[The left ventricular reconstructive surgery at the origin of the treatment of cardiac insufficiency]. / La reconstruction ventriculaire a l'origine du traitement chirurgical de l'insuffisance cardiaque.

The surgical method of ventricular reconstruction described by Dor is recalled with the clinical report of a patient who presented a ventricular aneurysm. The left ventricular reconstructive surgery is based on an anatomical design of the heart described by Torrent-Guasp, where the normal orientation of the left ventricular muscle fibers, oblique in direction, is found parallel with the base of the heart at the time of ventricular dilation. By giving again an elliptic form to the left ventricle, the left ventricular reconstructive surgery improves the cardiac function of the patient who developed a bulky aneurysm after an infarction. Based on this concept, other techniques of ventricular reconstruction intended for patients presenting dilated cardiomyopathy, of ischemic origin or not, are being studied.

Hemodynamic evaluation of a new stentless autologous pericardial mitral valve.

BACKGROUND: There is no satisfactory mitral valve prosthesis. An ideal mitral valve substitute should be biologic, nonantigenic, and anatomically correct. METHODS: We developed a stentless, chordal-supported (including anterior basal stay chords) mitral valve made with glutaraldehyde-treated autologous pericardium. Eight such prostheses were implanted in sheep. RESULTS: Seven animals survived the operation and were studied postoperatively immediately, at 1 week, and at 1 month. Simultaneous left ventricular and left atrial pressures showed peak and mean transvalvular pressure gradients of 6+/-2 mm Hg and 1+/-1 mm Hg, respectively. Echocardiography performed intraoperatively and then 1 week and 1 month postoperatively showed normal valve leaflet movements. Color and pulsed Doppler echocardiography showed no sign of transvalvular stenosis or regurgitation. Effective orifice area was 5.39+/-0.35 cm2 at intraoperative, 5.51+/-0.29 cm2 1 week after operation (n = 5), and 5.51+/-.28 cm2 1 month after operation (n = 3). Three animals were sacrificed at 19 days and at 1 and 3 months. One animal is alive at 10 months. CONCLUSIONS: This new stentless pericardial mitral valve performed satisfactorily with low gradients and no regurgitation. Possible advantages of this pericardial valve are excellent hemodynamics, ease of construction and implantation, lack of immunogenicity, and low cost. Similarly designed valves but with a shorter nonglutaraldehyde treatment time have been used in 3 sheep monitored for more than 3 months.

Congenital Heart Surgery Nomenclature and Database Project: hypoplastic left heart syndrome.

Hypoplastic left heart syndrome (HLHS) encompasses a spectrum of structural cardiac malformations that are characterized by severe underdevelopment of the structures in the left heart-aorta complex, including the left ventricular cavity and mass. The severe end of the spectrum consists of aortic atresia and mitral atresia with a nonexistent left ventricle, whereas at the mild end patients have aortic valve and mitral valve hypoplasia without intrinsic valve stenosis, and milder degrees of left ventricular hypoplasia, recently described as hypoplastic left heart complex (HLHC). Although the overwhelming majority of the patients can only have a univentricular repair, a small minority of patients with HLHS, particularly those that are described as having HLHC, may be candidates for biventricular repair. In this paper, the extant nomenclature for HLHS is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Nomenclature and Database Committee and representatives from the European Association for Cardiothoracic Surgery. Efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented, which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented which will allow for data sharing, and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Single-stage repair of aortic arch obstruction and associated intracardiac defects with pulmonary homograft patch aortoplasty.

OBJECTIVE: Intracardiac malformations associated with coarctation and aortic arch hypoplasia have traditionally been repaired in 2 stages, with a high mortality rate. We review our experience with single-stage biventricular repair of intracardiac defects associated with aortic arch hypoplasia by means of pulmonary homograft patch aortoplasty. METHODS: Between October 1988 and October 1997, 39 of 40 consecutive patients underwent single-stage biventricular repair for aortic arch obstruction and associated intracardiac defects. The median age at operation was 17 days and the mean weight was 3.71 +/- 1.09 kg. Nineteen patients had either dextrotransposition of the great arteries or the Taussig-Bing anomaly. Sixteen patients had multiple left-sided obstructive lesions (2 cases of critical aortic stenosis, 3 of subaortic stenosis and ventricular septal defect, and 11 of hypoplastic left heart complex). One patient had an associated complete atrioventricular septal defect. Four patients had only an associated ventricular septal defect. Through a median sternotomy, the hypoplastic aortic arch was enlarged with a pulmonary homograft patch in 36 patients. In 4 patients an extended end-to-end anastomosis was performed. RESULTS: There were 2 early deaths (5%) and 2 late deaths (5%). One late death was not cardiac related. The mean follow-up time was 36 months (range 1 month-9 years). The recoarctation rate after pulmonary homograft patch aortoplasty was 8. 3%, but after exclusion of those patients with associated left-sided obstructive lesions this decreased to 0%. No aneurysm formation in the aorta has occurred. The actuarial survival at 8 years is 89% +/- 10%. CONCLUSIONS: Single-stage biventricular repair of aortic arch obstruction and associated intracardiac defects can achieve excellent survival. We recommend pulmonary homograft patch aortoplasty because it achieves complete relief of anatomic afterload with a tension-free anastomosis and low incidence of recoarctation.

Biventricular repair in neonates with hypoplastic left heart complex.

BACKGROUND: Multiple obstructions in the left heart-aorta complex have been associated with poor survival. No consensus exists as to whether these patients will have a favorable outcome with biventricular repair where most advocate a univentricular approach. METHODS: Since late 1988, all 11 neonates seen with hypoplastic left heart complex, which includes aortic arch obstruction, underwent biventricular repair. All patients had antegrade aortic flow and no intrinsic aortic or mitral stenosis. Elimination of the extracardiac afterload was achieved by extensive ascending aorta and aortic arch reconstruction with a pulmonary homograft patch. All intracardiac shunts were eliminated to fully preload the left heart. The median age at first operation was 7 days and the mean weight, 3.59+/-0.49 kg. The echocardiographic variables used to evaluate the left heart-aorta complex were reviewed, and the preoperative and postoperative measurements were compared. RESULTS: There were two early deaths. Four patients had six reoperations for left ventricular outflow tract obstruction, 2 of whom have required prosthetic valve replacement (1, aortic and mitral; 1, aortic), and 2 patients had three reoperations for recurrent coarctation. There was one late death at 3 years from pulmonary hypertension. Mean follow-up was 44+/-35 months. The 8 current survivors are all in New York Heart Association class I or II. The actuarial survival rate at 8 years is 63%, and the freedom from reoperation at 3 years is 25%. CONCLUSIONS: We have successfully achieved biventricular repair in most of the patients with hypoplastic left heart complex, a subset of patients with hypoplastic left heart syndrome. Some growth of the left ventricular structures was already observed at the time of hospital discharge. However, reoperation, particularly for left ventricular outflow tract obstruction, appears likely. Increasing experience will more accurately define predictive criteria for the feasibility of biventricular repair.

Single-stage arterial switch with aortic arch enlargement for transposition complexes with aortic arch obstruction.

BACKGROUND: Patients with transposition complexes and aortic arch obstruction are a surgical challenge with significant mortality. We have adopted an aggressive approach of concurrent aortic arch repair and arterial switch operation with excellent results. METHODS: Since 1989, 12 of 13 patients with aortic arch obstruction and transposition of the great arteries or double-outlet right ventricle with subpulmonary ventricular septal defect have undergone complete single-stage repair. One patient underwent a two-stage repair because of hemodynamic instability. The median age of repair was 27 days and the median weight was 3.5 kg. Surgical technique involved the arterial switch operation and ventricular septal defect closure when present in 12 patients. One patient with severe subaortic stenosis underwent a modified Damus-Kaye-Stansel operation with concomitant aortic arch enlargement. The aortic arch was enlarged in 12 of 13 patients with a pulmonary homograft patch. RESULTS: There have been no early deaths and only one late death at 39 months postoperatively from hepatoblastoma. The mean follow-up is 42 months. There have been no reoperations for recurrent aortic arch obstruction. All survivors are currently well from a cardiac point of view. CONCLUSIONS: Concomitant single-stage repair for transposition complexes with aortic arch obstruction achieves excellent survival and should be the surgical procedure of choice.