Retrograde cerebral perfusion for brain protection in aortic aneurysm surgery.

INTRODUCTION: Retrograde cerebral perfusion is used as an adjunct to deep hypothermic circulatory arrest (DHCA) for cerebral protection while dealing with complex aortic lesions. PATIENTS AND METHODS: Sixty-six patients, operated for aneurysms of the aorta using DHCA, were studied. In 52 patients, retrograde cerebral perfusion was used as an adjunct to DHCA for cerebral protection. Forty patients were subjected to surgical correction of ascending aorta lesions, 10 were operated for ascending aorta and arch lesions, eight had distal arch aneurysm repair and eight had surgery for thoracoabdominal aortic aneurysms. RESULTS: Neurologic dysfunction was reported in 6% of patients. No neurologic complications were reported in any patient who had retrograde cerebral perfusion during the circulatory arrest period. CONCLUSION: A major limitation of DHCA is the time constraint imposed, beyond which DHCA in isolation may not be safe. Considering the simplicity and safety involved, more liberal use of retrograde cerebral perfusion as an adjunct to DHCA is advocated.

Specific issues after surgical repair of partial atrioventricular septal defect: actuarial survival, freedom from reoperation, fate of the left atrioventricular valve, prevalence of left ventricular outflow tract obstruction, and other events.

OBJECTIVE: Our aim was to define the prevalence of specific sequelae after repair of partial atrioventricular septal defect. PATIENTS AND METHODS: A total of 132 consecutive patients undergoing repair of partial atrioventricular septal defect were studied for mortality, left atrioventricular valve function, reoperations, left ventricular outflow tract obstruction, and supraventricular arrhythmias. Age was 2.5 months to 43 years (median, 54 months); 13 (9.8%) were more than 20 years old. Preoperatively, 26.5% patients were in New York Heart Association class III/IV, 15.9% had supraventricular arrhythmias, 25.7% had pulmonary artery hypertension, 16.6% had moderate-to-severe left valvular regurgitation, and 29.5% had additional left atrioventricular valvular malformations. Autologous pericardium (n = 127) and right atrial patch (n = 5) were used to patch the defect. Left atrioventricular valvuloplasty was performed in 91% of patients despite older age and additional malformations of the left atrioventricular valve. RESULTS: Operative and late mortalities were 4.5% and 3.2%, respectively. Postoperative supraventricular arrhythmias were observed in 11.3% of patients. Reoperations were required in 5.8% patients because of a residual atrial septal defect (n = 1) and severe left atrioventricular valvular regurgitation (n = 6). At a mean follow-up of 106.82 +/-55.04 months, actuarial survival was 83.70% +/- 0.07%. The risk of death was 38.92 (95% confidence intervals: 7.8-195.1) and 6.88 (95% confidence intervals: 1.79-38.18) times higher in patients with grossly malformed left atrioventricular valve and preoperative pulmonary artery hypertension, respectively, by logistic regression analysis. CONCLUSIONS: Detailed assessment of the valve morphology and individualized valvuloplasty techniques improves the long-term survival after repair of partial atrioventricular septal defects. The presence of grossly malformed left valvular apparatus, pulmonary artery hypertension, and moderate-to-severe left atrioventricular valve regurgitation are independent predictors of death and defect-related morbidity after surgical repair.

Histopathologic changes in ascending aorta and risk factors related to histopathologic conditions and aortic dilatation in patients with tetralogy of Fallot.

OBJECTIVE: The purposes of this study were to evaluate the histologic characteristics of the aortic wall and the risk factors related to histopathology and aortic dilatation in patients undergoing intracardiac repair of tetralogy of Fallot. METHODS: Operatively excised full-thickness aortic wall tissue from 98 consecutive patients undergoing intracardiac repair of tetralogy of Fallot aged 6 months to 47 years (mean 104.5 +/- 102.8 months; median 72 months) were studied by light microscopy. The receiver operating characteristic curve analysis was done to quantify the diagnostic accuracy of loss of lamellar counts and multiple logistic regression models. RESULTS: Twenty-five (25.5%) aortic tissue specimens were indicated as histologically normal and were used as normal controls. The incidence of elastic fragmentation, increased ground substance, medionecrosis, smooth muscle disarray, and fibrosis was 74.5%, 54%, 39.8%, 26.5%, and 57.1%, respectively. A lamellar count of less than 60 was associated with a sensitivity of 80% and a specificity of 87.67%. Area under the receiver operating characteristic curve indicated that 93.37% (standard error +/- 0.039) of the time the value of lamellar count was lower for the abnormal histopathology group than for the normal group (P < .001). The risk of aortic dilatation was 15.97 times higher in patients with histopathologically abnormal aorta. CONCLUSIONS: The majority of aortic media of the ascending aorta in cyanotic tetralogy of Fallot indicates significant loss of lamellar units and pre-existing intrinsic aortopathy. The changes are present since infancy and are more pronounced in older patients subjected to long-standing cyanosis and volume overload and may account for or may coexist with the higher incidence of aortic dilatation encountered in these patients.

Mixed total anomalous pulmonary venous connection: anatomic variations, surgical approach, techniques, and results.

OBJECTIVE: The purpose of this study was to identify the morphologic characteristics and other risk factors that may predispose patients with mixed totally anomalous pulmonary venous connection to continuing high mortality after surgery. METHODS: Fifty-seven consecutive patients aged 15 days to 18 years (median, 6 months) underwent rechanneling of mixed totally anomalous pulmonary venous connection. Twenty-three patients had "2+2" pattern (I category), 29 had "3+1" pattern (II category), and 5 patients had pulmonary venous connections of different combinations (III category). Obstructive patterns involving one or more pulmonary veins were present in 19 (33.3%) patients. RESULTS: Operative and late mortality rates were 19.3% and 4.3%, respectively. At a mean follow-up of 63.26 +/- 58.47 months, actuarial survival was 86.9% +/- 0.07% in category I, 86.2% +/- 0.06% in category II, and 20.0% +/- 0.18% in category III (log-rank, P = .001), respectively. At their last follow-up, all survivors (n = 43) had a Ross clinical heart failure score of 0 to 2. CONCLUSIONS: Patients with a "2+2" pattern of mixed totally anomalous pulmonary venous connection constitute the safe anatomic category for rechanneling, followed by the "3+1" variety. Cross-sectional echocardiography and/or computed tomographic angiography are mandatory to provide necessary diagnostic information and define the anatomy. Patients aged 2 months or younger, obstructive totally anomalous pulmonary venous connection, and perioperative pulmonary hypertensive crises were significant risk factors for death by logistic regression analysis. The risk of death was 5.85 times higher (95% confidence interval: 1.46-35.68; P = .02) in patients with category III of mixed TAPVC. The precise technique adopted in an individual patient depends on the pattern of anatomic drainage, and an individualized surgical approach is recommended.

Application of stem cell technology for coronary artery disease at the All India Institute of Medical Sciences, New Delhi, India.

Stem cell technology is rapidly gaining popularity as a way to improve the prognosis of patients with coronary artery disease and heart failure. In this review, we systematically analyze the basis, methods, and results of stem cell technology for coronary artery disease at the All India Institute of Medical Sciences, New Delhi, India.

A suggested new surgical classification for mixed totally anomalous pulmonary venous connection.

The morphologic variations of mixed totally anomalous pulmonary venous connection are many and varied. In this review, we give an account of all cases previously described as mixed totally anomalous pulmonary venous connection, analyzing in detail those cases where an accurate anatomical description was provided. We identified 182 suitable cases, from 54 investigations, and reviewed the clinical presentation, anatomic variations, diagnostic features, and management of the patients described.Cross-sectional echocardiography, and cardiac catheterization, provided the necessary diagnostic information, and defined the anatomy before surgery in 139 patients. Magnetic resonance imaging and computerized tomographic angiography had been used for further clarification of the pulmonary venous anatomy. An obstructive pattern of drainage, involving one or more pulmonary veins, had been described in over half of the patients. We then grouped the lesions into categories that have a bearing on the appropriate surgical approach, discussing the appropriate repair for each group. For the overall group, the operative mortality remains high, at 22.9%. We submit that an increased appreciation of various types of mixed totally anomalous pulmonary venous connection may well contribute to improved future surgical management.

A novel percutaneously adjustable device for ligature of the vertical vein in the setting of obstructive totally anomalous pulmonary venous connection.

BACKGROUND: A patent vertical vein might be desirable in patients with obstructive totally anomalous pulmonary venous connection with pulmonary hypertension, in order to decrease perioperative pulmonary arterial pressure and avoid pulmonary hypertensive crises. A subset of patients with an unligated vertical vein requires interruption of the vein due to the development of significant left-to-right shunt and right heart failure. We describe here a new device, permitting adjustable ligation of the vertical vein, which permits us to avoid multiple reoperations. PATIENTS AND METHODS: In five patients, aged 2, 4, 3, 4, and 3 months respectively, and undergoing rechannelling of totally anomalous pulmonary venous connection with an unligated vertical vein, were treated with a device permitting adjusted ligation of the vertical vein over the course of postoperative congestive cardiac failure. RESULTS: There was no early or late death. Postoperatively, all ligatures were tightened gradually over a period of 24 to 96 hours, maintaining stable haemodynamics. At a mean follow-up of 55.40 months, there was no evidence of congestive heart failure in any patient, the clinical risk score varying from zero to 2, and no requirement of anti-failure medications. Computed tomographic angiograms during follow-up revealed absence of flow through the vertical vein, and ruled out distortion of the left upper pulmonary and left brachiocephalic veins. CONCLUSION: Use of a percutaneously adjustable device to ligate the vertical vein allows gradual tightening or loosening of the ligature under optimal physiologic conditions, without re-opening the sternum, or having to resort to another thoracotomy once the reactive components of pulmonary hypertension disappear.

Rechanneling of total anomalous pulmonary venous connection with or without vertical vein ligation: results and guidelines for candidate selection.

OBJECTIVE: This study investigated whether postoperative low cardiac output and mortality in obstructed total anomalous pulmonary venous connection could be reduced by selective vertical vein patency. METHODS: Fifty-eight patients undergoing rechanneling of total anomalous pulmonary venous connection between 1997 and 2006 were studied. The vertical vein was left patent in 27 patients (group I) and ligated in 31 (group II). Mean ages were 1.49 +/- 1.63 and 4.37 +/- 3.38 months for groups I and II, respectively. RESULTS: Operative mortalities were 29.1% and 7.4% for ligated and unligated groups, respectively (relative risk 1.75, 1.16-2.64, P = .036). Age younger than 1 month, obstructive total anomalous pulmonary venous connection, hypoplastic pulmonary veins, pulmonary hypertensive crisis, low cardiac output, and vertical vein ligation were significant risk factors for death according to logistic regression analysis. Patients with obstructed total anomalous pulmonary venous connection undergoing vertical vein ligation demonstrated predominant right ventricular dysfunction (relative risk 2.93, 1.28-6.73, P = .011), pulmonary hypertensive crisis (relative risk 2.90, 1.25-6.75, P = .013), and 3.28 times the risk of death (95% confidence interval 1.08-9.99, P = .032) relative to the unligated group. CONCLUSIONS: In a subset of patients with obstructed total anomalous pulmonary venous connection, an unligated vertical vein reduces pulmonary arterial pressure, decreases perioperative pulmonary hypertensive crises, provides a temporary pop-off valve during pulmonary hypertensive crisis, and improves survival by providing superior hemodynamics. The high mortality in the ligated group suggests that patients with obstructed total anomalous pulmonary venous connection with postbypass moderate pulmonary hypertension possibly should not undergo vertical vein ligation. We propose routine use of an adjustable ligature around the vertical vein in all patients with more than moderate post-bypass pulmonary hypertension, allowing gradual tightening in increments without multiple reoperations.

Novel techniques for tumor thrombectomy for renal cell carcinoma with intraatrial tumor thrombus.

BACKGROUND: Radical nephrectomy with tumor thrombectomy in patients with renal cell carcinoma and level I to III thrombus extension is directly associated with an improved prognosis. However, radical surgery in patients with level IV thrombus extension is associated with high perioperative mortality, even if long-term survival is possible. In this report, we describe an alternative technique of vena caval and intraatrial tumor thrombectomy to decrease perioperative mortality and morbidity. METHODS: A cohort of 6 patients aged 46, 50, 53, 56, 54, and 52 years underwent radical nephrectomy with tumor thrombectomy from the vena cava and right atrium under mild hypothermic cardiopulmonary bypass and intermittent cross-clamping of the supraceliac abdominal aorta. Intraatrial tumor thrombectomy was performed on a beating, perfused heart in 4 patients and a hypothermic, cardioplegia-perfused heart in 2 patients. RESULTS: There were no early or late deaths. The aortic cross-clamp time was 12 and 15 minutes for patients 5 and 6, respectively. The cumulative hepatic and renal ischemic time was 16 minutes (range, 14 to 22 minutes) at 32 degrees C. The mean cardiopulmonary bypass time was 53.3 +/- 8.9 minutes (range, 40 to 65 minutes). At a mean follow-up of 43 +/- 24.6 months (range, 10 to 70 months), all patients are active and remain disease-free. CONCLUSIONS: We conclude that radical nephrectomy and tumor thrombectomy in patients with level IV thrombi can be safely performed with cardiopulmonary bypass, mild hypothermia. and intermittent supraceliac abdominal aortic occlusion, avoiding potential hematologic, hepatic, renal, neurologic, and septic complications associated with circulatory arrest.

A simplified circuit of modified ultrafiltration.

A simplified circuit of modified ultrafiltration (MUF) is described. The technique described is simple, inexpensive, allows both conventional ultrafiltration (CUF) and modified ultrafiltration with minimum manipulation of the circuit, allows re-institution of cardiopulmonary bypass (CPB) in an emergency, reduces the risk of air embolism and air cavitation and can be used in adults as well as children.

Primary repair of d-transposition with complete atrioventricular canal defect.

A 4-month-old boy underwent successful single-stage anatomic repair of d-transposition of the great arteries with complete balanced atrioventricular canal defect, using the arterial switch procedure and two-patch repair of the atrioventricular canal defect. He had associated persistent left superior vena cava draining to the coronary sinus, and a patent ductus arteriosus.

Anomalous right subclavian artery proximal to juxtaductal coarctation.

Two patients with anomalous right subclavian artery proximal to aortic coarctation are reported for their rarity. The embryological basis and surgical implications are briefly discussed. The major surgical implication of this anomaly relates to the risk of spinal cord ischemia and in these cases, the repair was performed safely.

Serial radionuclide angiographic assessment of left ventricular ejection fraction and regional wall motion after mitral valve replacement in patients with rheumatic disease.

BACKGROUND: This study was designed to prospectively investigate the effects of total or partial chordal-sparing and chordal-nonsparing mitral valve replacement (MVR) procedures on regional and global ventricular function in a rheumatic population using sequential multiple-gated acquisition scan. METHODS: One hundred five consecutive patients undergoing different techniques of chordal preservation procedures during MVR are included in this prospective study. Fifteen patients had complete excision of the chordopapillary apparatus (group 1), 34 had total chordal preservation (group 2), and 56 had preservation of the posterior chordopapillary apparatus (group 3). Radionuclide-derived left ventricular ejection fraction (LVEF) and regional wall motion (RWM) studies on 99 survivors were performed preoperatively, at discharge, at 1 year, and at 2 years. RESULTS: At discharge, there was a decline in LVEF in all the 3 groups. Statistically significant improvement in ejection fraction occurred in the chordal preservation groups (2 and 3) (P < .05) as compared with the nonchordal group immediately and late postoperatively. Only the total chordal group (2) demonstrated complete recovery of LVEF by 2 years postoperatively. Significant and persistent RWM abnormalities were noted in both the nonchordal and posterior chordal groups. CONCLUSIONS: We conclude that complete retention of the chordopapillary apparatus during MVR provides superior results compared with nonchordal and partial chordal preservation in terms of preservation of LVEF and reduced incidence of abnormal postoperative RWM.

Criterions for selection of patients for, and results of, a new technique for construction of the modified Blalock-Taussig shunt.

BACKGROUND: We describe alternative surgical techniques for construction of systemic-to-pulmonary arterial shunts, and propose criterions for their application in selected patients. PATIENTS AND METHODS: We constructed a variety of modified systemic-to-pulmonary arterial shunts, using polytetrafluoroethylene grafts, in 92 selected patients with cyanotic congenital heart disease and anomalies of the aortic arch and systemic veins. Their age ranged from 7 days to 3.6 years, with a mean of 7.08 months. We performed 88 operations through a thoracotomy. Of this cohort, 60 patients underwent a second-stage operation, with 15 receiving a superior cavopulmonary connection, 16 a total cavopulmonary connection, and 29 proceeding to biventricular repair after a mean interval of 15.6 months. We have 21 patients awaiting their second or final stage of palliation. RESULTS: There were five early (5.4%) and six late deaths (6.8%), two of which were related to construction of the shunts. At a mean follow-up of 45.29 months, the increase in diameter of pulmonary trunk and its right and left branches was uniform and significant (p value less than 0.001). Pulmonary arterial distortion requiring correction at the time of second-stage operation was observed in 5 patients (6.1%). Adequate overall palliation was achieved in 98% of the cohort at 8 months, 91% at 12 months, and 58% at 18 months. CONCLUSIONS: Patients with a right- or left-sided aortic arch and right-sided descending thoracic aorta, those with anomalies of systemic venous drainage masking the origin of great arterial branches, and those with disproportionately small subclavian arteries, constitute the ideal candidates for our suggested modification of the construction of a modified Blalock-Taussig shunt. The palliation provided by these shunts was satisfactory, with predictable growth of pulmonary arteries, insignificant distortion in the great majority, and easy take-down.

Total transatrial correction of tetralogy of Fallot: no outflow patch technique.

BACKGROUND: The aim of this study was to analyze the feasibility and early results of transatrial total correction of tetralogy of Fallot (TOF). METHODS: Of the 860 patients undergoing total correction for TOF between January 2000 and July 2005, 334 patients were considered morphologically suitable for transatrial total correction. The ventricular septal defect (VSD) closure, infundibular resection, and pulmonary valvotomy were performed through the right atrium without a right ventriculotomy. Age ranged from 6 months to 40 years (median, 2.8 years), and weight ranged from 5.5 to 70 kg (median, 14 kg). RESULTS: Peroperatively, 34 patients required right ventriculotomy and transannular patch; hence, they were excluded from the study. In addition, pulmonary arteriotomy was required in 71 patients (22.9%). There were 4 hospital deaths. There were 4 early reoperations (residual/additional VSD in 3 and tricuspid regurgitation in 1). Two patients had complete heart block requiring permanent pacemaker. Echocardiography at discharge showed a peak right ventricular outflow tract gradient of 20 +/- 5.2 mm Hg. Mean follow-up was 26.8 +/- 4.2 months (range, 1 to 52 months). The right ventricular outflow tract gradients reduced to 13 +/- 4.2 mm Hg after a mean interval of 18.8 +/- 5.2 months. Follow-up New York Heart Association class was I in 240 cases (82%), II in 49 (16%), and III in 7 (2%). There were no late deaths or reoperations. CONCLUSIONS: Transatrial total correction of TOF can be accomplished in selected patients with good early results. In 300 cases (90%), the feasibility of transatrial total correction could be predicted accurately.

Histopathology of the right ventricular outflow tract and its relationship to clinical outcomes and arrhythmias in patients with tetralogy of Fallot.

OBJECTIVES: The purposes of this study were to evaluate the myocardial histopathology and ultrastructure in patients with tetralogy of Fallot and to identify the histopathologic characteristics that may predispose patients to postoperative myocardial dysfunction and arrhythmias. PATIENTS AND METHODS: Operatively resected crista supraventricularis muscle from 183 patients undergoing intracardiac repair of tetralogy of Fallot aged 12 months to 42 years (mean, 106.84 +/- 79.35 months) were studied by light and electron microscopy. Biventricular function and cardiac rhythm were assessed by 2-dimensional echocardiography and electrocardiography. RESULTS: The incidence of moderate or severe cellular hypertrophy, endocardial thickening, and interstitial fibrosis was 36%, 68.3%, and 65%, respectively. Logistic regression analysis demonstrated age greater than 4 years, systemic arterial desaturation, higher hematocrit values, and elevated ventricular end-diastolic pressures as the major predisposing risk factors for pathologic changes. Twenty-seven (81.8%) patients more than 15 years of age and 29 (29.3%) patients between 4 and 15 years of age had predominant right ventricular dysfunction and low cardiac output (chi(2) [1 degree of freedom (df)] = 27.95; P < .001; odds ratio [OR] = 10.86 [3.75-33.10]). Ventricular arrhythmia was detected in 11 patients in whom repair was performed between 4 and 15 years of age and in 13 patients whose age at operation was 15 years or older. According to an additive logistic model, the effect of age at repair on the influence of ventricular arrhythmia was significant (chi(2) [1 df] = 24.4; P < .001; OR = 8.21 (2.96-23.11]). CONCLUSIONS: The great majority of myocardial tissues in cyanotic tetralogy of Fallot indicates pre-existing ultrastructural hypertrophic and degenerative changes. The changes are more pronounced in older patients subjected to long-standing cyanosis and pressure overload and may account for or may coexist with the higher incidence of myocardial dysfunction and ventricular arrhythmia.

Mitral stenosis after Duran ring annuloplasty for non-rheumatic mitral regurgitation--a foreign body response?

We report two cases of mitral stenosis after Duran ring annuloplasty for myxomatous mitral regurgitation. Simple explantation of the ring provided relief of mitral stenosis.