ABH-Glycan Microarray Characterizes ABO Subtype Antibodies: Fine Specificity of Immune Tolerance After ABO-Incompatible Transplantation.

Organ transplantation from ABO blood group-incompatible (ABOi) donors requires accurate detection, effective removal and subsequent surveillance of antidonor antibodies. Because ABH antigen subtypes are expressed differently in various cells and organs, measurement of antibodies specific for the antigen subtypes in the graft is essential. Erythrocyte agglutination, the century-old assay used clinically, does not discriminate subtype-specific ABO antibodies and provides limited information on antibody isotypes. We designed and created an ABO-glycan microarray and demonstrated the precise assessment of both the presence and, importantly, the absence of donor-specific antibodies in an international study of pediatric heart transplant patients. Specific IgM, IgG, and IgA isotype antibodies to nonself ABH subtypes were detected in control participants and recipients of ABO-compatible transplants. Conversely, in children who received ABOi transplants, antibodies specific for A subtype II and/or B subtype II antigens-the only ABH antigen subtypes expressed in heart tissue-were absent, demonstrating the fine specificity of B cell tolerance to donor/graft blood group antigens. In contrast to the hemagglutination assay, the ABO-glycan microarray allows detailed characterization of donor-specific antibodies necessary for effective transplant management, representing a major step forward in precise ABO antibody detection.

The changing profile of the patient undergoing coronary artery bypass surgery.

The first 100 consecutive patients undergoing isolated coronary artery bypass surgery in 1975 were evaluated with respect to the incidence of operative risk factors and outcome. When compared with an identically selected group from 1985, there was significant worsening of the preoperative condition over the decade with regard to mean age (p less than 0.0005), presence of congestive heart failure (p less than 0.05), left ventricular dysfunction (p less than 0.05), severity of coronary artery disease (p less than 0.001) and incidence of emergency operation (p less than 0.05). More patients in 1985 had associated medical diseases such as diabetes (p less than 0.01) and chronic lung disease (p less than 0.005). There was an increase in the occurrence of vascular diseases (hypertension, renal dysfunction, peripheral vascular and cerebrovascular disease) (p less than 0.05). Overall operative mortality increased from 1 to 8% (p less than 0.05) over the decade. Despite the deterioration in the clinical profile of the patient undergoing coronary bypass surgery, elective procedures were still performed with low mortality. The significant increase in overall mortality was chiefly in patients undergoing emergency operation (p less than 0.05). There were also increases in operative morbidity including low output syndrome (p less than 0.01) and respiratory (p less than 0.005) and neurologic (p = 0.06) complications.

Flow cytometric detection of HLA-specific antibodies as a predictor of heart allograft rejection.

BACKGROUND: Historically, panel reactive antibody (PRA) analysis to detect HLA antibodies has been performed using cell-based complement-dependent cytotoxicity (CDC) techniques. Recently, a flow cytometric procedure (FlowPRA) was introduced as an alternative approach to detect HLA antibodies. The flow methodology, using a solid phase matrix to which soluble HLA class I or class II antigens are attached is significantly more sensitive than CDC assays. However, the clinical relevance of antibodies detected exclusively by FlowPRAhas not been established. In this study of cardiac allograft recipients, FlowPRA was performed on pretransplant sera with no detectable PRA activity as assessed by CDC assays. FlowPRA antibody activity was then correlated with clinical outcome. METHODS: PRA analysis by anti-human globulin enhanced (AHG) CDC and FlowPRA was performed on sera corresponding to final cross-match specimens from 219 cardiac allograft recipients. In addition, sera collected 3-6 months posttransplant from 91 patients were evaluated. The presence or absence of antibodies was correlated with episodes of rejection and patient survival. A rejection episode was considered to have occurred based on treatment with antirejection medication and/or histology. RESULTS: By CDC, 12 patients (5.5%) had pretransplant PRA >10%. In contrast, 72 patients (32.9%) had pretransplant anti-HLA antibodies detectable by FlowPRA (34 patients with only class I antibodies; 7 patients with only class II antibodies; 31 patients with both class I and class II antibodies). A highly significant association (P<0.001) was observed between pretransplant HLA antibodies detected by FlowPRA and episodes of rejection that occurred during the first posttransplant year. Fifteen patients died within the first year posttransplant. Of nine retrospective flow cytometric cross-matches that were performed, two were in recipients who had no pretransplant antibodies detectable by FlowPRA. Both of these cross-matches were negative. In contrast, five of seven cross-matches were positive among recipients who had FlowPRA detectable pretransplant antibodies. Posttransplant serum specimens from 91 patients were also assessed for antibodies by FlowPRA. Among this group, 58 patients had FlowPRA antibodies and there was a trend (although not statistically significant) for a biopsy documented episode of rejection to have occurred among patients with these antibodies. CONCLUSIONS: Collectively, our data suggest that pre- and posttransplant HLA antibodies detectable by FlowPRA and not AHG-CDC identify cardiac allograft recipients at risk for rejection. Furthermore, a positive donor reactive flow cytometric cross-match is significantly associated with graft loss. Thus, we believe that detection and identification of HLA-specific antibodies can be used to stratify patients into high and low risk categories. An important observation of this study is that in the majority of donor:recipient pairs, pretransplant HLA antibodies were not directed against donor antigens. We speculate that these non-donor-directed antibodies are surrogate markers that correspond to previous T cell activation. Thus, the rejection episodes that occur in these patients are in response to donor-derived MHC peptides that share cryptic determinants with the HLA antigens that initially sensitized the patient.

Coronary artery bypass surgery in patients aged 80 years or older.

Between August 1980 and January 1986, 23 patients aged 80 years or older underwent coronary artery bypass grafting (CABG) operations. These patients had a higher incidence of severe left main coronary artery narrowing (p less than 0.0001), 3-vessel coronary artery disease (p less than 0.05) and moderate to severe left ventricular dysfunction (p less than 0.05) than patients in the Coronary Artery Surgery Study registry older than 65 years. Of 14 patients undergoing elective simple CABG procedures, none died; of 19 elective cases overall, 2 patients died (11%). Three of 4 patients undergoing emergency procedures (75%) and 4 of 6 patients (67%) requiring intraaortic balloon counterpulsation died. Significant complications occurred in 9 of 18 survivors (50%). All operative survivors improved at least 1 New York Heart Association class, with a mean classification improvement of 3.7 to 1.6 (p less than 0.0001); 13 of 16 long-term survivors were in class I or II. Actuarial survival at 1 and 2 years is 94% and 82%, respectively. CABG can be performed electively in octogenarian patients with increased but acceptable mortality and morbidity risks. Functional improvement and long-term survival are excellent.

Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children.

OBJECTIVE: Recurrent aortic narrowing after repair of aortic coarctation or interrupted aortic arch, as well as diffuse, long-segment aortic hypoplasia, can be difficult to manage. Extra-anatomic ascending aorta-descending aorta bypass grafting through a sternotomy is an alternative approach for this problem. METHODS: Since 1985, 19 patients aged 2 months to 18 years (mean 10.7 years) underwent extra-anatomic bypass with 10- to 30-mm Dacron grafts. The initial diagnosis was coarctation with hypoplastic arch in 15, interrupted aortic arch in 3, and diffuse long-segment aortic hypoplasia in 1. Seventeen of the children had a total of 22 previous operations: transthoracic interposition or bypass graft (n = 7), end-to-end anastomosis (n = 7), subclavian arterioplasty (n = 6), and synthetic patch (n = 2). The mean time from initial repair was 8.0 years (range 0.6-18 years). Three children had previous sternotomies. Cardiopulmonary bypass was avoided in all but 6 patients (5 with simultaneous intracardiac repairs). RESULTS: No hospital or late deaths occurred. On follow-up from 4 months to 14.7 years (mean 7.9 years), no reoperations for recurrent stenosis were performed. Two patients have arm-to-leg pressure gradients: 20 mm Hg at rest in 1 patient and a 60-mm Hg systolic exercise gradient with no resting gradient in the other. One patient required exclusion of an aortic aneurysm at the old coarctation repair site 13 years after extra-anatomic bypass. Three children had subsequent successful cardiac operations. CONCLUSIONS: Extra-anatomic bypass is an effective and relatively easy approach for selected cases of complex or reoperative aortic arch obstruction. It should be considered as an alternative operative technique for complex aortic arch reconstruction.

Anatomic correction for complete transposition and double-outlet right ventricle.

Between February, 1981, and December, 1984, 30 patients underwent anatomic correction of transposition of the great arteries with intact ventricular septum (n = 8), transposition with ventricular septal defect (n = 15), and double-outlet right ventricle with subpulmonary ventricular septal defect, the Taussig-Bing anomaly (n = 7). At operation, ages ranged from 18 hours to 6 years (mean 11.3 months) and weights ranged from 2.6 to 16.4 kg (mean 6.1 kg). The group with transposition and intact ventricular septum on average was younger (mean 1.2 months) and smaller (mean 3.5 kg) than the other two groups. Associated congenital heart defects were seen in 12 patients, including five with coarctation, three with multiple ventricular septal defects, two with right ventricular hypoplasia, two with juxtaposed atrial appendages, and one each with interrupted aortic arch, Wolff-Parkinson-White syndrome, and left ventricular outflow tract obstruction. All 10 patients who had undergone prior palliative operations had pulmonary artery banding. In addition, four of these patients had coarctation repairs, four had atrial septectomy, and one had systemic/pulmonary shunting. All recognized patterns of coronary anatomy were encountered. The aorta and pulmonary artery were side by side in 14 patients and anteroposterior in 16 patients. The Lecompte maneuver to establish right ventricular-pulmonary arterial continuity was successfully used in 12 of 13 patients with anteroposterior great vessels but in none of those with side-by-side arteries. Seven patients had subvalvular right ventricular outflow tract obstruction, recognized either at operation (five) or postoperatively (two). This was responsible for death in three patients. The 30 day hospital mortalities were as follows: one death (12.5%) in the group with transposition and intact ventricular septum, six deaths (40%) in the group with transposition plus ventricular septal defect, and one death (14.3%) among patients with double-outlet right ventricle and subpulmonary ventricular septal defect; the overall mortality was eight deaths (26.7%). There have been no late deaths (mean follow-up 17.2 months). Ninety-five percent of the survivors are in New York Heart Association Functional Class I. Postoperative catheterization in 13 patients has shown normal left ventricular function, no coronary stenosis, and no aortic incompetence. Sixty-nine percent of these patients had clinically unsuspected gradients across the right ventricular outflow tract, which may be prevented by avoiding the Lecompte maneuver or the use of conduits.

Extracorporeal membrane oxygenation for postoperative cardiac support in children.

Prolonged circulatory support for cardiac failure has been increasingly successful in adults but has had very limited use in children. From January 1982 to December 1985, 13 children with postoperative cardiac failure refractory to conventional therapy were treated with extracorporeal membrane oxygenation. Ages ranged from 9 days to 17.6 years (mean = 3.8 years); weights ranged from 2.8 to 50 kg (mean = 13.8 kg). Seven patients had obstructive lesions of the right ventricle, such as pulmonary stenosis and tetralogy; the other patients had tricuspid atresia, truncus arteriosus, complete transposition, total anomalous pulmonary venous connection, pericardial tamponade, and a drug reaction after heart transplantation. One patient (nonsurvivor), who could not be separated from cardiopulmonary bypass, required extracorporeal membrane oxygenation in the operating room. In the remaining 12, the interval between operation and the start of extracorporeal membrane oxygenation ranged from 9 to 50 hours (mean = 22.2 hours). Four patients were cannulated through the groin and nine through the chest. Peak flows ranged from 1.05 to 2.74 L/min/m2 (mean 1.92 L/min/m2). Duration of oxygenator support ranged from 12 hours to 9 days (mean = 3.4 days). Seven patients required reexploration for bleeding. Renal insufficiency developed in five patients, four of whom underwent hemodialysis or ultrafiltration during extracorporeal membrane oxygenation. Two patients had evidence of clots in the oxygenator circuit. Seven patients were weaned from extracorporeal membrane oxygenation. Failure to wean from the oxygenator was related to neurologic sequelae of prolonged hypotension before institution of oxygenation in three patients. Mediastinitis developed in three of the seven patients who were weaned. One of these three died in the hospital 74 days after being weaned from the oxygenator. There has been one late death 6 months after oxygenator support was withdrawn. At most recent examination, five children were well, with normal cardiac function 7 months to 4.3 years postoperatively (mean = 32 months). This series suggests that profound cardiac insufficiency in children after cardiac operations can be successfully managed with extracorporeal membrane oxygenation with excellent functional recovery, although major complications are common in this critically ill group of patients.

Follow-up of survivors of mechanical circulatory support.

Improvements in mechanical support for profound circulatory collapse have resulted in increasing survival of these critically ill patients. Since 1980, 27 patients aged 3 days to 69 years (mean 34.9 years) who required mechanical circulatory assistance have been followed up after discharge from the hospital. The refractory cardiogenic shock necessitating mechanical support occurred postoperatively in 22 patients (coronary artery bypass in nine, valve replacement in four, correction of congenital heart defects in nine) and with end-stage cardiomyopathy in five. Fourteen patients were supported with a Pierce-Donachy ventricular assist device (left ventricular assist in seven, right ventricular assist in three, both in four); nine were supported with extracorporeal membrane oxygenation, two with a Medtronic centrifugal left ventricular assist pump, one with biventricular Biomedicus pumps, and one with a Novacor left ventricular assist system. The duration of support ranged from 8 hours to 91 days with a mean of 3.5 days in patients supported for postoperative shock. Major complications occurred in 18 patients (67%), including bleeding that necessitated operative exploration in 14, serious infection in five, renal failure in two, and stroke in two. The five patients with cardiomyopathy underwent cardiac transplantation. The remaining 22 patients who had postoperative cardiogenic shock were weaned from support. There have been four late deaths: two cardiac related at 6 months and two of cancer at 46 and 53 months (one patient was in New York Heart Association class I and the other in class II before death). The remaining 23 survivors have been followed up for 3 to 79 months (mean 29 months) and at last examination 17 (74%) were in class I, two (9%) were in class II, three (13%) were in class III, and one (4%) was in class IV. Eight patients are employed full time, three are retired, four attend school, three are in preschool, one is a housewife, and one is unemployed but free of symptoms. Only four patients have significant cardiac disability, and one of these still works. In conclusion, mechanical circulatory assistance allows adequate support to permit satisfactory long-term survival in patients with refractory cardiogenic shock.

Left subclavian-left coronary artery anastomosis for anomalous origin of the left coronary artery. Long-term follow-up.

From 1972 to 1987, seven patients, from two to 28 months of age, underwent left subclavian artery-left coronary artery anastomosis for anomalous origin of the left coronary artery from the pulmonary trunk. All of these infants, median age 4 months, had severe congestive heart failure caused by anterolateral myocardial infarctions. There were two hospital deaths (29% mortality rate) with no late deaths after an average 10-year follow-up. All survivors have good exercise tolerance New York Heart Association class I), reduction in heart size, and significant improvement or normalization of ventricular function by echocardiography. Patency of the subclavian-left coronary artery anastomosis has been documented in two of four patients who have undergone catheterization. In contrast to other revascularizing procedures for treatment of an anomalous origin of the left coronary artery, anastomosis of the left subclavian to the left coronary artery may be performed without cardiopulmonary bypass or aortic occlusion. Moreover, this procedure appears to have an acceptable mortality rate with excellent long-term functional results in critically ill infants.

Seven years' experience with the Pierce-Donachy ventricular assist device.

Of currently available methods for mechanical circulatory support, the Pierce-Donachy external pneumatic ventricular assist device has proved to be one of the most versatile and effective. Since 1981, 48 patients, aged 15 to 71 years (mean 43.0), with profound cardiogenic shock refractory to conventional therapy with drugs and intra-aortic balloon support, were supported with the Pierce-Donachy ventricular assist device. There were four patient groups. The largest group consisted of 30 patients with cardiogenic shock after cardiac operations. Nine required left ventricular support, six needed right ventricular support plus an intraaortic balloon pump, and 15 had biventricular support. Duration of support ranged from 3 hours to 22 days (mean 3.6 days). Eight of the first 11 patients died in the operating room of bleeding and/or biventricular failure. However, 16 patients, (53%) had improved cardiac function, 15 (50%) were weaned, and 11 (36%) were discharged. Of the last 19 patients, 47% survived. Frequent factors in nonsurvivors were myocardial infarction (75%) and renal failure (90%). Common complications in all patients were bleeding (52%) and infection (27%). The second group consisted of 11 patients with end-stage cardiomyopathy or acute myocardial infarction in whom the Pierce-Donachy ventricular assist device was used as a bridge to transplantation (left ventricular support, four patients; biventricular support, seven patients). Renal failure, infection, or coagulopathy that precluded transplantation developed in five patients. Five patients were supported for 8 hours to 75 days (mean 20.7 days) before undergoing successful transplantation, with one late death (six months) from rejection owing to noncompliance. One has subsequently undergone successful transplantation after 84 days of support. The third group consisted of four patients, aged 40 to 56 years (means 47.2), who had refractory cardiogenic shock after cardiac transplantation caused by pulmonary hypertension (two patients), hyperacute rejection (one patient), or graft failure (one patient). Despite biventricular support in all four (biventricular assist devices, two patients; right ventricular assist device plus intraaortic balloon pump, two patients), all died of infection and/or renal failure after 12 hours to 6 days (mean 3.4 days) of support. The final group consisted of three patients, aged 36 to 51 years (mean 45), with cardiogenic shock caused by acute myocardial infarction. One patient was supported with biventricular assist devices (3.5 days) and two patients were supported with a left ventricular assist device (8.5 and 15 days).(ABSTRACT TRUNCATED AT 400 WORDS)

Single lung transplantation followed by contralateral bullectomy for bullous emphysema.

BACKGROUND AND METHODS: Single lung transplantation for emphysema is now standard practice despite initial concerns, including the possibility that the compliant diseased lung would compress the transplanted lung as a result of hyperinflation. We describe a patient with severe bilateral bullous emphysema and alpha-1-antitrypsin deficiency who underwent single lung transplantation after which hyperinflation of the native lung led to significant compression of the pulmonary allograft. The patient subsequently underwent bullectomy of the contralateral lung with marked improvement in his functional status. RESULTS: After bullectomy, the patient's forced expiratory volume in 1 second increased from 1.77 to 2.82 L, his total lung capacity fell from 7.23 to 6.19 L, and his 6-minute walk increased from 724 to 1269 feet. However, 7 months after bullectomy, there was evidence that the bullous disease in the native lung was recurring. CONCLUSIONS: Significant hyperinflation of the native lung with compromise of the pulmonary allograft can occur after single lung transplantation for bullous emphysema. Bullectomy of the diseased lung after transplantation improved allograft function in our patient. Alternatively, bilateral lung transplantation for severe bilateral bullous emphysema may be considered.

Heart transplantation in children who have undergone previous heart surgery: is it safe?

As heart transplantation becomes more commonly applied to the pediatric population, it is important to determine if previous palliative or reparative operations increase the risk of transplantation. Since 1988, 13 children aged 23 months to 14 years (mean 9.5 years) who had undergone previous heart operations underwent orthotopic heart transplantation. These children had undergone an average of 3.2 previous operations (range 1 to 7):1.9 sternotomies (range 0 to 5) and 1.2 thoracotomies (range 0 to 3). Three children had undergone only palliative operations (Norwood procedure, Waterston shunt, and transthoracic pacemaker); the remaining 10 had undergone at least one "corrective" operation: four valve replacements or repairs (three mitral and one aortic), three Fontan procedures, one Rastelli procedure, one double-outlet right ventricle repair, and one ventricular septal defect repair. At the time of transplantation, seven patients (54%) were on inotropic support, two with mechanical ventilation. Three patients (23%) had significant levels of preformed antibodies necessitating a prospective cross-match, which significantly delayed transplantation. The transplant procedure was complicated by the need for pulmonary arterial reconstruction in six patients (46%), transposition of the great arteries in three patients (23%), and atrial baffling to redirect anomalous venous drainage in one patient (8%). There was one death 4 days after surgery from sepsis in a patient who had undergone a previous Konno procedure who required 24 hours of mechanical right ventricular assistance after transplantation. Two children (15%) required mediastinal exploration for bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Medium-term results of pediatric patients undergoing orthotopic heart transplantation.

To establish the medium-term results of our transplant population, we retrospectively reviewed the charts of 51 consecutive patients who underwent orthotopic heart transplantation between July 1988 and April 1995. These patients comprised two groups: group A consists of 26 patients (age 6 days to 16.4 years, median 1.4 years) with no previous heart surgery, and group B consists of 25 patients (ages 0.1 to 14.3 years, median 8.3 years), all of whom had heart surgery before undergoing transplantation. There was no difference between these groups in early or late survival rates, and neither age at transplantation nor sex was an indicator of survival. There have been 14 deaths, six early (before hospital discharge) and eight late. Early deaths have predominantly been attributed to long-term ventilation and hemodynamic instability before transplantation, and late deaths to graft coronary artery disease (n = 4), acute coronary vasculitis (n = 3), and acute cellular rejection (n = 1). Although infection has resulted in significant morbidity (57 hospital admissions), there have been no late deaths resulting from infection. Sepsis accounts for four early deaths in chronically ill patients. Orthotopic heart transplantation in the pediatric patient with and without previous heart surgery is a viable option for those with end-stage heart disease and those in whom other surgical options carry a prohibitively high mortality rate.

Hypersensitivity myocarditis in heart transplant candidates.

Hypersensitivity myocarditis is a rare event; however, routine histologic examination of all (193) explanted hearts for heart transplantation in our institutions revealed hypersensitivity myocarditis in 15 patients (7%). This is a previously unreported finding in heart transplant recipients. None of the cases was detected clinically, although all manifested peripheral eosinophilia at some point during the 2 weeks before transplantation. Only one patient exhibited a skin rash interpreted as allergic. The severity of the interstitial infiltrate varied from grade I to grade IV (semiquantitative). This group of pretransplantation patients was receiving a multiplicity of drugs, some of which could have potentially triggered the hypersensitivity myocarditis, although in only one case was a definite association between a hypersensitivity reaction and a drug made. The unusually high rate (10.3% for the Emory cases) of drug-induced myocarditis in this group of patients, contrasted with the general autopsy population, probably reflects that these patients received more vigorous than usual drug treatment, particularly antibiotics, to sustain them until a suitable donor was found.

Single-field total lymphoid irradiation in the treatment of refractory rejection after heart transplantation.

Nine heart transplant recipients were treated with single-field total lymphoid irradiation (TLI) for early (<1 year) or late (>1 year) rejection that was refractory to multiple regimens of immunosuppressive therapy. For patients with early rejection (n = 6), the rejection frequency (rejections/patient/month) decreased from pre-TLI of 1.63 to post-TLI of .02 (p < .001), and for patients with late rejection (n = 3), the rejection frequency decreased from pre-TLI of .23 to post-TLI of .05 (p < .02). The reduced rejection frequencies have been maintained for a mean follow-up of 28.6 (8 to 78) months, and adverse events during or late after TLI were uncommon. Single-field TLI is a safe and effective technique in the management of refractory rejection early or late after heart transplantation.

Assessment of myocardial protection during global ischemia with myocardial gas tension monitoring.

Intramyocardial gas tension monitoring with mass spectrometry allows for the continuous assessment of myocardial metabolic activity during prolonged global ischemia. With aortic cross-clamping there is a rapid decrease in intramyocardial oxygen tension (PmO2) and a steady increase in carbon dioxide tension (PmCO2). In laboratory studies the extent to which myocardial metabolic activity is reduced has correlated with the degree of myocardial protection being afforded. In the present study the metabolic consequences of single-dose versus multiple-dose infusions of a hyperkalemic cardioplegic solution were compared in 23 patients undergoing aortic valve replacement (AVR) for severe aortic stenosis. Group I (n = 13) had single-dose cardioplegia during AVR, while group II (n = 10) had multiple-dose cardioplegia. The preoperative status and the surgical procedures were identical except for two multiple-dose patients who also underwent single coronary bypass grafting. In group I the PmCO2 rose steadily and at cross-clamp release was 182 +/- 20 mm Hg, while in group II the PmCO2 rose only to 77 +/- 8 mm Hg (P less than 0.01). During reperfusion the peak PmCO2 in group I was 219 +/- 22 mm Hg versus 111 +/- 5 mm Hg in group II (P less than 0.01). After operation six patients in group I required pharmacologic support, and two other patients died of low cardiac output. In contrast, only one patient in group II required inotropic support, and there were no deaths. The significantly lower PmCO2 values with multiple-dose cardioplegia suggest both reduced metabolic activity and washout of metabolic end products, with resultant improved myocardial protection, evidenced by less postoperative left ventricular dysfunction.

Improved technique for the proximal anastomosis with free internal mammary artery grafts.

A method for construction of the proximal aortic anastomosis using an autologous pericardial patch for free internal mammary artery bypass grafts is described. The use of pericardium allows for ease of suturing without the need for saphenous vein harvesting.

Importance of acquired systemic-to-pulmonary collaterals in the Fontan operation.

BACKGROUND: Children with chronic cyanotic heart disease often develop systemic-to-pulmonary collateral arteries that can be deleterious at the time of a Fontan procedure due to excessive pulmonary blood flow. We therefore occlude all significant collaterals during cardiac catheterization. METHODS: From June 1993 to May 1998, 93 children aged 1.5 to 15.8 years (median 2.5 years) underwent a fenestrated lateral tunnel Fontan procedure. Eighty-nine (96%) had a previous bidirectional Glenn anastomosis, including 31 (33%) with a Norwood procedure. RESULTS: Preoperatively, 33 children (35%) required occlusion of 1 to 11 (mean 3.6) collateral vessels. Two of the three perioperative deaths (operative survival 97%) were due to excessive pulmonary blood flow from unrecognized collaterals in one and uncontrollable collaterals in the other. Postoperatively, 19 children (20%) required coil occlusion of 1 to 21 (mean 5.6) collaterals for elevated pulmonary artery pressures, heart failure, or prolonged chest tube drainage. Duration of inotropic support, postoperative ventilation, intensive care unit stay, and postoperative hospitalization were all significantly longer in the patients who had postoperative occlusion of collaterals. On follow-up of 2 to 67 months (mean 35 months), there have been four late deaths (two infections, two heart failures); 6 patients underwent successful cardiac transplantation for refractory heart failure. All 8 patients with ventricular failure required occlusion of significant collaterals postoperatively. CONCLUSIONS: Hemodynamically significant collaterals are not uncommon in Fontan candidates, and aggressive control can result in good operative and medium-term survival. After the Fontan, significant collaterals may be a marker for eventual cardiac failure because 8 of 18 patients requiring postoperative coils went on to transplantation or died of heart failure.

Late-onset dysphagia lusoria.

Symptomatic vascular rings are uncommon in adults. We report a case of dysphagia in a 48-year-old woman from a right-sided aortic arch with aberrant left subclavian artery and left-sided ligamentum arteriosum. Through a left posterolateral thoracotomy, the ligamentum was divided, relieving the patient's dysphagia. Twenty-three cases of adult-onset dysphagia lusoria attributable to this anatomy have been reported. We recommend a left thoracotomy with division of the ligamentum as treatment.

Reverse subclavian flap repair of hypoplastic transverse aorta in infancy.

BACKGROUND: Management of hypoplastic aortic arch associated with coarctation in infancy can be challenging. Reverse subclavian flap aortoplasty plus coarctation resection offers simplicity without needing foreign material or cardiopulmonary bypass. METHODS: Since 1988, 46 of 162 infants less than 3 months undergoing coarctation repair had hypoplastic arch enlargement with reverse subclavian flap aortoplasty. Median age was 11 days; mean weight was 3.2 kg. Thirty-seven patients (80%) had associated cardiac defects including single or multiple ventricular septal defects (14 infants), transposition of the great arteries (7), aortic or mitral stenosis (5), and complete atrioventricular septal defect (5 infants). Twenty-eight patients had pulmonary artery banding; 2 had an arterial switch operation through a separate median sternotomy. RESULTS: There were two hospital deaths: one 4 months postoperatively in a patient requiring a Norwood procedure the next day for underestimated left ventricular hypoplasia; the other of sepsis more than 1 month postoperatively. On follow-up from 1 to 129 months (mean, 38 months), there were five recurrent obstructions: three at the coarctation site treated with balloon dilatation and two at the arch site. Twenty-six children had their heart defects corrected with 29 subsequent operations including an arterial switch operation for transposition of the great arteries/ ventricular septal defect (3 infants), relief of aortic or mitral stenosis +/- ventricular septal defect closure (5), multiple ventricular septal defect closure (3), a bidirectional Glenn (2), complete atrioventricular septal defect (2), and anomalous left coronary with ventricular septal defect repair (1 infant). Four children await debanding and ventricular septal defect closure or Glenn anastomosis. There have been two late deaths (overall survival, 91%). CONCLUSIONS: Reverse subclavian flap aortoplasty is excellent for relief of arch hypoplasia and coarctation in infants with low recurrence rates and acceptable operative and intermediate survival.