[Clinical course following partial cavo-pulmonary bypass: the Geneva experience from 1985 to 2000]. / Evolution après dérivation cavo-pulmonaire partielle: l'expérience genevoise de 1985 à 2000.

Partial cavo-pulmonary bypass (termino-lateral anastomosis between the superior vena cava and one of the pulmonary arteries) is an alternative to total cavo-pulmonary bypass because of a lower morbid-mortality, or a first step to this procedure. The authors report a retrospective study of 35 patients who underwent partial cavo-pulmonary bypass between November 1985 and October 1999 at the Geneva Children's Hospital with an average follow-up of 4 years. The mean age of the patients at the time of surgery was 6.4 years. Fourteen per cent of patients had tricuspid atresia, 37% had a single ventricle, 49% had an irreparable biventricular cardiopathy and 71% had already had a previous palliative procedure. There were 2 early and 6 late deaths. The 5 year survival was 71.2% and the 10 year survival: 62.3%. The commonest early complications were arrhythmias (11/35), chylothorax (9/35) and superior vena cava syndromes (9/35). The late complications observed were arrhythmias (4/35) and suboptimal function of the partial cavo-pulmonary bypass (7/35). Eighty eight per cent of patients were symornatically improved at one year (average NYHA Class 2.8 before and 1.7 after one year), and 40% of patients were asymptomatic at this time. The haematocrit decreased after partial cavo-pulmonary bypass but tended to rise again progressively to preoperative values after 9 years. Only 49% of survivors had not been reoperated 10 years after partial cavo-pulmonary bypass. Partial cavo-pulmonary bypass is therefore associated with a temporary improvement of symptoms and polycythaemia in children with complex cyanotic heart disease: later reoperation is often required.

[False aneurysm complicating ligation of patent ductus arteriosus operated on successfully]. / Faux anévrisme après ligature d'un canal artériel opéré avec succès.

Postoperative aneurysm of ductus arteriosus is a rare complication but may be lethal without treatment. It is less frequent than spontaneous aneurysm of ductus arteriosus. We report the case of 5 years-old girl who underwent a ligation of patent ductus arteriosus complicated, 6 months later, with a false aneurysm of ductus arteriosus and endocarditis of the ductus and the aortic valve. The diagnosis of the aneurysm was suspected on the anteroposterior chest X-ray which showed a left superior mediastinal opacity and confirmed by echocardiography. Through bilateral thoracotomy, an anevrismorraphy and aortic repair was carried out without problem. The postoperative course was unremarkable.

Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy.

Secondary aorto-enteric fistula (AEF) is a serious, but rare, complication following surgery of the abdominal aorta. AEF occurs in 0.3-2%, but is associated with a hospital mortality between 25-90%. It is also associated with an important morbidity with a lower limb amputation rate of 9%, and a 15% risk for renewed graft infection. Nine secondary AEF were surgically treated. The hospital mortality was high,44% (4/9). Recurrent AEF was observed in 1 patient 2 years after the first operation. During follow-up 2 patients had mild infections which were resolved by antibiotic treatment. Diagnostic modalities, and recent advancements in surgical treatment as well as preventive measures are discussed.

Choice of graft material at primary CABG influences cardiac death and reintervention rates.

OBJECTIVES: To evaluate long-term survival and need for reintervention (redo CABG or percutaneous coronary artery transluminal angioplasty, PTCA) as a result of graft materials employed at the primary coronary artery bypass grafting (CABG). SUBJECTS AND METHODS: 2,327 patients who underwent primary CABG between 1980 and 1990 were followed with regard to survival and reintervention requirements for a period of 10 years. There were three groups of patients. In group 1, CABG was performed between 1980 and 1982 using veins only. Group 2 subjects had CABG done from 1983 to 1985 using veins and internal thoracic artery (ITA). Those in group 3 received two ITAs (double ITA) from 1985 to 1990. Redo CABG and PTCS were performed as needed. RESULTS: The 10-year cumulative survival figures for the groups were 92.8 % (group 1), 94.8% (group 2) and 95.4% (group 3). The difference between the groups was statistically significant (p < 0.001). Cardiac event-free survival was 74.4% (group 1), 83.5% (group 2) and 92.6% (group 3), with p < 0.0001. Myocardial infarction occurred more frequently in group 1 (4.7%) than in groups 2 or 3 (2.2 and 1.3%, respectively). The redo rates for CABG were 13.6% (group 1), 8.1% (group 2), and 1.3% (group 3). The corresponding PTCA rates for the three groups were 7.1, 3.7 and 1.6%, respectively (p < 0.0001). CONCLUSIONS: Double ITA, compared with single ITA and/or vein grafts, was the optimal graft material at the time of primary CABG because it had the lowest reintervention rate. It also did not increase postoperative morbidity.

Aortic arch replacement using a four-branched aortic arch graft.

Surgical repair for aortic arch aneurysms is associated with considerable mortality and morbidity. Adequate brain protection is essential. Experience of aortic arch repair in six patients using a four-branched arch graft is described. There were two emergency and three reoperations. One patient had ruptured aneurysm. Hypothermic cardiopulmonary bypass (18-22 degrees C) was employed. A four-branched polymer albumin-coated arch graft was used. The fourth branch of the graft was used for secondary arterial cannulation to ensure continuous brain circulation. One hospital death occurred. No permanent neurological event occurred. The four-branched arch graft facilitates fashioning arch branch anastomoses and provides better brain protection.

Impact of double internal thoracic artery grafts on long-term outcomes in coronary artery bypass grafting.

We performed this study to determine if bilateral internal thoracic artery grafts provide greater benefit than single internal thoracic artery grafts. Six hundred ninety-four consecutive patients who received 2 coronary grafts in a single operation during 1983-1989 were given 10 years of follow-up and then analyzed retrospectively. Group 1 (n=382) received 2 internal thoracic artery grafts, Group 2 (n= 139) received 1 internal thoracic artery graft and 1 saphenous vein graft, and Group 3 (n= 173) received 2 saphenous vein grafts. Patient demographics, preoperative angiographic findings, and operative indications were the same. Hospital mortality rates were 2.6%, 2.2%, and 2.3%, respectively. Hemorrhage, sternal wound infection, mediastinitis, sternal dehiscence, and prolonged ventilatory support showed no group differences. Follow-up over 10 years was complete in 677 survivors. Mortality rates during follow-up were 1.8%, 2.9%, and 4.7%, respectively. Cardiac-related mortality rates were 71%, 75%, and 88%, respectively (Group 1 vs Group 3, P=0.0412). Ten-year survival was better for Group 1 than for Groups 2 and 3 (P=0.0356 and P <0.0001). Cardiac-event-free survival at 10 years was 93% in Group 1, 84% in Group 2, and 74% in Group 3 (all P <0.0001). The use of 2 internal thoracic artery grafts resulted in significantly lower risk of cardiac death and re-intervention, compared with the use of 1 internal thoracic artery, which in turn was superior to the use of vein grafts. Use of double internal thoracic arteries did not increase postoperative complications.

Obtaining a superficial femoral artery graft in adolescents and children with the deep femoral artery transposition.

A new technique to obtain a segment of the superficial femoral artery as an arterial conduit in young patients while an unobstructed peripheral blood flow is maintained by superficial femoral artery-deep femoral artery transposition is illustrated with two clinical examples. The explanted arterial autograft requires no replacement by another graft and provides a conduit of up to 10 cm in length. Excellent results were achieved in both patients at 1 year. This technique is recommended instead of saphenous vein conduits in very young patients because of the risk for late vein degeneration.

Cardiac sarcoma originating from the tricuspid valve.

Primary cardiac sarcomas are uncommon. We report an unusual presentation of a cardiac sarcoma that originated from the posterior leaflet of the tricuspid valve. This tumor, which provided a working diagnosis of tricuspid valve myxoma before and during surgery, should be considered in the differential diagnosis of right atrial and ventricular masses.

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

[Follow-up of patients treated by conduits between the right ventricle and the pulmonary artery]. / Suivi des patients traités par conduits entre le ventricule droit et l'artère pulmonaire.

Between 1981 and 1998, 77 right ventricle-pulmonary artery conduits were implanted in 67 patients (37 boys, 30 girls, average age 6.3 years; range: 3 months to 17 years). The diagnoses were transposition of the great arteries with ventricular septal defect and obstruction of the pulmonary outflow tract (N = 22), tetralogy of Fallot (N = 16), truncus arteriosus (N = 9), double outlet right ventricle with pulmonary stenosis or atresia (N = 8) and agenesis of the pulmonary valve with pulmonary stenosis (N = 2). The implanted conduits were homografts in 50 cases (43 aortic and 7 pulmonary), 11 valved Dacron grafts, 4 valved polystans grafts and 2 non-valved conduits. The average follow-up period was 3.6 years (range: 1 month to 17 years). Early death was observed in 8 patients (12%) and late death in 6 patients (9%). The 5, 10 and 15 year survival rates were 78.4%, 65.3%, and 65.3%, respectively. The conduits had to be replaced in 10 patients (15%). The non-replacement rate of all conduits at 5, 10 and 15 years was 81.4%; 40.7% and 40.7%, respectively. The causes of replacement were pure stenosis (54.5%), pure regurgitation (9%) and mixed stenosis and regurgitation (27.2%). These results are comparable to other published series showing a 15 year survival rate of 65% and a 59% reoperation rate at 15 years. Homografts have a slightly longer life compared with valved Dacron conduits but the difference is not statistically significant.

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.

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.

Paediatric living related intestinal transplantation between two monozygotic twins: a 1-year follow-up.

We report on a syngeneic living related intestinal transplant in a paediatric setting with a 1-year follow-up. This procedure has allowed progressive growth and weight gain of a recipient patient and a resumption of normal activities with full social and familial reintegration.

Interventional catheterization in surgically treated patients with congenital heart disease.

Interventional catheterization is an alternative to surgery for some congenital heart defects. For other malformations, the surgeon and the interventionist will join in an effort to obtain an optimal result: the typical example is pulmonary atresia with VSD and aortopulmonary collaterals. In other cases, the cardiologist may be called upon to intervene with catheter techniques to correct sequelae or residual lesions after surgical correction, avoiding redo surgery. Most often, the task consists of opening stenoses by balloon dilatation and/or stenting the main targets being pulmonary artery branch stenoses, venous obstructions after Mustard procedure, and recoarctations. Whereas simple balloon dilatation of recoarctation often brings good results, stents are often needed to obtain optimal results in pulmonary branch stenoses. Stenting of pulmonary veins has been disappointing. Closing unwanted vessels and defects is another task for the interventional cardiologist after cardiac surgery. Here, the most frequent procedure is closing aortopulmonary collaterals in pulmonary atresia and VSD after corrective surgery. Advantages and limitations of these procedures are discussed.

Systemic pulmonary artery shunt using a bovine mesenteric venous graft in newborns.

A new bovine mesenteric venous graft 3 or 4 mm in diameter was used for performing systemic pulmonary artery shunts in six cyanotic newborns (aged 2 to 30 days) from March 1997 onward. Clinical and echocardiographic studies proved that all shunts were patent and functioning well after an average of 8.8 months despite no postoperative anticoagulation or antiplatelet regimen. Histological examination of two grafts explanted at the time of bidirectional cavopulmonary anastomosis showed no dense fibrotic mural infiltration, calcification, or anastomotic hyperplasia. Bovine mesenteric venous grafts can be used for the construction of systemic pulmonary artery shunts with advantages similar to that of human vein allografts, such as the facility of implantation, good short- and mid-term patency, easy takedown, and avoidance of complications presumably specific to polytetrafluoroethylene.

Aorta-cutaneous fistula as a rare complication of localized chronic mediastinitis.

A 35-year-old man was admitted 5 years after congenital heart surgery complicated by Staphylococcus aureus and a cutaneous fistula located at the left fourth intercostal space. He was febrile (40 degrees C), suffering from sternal pain and suppuration from the old fistula. During examination arterial blood suddenly discharged from the fistula, so that surgery was immediately instituted. An infected Dacron tube implanting on the ascending aorta for a central aorto-pulmonary shunt was at the origin of a false aneurysm: this had led to the repeat formation of an aorta-cutaneous fistula and outbreak of external bleeding.