Repeat sternotomy after reconstruction of the pericardial sac with glutaraldehyde-preserved equine pericardium.

The risk of repeat sternotomy is higher than that of the initial sternotomy, especially if the pericardial sac was left open at the first intervention. In 200 consecutive patients with a pericardial defect after open heart operations, the pericardium was closed with a glutaraldehyde-preserved equine pericardial patch. Precardiac adhesions at reoperation were assessed in four groups of patients on a scale of 6, ranging from 0 (no adhesions) to 5 (calcified or ossified adhesions). Group I comprised 13 patients in whom the pericardium was left open at the first operation and an equine pericardial patch was implanted at reoperation. Group Ia included the first five Group I patients who underwent reoperation less than 1 year (early reoperation) after the initial procedure. Group Ib included the other eight patients of Group I, who underwent reoperation more than 1 year (late reoperation) after the first procedure. Group II comprised nine patients who were reoperated on after reconstruction of the pericardial sac with a glutaraldehyde-preserved equine pericardial patch. After a mean follow-up of 20.2 months, the incidence of patch-related complications was 1%. Statistical analysis shows less severe adhesions on reoperation in Group II patients (pericardial defect patched) than in Group I patients (pericardial defect left open): mean grade of adhesions 1.6 +/- 0.9 (Group II) versus 3.2 +/- 0.6 (Group I), p less than 0.001. Precardial adhesions with the pericardium left open were similar in patients having early and late reoperations: mean grade of adhesions 3.0 +/- 0.7 (Group Ia) versus 3.4 +/- 0.5 (Group Ib), no significant difference. Therefore, the glutaraldehyde-preserved equine pericardial patch can be considered a suitable material for primary closure of the pericardial sac in patients with inadequate autologous pericardium.

Right ventricular outflow obstruction after radiation therapy.

A unique case of radiation-induced heart disease associated with acquired right ventricular outflow obstruction is presented. Surgical management of this case is described.

Implantation of antibiotic-releasing carriers for treatment of recurrent prosthetic endocarditis.

A 26-year-old man had early recurrence of aortic prosthetic endocarditis with recurrent prosthetic valve dysfunction. Tertiary valve replacement with implantation of antibiotic-releasing carriers for local treatment of aortic root abscesses was performed successfully in this highly lethal condition.

Aortic valve replacement with the freestyle stentless bioprosthesis with respect to spacial orientation of patient coronary ostia.

OBJECTIVE: This study evaluates our results for safety and efficacy of aortic valve replacement using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, Minn) with a new modified subcoronary implantation technique. This technique takes into account the spacial orientation of the stentless bioprosthesis in the aortic root with respect to the patient's coronary ostia rather than the native commissures. METHODS: Fifty-two consecutive patients with predominant aortic valve stenosis underwent aortic valve replacement with a Freestyle bioprosthesis by means of the described modified subcoronary technique over a 15-month period. Fifty of them were followed up by means of echocardiography at discharge, 6 months, and 1 year. There were 19 men and 31 women, with a mean age of 76 +/- 7 years (range, 58-87 years). Valve size ranged from 21 to 27 mm. RESULTS: Patients with bicuspid aortic valves had a significantly larger angle between both coronary ostia than patients with tricuspid aortic valves (P =.0001). The peak and mean systolic gradients decreased significantly during the first postoperative year for each valve size (P

Prosthetic heart valve replacement in children. Results and follow-up of 273 patients.

We report the results and long-term follow up in 273 children (aged 2 to 16 years) who underwent prosthetic valve replacement. Mechanical valves (mostly Starr-Edwards) were used in almost all, and in 62 children more than one valve was replaced. Operative mortality was 4.7%. Actuarial survival curves (including hospital mortality) indicate a 86% survival rate at 5 years and 75% at 10 years. For isolated mitral valve prostheses (the largest subgroup), the figures are 87% at 5 years and 82% at 10 and 15 years. The main complication was thromboembolism, which occurred at a linearized rate of 2.7 per 100 patient-years. Actuarial curves indicate that 88% of patients are embolus free at 5 years, and 77% at 10 years. No patient with aortic valve replacement only had an embolism. Five of eight tricuspid prostheses thrombosed. Patients given aspirin and dipyridamole only did not have a higher rate of thromboembolic events than those given warfarin. There were five cases of endocarditis (two fatal) and four of dehiscence. No patient so far has needed replacement of a prosthesis because of somatic growth. Thus valve replacement can be performed with low mortality in children, and with satisfactory long-term survival. Thromboembolism remains a significant problem, although it appears to be less common than in adults. In this study, treatment with antiplatelet drugs only did not carry a higher rate of thromboembolic events than did treatment with warfarin.

Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency.

OBJECTIVES: Our goal was to evaluate the midterm results of aortic valve repair by a more sophisticated tailoring of cusp extension-taking into account the dimensions of the native aortic cusps-with the use of fresh autologous pericardium. PATIENTS AND METHODS: Forty-one children who had severe rheumatic aortic insufficiency (mean age 11.5 +/- 2.7 years) underwent aortic valve repair by means of this cusp extension technique over a 5-year period. Twenty-four of them underwent concomitant mitral valve repair for associated rheumatic mitral valve disease. All children were then followed up by transthoracic echocardiography before discharge, at 3 and 6 months after the operation, and at yearly intervals thereafter. RESULTS: Follow-up was complete in all patients and ranged from 3 months to 5 years (median 3 years). No operative and no early postoperative deaths occurred. Only 1 patient died, 9 months after the operation, of septicemia and multiple organ failure. Actuarial survival was 97% at 1 year and has remained unchanged at 3 years. On discharge, the degree of aortic insufficiency was grade 0 for 27 children and grade I for 14. Exacerbation of aortic insufficiency from grade I to grade II was observed in only 1 patient, and none of the children required reoperation for aortic insufficiency during the follow-up period. Mean peak systolic aortic valve gradients at discharge were lower than preoperative values (P =.04), and no significant increase in the peak systolic transvalvular gradient was detected thereafter during the follow-up period. Mean left ventricular dimensions were significantly reduced at discharge when compared with preoperative values (P <.0001). CONCLUSIONS: Functional results of aortic valve repair with cusp extension using fresh pericardium have been satisfactory at medium term, particularly in children with a small aortic anulus at the time of initial repair, because the expansion potential of fresh autologous pericardium is equivalent to that of the growing sinotubular junction and aortic anulus diameters.

Blunt carotid artery injury: difficult therapeutic approaches for an underrecognized entity.

GOALS: To assess the damage inflicted by carotid artery injuries, to attempt to explain some differences between published series, and to summarize the management of different types of lesions. METHOD: Retrospective analysis of patients treated for nonpenetrating injury of the carotid arteries in our hospital from 1985 to 1991. RESULTS: Seven patients (all men, with ages ranging from 19 to 55 years) had eight injuries to the carotid arteries. One patient was asymptomatic; another patient had neurologic symptoms unrelated to the carotid artery injury; severe neurologic deficits developed in the remaining five patients, of whom three died. Symptoms occurred immediately in one patient, after a few days in two patients, and after a few weeks in two patients. Arterial damage included dissection (four cases), pseudoaneurysm (two cases), local contusion (one case), and occlusion (one case). Surgical treatment consisted of aneurysmorraphy and extraintracranial bypass in one patient each. Surgical intervention was not considered in the other patients because of the severity of their neurologic symptoms. Besides collective reviews, very few series pertaining to this pathologic condition exist in the literature; however, some report good overall results. These reports comprise a high proportion of asymptomatic cases; the internal injury is usually only discovered incidentally on thoracic aortograms or by scanning the neck during head computed tomography scans. CONCLUSIONS: Nonpenetrating trauma to the carotid arteries carries significant morbidity and mortality rates. Wide-scale screening for carotid lesions in victims of blunt trauma would be necessary to determine the true incidence and gravity of this pathologic condition. A search for carotid artery injury should be performed in patients with a history of neck or head trauma to detect whether the correction of any lesion would lead to improvement or prevention of neurologic deficits.

Blunt injury to the ascending aorta: three patterns of presentation.

BACKGROUND: Injury to the ascending aorta is a rare lesion that may present in various forms. A thorough analysis of this lesion is lacking in the literature. This study was undertaken to delineate the prevalence and modes of presentation of injuries to the ascending aorta after blunt trauma and to suggest guidelines for management. METHODS: A retrospective analysis of autopsies performed in our department of forensic medicine on blunt trauma victims from 1984 to 1993 and a literature review of autopsy series were undertaken to delineate the prevalence and relevant characteristics of this injury. A cash report from our institution and a review of the literature were used to provide information regarding clinical presentations of this injury and treatment approaches. RESULTS: Three modes of presentation were encountered. (1) Presentation at autopsy: The prevalence of injury to the ascending aorta after a traffic accident was 2% in our autopsy series. Among 13 patients with this injury 12 had other associated, potentially lethal lesions. A massive hemopericardium was present in two patients only. In autopsy series the incidence of injury to the ascending aorta in patients with an injury to the aorta ranged from 0% to 23%. (2) CLINICAL PRESENTATION: Twenty-one patients were treated surgically and reported in the literature. Fourteen presented with a pseudoaneurysm and seven with a chronic sinus of Valsalva fistula. One patient with a pseudoaneurysm presented with signs of cardiac tamponade and required immediate decompression; the others were hemodynamically stable. Seven patients had a cardiac lesion (valve tear in six and cardiac contusion in one), and three had an arch vessel lesion. Aorta repair was performed under cardiopulmonary bypass in every patient. (3) Incidental presentation: Seven patients with a traumatic tear of the aortic valve presented an incidental lesion of the ascending aorta. It was a subadventitial hematoma in three patients and an intimal and medial tear in four patients. Aortic tears were reinforced by direct suture. CONCLUSIONS: Injury to the ascending aorta after blunt trauma is rare but lethal mostly from associated injuries. Survivors may appear in stable condition and present mostly with pseudoaneurysms of the ascending aorta or sinus of Valsalva fistula. Associated lesions to the heart and arch vessels should be looked for. Repair of the ascending aorta injury is performed under cardiopulmonary bypass.

Surgical management of aortic valve injury after nonpenetrating trauma.

A case report and a literature review of the patients who underwent surgical repair of an aortic valve injury secondary to nonpenetrating trauma are presented. Thirty-seven patients (32 male and 5 female patients) with a median age of 43 years sustained either blunt chest trauma (34 patients) or muscular strain (3 patients) as a cause of injury. Primary repair was undertaken on 4 patients before 1964 (when the first aortic valve replacement was performed for this condition) and on 6 other patients after 1964. In the former group, 2 patients died because of heart failure and 1 subsequently required a prosthesis. The last patient had an excellent result at 17 years. In the latter group, 1 patient with a complex lesion had persistent moderate aortic regurgitation. The 5 remaining patients had a simple lesion to the valve and showed excellent results on follow-up evaluation (ranging from 6 months to 6 years). Aortic valve replacement successfully corrected the valvular dysfunction in 26 patients. Except for 1 case of hemolytic anemia, specific complications of prosthesis were not encountered, but median follow-up of this review was only 9 months. A modulated approach to this condition is proposed where primary repair is selected for cases with a simple tear or avulsion of one cusp. Intraoperative control of the repair by transesophageal echocardiography increases the safety of this approach. Valve replacement is indicated for more complex lesions or for ineffective primary repair as assessed by intraoperative echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful repair of a right ventricular rupture at the atrioventricular groove.

We report a patient who presented with a delayed spontaneous right ventricular rupture at the anterior atrioventricular groove after open heart operation. Successful surgical repair consisted of reestablishing anterior atrioventricular groove continuity by pericardial patch placement on the arrested heart. We discuss the risk factors that could initiate the primary tear and contribute to the extension of this type of right ventricular rupture.

Tricuspid valve repair by septal of posterior leaflet transposition.

We report 2 patients who presented extensive rupture of chordae tendineae caused by blunt thoracic trauma leading to flail anterior leaflet of tricuspid valve. Transposing a segment of septal leaflet in 1 patient and the posterior leaflet in the other patient onto the flail anterior leaflet's margin abolished massive tricuspid regurgitation. Fifteen and 33 months postoperatively the patients are in good clinical condition and the echocardiographic controls show a competent tricuspid valve.

Leaflet's free edge suspension for correction of aortic insufficiency associated with ventricular septal defect.

Aortic valve regurgitation in association with ventricular septal defect results from the mechanical effect of the ventricular septal defect, which primarily affects the free edge. The elongated free edge can be repaired by plicating it using several techniques designed to restore a normal geometry to the prolapsing aortic leaflet. We describe 4 cases in which aortic insufficiency was treated by a technique of plication that allows suspension of the free edge along a pericardial strip applied from one commissure to the other.

Conversion from routine CPB to centrifugal mechanical assist by transaortic inflow cannulation of the left ventricle.

We describe a technique of conversion from cardiopulmonary bypass to centrifugal mechanical assist that consists of using the existing aortic cannula for outflow and inserting a cannula into the left ventricle through a Dacron tube and across the aortic valve for inflow.

Multiple-leaflet mitral valve as a rare cause of congenital mitral insufficiency.

A rare case of congenital mitral insufficiency characterized by six well-demarcated leaflets of mitral valve and annular dilatation is reported. At operation, the mitral valve was successfully repaired by resection of the posterior median leaflet with subsequent annular plication, closure of unusual valvular tissue divisions, and ring annuloplasty.

Aorticoright atrial tunnel.

Two unusual cases of aorticoright atrial tunnel are described. Both patients were referred to our institution for evaluation of a continuous heart murmur best heard along the right upper sternal border. Ascending aortography showed the tunnel taking its origin from the aortic root and entering the right atrium through a tortuous link. Both patients underwent surgical closure. In addition, a review of similar cases in the literature is presented.

Ascending aortic aneurysm associated with aortic insufficiency due to Takayasu's arteritis.

We report the case of a child with an ascending aortic aneurysm associated with aortic insufficiency. Histopathological examination of the ascending aorta and aortic valve showed findings in favor of Takayasu's arteritis, and subsequent evaluation of the entire aorta demonstrated the presence of multiple steno-occlusive lesions. This unusual clinical problem in the young population is discussed with regard to other eventual pathologies that should be taken into account in the differential diagnosis.

Partial left ventriculectomy combined with transmyocardial laser revascularization.

We report the use of transmyocardial laser revascularization in combination with partial left ventriculectomy for treatment of end-stage dilated ischemic cardiomyopathy. The disappearance of the reversible perfusion defects in the treated left ventricular territories and improvement of the systolic function led us to believe that the simultaneous use of these two techniques was complementary in our patient.

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency.

BACKGROUND: This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children. METHODS: From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism. RESULTS: All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair. CONCLUSIONS: Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.

Successful palliation of acute superior vena caval obstruction after the Senning operation.

Superior vena caval obstruction after an intraatrial baffle procedure can lead to acute cerebral complications and hence requires immediate management. We present a case of successful palliation of acute superior vena caval obstruction after a Senning procedure by establishing a venous shunt between the innominate vein and pulmonary artery. This technique resulted in immediate hemodynamic and functional improvement that subsequently allowed for the enlargement of the superior vena cava-right atrial junction with a pericardial patch.

Blunt injury to the subclavian or axillary artery.

BACKGROUND: This study is an analysis of our experience with blunt injuries to the subclavian or axillary artery in order to delineate the immediate challenges encountered and to assess immediate and long-term outcome. STUDY DESIGN: A retrospective analysis was performed of 15 consecutive patients treated for a blunt injury to the subclavian or axillary artery in our hospital between 1988 and 1992. RESULTS: Ten patients had multiple injuries, and six were in a state of shock at admission. Bleeding from the artery contributed significantly to shock in three patients. Ischemia of the upper extremity was overt in ten patients. Two patients died as a result of associated injuries. Two patients with extensive tissue destruction underwent immediate amputation, one at shoulder level and one at middle arm. Five patients survived with a denervated limb from brachial plexus damage; in only one was the neurologic injury consistent with a potentially reversible lesion. Arterial repair, performed upon patients not undergoing amputation, was patent at a median time of 33 months in all but one patient. Among the seven patients with extensive disability (two amputated and five denervated extremities), only one patient resumed previous work. CONCLUSIONS: Blunt trauma to a subclavian or axillary artery is associated with significant immediate morbidity and mortality. In the long-term, associated brachial plexus lesions plague most patients, who are left with a severe disability of the upper limb, which complicates their return to society.