Pulmonary artery translocation: a surgical option for complex anomalous coronary artery anatomy.

Rather than perform a difficult and potentially high risk coronary reimplantation in a patient with an aberrant right coronary artery coursing between the aorta and pulmonary artery, the main pulmonary artery was translocated toward the left pulmonary hilum to create additional space between the aortic and pulmonic trunks.

Utility of intraoperative transesophageal echocardiography in the assessment of residual cardiac defects.

To investigate the accuracy of immediate postbypass transesophageal echocardiography in the assessment of residual cardiac defects, we compared intraoperative transesophageal echocardiograms with intra/postoperative data in 86 patients, aged 4 days to 30.7 years (median = 1.4 years), at risk for a total of 174 postoperative lesions: right (n = 55) or left (n = 26) ventricular outflow tract obstruction, ventricular septal defect (n = 65), aortic (n = 12) or mitral regurgitation (n = 8), or mitral stenosis (n = 8). Accuracy of intraoperative transesophageal echocardiography was evaluated based on comparison with (1) immediate post-bypass left (n = 4) or right (n = 9) ventricular outflow tract pressure gradients by pullback in the operating room, (2) direct surgical inspection of residual ventricular septal defects (n = 3), (3) pulmonary artery oxygen saturation (n = 49), (4) right ventricular outflow tract pullback gradient (n = 24), and (5) transthoracic echocardiogram (n = 51) performed within 40 days of surgery. The results indicate that intraoperative transesophageal echocardiography agreed with intra/postoperative data in 87% of patients at risk for right ventricular outflow tract obstruction, 96% at risk for left ventricular outflow tract obstruction, 97% at risk for ventricular septal defect, and 100% at risk for aortic regurgitation, mitral regurgitation, or mitral stenosis. Significant residual lesions led to immediate surgical revision in 11 cases: 3 ventricular septal defects, 6 right and 2 left ventricular outflow tract obstructions. Of these, intraoperative transesophageal echocardiography confirmed and quantified suspected residual lesions in 7 and identified unsuspected lesions in 4 cases. Immediate postbypass transesophageal echocardiography proved reliable for assessing residual ventricular septal defect, mitral stenosis, and mitral or aortic regurgitation. Although accurate for assessment of the left and right ventricular outflow tracts in most patients, transesophageal echocardiography may not reliably reflect the severity of obstruction in all cases.

Video-assisted thoracoscopic vascular ring division in infants and children.

OBJECTIVES: This study evaluated our early experience with video-assisted thoracoscopic vascular ring division and compared this approach with division by means of a conventional open thoracotomy. BACKGROUND: Video-assisted thoracoscopic techniques reduce surgical trauma and have been applied to several adult thoracic procedures; however, pediatric applications have been limited. We developed instruments and techniques for video-assisted thoracoscopic vascular ring division in the pediatric population. METHODS: We compared patient characteristics, operative results and postoperative hospital courses of all patients undergoing vascular ring division by a video-assisted approach with a historical control group of all patients undergoing division by an open thoracotomy between January 1991 and December 1992. RESULTS: Eight patients (median age 5 months, range 40 days to 5.5 years; median weight 6.2 kg, range 1.8 to 17.1) underwent video-assisted thoracoscopic vascular ring division. Four had a double aortic arch with an atretic left arch and a left ligamentum, and four had a right aortic arch with aberrant left subclavian artery and a left ligamentum. All eight had successful ring division with symptomatic relief and no mortality. A limited thoracotomy was performed in three patients to divide patent vascular structures, and the hospital period was prolonged in one because of chylothorax. These eight patients were compared with a historical cohort of eight pediatric patients having vascular ring division performed by a conventional thoracotomy. The two groups did not differ in age, weight, intensive care unit or postoperative hospital stay, duration of intubation or thoracostomy tube or hospital charges. Total operating room time was longer for the group undergoing video-assisted operation. CONCLUSIONS: Early results for video-assisted thoracoscopic vascular ring division are comparable to those of the conventional surgical approach. With further refinement in technique and instrumentation, video-assisted surgical intervention may become a viable alternative to open thoracotomy for management of the symptomatic vascular ring.

Echocardiographic predictors of candidacy for successful transcatheter atrial septal defect closure.

We reviewed pre-closure echocardiograms on all patients undergoing transcatheter atrial septal defect (ASD) closure with the Bard double-umbrella occluder device aided by simultaneous transesophageal echocardiography to determine precatheterization predictors of outcome. Transesophageal echocardiograms were performed on 28 of 132 patients (22%) undergoing device closure (age = 3-72 years, mean = 14 years; weight = 15-68 kg, mean = 35 kg). Three devices were removed because of unstable position. Of the remaining 25 patients, 21 had effective closure (residual flow diameter < or = 3 mm) and 18 had favorable arm position (device arm on proper side of the septum and not in contact with an atrioventricular valve leaflet). Only ASD size predicted effective closure. All patients with a maximum defect size of < 13 mm had effective closure. Among the 17 patients with defects > or = 13 mm, 10 had effective closure, 4 had significant residual flow, and 3 had devices removed for unstable position. Atrial dimensions and rim size did not predict effective closure. There were no pre-closure predictors of favorable arm position which was associated only with the size of the device implanted.

Pediatric biplane transesophageal echocardiography: preliminary experience.

Recent development of prototype pediatric biplane transducers has extended the use of biplane TEE imaging to the neonate. One such TEE probe with 64 imaging elements in each pallet was used perioperatively in 46 infants and children (weight 2.9 to 32 kg) undergoing surgery for complex congenital heart disease. The success rate for passing the transducer, complications of the procedure, and the number of cases in which the vertical plane provided information that was not available from the horizontal plane were determined. Probe insertion was successful in all patients. Imaging was discontinued in one neonate because of possible airway compression by the probe. Image quality was excellent in the other 45 patients. The vertical plane added information over that obtained from the horizontal plane in 58 (44%) of the 132 anomalies identified. The addition of the vertical plane was especially useful in imaging abnormalities of the ventricular outflow tracts.

Primary repair of aortopulmonary septal defect, interrupted aortic arch, and anomalous origin of the right pulmonary artery.

Aortopulmonary septal defect, interruption of the aortic arch, and anomalous origin of the right pulmonary artery from the aorta comprised a challenging constellation of defects in a 13-day-old neonate, who underwent complete repair without homograft tissue or synthetic graft. After the aorta was separated from the pulmonary artery, the descending aorta was anastomosed to the septal defect in the ascending aorta. The right pulmonary artery was anastomosed to the septal defect in the main pulmonary artery, anterior to the aorta. The postoperative course was uncomplicated, and the potential for growth of both great vessels was optimized.

Balloon aortic valvuloplasty in the young adult with congenital aortic stenosis.

Although balloon aortic valvuloplasty (BAV) is effective in the acute management of valvar aortic stenosis (AS), sustained benefit of this technique has been shown to vary in differing age groups. The role of BAV in the young adult with congenital, nondegenerative AS is poorly defined. The catheterization results and follow-up echocardiographic data were reviewed for all patients (n = 18) between the ages of 17 and 40 years (mean 23 +/- 7) undergoing BAV at our institution between March 1986 and January 1992. Peak-to-peak systolic ejection gradient was reduced by 55%, from 85 +/- 29 to 38 +/- 17 mm Hg (p < 0.001). Aortic valve area increased from 0.9 +/- 0.2 to 1.1 +/- 0.3 cm2 (p = 0.003). Results of dilation were inadequate in 2 patients. There were no deaths, myocardial infarction, or embolic events. The 16 "effectively" dilated patients were followed with serial echocardiography for a period of 1 to 82 months, demonstrating persistent gradient relief in most patients (maximal instantaneous gradient at follow-up, 55 +/- 17 vs 79 +/- 22 mm Hg before dilation, p < 0.001). Aortic valve replacements were performed in 5 patients, 2 with unsuccessful initial dilations. At the time of the most recent echocardiogram, 8 of 16 patients remained "incident free," with no subsequent catheterization or surgical interventions, a maximal instantaneous gradient of < or = 55 mm Hg, no more than moderate aortic regurgitation, and preserved ventricular function.(ABSTRACT TRUNCATED AT 250 WORDS)

Early bidirectional cavopulmonary shunt in young infants. Postoperative course and early results.

BACKGROUND: Despite the recent wide applicability of the bidirectional cavopulmonary shunt, there is limited reported experience in performing these shunts in infants 6 months or younger. METHODS AND RESULTS: Before October 1992, 17 consecutive infants aged 4.2 to 6.5 months (median, 6.1 months) underwent bidirectional cavopulmonary shunts. The diagnoses were hypoplastic left heart syndrome (n = 7), single right ventricle (n = 5), and single left ventricle (n = 5). All but 2 patients had prior palliative surgery. The bidirectional cavopulmonary shunt was performed early on an elective basis in 9 patients; the remaining patients had progressive cyanosis (6 patients), severe ventricular failure (1 patient), and coexisting restrictive bulboventricular foramen (1 patient). The median preoperative pulmonary arterial pressure and pulmonary vascular resistance were 15 mm Hg and 2.3 U.m2, respectively. One patient died; the overall hospital survival was 94%. The most common postoperative problem was transient systemic hypertension, observed in 14 (88%) of 16 survivors. Systemic arterial oxygen saturation increased from a median of 75% before surgery to a median of 85% after surgery (P < .05). The median hospital stay was 6 days. There were no late deaths during follow-up (median, 12.4 months). At postoperative cardiac catheterization performed in 9 of 16 survivors, there was no evidence of severe hypoxemia, shunt narrowing, or pulmonary arteriovenous fistulas. Of the 16 survivors, 6 have had a subsequent Fontan operation at a median age of 1.9 years; there were 5 survivors. CONCLUSIONS: Early bidirectional cavopulmonary shunt in young infants has shown encouraging early results and provides improved oxygenation with low morbidity and mortality. We speculate that an early bidirectional cavopulmonary shunt on an elective basis may reduce the deleterious sequelae of chronic hypoxemia, long-term ventricular volume overload, and repeated palliative procedures, thus yielding a more suitable Fontan candidate.

Unbiased and unnoticed verbal conditioning: the double agent robot procedure.

Subjects who were told they were "experimenters" attempted to reinforce fluent speech in a supposed subject with whom they spoke via intercom. The supposed subject was to say nouns, one at a time, on request by the "experimenter", who reinforced fluent pronunciation with points. Actually, the "experimenter" was talking to a multi-track tape recording, one track of which contained fluently spoken nouns, the other track containing disfluently spoken nouns. If the "experimenter's" request for the next noun was in a specified form a word from the fluent track was played to him as reinforcement; requests in any other form produced the word from the disfluent track. Repeated conditioning of specific forms of requests was accomplished with two subject-"experimenters," who were unable to describe changes in their own behavior, or the contingencies applied. This technique improved upon an earlier method that had yielded similar results, but was less thoroughly controlled against possible human bias.