBP assessment and prevention programs in Occupational Health Services.

Anatomic correction of transposition of the great arteries in neonates.

OBJECTIVES: This retrospective study attempts to assess the results of the neonatal anatomic repair of transposition of the great arteries by a single institution. BACKGROUND: Anatomic correction of transposition of the great arteries by means of the arterial switch operation is now widely accepted as the therapeutic method of choice. METHODS: Four hundred thirty-two consecutive neonates underwent an arterial switch operation for various forms of transposition of the great arteries. There were 362 neonates with transposition and intact ventricular septum, 47 with a ventricular septal defect, 6 with intact ventricular septum and coarctation of the aorta and 17 with ventricular septal defect and coarctation. Among patients with coarctation, 18 underwent a single-stage repair through median sternotomy. The mean age was 13.1 +/- 4.2 days. Coronary artery distribution was described according to the origin and initial course of the arteries. RESULTS: Overall in-hospital mortality was 7.8% (34 patients) and was 7.6% for transposition with intact ventricular septum, 8.5% for transposition with ventricular septal defect and 13.3% for transposition with ventricular septal defect and coarctation. Univariate analysis of risk factors revealed that coronary anatomy was the main determinant for operative survival. A mean follow-up time of 44 +/- 19 months was achieved in all but five survivors. More than 95% were in New York Heart Association functional class I, without medication and with normal left ventricular function. Reoperation was performed in 20 patients: early reoperation (< 30 days) in 4 and late reoperation in 16. Actuarial survival rates at 5 years were 91.3% (transposition with intact ventricular septum) and 81.06% (transposition with ventricular septal defect). As well, freedom from reoperation at 5 years was 96.8% (transposition with intact ventricular septum) and 84.6% (transposition with ventricular septal defect). CONCLUSIONS: The arterial switch operation is feasible in almost all forms of transposition of the great arteries in neonates as primary and definitive repair. Palliative surgery is recommended in cases with complex intracardiac anatomy not amenable to early repair.

Reoperation after the arterial switch operation for transposition of the great arteries.

Although most children after an arterial switch operation for transposition of the great arteries have normal development and cardiac function, a few require reoperation. During the last 10 years, 68 of 753 patients who underwent arterial switch operations (9.3%) underwent 75 reoperations. Thirty underwent early reoperation (< 30 days or during the same hospital stay) and 38 underwent late reoperation. Causes for reoperation included pacemaker insertion (n = 5), left diaphragm plication (n = 4), revision for hemostasis (n = 1), mediastinitis (n = 2), superior vena cava thrombosis (n = 9), subvalvular pulmonic stenosis (n = 5), supravalvular pulmonic stenosis (n = 16), residual atrial (n = 2) or ventricular (n = 8) septal defects, isolated mitral valve insufficiency (n = 2), aortic valve insufficiency (either isolated [n = 1] or in association with mitral incompetence [n = 1] or stenosis [n = 1]), left coronary artery ostial stenosis (n = 1), and recurrent aortic (n = 6) or neoaortic (n = 4) aortic coarctation. In all but 27 patients, the residual defects were already present immediately after the completion of the arterial switch operation; however, only patients with critical lesions were reoperated on early. Interventional catheterization procedures were performed when indicated; however, they only postponed inevitable reoperation. Successful relief of superior vena cava thrombosis was achieved by atriojugular bypass grafting in two patients, by early open thrombectomy in six patients, and by direct patch angioplasty of the superior vena cava once. Patch plasty for subvalvular or supravalvular pulmonic stenosis was carried out in 21 patients, septal defect closure was carried out in nine patients, and pulmonary artery banding was performed in one patient with criss-cross atrioventricular relationship and multiple ventricular septal defects. Valve repair was performed in all five patients with either isolated or combined aortic and mitral valve dysfunction. One patient with left coronary ostial stenosis underwent a patch enlargement of this ostium. Recoarctation was repaired by end-to-end anastomosis in eight patients and by a subclavian flap and a patch angioplasty in one patient each. Seven patients underwent a second reoperation for supravalvular pulmonary stenosis (n = 3), mitral valve replacement (n = 1), ventricular septal defect closure (n = 1), and recurrent coarctation (n = 2). There were six intraoperative (8.8%) and two late deaths. All early deaths occurred after early reoperations.(ABSTRACT TRUNCATED AT 400 WORDS)

Repair of interrupted aortic arch: a ten-year experience.

Eighty-two consecutive patients with interrupted aortic arch were referred to our institution between 1985 and 1995. Three died before any attempt at operation and 79 underwent surgical repair. Median age at operation was 9 days (range 1 day to 6 years) and median weight was 3.0 kg (range 1.8 to 20 kg). All but one were in severe congestive heart failure and 31.5% had oliguria or anuria. Preoperative pH varied between 6.8 and 7.4 (median 7.3). Sixty-nine received prostaglandin E1 infusion and 54 received mechanical ventilation. Aggressive preoperative ressucitation was necessary in 43 cases. Preoperative transfontanellar echography (performed routinely) since 1987 revealed intracerebral bleeding in six patients. Type A interrupted aortic arch was present in 37 cases, 41 patients had type B, and one had type C. Interrupted aortic arch was associated with single ventricular septal defect in 35 cases, 24 patients had associated complex heart defects, and 30 had significant subaortic stenosis (six had both subaortic stenosis and complex association). Aortopulmonary window was found in four patients, truncus arteriosus was found in eight, and transposition of the great arteries was found in five, double-outlet right ventricle was found in one, single ventricle was found in three, multiple ventricular septal defects were found in two and superior-inferior ventricles were found in one. Sixty-four patients underwent single-stage repair and 15 underwent multistage repair. Aortic arch repair consisted of direct anastomosis in 59 cases, patch augmentation in eight, and conduit interposition in 12. Ten patients underwent associated pulmonary artery banding and 19 underwent concomitant repair of complex associated lesions. The subaortic stenosis was addressed by four surgical techniques: myotomy or myectomy in five patients; creation of a double-outlet left ventricle, aortopulmonary anastomosis, and conduit insertion between the right ventricle and pulmonary artery bifurcation in four; no direct attempt to relieve the subaortic stenosis in six; and left-sided ventricular septal defect patch in 15. Mean duration of deep hypothermic circulatory arrest, crossclamp time, and cardiopulmonary bypass time were 38.8 +/- 15.6 min, 60.5 +/- 24.7 min, and 143 +/- 40.1 min, respectively. Postoperative mortality rate was 18.9% (70% confidence limits 14% to 24.6%), and overall mortality rate was 31% (70% confidence limits 20.9% to 42.2%). The results have improved with time, with an overall operative mortality rate of 12% since 1990. Univariate statistical analysis revealed that early survival was influenced by preoperative renal function, detection of cerebral bleeding by transfontanellar echography, the number of cardioplegic injections, and the date of operation. Multivariate analysis revealed that preoperative renal function and the number of cardioplegic injections were independent risk factors for early mortality. Echocardiographic measurements of the left heart-aorta complex with preoperative Z values as low as-4 demonstrated rapid growth after repair. In the presence of subaortic stenosis, better survival was obtained with a left-sided patch for ventricular septal defect closure (p < 0.05). Twenty-three patients underwent 26 reoperations for recoarctations (seven), left bronchial compression (two), second-stage repair (eight), right ventricle-pulmonary artery conduit replacement (three), and miscellaneous (four). One of the survivors was reoperated on for subaortic membrane. Survival at 5 years for the entire series was 70%. For isolated forms, it was 73.5% (90% for 1990 to 1995), for complex forms it was 70%, and in the presence of subaortic stenosis it was 60%. In conclusion, interrupted aortic arch remains a surgical challenge with continually improving results. Early diagnosis with preoperative resuscitation and adequate myocardial protection seem extremely important for further improvements. Associated subaortic stenosis or complex lesions

Surgical management of neonatal coarctation.

Between 1983 and 1994, 307 consecutive neonates underwent coarctation repair by a single surgical technique: extended end-to-end anastomosis. Mean age at operation was 13 +/- 8 days. Isolated coarctation was present in 95 patients (group 1), 102 patients had associated ventricular septal defect (group 2), and 110 patients had associated complex intracardiac lesions (group 3). Aortic arch hypoplasia was present in 81% of the patients (62% in group 1 versus 85% in group 2 and 93% in group 3: p < 0.001). In 271 patients, the aortic arch reconstruction was performed via a left thoracotomy with normothermia (100% of group 1, 95% of group 2, and 72% of group 3); in the other 36 patients, undergoing one-stage repair or palliation of the associated lesion, it was performed via a midline sternotomy during a short period of deep hypothermia and circulatory arrest (5% of group 2 and 28% of group 3). Pulmonary artery banding was performed in 94 patients. Spontaneous ventricular septal defect closure was observed in 39% of the patients of group 2 operated on via thoracotomy. Early mortality rates in groups 1 (2%) and 2 (2%) were significantly lower than in group 3 (17%) (p < 0.001). There were 29 late deaths, all related to associated cardiac lesions or their subsequent repair. The overall total mortality was 16.9%. In group 3 this rate was significantly higher in patients undergoing two-stage procedures (47%) than in those undergoing one-stage repair (23%) (p < 0.05). All but 14 survivors were followed up for a mean of 61 +/- 36 months. Actuarial survivals at 10 years were 98% in group 1, 94% in group 2, and 60% in group 3. The recoarctation rate was 9.8%, leading to 21 reoperations and three angioplasties without mortality. Patients with a more extended or severe form of aortic arch hypoplasia had a significantly higher risk of recoarctation (p < 0.001). Actuarial freedom from reoperation for recoarctation at 10 years was 93%. The findings of this study suggest that extended end-to-end anastomosis provides an adequate and safe repair of neonatal coarctation. Low recoarctation rate, owing to effective relief of the obstruction created by aortic arch hypoplasia and to complete resection of ductal tissue, freedom from major morbidity, and feasibility via both lateral and anterior approaches are the main advantages of the extended end-to-end anastomosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgery for tetralogy of Fallot at less than six months of age.

Absence of consensus persists regarding the optimal procedure and timing for the surgical treatment of young infants with symptomatic tetralogy of Fallot. From 1987 through 1992, 56 patients with tetralogy of Fallot were operated on at less than 6 months of age. Forty-one patients (median age 2.9 months) underwent primary repair and 15 (median age 2.4 months) underwent initial palliation. Mean follow-up was 24.2 +/- 16.4 months. No strict protocol was used but patients who received initial palliation were younger, had a smaller pulmonary arterial tree, or had anomalous coronary artery. Two patients died (overall mortality 3.6%; 95% confidence limits 0% to 11%), one after initial palliation (6.7%), and one after primary repair (2.4%) (P = 0.47). Eight of the 15 patients who received initial palliation underwent repair and had an increase in pulmonary anulus size at the time of definitive repair (mean difference Z-value = 2.2 +/- 1.6 standard deviation; p = 0.006). Transannular patch was required in 50% of patients who underwent repair (56% among patients having primary repair versus 13% for patients having initial palliation; P = 0.03). Five patients underwent reoperation. Early primary repair of symptomatic tetralogy of Fallot was achieved with a low mortality rate and is the preferred protocol. Initial palliation remains indicated in case of associated cardiac anomaly, very low weight, or severely hypoplastic pulmonary artery tree.

Truncus arteriosus repair: influence of techniques of right ventricular outflow tract reconstruction.

Fifty-six consecutive patients underwent total correction of truncus arteriosus. Median age at repair was 41 days, with a range of 2 days to 8 months. In 71% the operation was done in the first 2 months of life. Nine patients had complex forms of truncus and 11 patients had aortic insufficiency. The truncal aortic root was transected, which provides a clear exposure of the coronary ostia. The aorta was reconstructed by direct end-to-end anastomosis, and the truncal valve was preserved in every case. Several different techniques were used for pulmonary reconstruction, including three types of anatomic reconstruction of the pulmonary valve with a trisigmoid leaflet system and two types of nonanatomic reconstruction. The anatomic techniques included use of 33 Dacron valved conduits, eight homograft valved conduits, and one porcine aortic root bioprosthesis. The nonanatomic reconstructions included direct anastomosis to the right ventricle in nine patients and insertion of autologous pericardial valved conduits in five. The hospital mortality was 16% (9/56; 95% confidence limits, 2% to 30%). Multivariate analysis outlines two independent incremental risk factors for hospital death: nonanatomic pulmonary valve reconstruction techniques and age younger than 1 month. The hospital mortality was 7.1% in the group with anatomic pulmonary valve reconstruction versus 43% in the group with nonanatomic pulmonary valve reconstruction (p = 0.015). The hospital mortality was 5.7% in those older than 1 month versus 33% in those younger than 1 month of age (p = 0.04). There were two late deaths. The actuarial freedom from reoperation and angioplasty at 7 years was 100% for patients receiving pericardial conduits, 80% for those undergoing direct anastomosis, 77% for those receiving Dacron conduits, and only 43% for those receiving homografts (p = 0.02). In conclusion, anatomic reconstruction of the pulmonary valve seems important at the time of the operation, age younger than 1 month remains an incremental risk factor, and the truncal valve can be preserved.

Surgical approaches for double-outlet right ventricle or transposition of the great arteries associated with straddling atrioventricular valves.

The surgical management of patients with double-outlet right ventricle or transposition of the great arteries and straddling atrioventricular valves remains a subject of controversy. Biventricular repair has theoretic advantages because it establishes normal anatomy and physiology. In some instances, however, it seems to carry too high operative risk, and a univentricular heart repair is preferred. Since 1984, we have operated on 34 patients with double-outlet right ventricle (n = 15) or transposition of the great arteries (n = 19) with isolated straddling tricuspid valve (n = 17), isolated straddling mitral valve (n = 9), both mitral and tricuspid straddling (n = 2), or abnormal insertion of tricuspid (n = 7) or mitral (n = 2) chordae in the left ventricular outlet, precluding an adequate tunnel construction. Straddling was categorized according to the location of the papillary muscle insertion in the opposite ventricular chamber: type A, on the edge of the ventricular septal defect (n = 14); type B, on the opposite side of the ventricular septum away from the edge of the defect (n = 8); type C, on the free wall of the opposite ventricular chamber (n = 8). Abnormal chordal insertions were classified according to the location of their attachments around the edges of the defect. Three types of chordal distribution were identified: on the aortic conus, on the pulmonary conus crossing the ventricular septal defect, or around the defect closing it like a curtain. All but three patients had two ventricles of adequate size. Sixteen patients underwent palliation. Median age at the definitive operation was 6.5 months (range 1 to 130 months). Thirty patients underwent a biventricular repair and four had a univentricular repair. Biventricular repair was achieved by an arterial switch operation in 18 patients and by tunnel construction from the left ventricle to the aorta in 12. In isolated straddling of types A and B, the ventricular septal defect was closed by adjusting the septal patch on the ventricular side above the straddled papillary muscle. In type C, the patch was sewn over the papillary muscle by applying it on the septum. In double straddling, the ventricular septum was incised between the two papillary muscles, and an ellipsoid patch was used to reconstruct the septal defect, directing each subvalvular apparatus into its own ventricular chamber. When the abnormal chordae in the left outflow tract inserted on the aortic or pulmonary conus, the conus was incised and tailored to make a flap, leaving an unobstructed left ventricular outflow tract. In two patients the subvalvular apparatus was resected and reattached to the patch. Curtainlike chordae were a contraindication to biventricular repair in double-outlet right ventricle but not in transposition. There were four early deaths and one late death, all occurring in the group having biventricular repair. Death was due to myocardial ischemia (n = 1), right ventricular hypoplasia (n = 1), pulmonary hypertension (n = 1), and residual subaortic stenosis (n = 1). Two patients had moderate to severe postoperative atrioventricular valve incompetence, caused by a cleft in the mitral valve in one patient. Three patients were reoperated on for subaortic stenosis (n = 1), pulmonary stenosis (n = 1), and mitral regurgitation (n = 1). Mean follow-up of 30.7 +/- 19.4 months was achieved in the survivors. All but one patient (univentricular repair) were in New York Heart Association class I, without atrioventricular valve incompetence. Actuarial survival at 4 years was 85.3% +/- 3%. We conclude that straddling or abnormal distribution of chordae tendineae of the atrioventricular valves does not preclude biventricular repair in double-outlet right ventricle or transposition of the great arteries provided that the ventricles are of adequate size. Curtainlike abnormal tricuspid chordae remain a contraindication to biventricular repair in double-outlet right ventricle.

Surgical treatment of asymptomatic and mildly symptomatic mitral regurgitation.

OBJECTIVE: The purpose of this study was to review the risk-benefit ratio of mitral valve repair in patients with severe mitral regurgitation and no or mild symptoms. METHODS: From January 1989 to December 1994, 584 patients were operated on for mitral regurgitation. Of these, 175 patients were in New York Heart Association class I or II with grade 3 to 4 isolated chronic mitral regurgitation. They comprise our study population. Mean age was 51.3 +/- 14.3 years. Principal causes of mitral regurgitation were degenerative in 128 (73%) and rheumatic in 26 patients (15%). Leaflet prolapse was the mechanism responsible for regurgitation in 152 patients (86%). Mitral valve repair was performed in 174 patients, and one patient required initial valve replacement. Mean follow-up was 34.3 +/- 18.8 months. RESULTS: Three patients died, for an overall mortality of 1.7%. Five patients were reoperated on, for an actuarial freedom from reoperation of 97.0% +/- 0.8% at 5 years. Actuarial freedom from thromboembolism and endocarditis was 96.3% +/- 1.7% and 99.4% +/- 0.6%, respectively, for an event-free survival of 91.0% +/- 2.0% at 5 years. Left atrial diameter decreased from 54.3 +/- 11.6 mm to 43.6 +/- 10.5 mm (p < 0.001). Left ventricular end-systolic and end-diastolic diameters decreased from 40.0 +/- 6.8 mm and 64.8 +/- 7.0 mm to 34.6 +/- 6.7 mm (p < 0.001) and 52.7 +/- 7.4 mm (p < 0.001), respectively. Mean residual mitral regurgitation was 0.44 +/- 0.6. CONCLUSION: Mitral valve repair for chronic mitral regurgitation in patients having mild or no symptoms was performed with low mortality and morbidity, good valve function, and preserved late left ventricular performance. Early repair may be advocated on the basis of severity of regurgitation and valve repairability, regardless of symptoms.

Systemic obstruction in univentricular hearts: surgical options for neonates.

BACKGROUND: The surgical management for bridging patients with univentricular heart and systemic obstruction to a Fontan procedure remains controversial. METHODS: Twenty-seven of 96 patients with univentricular heart and unobstructed pulmonary blood flow referred for surgical palliation were seen with systemic obstruction. Twenty-six were neonates with coarctation of the aorta in 21 and subaortic stenosis in 5. In 8 other patients, subaortic stenosis developed after initial pulmonary artery banding. Four different palliative procedures were performed: coarctation repair with pulmonary artery banding (group I, n = 15); Norwood or Damus-Kaye-Stansel or arterial switch operation (group II, n = 9); coarctation repair with pulmonary artery banding and bulboventricular foramen enlargement (group III, n = 2); and orthotopic heart transplantation with coarctation repair (group IV, n = 1). RESULTS: The mortality rate was 34.3% (n = 12) for all patients, 53.3% in group I, 33.3% in group II (p = 0.003 versus group I), and 50% in group III. Nine patients (8 in group I and 1 in group II) had development of subaortic stenosis and underwent a subsequent procedure: Damus-Kaye-Stansel operation in 5, arterial switch operation in 3, and bulboventricular foramen enlargement in 1. Three had a concomitant or subsequent Fontan procedure and 2, a bidirectional Glenn procedure. In group II, 1 patient underwent a subsequent Fontan procedure and another, a bidirectional Glenn anastomosis. Six of the 8 patients with subaortic stenosis after initial pulmonary artery banding underwent a second stage consisting of a Damus-Kaye-Stansel procedure (n = 3), bulboventricular foramen enlargement (n = 2), or creation of an aortopulmonary window (n = 1). Three had a concomitant Fontan procedure and 2, a bidirectional Glenn procedure. Actuarial 4-year survival was 65.5% +/- 8.4% (70% confidence limits) for all patients; it was 40% +/- 13.3% in group I and 66.6% +/- 16.3% in group II (p < 0.05). CONCLUSIONS: Initial management of patients with univentricular heart and systemic obstruction by Norwood-like procedures provides a better outcome. Success of the Fontan operation relies on the ability to provide timely relief of subaortic stenosis.

Modified superior approach for repair of supracardiac and mixed total anomalous pulmonary venous drainage.

BACKGROUND: The main goal in the surgical repair of total anomalous pulmonary venous drainage is to reestablish a wide patent connection between the common pulmonary vein and the left atrium. Several techniques have been proposed for achieving this objective, each of which has advantages and disadvantages. The superior approach between the superior vena cava and the ascending aorta was introduced in 1976 for the repair of supracardiac forms of total anomalous pulmonary venous drainage, but it often provides a less than optimum exposure, particularly in tiny infants. We proposed a modification of this approach that includes division of the ascending aorta and offers excellent exposure. METHODS: Seventeen patients (15 neonates and 2 infants) with supracardiac total anomalous pulmonary venous drainage (n = 13) or mixed forms of total anomalous pulmonary venous drainage (n = 4) underwent surgical repair with the use of the modified superior approach. Circulatory arrest was not required in 10 patients and the mean cross-clamp time was 32.5 +/- 13.8 minutes. RESULTS: There was 1 postoperative death resulting from intractable pulmonary hypertension in a compromised infant who was referred to our unit receiving extracorporeal membrane oxygenation. One patient with common hypoplasia underwent reoperation twice at 2 months and then 3 months after the first procedure. All the other patients had a smooth postoperative course, and midterm evaluation showed a widely patent anastomosis between the common vein and the left atrium. CONCLUSIONS: The modified superior approach for the repair of supracardiac total anomalous pulmonary venous drainage can be useful to enhance exposure during surgical repair and may contribute to improved patient outcome.

Aortico-left ventricular tunnel in fetuses and infants.

BACKGROUND: Aortico-left ventricular tunnel is a rare congenital abnormal communication between the aorta and the left ventricle presenting in early childhood as aortic regurgitation and cardiac failure. This condition has rarely been reported in fetuses. Operation is the only treatment, and postoperative aortic incompetence could be related to the age or the type of repair. METHODS: We conducted a retrospective, two-institution review, from 1983 to 1995, of aortico-left ventricular tunnel diagnosed in utero and before 6 months of age. RESULTS: Three cases of aortico-left ventricular tunnel were diagnosed in utero by Doppler echocardiography between 22 and 24 weeks' gestation. Prenatal aortico-left ventricular tunnel was associated with severe left ventricular dysfunction, aortic valve anomalies, and fetal hydrops. One death occurred in utero and one immediately after birth, and in 1 case pregnancy was interrupted. In these 3 cases the diagnosis was confirmed by autopsy. Three neonates and 2 infants had the diagnosis of aortico-left ventricular tunnel made after birth and underwent successful surgical repair. At short and midterm follow-up all patients are alive and aortic valve regurgitation is absent or trivial. CONCLUSIONS: This series shows that aortico-left ventricular tunnel covers an anatomic spectrum of lesions. Cases diagnosed in utero by Doppler echocardiography are characterized by severe ventricular dysfunction, associated aortic valve lesions, and poor outcome. Postnatal cases represent the more favorable end of the spectrum, with no associated lesions, and can be repaired without mortality and with good functional results.

Absent pulmonary valve syndrome: surgical treatment and considerations.

BACKGROUND: The operative management of absent pulmonary valve syndrome remains controversial regarding the need for pulmonary valve implantation and remodeling of pulmonary arteries. Moreover, symptomatic infants are considered to have a poor prognosis. This retrospective report summarizes the experience of a single institution. METHODS: Between May 1977 and May 1995, 37 consecutive patients underwent repair of absent pulmonary valve syndrome. Patients were divided into two groups according to age at operation: group A (10 infants less than 1 year old) and group B (27 patients older than 1 year). Mean age at operation was 5 +/- 4 months in group A and 72 +/- 42 months in group B. Initially, repair consisted of ventricular septal defect closure and relief of right ventricular outflow tract obstruction combined with pulmonary valve implantation. More recently, the concept of treatment has evolved with pulmonary arterioplasty without pulmonary valve insertion, except in patients with elevated pulmonary artery pressure. RESULTS: Of the 37 patients, 34 had successful repair. The overall in-hospital mortality rate was 8% (two deaths in group A and one in group B). No hemodynamic data were correlated with operative death. Death was associated with longer extracorporeal circulation time (p = 0.005) and longer aortic cross-clamping time (p = 0.019). In fact, these were clearly related to more complex anatomy (p = 0.001): multiple ventricular septal defects in 1, left pulmonary artery arising from the ductus in another, and left pulmonary artery arising from the aorta in the remainder. Follow-up was available in 22 of the 34 survivors. Mean follow-up time was 30 +/- 47 months in group A and 38 +/- 33 months in group B. All but 1 had no restriction of exercise, and most of them had pulmonary incompetence of Doppler echocardiography. One developed severe exercise intolerance because of pulmonary valve stenosis (xenograft), leading to uneventful reoperation 123 months after initial repair. One infant died suddenly of complete atrioventricular block 3 months after repair. The late mortality rate was 5%. CONCLUSIONS: Surgical treatment of absent pulmonary valve syndrome should include pulmonary arterioplasty to reduce bronchial obstruction, with no need for pulmonary valve insertion. This procedure is feasible and is recommended especially in markedly symptomatic infants.

Surgical management of atrio ventricular septal defects with normal caryotype.

OBJECTIVE: Atrio ventricular septal defects (AVSD) with normal caryotype represent in average 25% of AVSD. They constitute a more complex group of patients characterized by frequent left sided heart obstructive lesions, raising the problem of the appropriate indications between biventricular and univentricular procedures. METHODS: Sixty-nine consecutive patients, who had AVSD with normal caryotype underwent surgery. According to the anatomical complexity there were 22 intermediate AVSD, 36 complete AVSD and 11 complex AVSD. Associated lesions were present in 68% of the patients including left sided heart anomalies in 57%. According to the size of the left ventricle (LV) evaluated on the LV/RV end diastolic diameter ratio calculated at 2D echocardiogram: right ventricular (RV) dominance was found in 29%; with border line LV in 13 patients and truly hypoplastic LV in 7 patients. Biventricular repair was always favored in case of border line LV and precluded when the LV/RV ratio was less than 0.33. RESULTS: There were 57 biventricular repairs with 10 years actuarial survival of 70 +/- 8% and respectively, 100% in the complex AVSD, 86% in the intermediate AVSD and 51% in the complete AVSD (P = 0.006). The risk factors for biventricular repair were the association to a subaortic stenosis (P = 0.01) and the severity of the mitral valve lesions (P = 0.03) that led to 38% reoperation. There were 12 univentricular palliation with 10 years survival of 66 +/- 14%. The risk factor for univentricular palliation was the association to a severe pre-operative mitral regurgitation (P = 0.005). CONCLUSIONS: Biventricular repair should be precluded in patients presenting with subaortic stenosis. Severe mitral valve anomalies lead to elevated mortality and morbidity with frequent reoperations. Univentricular repair might have larger indications and cardiac transplantation might be considered in patients with truly hypoplastic LV presenting with severe pre-operative AV valve regurgitation.

Surgery for tetralogy of Fallot at less than six months of age. Is palliation "old-fashioned"?

There is still no consensus regarding the most appropriate protocol for managing symptomatic patients with tetralogy of Fallot (TOF) presenting during early infancy. From January 1987 to April 1994, 83 patients with TOF were operated on at less than 6 months of age. Sixty patients (mean age 109 +/- 5 days) underwent primary repair and 23 (mean age 72 +/- 10 days) underwent initial palliation with a modified Blalock-Taussig shunt (MBTS) in 22 cases. No strict protocol was used but patients who received initial palliation had lower weight, smaller pulmonary annulus or had an anomalous coronary artery. Nineteen of the patients initially palliated underwent repair at a median of 13 months after palliation. During this interval, the pulmonary annulus size increased from a Z-value of -3.0 +/- 0.4 at palliation to -1.6 +/- 0.7 at repair (P = 0.06) and the summed diameters of pulmonary artery branches from -2.2 +/- 0.4 to -1.6 +/- 0.7 (P = 0.2). There were no operative deaths among the repaired patients, but two patients died early after shunt insertion. Transannular patch was required in 58% of the patients regardless of the management protocol. Actuarial survival rate and freedom from reoperation at 48 months were 98.0% and 77.4% (P = 0.003) and 87.6% and 90.0% in primarily repaired and initially palliated patients, respectively. Primary repair of TOF at the time of presentation is the preferred approach regardless of age.(ABSTRACT TRUNCATED AT 250 WORDS)

Traumatic ventricular septal defects. Report of 3 cases with tricuspid valve rupture in 2 cases.

Traumatic ventricular septal defects (TVSD) are rare complications of cardiac trauma. This report describes 3 cases of TVSD secondary to penetrating trauma in 2 patients and to blunt trauma in one case. Echocardiography confirmed the diagnosis in all cases. Surgical correction was performed in the 3 cases. In 2 patients associated tricuspid trauma was present requiring tricuspid valve repair.

[Surgical treatment of isolated multiple ventricular septal defects. apropos of a series of 175 consecutive cases]. / Traitement chirurgical des communications interventriculaires multiples isolées, A propos d'une série consécutive de 175 cas.

Between January 1980 and September 1995, 175 children were operated for closure of isolated multiple ventricular septal defects (VSD) (mean age 20 +/- 8 months, mean weight 8.1 +/- 4.4 kg). Eighty-nine patients had pulmonary protection: pulmonary artery banding (n = 76) and pulmonary valvular stenosis (n = 13). The remainder had severe pulmonary hypertension (mean pulmonary systolic pressures: 75.7 +/- 20.5 mmHg). The surgical strategy was based on the site of the VSD and the ventricular dominance determined preoperatively or at surgery. The VSD were perimembranous in 141 cases, muscular in 175 cases, of the inlet septum in 19 cases and infundibular in 13 cases. A surgical approach through a right atriotomy was adequate for complete repair in 122 patients; a second approach was necessary by right (n = 35) or left ventriculotomy (n = 4) or both (n = 2) or via the pulmonary artery in 2 cases. The operative mortality was 7.4% (13 patients). The causes of death were: residual (VSD (n = 6), pulmonary hypertension (n = 2), ventricular hypoplasia (n = 2), myocardial infarction (n = 3). Of the 162 survivors, 33 had residual VSDs, 12 were reoperated once (n = 11) or twice (n = 1). The mortality was 54.5%. The patients were classified in two groups: Group I (n = 130), those operated before 1990, and Group II (n = 45), the ones operated afterwards. The low muscular VSDs and left ventriculotomy were risk factors for mortality in univariate analysis for Group I and the "Swiss Cheese" type for Group II.

[Comparison of long-term results of arterial switch and Senning procedure in transposition of great vessels with intact ventricular septum]. / Comparison des résultats à long terme du switch artériel et de l'opération de Senning dans la transposition des gros vaisseaux à septum intact.

One hundred and five survivors after the 30th day of complete cure of transposition of the great arteries with intact ventricular septum between 1980 and 1985 were followed up. Fifty-four had an arterial switch (AS) in a single stage at an average age of 10 +/- 9 days and 51 had Senning's procedure (S) at an average age of 4 +/- 2.5 months. The average follow-up (97% of patients) was 5.8 +/- 1.1 years for the AS group and 9.3 +/- 2.3 years for the S group. The actuarial survival at 5 years was 100% in the AS group and 85.8% in the S group (p < 0.01) (8 late deaths). In the AS group, 3 patients were reoperated for stenosis of the pulmonary artery and, in the S group, 4 patients underwent 6 reoperations. All but 3 patients in the S group and all but 1 patient in the AS group are in functional Class I of the NYHA classification. Doppler echocardiographic studies have shown mild to severe dysfunction of the systemic ventricle in 2% of the AS group and 26% of the S group (p < 0.001). Holter monitoring, performed in 70% of patients in the S group showed sinus node dysfunction in 60% and sinus rhythm in 40% of cases. In conclusion, good functional results were observed at over 5 years in both groups. However, the absence of late mortality and the minimal incidence of systemic ventricular dysfunction in the AS group confirm the authors' choice of indication of arterial switch for the treatment of transposition of the great arteries with intact ventricular septum.

[Atresia or congenital stenosis of the left coronary ostium. Myocardial revascularization in 5 children]. / Atrésie ou sténose congénitale de l'ostium coronaire gauche. Revascularisation myocardique chez 5 enfants.

Five patients, 3 months to 13 year old with atresia (4) or stenosis (1) of the left coronary artery underwent myocardial revascularisation at Marie Lannelongue Hospital. The preoperative symptoms were dominated in one case by cardiac failure due to myocardial infarction and in the other cases by effort angina with syncope. The operative technique of revascularisation in one case was angioplasty with enlargement of the left main coronary artery with a patch and, in the others, bypass graft of the left coronary artery with the left internal mammary artery. All 5 patients survived surgery and are asymptomatic with a follow-up of 6 months to 7 years. Control coronary angiography confirmed the patency of the different procedures of myocardial revascularisation. In 3 children, exercise electrocardiography was normal. Myocardial revascularisation of a child with a congenital stenotic abnormality of the left coronary network is possible, the technique of which depends on the diameter of the left main stenosis when the vessel is absent or atresic, left internal mammary artery bypass graft is the only solution. When the left main coronary is stenosed but patent, direct reconstructive surgery is an interesting alternative.

[Atypical coarctation of the thoracic aorta caused by fibromuscular dysplasia]. / Coarctation atypique de l'aorte thoracique par dysplasie fibromusculaire.

Fibromuscular dysplasia is a non-inflammatory disease unrelated to atherosclerosis of the small and medium sized arterial walls, which often affects the renal and carotid arteries and occurs mainly in women. The authors report a case of atypical coarctation of the thoracic aorta due to fibromuscular dysplasia confirmed histologically in a 27 year old man. Arteriography was performed because of hypertension and asymmetry of blood pressure measurements and showed irregular stenosis of the aortic isthmus and of the origin of the left subclavian artery. Surgery comprised resection of the pathological segment of the aorta which was replaced by a prosthetic tube with reimplantation of the left subclavian artery. Histological examination showed fibromuscular dysplasia in perimedial areas and diffusely throughout the media. To the author's knowledge this is the first case to be reported in the medical literature.