Cardiac surgery with extracorporeal circulation in 23 infants weighing 2500 g or less: short and intermediate term outcome.

OBJECTIVE AND METHODS: From September 1990 to February 1997, 23 consecutive critically ill infants (12 males, 11 females) weighing 2500 g or less underwent cardiac surgery necessitating extracorporeal circulation (ECC). A retrospective study was carried out to evaluate short- and intermediate-term outcome. Mean weight at operation was 2265 g (range 1750-2500 g). Mean age at operation was 24 days. The indications for surgery were transposition of the great arteries (TGA; 7), ventricular septal defect (VSD; 4), aortic stenosis (AS; 3), univentricular heart (UVH; 2), tetralogy of Fallot (TOF; 2), interrupted aortic arch (IAA; 2), atrial septal defect (ASD; 1), atrioventicular septal defect (AVSD; 1) and total abnormal pulmonary venous return (TAPVR; 1). All patients were in NYHA class IV; 17 patients (74%) were intubated pre-operatively. RESULTS: The mean aortic cross-clamping time was 40 min. Twelve patients required deep hypothermia (<20 degrees C) with total circulatory arrest (mean duration 19 min). All patients were successfully weaned from extracorporeal circulation (ECC). Five patients left the operating room with an open sternum (mean duration before closure: 3.5 days). Mean duration of artificial ventilation was 10.6 days; of inotropic support 6.7 days and of intensive care stay 17.8 days. Severe complications were observed in 19 patients (83%): cardiac failure requiring high inotropic support (13), sepsis (7), and acute renal insufficiency (5). One patient needed a ventricular assist device. Five patients (22%) died in the intensive care unit (ICU): 2 AS with fibroelastosis, 2 IAA with VSD. and 1 UVH with pulmonary atresia. At discharge from the ICU, 7 patients were receiving no treatment. Mean duration of follow-up was 32 months (range 2-80 months). We had 2 reoperations: 1 for right ventricular outflow tract obstruction 1 year after a switch operation and 1 for mitral valve replacement 1 year after total abnormal pulmonary venous return repair (death 30 days post mitral valve replacement). Survival at I year was 73%. At the last clinical examination 16 patients were in NYHA class I. CONCLUSION: Despite the severity of pre-operative cardiac disease, early surgical repair with ECC in infants weighing 2500 g or less is feasible with tolerable mortality yet with significant early morbidity.

Early coronary sinus reroofing using the left atrial baffle.

Surgical correction of unroofed coronary sinus, left superior vena cava, dextrocardia, and situs solitus in a 4-month-old infant consisted of reroofing the coronary sinus by means of a left atrial flap while redirecting the left superior vena cava to the right atrium. Excellent access to the left side of the left atrium was afforded by the associated dextrocardia.

Nonvalved homografts of thoracic aorta in operation for complex congenital cardiac disease.

BACKGROUND: In contrast to the wide and successful use of valved aortic and pulmonary homografts, the non-valved prolongation of the thoracic aorta for the repair of some complex congenital heart diseases has rarely been described. We present here our experience with the use of descending aorta and aortic arch homografts as non-valved conduits for the surgical repair of complex cardiac malformations in 8 patients. METHODS: One atriopulmonary conduit replacement four extraatrial cavopulmonary connections, and one intraatrial cavopulmonary repair were achieved by means of a homograft of the descending aorta with a diameter of 15 to 17 mm. Three pulmonary unifocalization procedures were carried out in 2 more patients using a curved homograft of the aortic arch with a diameter of 18 mm. Except for 1 patient, whose incompetent common atrioventricular valve was replaced with a mechanical prosthesis, all other patients were managed without anticoagulation. RESULTS: No conduit-related complications were seen during a follow-up of 18 to 42 months. One patient died perioperatively during an emergency central repair of the right ventricular outflow tract after bilateral unifocalization with arch homografts. Another patient died suddenly 4 months after cavopulmonary connection. The remaining 6 patients are currently doing well. CONCLUSIONS: Regardless of the complexity of the underlying malformations, we are encouraged to use nonvalved thoracic aortic homografts in the repair of congenital cardiac diseases because of the reduction in thrombotic, hemorrhagic, and infectious complications associated with their use; convenience in handling; and their versatility in size and shape.

Insertion of an aortic and pulmonary homograft for simultaneous reconstruction of the left and right ventricular outflow tracts. A case report.

We present the case of the successful reconstruction in a child of a congenital cardiac malformation (tetralogy of Fallot) complicated by acquired aortic regurgitation and aneurysm formation of the left pulmonary artery due to previous endocarditis, by using an aortic homograft for reconstruction of the left ventricular outflow tract and a pulmonary homograft for reconstruction of the right ventricular outflow tract. Regarding the excellent results recently obtained with cryopreserved homografts, the many advantages of these valves compared to mechanical prostheses, we feel that aortic and or pulmonary homografts might constitute ideal biological valves for reconstruction of left and or right ventricular outflow tract in children when the presence of a congenital anomaly of the pulmonary valve renders an autograft impossible.

Endoscopic obliteration of recurrent tracheoesophageal fistula.

We report a successful endoscopic obliteration of a large recurrent tracheoesophageal fistula (diameter 0.6 cm, length 2.0 cm) in a 12-year-old girl, using a combination of Histoacryl (n-butyl-z-cyanoacrylate) and Aethoxysclerol injected through a polyethylene catheter. The severe pulmonary infection, which rendered surgery potentially life threatening, disappeared after the endoscopic closure. Since the obliteration, now over 12 months ago, the girl is asymptomatic. Endoscopic obliteration is a worthwhile technique and should be considered as an alternative to surgery in patients presenting with a complicated recurrent tracheoesophageal fistula.

[Endoscopic closure of a recurrent tracheoesophageal fistula]. / Fermeture endoscopique d'une fistule trachéo-oesophagienne récidivante.

We report a successful endoscopic obliteration of a large recurrent tracheo-esophageal fistula (diameter 0.6 cm, length 2 cm) in a 12-year old girl, using a combination of N-butyl-2-cyanoacrylate followed by polidocanol injected through a polyethylene catheter. The severe pulmonary infection, that rendered surgery potentially life-threatening, resolved after endoscopic closure. The girl remained asymptomatic for 14 months after the first obliteration. Chronic coughing was the symptom of relapse. A follow-up endoscopy revealed that most of the N-butyl-2-cyanoacrylate had disappeared from the fistula, whose endoscopic appearance was unchanged. A second obliteration with the same products was performed. The girl has again been asymptomatic for 10 months. The endoscopic obliteration is a worth-while technique, to be considered as an alternative to surgery in patients presenting with a complicated recurrent tracheo-oesophageal fistula.