Hepatic Vein Incorporation Into the Azygos System in Heterotaxy and Interrupted Inferior Vena Cava.

BACKGROUND: Patients with heterotaxy, single ventricle and interrupted inferior vena cava are at risk of developing significant pulmonary arteriovenous malformations and cyanosis, and inequitable distribution of hepatic factor has been implicated in their development. We describe our experience with a technique for hepatic vein incorporation that reliably provides resolution of cyanosis and presumably equitable hepatic factor distribution. METHODS: A retrospective review of a single-surgeon experience was conducted for patients who underwent this modified Fontan operation utilizing an extracardiac conduit from the hepatic veins to the dominant superior cavopulmonary connection. Preoperative characteristics and imaging, operative details, and postoperative course and imaging were abstracted. RESULTS: Median age at operation was 5 years (2-10 years) and median weight was 19.6 kg (11.8-23 kg). Sixty percent (3/5) of patients had Fontan completion without cardiopulmonary bypass, and follow-up was complete at a median of 14 months (range 1-20 months). Systemic saturations increased significantly from 81% ± 1.9% preoperatively to 95% ± 3.5% postoperatively, P = .0008. Median length of stay was 10 days (range: 7-14 days). No deaths occurred. One patient required reoperation for bleeding and one was readmitted for pleural effusion. Postoperative imaging suggested distribution of hepatic factor to all lung segments with improved pulmonary arteriovenous malformation burden. CONCLUSIONS: Hepatic vein incorporation for patients with heterotaxy and interrupted inferior vena cava should optimally provide equitable pulmonary distribution of hepatic factor with resolution of cyanosis. The described technique is performed through a conventional approach, is facile, and improves cyanosis in these complex patients.

Aortic Translocation for Repair of Transposition of the Great Arteries (S,D,L) With Ventricular Septal Defect and Pulmonic Stenosis.

Biventricular repair for (S,D,L) transposition with ventricular septal defect, pulmonary stenosis, and superior-inferior ventricular malposition has not been described, to our knowledge. Herein we report biventricular repair of this complex lesion by aortic translocation.

Adoption of endovascular repair of abdominal aortic aneurysm in California: lessons for future dissemination of surgical technology.

BACKGROUND: Knowledge of the pattern of adoption of endovascular approach (endovascular aortic repair [EVAR]) to abdominal aortic aneurysm (AAA) could direct future dissemination of complex surgical technology. METHODS: Retrospective longitudinal analysis of the California Office of Statewide Health Planning and Development inpatient database from 2001 to 2008, accompanied by a cross-sectional survey of surgeons. The setting was all inpatient hospitals in California. Patients were those who underwent repair of AAA. The main outcome measure was the endovascular repair of AAA and the training experience of the surgeons. RESULTS: Of the 33,277 patients with AAA, 11,755 (35%) underwent endovascular repair; 76% were men, mean age was 73 (median, 75) years, 13% of aneurysms were ruptured, and 20% were treated at teaching hospitals. The rate of EVAR increased from 19% in 2001 to 55% in 2008. On multivariate analysis, calendar year, older age, male gender, nonruptured status, teaching hospitals, and high-volume hospitals, but not race or insurance status, were identified as independent predictors of EVAR. The survey revealed that surgeons with ≥15 years of experience obtained their training primarily from the manufacturer (58.8%), whereas those with <15 years of experience obtained their training primarily during residency or fellowship (96.7%). CONCLUSION: Between 2001 and 2008, there was a 290% increase in the rate of EVAR for AAA in California. The early adopters obtained their training directly or indirectly from the manufacturers. Training programs did not begin to offer formal training in this technology until the rapid growth was already taking place. This suggests that academic medical centers and/or professional organizations should develop plans to play a stronger and earlier role in educating physicians about a new technology.