Vascular proteomics in metabolic and cardiovascular diseases.

The vasculature is essential for proper organ function. Many pathologies are directly and indirectly related to vascular dysfunction, which causes significant morbidity and mortality. A common pathophysiological feature of diseased vessels is extracellular matrix (ECM) remodelling. Analysing the protein composition of the ECM by conventional antibody-based techniques is challenging; alternative splicing or post-translational modifications, such as glycosylation, can mask epitopes required for antibody recognition. By contrast, proteomic analysis by mass spectrometry enables the study of proteins without the constraints of antibodies. Recent advances in proteomic techniques make it feasible to characterize the composition of the vascular ECM and its remodelling in disease. These developments may lead to the discovery of novel prognostic and diagnostic markers. Thus, proteomics holds potential for identifying ECM signatures to monitor vascular disease processes. Furthermore, a better understanding of the ECM remodelling processes in the vasculature might make ECM-associated proteins more attractive targets for drug discovery efforts. In this review, we will summarize the role of the ECM in the vasculature. Then, we will describe the challenges associated with studying the intricate network of ECM proteins and the current proteomic strategies to analyse the vascular ECM in metabolic and cardiovascular diseases.

Patients' expectation of postoperative course and satisfaction following cardiac surgery.

INTRODUCTION: In patients undergoing cardiac surgery, preoperative concerns, expectations of the impact of surgery, anticipated recovery timelines, and pre- and postoperative education, which impact recovery and quality-of-life, are not well documented. These factors are important with the increase in virtual consultations, the availability of internet-based information and increased use of minimally invasive surgical procedures. METHODS: Patients who underwent cardiac surgery between January 2016 and December 2019 took part in an online survey examining preoperative concerns, information provision, use of digital channels, satisfaction with surgery, impact on health and resumption of daily activity. 80 patients completed the survey. RESULTS: There was a high rate of overall post-surgical satisfaction (86%); 71% of respondents reported an improvement in physical health, 45% in mental health and 70% in their quality-of-life. The usefulness of information provided by the National Health Service varies across different stages of the patient experience. Although approximately 90% of respondents found the information provided at each stage at least 'somewhat' helpful, the proportion who found the information 'very' helpful was lower (68% for pre-procedure; 55% for post-discharge). The majority (79%) said that they felt prepared for their operation. Survey responses highlighted areas of lower understanding, including survival rate, levels of postoperative pain, duration of hospital stay and when the patient could return to normal physical activity. CONCLUSIONS: Levels of satisfaction with the outcomes of heart surgery are high, and the majority of patients report positive health outcomes. However, there is room for improvement in patients' understanding of survival rate and level of pain post-procedure. There is also a clear desire among patients for a more surgical team-based face-to-face consultation.

Progress in endovascular management of type A dissection.

Proximal acute aortic dissection [type A] remains a disease with a poor prognosis. High peri-operative open surgical mortality [up to 30%] and a significant turn-down rate [up to 40%] substantiate the bleak prospects for patients with this disease. Thoracic endovascular stent grafting has revolutionized the treatment of distal [type B] acute aortic dissection. Endovascular surgeons are now looking to improve the treatment of type A dissection by offering endovascular techniques to supplement conventional surgical therapy. Less invasive endovascular therapy, obviates the need for sternotomy and cardiopulmonary bypass, may reduce perioperative morbidity and offers a solution for those patients declined conventional intervention due to co-morbidity or severe complications of the disease. Thoracic stent grafting in the ascending aorta presents specific challenges due to proximity to the aortic valve, navigation over the steep aortic arch and pulsatile aortic movement. Endovascular surgeons have treated type A dissection off-license using aortic cuffs and stents designed for infra-renal aortic surgery. Now grafts specifically designed for treating type A dissection are being developed and deployed under trial [compassionate license] in patients deemed unfit for open surgery. This paper explores how endovascular solutions may fit into the future care of patients with acute type A dissection.

Nurses' uncertainty about medical gloves safety during the COVID-19 pandemic.

BACKGROUND: Nurses, as the largest group of health professionals, are at the frontline of the healthcare system in response to COVID-19 epidemic. This study aimed to evaluate the nurses' certainty and satisfaction with medical gloves when exposed to coronavirus in Fars province, south of Iran. METHODS: Using convenience sampling, 400 hospital nurses during the COVID-19 outbreak were selected from eight hospitals of Shiraz University of Medical Sciences (SUMS). A questionnaire about glove reliability, including protection in tasks, durability, integrity and tear resistance, feeling fearful, and focusing on duties, and the nurses' anxiety regarding their infection with coronavirus was distributed to the selected nurses to complete. 375 questionnaires were completed (response rate of 93.75%). Among the participants, 180 (48%) were in the corona section and 195 (52%) were hardly possible to have contact with coronavirus pneumonia patients. RESULTS: The mean score (SD) of anxiety about infection with COVID-19 for nurses in the COVID-19 section and those in the non-COVID-19 section were 6.08 (2.8) and 4.56 (2.58), respectively (p<0.05). The mean duration of gloves usage in a day was almost similar in the two groups (about 5h), but the number of glove replacements was significantly higher among the nurses in the corona section (6 times) compared to those in the non-corona section (3 times). The two groups were also significantly different regarding glove protection in daily tasks and glove durability. CONCLUSION: The nurses in the corona section had more concerns about medical gloves as a type of personal protective equipment. In addition to health education on controlling and preventing the spread of diseases, raising awareness about the reliability of personal protective equipment can improve nurses' performance.

Variation between hospitals in outcomes following cardiac surgery in the UK.

INTRODUCTION: We examine the influence of variations in provision of cardiac surgery in the UK at hospital level on patient outcomes and also to assess whether there is an inequality of access and delivery of healthcare. Cardiothoracic surgery has pioneered the reporting of surgeon-specific outcomes, which other specialties have followed. We set out to identify factors other than the individual surgeon, which can affect outcomes and enable other surgical specialties to adopt a similar model. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data of patient and hospital level factors between 2013 and 2016 from 16 cardiac surgical units in the UK were analysed through the Society for Cardiothoracic Surgery of Great Britain and Ireland and the Royal College of Surgeons Research Collaborative. Patient demographic data, risks factors, postoperative complications and in-hospital mortality, as well as hospital-level factors such as number of beds and operating theatres, were collected. Correlation between outcome measures was assessed using Pearson's correlation coefficient. Associations between hospital-level factors and outcomes were assessed using univariable and multivariable regression models. RESULTS: Of 50,871 patients (60.5% of UK caseload), 25% were older than 75 years and 29% were female. There was considerable variation between units in patient comorbidities, bed distribution and staffing. All hospitals had dedicated cardiothoracic intensive care beds and consultants. Median survival was 97.9% (range 96.3-98.6%). Postoperative complications included re-sternotomy for bleeding (median 4.8%; range 3.5-6.9%) and mediastinitis (0.4%; 0.1-1.0%), transient ischaemic attack/cerebrovascular accident (1.7%; range 0.3-3.0%), haemofiltration (3.7%; range 0.8-6.8%), intra-aortic balloon pump use (3.3%; range 0.4-7.4%), tracheostomy (1.6%; range 1.3-2.6%) and laparotomy (0.3%; range 0.2-0.6%). There was variation in outcomes between hospitals. Univariable analysis showed a small number of positive associations between hospital-level factors and outcomes but none remained significant in multivariable models. CONCLUSIONS: Variations among hospital level factors exists in both delivery of, and outcomes, following cardiac surgery in the UK. However, there was no clear association between these factors and patient outcomes. This negative finding could be explained by differences in outcome definition, differences in risk factors between centres that are not captured by standard risk stratification scores or individual surgeon/team performance.

Decompressive hemicraniectomy without clot evacuation in supratentorial deep-seated intracerebral hemorrhage.

OBJECTIVE: Decompressive craniectomy (DC) lowers intracranial pressure and improves outcomes in patients with malignant middle cerebral artery stroke; yet, its usefulness in intracerebral hemorrhage (ICH) is unclear. The authors sought to assess the preliminary utility of decompressive hemicraniectomy (DHC) without clot evacuation in patients with deep-seated supratentorial ICH. PATIENTS AND METHODS: Patients with deep seated spontaneous ICH who were admitted to the Golestan Hospital, of Ahvaz, from November 2014 to February 2016, were prospectively enrolled in this study. A prospective clinical trial where 30 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B using permuted-block randomization. These patients (n = 30), who all had large deep seated supratentorial ICH with surgery indications, were randomly divided to two groups. ultimately, in one group (n = 13), large DHC was performed without clot evacuation, while in the other (n = 17), craniotomy with clot evacuation was done. Data pertaining to the patients' characteristics and treatment outcomes were prospectively collected. RESULTS: There was no statistically significant difference between two treatment groups (P > 0.05). No significant difference was observed between the two groups in terms of mortality and GOS at 6 months (P > 0.05); nevertheless, the good outcome (Glasgow Outcome Scale = 4-5) for patients with hematoma evacuation was slightly higher (35.3%) as compared to the DHC patients without clot evacuation (30.7%). CONCLUSION: Decompresive craniectomy without clot evacuation in deep seated ICH can be accomplished with identical mortality and outcome in comparison to patient that undergone clot evacuation.

Autoimmune mechanisms of atherosclerosis.

Accumulating evidence supports an autoimmune mechanism as one of the prime pathogenic processes involved in the development of atherosclerosis. So far, three proteins, including heat shock proteins (HSPs), oxidized low-density lipoprotein (oxLDL), and beta2 glycoprotein1 (beta2GP1) have been recognized as autoantigens. It has been demonstrated that risk factors for atherosclerosis, such as hypercholesterolemia, hypertension, infections, and oxidative stress, evoke increased expression of HSPs in cells of atherosclerotic lesions. Autoantibody levels against HSPs are significantly increased in patients with atherosclerosis and T lymphocytes specifically responding to these autoantigens have been demonstrated within atherosclerotic plaques. Subcutaneous immunization of animals with HSP65 induced atheroma formation in the arterial wall. Furthermore, circulating immunoglobulin (Ig) G and IgM oxidized low-density lipoprotein (oxLDL) antibodies are present in the plasma of animals and humans and form immune complexes with oxLDL in atherosclerotic lesions. These antibodies closely correlate with the progression and regression of atherosclerosis in murine models. Interestingly, recent reports demonstrated that pneumococcal vaccination to LDL receptor-deficient mice results in elevation of anti-oxLDL IgM Ab EO6, which is inversely correlated with the development of atherosclerosis. Finally, it has been observed that autoantigen beta2GP1 localizes in the atheroma and that autoantibodies to beta2GP1 are correlated with the incidence of atherosclerosis in patients. Hence, these autoimmune reactions to HSPs, oxLDL and beta2GP1 can contribute to the initiation and progression of atherosclerosis.

Hydatid disease of the heart.

A 27-year-old physical education teacher, from a rural sheep farming area of South Africa, was referred following an isolated episode of collapse. Transthoracic echocardiography and MRI showed a cystic lesion under the septal leaflet of the tricuspid valve attached to the right ventricular wall. A provisional diagnosis of hydatid cyst was made. Hydatid serology was negative and there was no evidence of hydatidosis elsewhere. Preoperatively, the patient was treated with praziquantel and albendazole. Surgery was performed using cardiopulmonary bypass. Cyst was excised without any spillage. The patient was weaned off bypass without any support and made an uneventful recovery. Cytology and microbiology of the specimen confirmed hydatid pathology. This case describes excision of a right ventricular hydatid with techniques used to avoid spillage. It also describes an up-to-date antihelminthic therapy used in the management of hydatid cysts.

Respiratory disorders associated with occupational inhalational exposure to bioaerosols among wastewater treatment workers of petrochemical complexes.

BACKGROUND: Workers in wastewater treatment plants are exposed to a wide range of chemicals as well as biological contaminants. OBJECTIVE: To ascertain whether exposure to bio-aerosols under the normal working conditions in wastewater treatment plants is associated with any significant changes in the prevalence of respiratory symptoms and lung function capacities. METHODS: 198 employees of wastewater treatment plants and 99 unexposed persons were studied. American thoracic society (ATS) standard respiratory symptom questionnaire was used to determine the prevalence of respiratory symptoms. Pulmonary function tests were conducted for each participant. RESULTS: The prevalence of respiratory symptoms among exposed persons was significantly higher than that of unexposed people. Mean values of most pulmonary function test parameters were significantly lower in the exposed compared to the comparison group persons. CONCLUSION: Increased prevalence of respiratory symptoms and decrements in pulmonary function test parameters may be attributed to exposure to bio-aerosols released from wastewater treatment plants.

Endobronchial stenting for extrinsic compression caused by pulsatile pulmonary artery in a 4-week-old infant.

Respiratory compromise secondary to external vascular compression may complicate the course of infants and neonates undergoing repair of congeni tal heart disease. Management of such complications usually involves prolonged ventilatory support and even additional high-risk surgical procedures. In recent years, endobronchial placement of self-expanding stents became a realistic treatment option, although there is controversy as to which of the many stents available today give the best results. We report the first successful endobronchial placement of a self-expanding stent in a 4-week-old infant. This conservative treatment for extrinsic airway compression led to the rapid extubation and recovery of the patient.

Coagulation factor abnormalities after the Fontan procedure and its modifications.

OBJECTIVE: Recently we reported the prevalence of thromboembolism in patients who underwent the Fontan procedure and its modifications. Although hemodynamic factors may well contribute to thromboembolism, recent evidence suggests that coagulation factor abnormalities may also play a role. We therefore set out to investigate the coagulation status in a group of patients who had undergone the Fontan procedure. METHODS: The study population consists of 20 children who had undergone the Fontan procedure and its modifications. They were examined for coagulation factor abnormalities. Concentrations of serum albumin, total protein, and liver enzymes were also measured. The median age at the time of the operation was 6.2 years (17 months to 8 years) with a male/female ratio of 2.3:1. The median time from the Fontan repair was 4.9 years (18 to 76 months). RESULTS: Protein C (p < 0.001), protein S (p < 0.02), and factor VII (p < 0.001) were significantly lower than the normal range. The changes in serum albumin and total protein and factors II, IX, and X were not significant. CONCLUSIONS: It is possible that deficiency in protein C, protein S, and factor VII partly account for the prevalence of thromboembolism after Fontan-type repairs. The risk of long-term anticoagulation should be weighed against the best palliative procedure for these patients. We suggest that reduced protein C, protein S, and factor VII levels in this group of patients should be regarded as risk factors and that such patients should be treated with anticoagulants.

Evaluation of hemostatic and coagulation factor abnormalities in patients undergoing the Fontan operation.

OBJECTIVE: Low-velocity and nonlaminar flow patterns in the Fontan circulation, as well as abnormal liver function in some patients, may partly account for the coagulation abnormalities seen. We examined (1) coagulation factor abnormalities before and after the Fontan procedure and (2) regional coagulation factor abnormalities in the Fontan circulation. METHODS: Levels of factors V, VII, VIII, X, antithrombin III, prothrombin fragment F1+2, protein C, and protein S were measured in 2 groups of patients: In 14 patients undergoing the Fontan procedure, blood was analyzed before the operation and 5 days after the operation (group 1). The median age in this group was 3.2 years. In 10 patients who had undergone the Fontan procedure, cardiac catheterization was performed and samples were taken from the femoral vein, inferior vena cava, right atrium, and pulmonary artery (group 2). The median age in this group was 6.2 years and the median follow-up from the Fontan procedure was 4.1 years. RESULTS: In group 1 a significant increase was noted postoperatively in the concentration of factor VIII (P<.001), factor X (P<.001), and prothrombin fraction F1+2 (P <.001). A significant decrease in the levels of antithrombin III (P <.001), protein C (P<.004), and protein S (P<.02) was also found. The increase in factors VIII and X persisted at 4 years' follow-up in group 2 patients. In group 2, no significant regional differences were observed between the coagulation factors measured at different sites. CONCLUSIONS: There is an increased tendency toward coagulation after the Fontan procedure. A prothrombotic state is supported by thrombin generation associated with reduced antithrombin III concentration. This increase in coagulation may contribute to the early and late risks of thromboembolism observed after the Fontan procedure. We did not find any regional differences in coagulation abnormalities in patients late after the Fontan procedure. Therefore, the mechanisms and causes of the coagulation abnormalities remain unclear.

Repair of the truncal valve and associated interrupted arch in neonates with truncus arteriosus.

OBJECTIVE: Truncal valve regurgitation and interrupted aortic arch have frequently been identified as risk factors in the repair of truncus arteriosus. We wished to examine these factors in the current era including the impact of truncal valve repair. METHODS: Between January 1992 and August 1998, 50 patients underwent surgical repair of truncus arteriosus. Their ages ranged from 2 days to 6 months (median, 2 weeks). Nine patients had associated interrupted aortic arch. Of the 14 patients (28%) in whom truncal valve regurgitation was diagnosed preoperatively, 5 had mild regurgitation, 5 had moderate regurgitation, and 4 had severe regurgitation. Five underwent truncal valve repair and 1 underwent homograft replacement of the truncal valve with coronary reimplantation. RESULTS: The actuarial survival was 96% at 30 days, 1 year, and 3 years. There were no deaths in patients with associated interrupted aortic arch. The 2 deaths in the series occurred in patients with truncal valve regurgitation, neither of whom underwent repair. Postoperative transthoracic echocardiography in patients who underwent valve repair showed minimal residual valvular regurgitation. None of the patients has required reoperation because of truncal valve problems or aortic arch stenosis at a median follow-up of 23 months (range, 1-60 months). Conduit replacement has been done in 17 patients (34%) after a mean duration of 2 years. The freedom from reoperation for those who had an aortic homograft was 4 years and for those who had a pulmonary homograft was 3 years. CONCLUSION: Despite the magnitude of the operation, excellent results can be achieved in complex forms of truncus arteriosus. In the current era interrupted aortic arch is no longer a risk factor for repair of truncus. Aggressive application of truncal valvuloplasty methods should neutralize the traditional risk factor of truncal valve regurgitation.

Improved results with selective management in pulmonary atresia with intact ventricular septum.

OBJECTIVE: Late outcome of neonatal pulmonary atresia with intact ventricular septum remains poor in most reported series. We have followed a selective approach toward either single ventricle repair versus complete or partial biventricular repair based on the presence of right ventricle-dependent coronary circulation and growth of the right ventricle. METHODS: A retrospective chart review was conducted of 47 patients who underwent surgery between January 1991 and September 1998. RESULTS: Sixteen (34%) patients had a right ventricle-dependent coronary circulation, with a tricuspid valve Z-score of -3.0 +/- 0.66 versus -2.0 +/- 0.95 (P =.002) for those without a right ventricle-dependent coronary circulation. A systemic-pulmonary artery shunt only was performed in all patients with a right ventricle-dependent coronary circulation, with 1 death. Fourteen of 16 patients with a right ventricle-dependent coronary circulation underwent a bidirectional Glenn shunt at a median of 9 months after their first operation, 9 of whom have had a Fontan procedure (no deaths). In the 31 (66%) patients without a right ventricle-dependent coronary circulation, 6 patients underwent only a systemic-pulmonary artery shunt, 23 had a shunt and right ventricular decompression, and 2 had only a transannular patch. In this group, 10 patients received a 2-ventricle repair, 6 a 1. 5-ventricle repair, and 8 patients had a Fontan procedure. There was 1 early death and the overall survival was 98% at 1 year, 5 years, and 7 years. CONCLUSIONS: If patients are stratified well, excellent survival can be achieved in the treatment of pulmonary atresia with intact ventricular septum. This result may be at the price of achieving a 1-ventricle as opposed to a 2-ventricle repair.

Subclavian flap angioplasty: does the arch look after itself?

OBJECTIVES: We sought to assess the early and long-term results of subclavian flap angioplasty in neonates and infants, with particular attention to growth of the hypoplastic arch. METHODS: A retrospective analysis of 185 consecutive patients who underwent subclavian flap angioplasty between 1974 and 1998 was carried out. The patients included 125 neonates and 60 infants, with a median age of 18 days. Sixty-six (36%) patients had an additional ventricular septal defect, 41 (22%) patients had aortic arch hypoplasia diagnosed preoperatively, 141 (76%) had an associated patent ductus arteriosus, and 41 (22%) had additional complex heart disease. Follow-up was with transthoracic Doppler echocardiography in all patients. RESULTS: The early mortality was 3%. Recoarctation, defined as a Doppler gradient of 25 mm Hg or more, occurred in 11 (6%) patients at a median follow-up of 6.2 years (6.2 +/- 4.6 years). This included 4 of the 41 patients in whom arch hypoplasia was diagnosed preoperatively. There were no complications with the left arm. By multivariate analysis, risk factors for death were determined to be residual arch hypoplasia and low birth weight. The only risk factor for recoarctation was persistent arch hypoplasia after surgical treatment. However, angiographic imaging of the aorta showed that recoarctation was not due to a hypoplastic transverse arch, and it was probably at the site of ductal tissue. Survival at 5 and 10 years was 98% and 96%, respectively. Freedom from reoperation for recoarctation at 2 years was 95%, and at 5, 10, and 15 years, it was 92%. CONCLUSIONS: Subclavian flap repair remains an effective technique for repair of aortic coarctation with excellent results and low mortality. In the majority of patients, arch hypoplasia regresses after this procedure.

A case for anatomic correction in atrioventricular discordance? Effects of surgery on tricuspid valve function.

OBJECTIVE: To assess tricuspid valve function in atrioventricular discordance after palliative procedures (pulmonary artery banding and Blalock-Taussig shunt) and corrective procedures (anatomic and physiologic repair). METHODS: Tricuspid valve dysfunction was assessed by transthoracic echocardiography and graded as no regurgitation (0), mild (1), moderate (2), and severe (3) before and after palliative and corrective procedures performed in 97 patients with atrioventricular discordance between 1988 and 1999. Thirty-two percent had an isolated ventricular septal defect, 43% had a ventricular septal defect and pulmonary stenosis, and 16% had pulmonary stenosis. Twenty-six patients underwent pulmonary artery banding and 28 had a Blalock-Taussig shunt. Seventy patients underwent physiologic and 19 underwent anatomic repair. Six patients underwent one-ventricle repair. RESULTS: After pulmonary artery banding, the tricuspid regurgitation score decreased from 1.7 +/- 0.8 to 0.9 +/- 0.6 (P <.001). In patients who underwent a Blalock-Taussig shunt, the tricuspid regurgitation score increased from 0.7 +/- 0.5 preoperatively to 1.4 +/- 0.6 postoperatively (P <.001). After physiologic repair, there was no significant change in the tricuspid regurgitation score; however, 7 patients required additional repair or replacement. The regurgitation score was significantly reduced from 1.5 +/- 0.8 to 0.4 +/- 0.5 (P <.001) after anatomic repair. The operative mortality in patients who underwent physiologic repair was 7% as compared with 0% in the anatomic repair group (P =.59). The median follow-up was 3.2 years. CONCLUSIONS: Right ventricular volume loading (shunt) worsens tricuspid regurgitation, whereas volume reduction (banding) or left-to-right septal shift (anatomic repair) has beneficial effects. We have not observed a significant change in the tricuspid regurgitation score after physiologic repair. Anatomic repair can be performed in selected patients with atrioventricular discordance and provides superior functional results.

The role of mediastinoscopy in superior vena caval obstruction.

The role of mediastinoscopy in superior vena caval obstruction is not defined. To examine the safety and efficacy of mediastinoscopy, we reviewed 34 patients with superior vena caval obstruction who required mediastinoscopy to establish a histologic diagnosis after less invasive techniques had failed. They were referred to one surgical team between 1982 and 1993. Of the 34 patients, 26 had lung cancer, 6 had lymphoma, 1 had malignant thymoma, and 1 had fibrosing mediastinitis. Definitive tissue diagnosis was obtained in all patients. There was one complication of mediastinoscopy where arterial bleeding from the innominate artery occurred and limited sternotomy was required to control the bleeding. We conclude that mediastinoscopy is a safe and effective technique for establishing histologic diagnosis in superior vena caval obstruction when less invasive techniques have been unsuccessful. The use of blind radiotherapy means that patients with lymphoma and small cell carcinoma will not receive optimum therapy with chemotherapy and patients with benign lesions will receive inappropriate therapy.

Cerebrovascular accident after vacuum-assisted venous drainage in a Fontan patient: a cautionary tale.

Vacuum-assisted venous drainage was used in a 24-year-old woman who underwent a redo Fontan procedure. She developed a hemiparesis, which is thought to be caused by cerebral air embolism.

Does the modified Blalock-Taussig shunt cause growth of the contralateral pulmonary artery?

BACKGROUND: Although some pediatric cardiology departments have a policy of adopting primary correction of tetralogy of Fallot in all symptomatic infants, we and others still palliate neonates and infants. Effective palliation should ameliorate symptoms and allow growth of the pulmonary arteries. Although studies on the growth of the ipsilateral and contralateral pulmonary arteries after a classic Blalock-Taussig shunt have been reported, pulmonary artery growth after a modified Blalock-Taussig shunt has not been studied as thoroughly. Therefore, we examined whether there is equal growth of the contralateral pulmonary artery after a modified Blalock-Taussig shunt. METHODS: We retrospectively analyzed the records of 140 patients with symptomatic tetralogy of Fallot who had a modified Blalock-Taussig shunt between October 1985 and October 1995. The median age at the time of the Blalock-Taussig shunt was 1.6 months. All patients had corrective procedures at a median age of 1.7 years. Cineangiography was done before the corrective procedure. From the angiograms the diameter of the right and left pulmonary arteries before their first lobar branches and the diameter of the descending thoracic aorta at the level of the diaphragm were measured. For each patient the ratios of right pulmonary artery to descending thoracic aorta and left pulmonary artery to descending thoracic aorta were determined and compared using Student's t test. RESULTS: Of the 140 patients, 114 had a left-sided Blalock-Taussig shunt, 20 had a right-sided shunt, and 6 patients had bilateral shunts. The mean right pulmonary artery to descending thoracic aorta ratio was 1.10 and the mean left pulmonary artery to descending thoracic aorta ratio was 0.98. This difference was not significant. CONCLUSION: We showed equal growth of the right and left pulmonary arteries with no distortion after a modified Blalock-Taussig shunt. If palliation is considered, the modified Blalock-Taussig shunt remains our choice.

Anatomic correction for post-mustard pulmonary venous obstruction.

Pulmonary artery banding and arterial switch operation as a two-stage approach have offered a surgical solution to the failing right ventricle after intraatrial repair of the transposition of the great arteries. Banding of the pulmonary artery increases the resistance to the left ventricular output and, therefore, "prepares" the left ventricle for supporting the systemic circulation and arterial switch operation. We report a case of anatomic correction for transposition of the great arteries after intraatrial repair (Mustard's operation) in which the left ventricle was retrained serendipitously as a consequence of pulmonary venous obstruction complicating Mustard's procedure.