Factors influencing the intermediate outcome in patients with single-ventricle physiology after Fontan operation.

OBJECTIVE: This study was conducted to analyze the factors affecting the intermediate outcome following the Fontan procedure in the current era. METHODS: Between January 1992 and December 2008, 189 patients underwent Fontan procedure at a median age of 3.4 years (0.4-37 years). Single left ventricle was present in 77 (40%) patients, right ventricle in 70 (37%), in 7 (3.7%) patients, the ventricular morphology was indetermined and in 35 (18.5%) a dominant systemic ventricle with smaller second ventricle was present. The Fontan procedure was performed using an atriopulmonary connection (n=5, 5.6%), lateral atrial tunnel (n=99, 52%) or extracardiac conduit (n=85, 45%). 97.4% of patients recieved fenestration. RESULTS: The hospital survival was 95% and five patients required a takedown of Fontan circulation. The survival at 1.5 and 10 years was 94%, 93% and 92%, respectively. Multivariate analysis identified that the outcome was influenced by the diagnosis of a complete common AV canal (p = 0.015), duration of ventilation (p < 0.0001) and duration of pleural effusions (p = 0.003). Failure-free survival at 1.5 and 10 years was 95%, 92% and 89%, respectively. The overall freedom from reoperation was 73%. Risk factors for reoperation were preoperative pulmonary artery pressure and duration of ventilation. CONCLUSIONS: The Fontan procedure is associated with excellent operative and intermediate survival. Common atrioventricular canal, duration of pleural effusions and ventilation have an adverse influence on the intermediate outcome. Reintervention is associated with pulmonary artery pressure and duration of ventilation (Tab. 7, Fig. 3, Ref. 16).

Long-term results of surgical treatment of total anomalous pulmonary venous drainage in children.

AIM OF STUDY: Retrospective analysis of surgical correction of TAPVD performed between January 1992 and March 2008. METHODS: Review of patients' medical records. Patients' preoperative, operative as well as postoperative data were collated and analyzed using JMP statistical program version 5. RESULTS: A total of 51 patients with total anomalous pulmonary venous drainage underwent surgery at our center during a period of over seventeen years. Actuarial survival was 90.2%. Early postoperative death was recorded in 4 patients (7.8%) as against one late postoperative death. The only statistically significant risk factor for death was the time of surgical repair. Patients undergoing the repair before 1997 were more likely to die than those operated on after this period, p=0.006. Patients' survival following the surgical correction prior to the year 1997 was 63.63% as opposed to 97.5% for the period between 1997 and 2008. Freedom from surgical re-intervention over the period of follow-up was 92%. The obstructive type of TAPVD was associated with longer ICU stay and higher postoperative complications, p=0.003. CONCLUSION: We have recorded a significant improvement in patients' survival following surgery for total anomalous pulmonary venous drainage in the last decade. This can be attributed to a number of new measures both surgical and medical employed in the treatment of our patients (Tab. 3, Fig. 7, Ref. 17). Full Text (Free, PDF) www.bmj.sk.

Sildenafil as a pulmonary vasodilator after repair of congenital heart disease.

We describe successful use of enteral sildenafil following surgery for congenital heart disease in three cases. One infant after repair of ventricular septal defect and aortic coarctation had pulmonary hypertension non-responsive to nitric oxide, another infant and 3.5 year child following palliative surgery for congenital heart disease with univentricular physiology were treated with inhaled nitric oxide and had severe systemic desaturations associated with endotracheal suctioning. Therapy with sildenafil reduced pulmonary arterial pressure, prevented episodes of arterial desaturations and allowed weaning from nitric oxide (Ref. 7). Full Text (Free, PDF) www.bmj.sk

Surgical closure of patent ductus arteriosus in pre-term babies.

OBJECTIVES: To present by illustration the surgical options in neonatal PDA closure with emphasis on clip application. METHODS: Photo/video-documentation of surgical closure of PDA in a neonate by clip application coupled with free-hand drawings showing PDA closure by ligation and division. Review of 38 neonates undergoing surgical PDA closure in our institution between 1998 and 2006. RESULTS: Overall survival following surgery was 100%. There was one case of residual PDA and three postoperative complications - 2 cases of pneumothorax and one chylothorax. CONCLUSION: The outcome of surgical closure of PDA in neonates is very good with zero mortality in our series and only few postoperative complications.

Surgical treatment of aortic coarctation.

Coarctation of the aorta accounts for about 8% of all congenital heart diseases. Since the first successful case of surgical treatment in 1944 by Crafoord and Nylin1 in Sweden, several surgical techniques have been employed in the treatment of this anomaly. Here, we review by illustration the various surgical options in coarctation of the aorta with emphasis on our preferred technique - the extended resection and end-to-end anastomosis. Why the extended resection technique? Our experience - and that of other institutions - has shown that this is a better option in childhood as it is associated with a lesser degree of recoarctation and subsequent need for re-intervention.2.

Functional outcome of surgery for coarctation of the aorta.

AIM OF STUDY: Coarctation of the aorta (CoA) accounts for about 8% of all congenital heart diseases. This represents about 30 new cases of coarctation every year in Slovakia, of which more than half will require surgical treatment. Over the past years, many children with this diagnosis have been successfully operated on at the Department of Cardiac Surgery of the Children's University Hospital, Bratislava. Thus, the need for a comprehensive follow-up and analysis of the postoperative well being of these young patients arises. Our study is therefore aimed at: 1) identifying factors affecting the incidence and persistence of postoperative systemic hypertension, as well as the need for heart failure and hypertension treatment, 2) assessing patients' psychomotor development following surgery for coarctation of the aorta. METHODS AND DATA: Between January 1992 and December 2001, a total of 201 patients with aortic co-arctation were operated on at our institution. The three classes of aortic coarctation namely: isolated coarctation, coarctation with ventricular septal defect and coarctation with complex cardiac anomalies were represented. Patients' medical records were retrospectively reviewed, with attention paid to such variables as the type of lesion, gradient across the site of coarctation, type of surgical technique employed and surgery-related complications. Subsequently, these patients were followed for a time period ranging between six months and ten years during which their psychomotor development and overall clinical state were evaluated. RESULTS: Of the 201 operated patients, 64 (33%) had early postoperative hypertension, so-called paradoxical hypertension. There was a significant correlation between the incidence of early postoperative hypertension and patients' age at operation (p < 0.0001). Age at operation was also a significant risk factor for late hypertension (p = 0.005). In both cases we noticed a higher incidence of high blood pressure in patients operated on after the age of six years. The need for antihypertensive treatment of patients with early postoperative hypertension decreases with a younger age at operation. At five years of follow-up, the need for antihypertensive treatment was 15%. Clinical psychological evaluation of 64 patients showed a normal distribution of patients' intelligence quotients. No surgery-related variable correlated with the incidence of delayed mental development. There was, however, a certain correlation between the presence of complex anomalies and low verbal IQ in examined patients (p = 0.04) CONCLUSIONS: Early surgical treatment of aortic coarctation reduces the likelihood of early, as well as late postoperative hypertension. The preferred protocol in our institution is early surgical treatment of patients at about the age of two years. The need for antihypertensive treatment of patients at five years of follow-up is 15%. Patients' psychomotor development following surgery for aortic coarctation is not affected by type of surgical procedure. On the whole, we can conclude that patients' psychomo-whole, we can conclude that patients' psychomotor development does not differ from the rest of population. There is however, a certain correlation between complex cardiac anomalies and a tal, Bratislava delay in some components of patients' psychomotor development. (Tab. 3, Fig. 4, Ref. 17.)

Recoarctation and patients' freedom from re-intervention--a study of patients undergoing surgery for coarctation of the aorta at the Department of Cardiac Surgery of the Children's University Hospital, Bratislava.

BACKGROUND: Many children and young adults have undergone surgery for coarctation of the aorta. Individual surgical techniques employed in the treatment of patients and their effects on incidence of recoarctation were reviewed. METHODS AND DATA: Over the last ten years, a total of 201 cases of aortic coarctation were surgically treated at our department. The three forms of coarctation of the aorta recognized by the Society for Cardiothoracic Surgeons namely: isolated coarctation, coarctation with ventricular septal defects and coarctation with complex cardiac anomalies, were represented. RESULTS: 19 cases of recoarctation were recorded over the period of follow-up, representing 10% of all operated patients. On univariate analysis, the risk of recoarctation was closely linked with the following variables: use of resection and end-to-end anastomosis (p=0.01), age at operation less than one month (p=0.0002) and weight at operation less than 3 kg (p=0.01). The risk of recoarctation was found to be highest when resection and end-to-end anastomosis was employed in neonates (p<0.0001). Most cases of recoarctation as shown by the Kaplan-Meier plot occurred within the first year after surgery. CONCLUSION: The use of simple resection and end-to-end anastomosis in neonates is associated with a high risk of recoarctation. Hence, our preferred surgical technique in neonates is the extended resection and end-to-end anastomosis, which is associated with a considerably lower risk of recoarctation in this age group. (Tab. 4, Fig. 5, Re. 7)

Improved patient survival following surgery for coarctation of the aorta.

BACKGROUND: We conducted a retrospective review of children undergoing surgery for coarctation of the aorta in our institution over the last ten years with the aim of evaluating overall patient survival as well as detecting factors affecting it. We tried to identify the risk factors for mortality. METHODS AND DATA: Between January 1992 and December 2001, 201 patients with aortic coarctation were operated on at the Department of Cardiac Surgery of the Children's University Hospital, Bratislava. The three classes of aortic coarctation were represented: isolated coarctation, coarctation with ventricular septal defect (VSD) and coarctation with complex cardiac anomalies. Patients' preoperative, operative and immediate postoperative medical records were carefully studied with special attention paid to the type of lesion, patients' preoperative state, type of surgical technique employed, as well as the period of operation. For comparison, two equal time periods of follow-up were reviewed--1992 to 1996 and 1997 to 2001. The overall postoperative conditions of patients were also regularly monitored. Patient data were statistically analyzed using the JMP program version 4.04. RESULTS: An overall survival of 90% was recorded over the period of follow-up, ranging between one and ten years. A further break down showed a statistically significant difference between the various types of aortic coarctation, p=0.0001. Patients with simple or isolated coarctation had a survival rate of 100%, those with ventricular septal defect (VSD) in addition to coarctation had a survival rate of 80% while patients with associated complex cardiac anomalies had a survival rate of 65%. An improvement on overall patient survival was recorded in the period between 1997 and 2001--96% as against 86% for the period between 1992 and 1996. On univariate statistical analysis, the following variables were identified as significant risk factors for death: 1) Complex cardiac anomalies (p<0.0001), 2) Age at operation less than one month (p<0.0001) and 3) Treatment prior to the year 1997 (p=0.02). CONCLUSION: A considerable improvement on patient survival following surgery for coarctation of the aorta was recorded over the last five years. This could be attributed to new measures in preoperative, operative and postoperative care for patients with aortic coarctation. (Tab. 4, Fig. 5, Ref. 8.).

Results of modified Norwood's operation for hypoplastic left heart syndrome.

OBJECTIVE: The aim of the study was to analyze intermediate results of treatment of the hypoplastic left heart syndrome based on selective indication criteria. METHODS: Between February 1997 and May 1999 38 patients with hypoplastic left heart syndrome (n=35), or with functional variant of hypoplastic left heart syndrome (n=3) were admitted to our department. Contraindications for surgery were birth weight <2500 g, diameter of ascending aorta <2 mm, severe tricuspid regurgitation persisting after initial stabilization, pulmonary regurgitation more than mild, dysfunction of the systemic right ventricle and failure to effectively resuscitate circulation before surgery. RESULTS: Based on these criteria surgery was not indicated in 17 patients. Twenty-one infants were operated on by modified Norwood's procedure using only autologous great vessel tissue for reconstruction of systemic outflow. Overall hospital mortality was 14% (three patients). Eighteen survivors (86%) were discharged with well-balanced circulation. There was one late death (5%). Thirteen patients had already undergone the second stage (bi-directional Glenn) with no death. The mean follow-up was 13. 2+/-9.1 months (range 4-32 months). Considering both early and late events the probability of survival for the whole group (n=21) from the time of surgery was 86% at 1 month, 80% at 12 months, and it remained unchanged at 18 and 24 months of follow-up. CONCLUSIONS: Only a limited number of European countries offer surgical treatment of hypoplastic left heart syndrome. Promising intermediate results (80% survival rate after stage I and II) achieved at our department do not only reflect overcoming the learning curve but also a selective approach to indication for surgery as well. In a country with limited resources selective approach to the patients with hypoplastic left heart syndrome is justified.

Surgical treatment of transposition of the great arteries.

BACKGROUND: With regard to risk of the failure of systemic right ventricle after physiological correction of transposition of great arteries, anatomic repair is a current method of choice. OBJECTIVE OF STUDY: Analysis of results of surgical correction of transposition of great arteries performed between 1992 and October 1998. METHOD: A total of 111 patients were operated on for transposition of the great arteries. In the 1st group of patients (n = 21, mean age was 135 +/- 55 days), physiological correction according to Senning was performed. Patients of the 2nd group (n = 90, mean age was 15.4 +/- 21.6 days) underwent anatomic repair. RESULTS: Early mortality was 6% (7 patients). Mean follow-up is 2.95 years (1.9 SD) ranging from 0.2 years to 6.1 years. Actuarial 1-month survival in the whole cohort (n = 111) is 94%, and it remains unchanged at 1, 2, 3, 4, 5, and 6 years of follow-up. Patients, who underwent surgery after 1997, show significantly better survival compared to those operated before 1997 (p = 0.0997). Thus, a date of operation (before 1997) is the only significant risk factor for death. Survival in patients operated after 1997 (n = 40) is 98%. All patients belonging to the 2nd group are in functional group NYHA 1. CONCLUSION: Anatomic repair of transposition of the great arteries is a method of choice for treatment of this congenital heart defect. Left ventricle becomes systemic ventricle, which is essential in view of long-term performance. Psychomotor development of children, who underwent ASO, is comparable with that of healthy population. (Tab. 3, Fig. 3, Ref. 18.)

[Surgical treatment of total anomalous pulmonary venous return]. / Chirurgická liecba totálneho anomálneho pl'úcneho venózneho návratu.

BACKGROUND: Total abnormal pulmonary venous return (TAPVR), mainly the obstructive type represents the most riskful critical congenital heart defect requiring urgent surgery immediately after birth. THE AIM OF THE STUDY: Analysis of surgical correction of TAPVR results performed from December 1992 to December 1998. METHODS: Twenty-seven patients underwent surgery for TAPVR. 13 of them (48%) presented with hemodynamically severe obstruction. Mean age in the group with obstruction was 3.6 +/- 3.2 days with mean weight of 3282 +/- 537 grams. RESULTS: From the 27 studied patients 5 (18.5%) died. Mean duration of the study in the whole group is 1.91 +/- 2.01 years. Actuarial survival in the first month is 85%, in the second month 81% and remains identical in the 1., 2., 3., 4., 5., 6. year of the study. Univariate analysis identified operation before the year 1996 (p = 0.0056) as a risk factor of immediate mortality. Introduction of ultrafiltration significantly eliminated mortality (p = 0.0101). Remaining variables (age, weight, sex, obstructive TAPVR, TAPVR, extracorporeal circulation duration, pulmonary hypertension) did not significantly influence the survival (p more than 0.05). Multivariate analysis defined operation before the year 1996 as the sole risk factor of mortality (p = 0.0033). In patients operated on in the year 1996 (n = 15) was the survival in the studied period 100%. CONCLUSION: Since the year 1996 the results of surgical treatment of TAPVR significantly improved. The key role in the improvement have better urgent diagnostic and surgery, improvement of surgical technique and myocardial protection, introduction of modified ultrafiltration and the quality of postoperative care. Psychomotor development of children after correction is comparable with healthy population, all patients are in NYHA I class. (Tab. 2, Fig. 4, Ref. 9.)

Ambient ozone (O3) and adverse crop response: a unified view of cause and effect.

This paper presents a cohesive view of the dynamics of ambient O(3) exposure and adverse crop response relationships, coupling the properties of photochemical O(3) production, flux of O(3) from the atmosphere into crop canopies and the crop response per se. The results from two independent approaches ((a) statistical and (b) micrometeorological) were analyzed for understanding cause-effect relationships of the foliar injury responses of tobacco cv Bel-W3 to the exposure dynamics of ambient O(3) concentrations. Similarly, other results from two independent approaches were analyzed in: (1) establishing a micrometeorological relationship between hourly ambient O(3) concentrations and their vertical flux from the air into a natural grassland canopy; and (2) establishing a statistical relationship between hourly ambient O(3) concentrations in long-term, chronic exposures and crop yield reductions. Independent of the approach used, atmospheric conditions appeared to be most conducive and the crop response appeared to be best explained statistically by the cumulative frequency of hourly ambient O(3) concentrations between 50 ppb and 90 ppb (100 and 180 microg m(-3)). In general, this concentration range represents intermediate or moderately enhanced hourly O(3) values in a polluted environment. Further, the diurnal occurrence of this concentration range (often approximately between 0900 and 1600 h in a polluted, agricultural environment) coincided with the optimal CO(2) flux from the atmosphere into the crop canopy, thus high uptake. The frequency of occurrence of hourly O(3) concentrations > 90 ppb (180 microg m(-3)) appeared to be of little importance and such concentrations in general appeared to occur during atmospheric conditions which did not facilitate optimal vertical flux into the crop canopy, thus low uptake. Alternatively, when > 90 ppb (180 microg m(-3)) O(3) concentrations occurred during the 0900-1600 h window, their frequency of occurrence was low in comparison to the 50-90 ppb (100-180 microg m(-3)) range. Based on the overall results, we conclude that if the cumulative frequency of hourly ambient O(3) concentrations between 50-62 ppb (100-124 microg m(-3)) occurred during 53% of the growing season and the corresponding cumulative frequency of hourly O(3) concentrations between 50-74 ppb (100-148 microg m(-3)) occurred during 71% of the growing season, then yield reductions in sensitive crops could be expected, if other factors supporting growth, such as adequate soil moisture are not limiting.

Use of tobacco cultivars as biological indicators of ambient ozone pollution: an analysis of exposure-response relationships.

A summary is presented of the numerical analysis of the results from a study of exposure in an open-top chamber conducted at two locations in the north-east USA, utilizing tobacco (Nicotiana tabacum L.) cv. Bel-W3 (sensitive) and cv. Bel-B (tolerant) as differential indicators of ambient O(3) pollution. At both study sites, Bel-W3 was significantly more sensitive than Bel-B. There were differences in the weekly O(3) exposure dynamics and the consequent foliar injury scores on Bel-W3 between the two study sites. During the individual weekly exposures, the bottommost fully expanded leaf (leaf no. 1) on Bel-W3 was more sensitive than the second fully expanded leaf (leaf no. 2). There were no statistically significant differences in the injury scores on Bel-W3 leaf no. 1 between the non-filtered air open-top chamber and the chamberless, ambient field plot treatments at both study sites. In Mallow's critical-point best regression, among the many O(3) descriptors tested, number of hours during each week with O(3) concentrations > 40 ppb (N40) and > 60 ppb (N60) or the corresponding sums of their concentrations (SUM40 and SUM60) proved to be the best predictors of foliar injury on Bel-W3, leaf no. 1. The regression used N40 and N60 or SUM40 and SUM60 together and did not identify each variable alone or by itself as being important. Independent of this, all the R(2) values could account for only about 30-32% of the variability of the foliar injury responses, although these values were statistically significant. Covariance time-series analysis between weekly O(3) concentrations > 40 ppb and the corresponding foliar injury scores on Bel-W3 leaf no. 1 showed that foliar injury was in best spectral coherence with the O(3) exposure (> 40 ppb) during periods of moderate periodicity (variance). The overall results suggest that the visible foliar responses of tobacco Bel-W3 can be used as a qualitative, but not necessarily as a quantitative indicator of relative ambient O(3) pollution on a generalized temporal or spatial scale.

Trace elements in kidney stones from three areas in the United States.

A large number of trace elements has been found in calcium stones (whewellite, weddellite, and apatite) and in struvite. Significantly fewer elements, with lower abundances, are found in uric acid and cystine. With the exception of four trace elements (lead, silicon, strontium, and zine), the trace element assemblages are identical in the oxalates (whewellite and weddellite); struvite is also similar but with notable exceptions. In general, apatite contains approximately twice the level of trace element abundances as do the oxalates. This study is based on the distribution of 20 elements in 186 mimeralogically identified urinary calculi from three generalized areas of the United States (northeast, southeast, and midwest). In general, there is no statistical difference in the trace element assemblages of mineralogically identical stones from the three areas.