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2.
Artigo em Inglês | MEDLINE | ID: mdl-29310555

RESUMO

BACKGROUND: Mechanical circulatory support (MCS) of a failing Fontan circulation remains challenging. We hypothesized that MCS can be provided by converting the Fontan circulation into a mechanically assisted single ventricle parallel circulation (MASVC). METHODS: A porcine model of functionally univentricular circulation was created under cardiopulmonary bypass (CPB) by performing an atrial septectomy, tricuspid valvectomy, and interrupting antegrade pulmonary blood flow. A centrifugal flow pump was placed with inflow from the common atrium. Eight millimeter Dacron grafts anastomosed to the ascending aorta and main pulmonary artery supplied systemic (Qs) and pulmonary (Qp) blood flow. Ultrasonic flow probes were used to measure Qs and Qp after weaning from CPB. The Qp/Qs ratio was regulated using an adjustable clamp. Hemodynamic and laboratory data were recorded. RESULTS: All four animals were successfully weaned from CPB onto the MASVC for a duration of two hours. Mechanically assisted single ventricle parallel circulation achieved satisfactory hemodynamics. As anticipated, the arterial oxygen saturation and partial pressure of oxygen in arterial blood were lower in the MASVC compared to baseline biventricular circulation. At the conclusion of the study, there was a trend towards a decrease in the mixed venous saturation with increasing oxygen extraction compared to the baseline. Serum lactate levels increased after weaning from CPB and did not return to baseline after two hours of support. CONCLUSION: Mechanically assisted single ventricle parallel circulation can be established in a single ventricle animal model. This strategy could potentially provide MCS of a single ventricle circulation. Studies with longer duration of support are required to assess adequacy of support and long-term sustainability.


Assuntos
Ventrículos do Coração/anormalidades , Animais , Ponte Cardiopulmonar , Modelos Animais de Doenças , Técnica de Fontan , Ventrículos do Coração/cirurgia , Humanos , Sus scrofa
3.
Artigo em Inglês | MEDLINE | ID: mdl-27979912

RESUMO

BACKGROUND: Intra-atrial reentrant tachycardia (IART) after the Fontan operation had an early reported incidence of 10% to 35% during early and intermediate follow-up and posed substantial management challenges. METHODS AND RESULTS: To reduce the incidence of IART after the Fontan procedure, we performed a randomized, double-blind study to evaluate the impact of an incision in the right atrium joining the lateral tunnel suture line and the tricuspid valve annulus. Between March 1998 and September 2003, 134 subjects (median age: 1.8 years; range: 1.3-5.2 years; 91 men) were randomly assigned to receive the incision. All 134 patients had a form of single ventricle pathological anatomy. The clinical course, electrocardiograms, and Holter monitoring were available for review in 114 subjects at a median of 8.2-year follow-up (range: 0.9-11.9 years). There were 2 late deaths, neither subject had IART. The combined incidence of sustained IART was 3.5% (4/114). There was no difference in the occurrence of sustained IART between those subjects receiving the incision and those who did not (2 in each group) during follow-up. No patients of either group experienced short-term complications. CONCLUSIONS: Despite the fact that the primary outcome of this trial was not reached, the most significant finding was that with current management, the incidence of IART is considerably lower than the early retrospective, observational studies suggested.


Assuntos
Técnica de Fontan , Cardiopatias Congênitas/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Taquicardia por Reentrada no Nó Sinoatrial/etiologia , Taquicardia por Reentrada no Nó Sinoatrial/prevenção & controle , Método Duplo-Cego , Eletrocardiografia , Eletrocardiografia Ambulatorial , Feminino , Seguimentos , Sistema de Condução Cardíaco/fisiopatologia , Humanos , Incidência , Recém-Nascido , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Taquicardia por Reentrada no Nó Sinoatrial/epidemiologia
5.
Ann Thorac Surg ; 102(2): 602-7, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27154149

RESUMO

BACKGROUND: The optimal choice for pulmonary valve replacement (PVR) remains controversial. This study hypothesized that xenografts used for PVR would result in prolonged long-term survival and freedom from reoperation. METHODS: Children and adults with congenital heart disease requiring PVR using a xenograft from 1980 to 1985 were reviewed. In all cases, the xenograft valve was either sewn or manufactured into a Dacron conduit, and the conduit was sewn to the pulmonary artery bifurcation. Clinical data were analyzed, and survival and freedom from reoperation were determined using Kaplan-Meier analysis. RESULTS: Twenty-four patients received a xenograft for PVR at 14.6 ± 5.6 years. Conduit size ranged from 21 to 27 mm. Most patients received a Carpentier-Edwards valved conduit (n = 17), followed by a Hancock valved conduit (n = 5) and an Ionescu-Shiley valve sewn into a Dacron graft (n = 2). No perioperative deaths occurred. Reoperation was required mainly for pulmonary stenosis (72.7%), followed by pulmonary insufficiency (18.2%), or both stenosis and insufficiency (9%). Freedom from reoperation was 90%, 56%, 43%, and 14% at 10, 20, 25, and 30 years, respectively. At most recent follow-up the was only death, which was related to severe biventricular failure 25 years after conduit implant. CONCLUSIONS: PVR using a xenograft valved conduit results in prolonged freedom from reoperation and excellent long-term survival. These data, which provide long-term follow-up information on xenograft valves after PVR.


Assuntos
Bioprótese , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias/mortalidade , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Adolescente , Cateterismo Cardíaco , Criança , Ecocardiografia , Feminino , Seguimentos , Xenoenxertos , Humanos , Masculino , Desenho de Prótese , Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/diagnóstico , Insuficiência da Valva Pulmonar/mortalidade , Reoperação , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estudos de Tempo e Movimento , Estados Unidos/epidemiologia
6.
Cardiol Young ; 26(8): 1471-1473, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28148324

RESUMO

Congenital heart surgery has evolved into its own specialty requiring unique techniques and skills. Recognizing the need to establish a special certification in congenital heart surgery, the American Board of Thoracic Surgery began the process in 2005, eventually granting the first certifications to qualified applicants in 2009. The American Council for Graduate Medical Education and the Thoracic Surgery Residency Review Committee have now approved specific training programs throughout the United States that will help to ensure the proper training of congenital heart surgeons for the future.


Assuntos
Certificação/normas , Educação de Pós-Graduação em Medicina/normas , Pediatria/educação , Cirurgia Torácica/educação , Cardiopatias Congênitas/cirurgia , Humanos , Estados Unidos
7.
Semin Thorac Cardiovasc Surg ; 28(3): 705-711, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28285677

RESUMO

In 1928, the University of Michigan opened its thoracic surgery residency under the leadership of Dr John Alexander. Initially tasked with providing surgical care for patients with thoracic diseases such as tuberculosis, thoracic surgery subspecialties now provide surgical treatment for a spectrum of diseases, ranging from congenital cardiopulmonary abnormalities to thoracic malignancy to acquired heart and great vessel diseases. Both the residency and the medical center have evolved to mirror the changing practice of thoracic surgery.


Assuntos
Centros Médicos Acadêmicos , Procedimentos Cirúrgicos Cardíacos , Cardiologia , Cardiopatias/cirurgia , Cirurgia Torácica , Centros Médicos Acadêmicos/história , Procedimentos Cirúrgicos Cardíacos/educação , Procedimentos Cirúrgicos Cardíacos/história , Cardiologia/educação , Cardiologia/história , Difusão de Inovações , Educação de Pós-Graduação em Medicina , Cardiopatias/história , História do Século XX , História do Século XXI , Humanos , Internato e Residência , Michigan , Cirurgia Torácica/educação , Cirurgia Torácica/história
8.
Ann Thorac Surg ; 100(4): 1416-21, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26184555

RESUMO

BACKGROUND: There is an increasing focus on optimizing health care quality and reducing costs. The care of children undergoing heart surgery requires significant investment of resources, and it remains unclear how costs of care relate to quality. We evaluated this relationship across a multicenter cohort. METHODS: Clinical data from The Society of Thoracic Surgeons Database were merged with cost data from the Pediatric Health Information Systems Database for children undergoing heart surgery (2006 to 2010). Hospital-level costs were modeled using Bayesian hierarchical methods adjusting for case-mix, and hospitals were categorized into cost tertiles. The primary quality metric evaluated was in-hospital mortality. RESULTS: Overall, 27 hospitals (30,670 patients) were included. Median adjusted cost per case was $82,360 and varied fivefold across hospitals, while median adjusted mortality was 3.4% and ranged from 2.4% to 5.0% across hospitals. Overall, hospitals in the lowest cost tertile had significantly lower adjusted mortality rates compared with the middle and high cost tertiles (2.5% vs 3.8% and 3.5%, respectively, both p < 0.001). When assessed at the individual hospital level, most (75%) but not all hospitals in the lowest cost tertile were also in the lowest mortality tertile. Similar relationships were seen across the spectrum of surgical complexity. Lower cost hospitals also had shorter length of stay and trends toward fewer major complications. CONCLUSIONS: Lowest cost hospitals generally deliver the highest quality care for children undergoing heart surgery, although there is some variation in this relationship. This information is important in the design of initiatives aiming to optimize health care value in this population.


Assuntos
Procedimentos Cirúrgicos Cardíacos/economia , Procedimentos Cirúrgicos Cardíacos/normas , Custos Hospitalares , Qualidade da Assistência à Saúde , Pré-Escolar , Humanos , Lactente , Recém-Nascido
9.
Artigo em Inglês | MEDLINE | ID: mdl-25939841

RESUMO

Congenitally corrected transposition of the great arteries or l-transposition of the great arteries is characterized by discordance of both the atrioventricular and ventriculoarterial connections. Physiologic repair of associated conditions, whereby the morphologic right ventricle remains the systemic ventricle, has resulted in unsatisfactory long-term outcomes due to the development of right ventricular failure and tricuspid valve regurgitation. While intuitively attractive, anatomic repair also has inherent challenges and risks, particularly for those patients who present late and require left ventricular retraining. Although early and intermediate-term outcomes for anatomic repair have been encouraging, longer-term follow-up has demonstrated concern for late left ventricular dysfunction in this subgroup of patients. Continued monitoring of this challenging patient population will clarify late outcomes and inform clinical management in the future.


Assuntos
Transposição das Grandes Artérias/efeitos adversos , Transposição dos Grandes Vasos/cirurgia , Disfunção Ventricular Esquerda/prevenção & controle , Humanos , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/etiologia
10.
World J Pediatr Congenit Heart Surg ; 6(2): 226-38, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25870342

RESUMO

Truncus arteriosus (common arterial trunk) is an uncommon but complex congenital heart anomaly. Until the early 1970s, typically, patients died between the age of a few weeks to six months. Congestive heart failure owing to large pulmonary blood flow and truncal valve regurgitation was the major cause of death until innovative surgical techniques were discovered. In 1963, Herbert Sloan at the University of Michigan completed the first repair using a nonvalved conduit with long-term survival (not reported until 1974). At the Mayo Clinic, Rastelli and McGoon studied and completed the first repair with a valved homograft in 1967. In 1976, Ebert used the 12-mm Hancock valved conduit in infants under six months of age (University of California, San Francisco). In Boston (mid-1980s), Jonas and Castañeda used aortic homografts, which greatly reduced bleeding as a postoperative complication. In the early 1990s, Bove (University of Michigan) reported outstanding results with an approach based on primary repair within the first few days of life for patients with truncus arteriosus. Improved prognosis for patients with truncus arteriosus resulted from these corrective operations by analyzing the natural history of this condition while applying innovative ideas, improved technology, and perioperative care.


Assuntos
Persistência do Tronco Arterial/cirurgia , Implante de Prótese Vascular/história , Implante de Prótese Vascular/métodos , Feminino , Seguimentos , Doenças das Valvas Cardíacas/etiologia , Doenças das Valvas Cardíacas/história , Doenças das Valvas Cardíacas/cirurgia , História do Século XVIII , História do Século XIX , História do Século XX , Humanos , Lactente , Masculino , Complicações Pós-Operatórias/cirurgia , Desenho de Prótese/história , Reoperação/história , Reoperação/estatística & dados numéricos , Transplante Homólogo/história , Transplante Homólogo/métodos , Persistência do Tronco Arterial/história
11.
Ann Thorac Surg ; 99(6): 2086-94; discussion 2094-5, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25921260

RESUMO

BACKGROUND: There are limited data regarding long-term outcomes after the Ross procedure in children. We evaluated mortality and reintervention in a large pediatric cohort. METHODS: A retrospective analysis of all patients aged younger than 18 years who underwent the Ross procedure at our institution (1991 to 2013) was conducted. Kaplan-Meier curves and Cox proportion hazard models were used to evaluate long-term outcomes and associated risk factors. RESULTS: Included were 240 consecutive patients undergoing a Ross/Ross-Konno procedure: 18% infants, 48% children, and 33% adolescents. Infants were more likely to have complex left heart disease (p = 0.005). Overall survival to hospital discharge was 96%; infants had the highest mortality (18%). Long-term survival status was known for 99.6% (median follow-up, 10.7 years). Overall 15-year survival was 87% (lowest in infants, 72%; p = 0.003). Reintervention status was known in 87%. Overall 15-year freedom from any left ventricular outflow tract reintervention was 59%; 85% still had their autograft valve at the latest follow-up. Left ventricular outflow tract reintervention was uncommon in infants (n = 2). Overall 15-year freedom from right ventricular outflow tract reintervention was 53%, and was lower in infants (19%) than in children (51%) and adolescents (76%; p < 0.0001). CONCLUSIONS: Outcomes after the Ross procedure in children vary by age. Infants more commonly have complex left heart disease and experience higher mortality but have excellent long-term autograft durability. Children and adolescents have higher rates of left ventricular outflow tract reintervention, whereas infants are at highest risk of right ventricular outflow tract reintervention.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Cardiopatias Congênitas/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Distribuição por Idade , Fatores Etários , Valva Aórtica/cirurgia , Criança , Pré-Escolar , Feminino , Seguimentos , Cardiopatias Congênitas/mortalidade , Doenças das Valvas Cardíacas/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Michigan/epidemiologia , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo
12.
Ann Thorac Surg ; 96(3): 910-6, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23866807

RESUMO

BACKGROUND: Blood product transfusion during cardiopulmonary bypass has been demonstrated to be associated with increased morbidity and mortality in adult cardiac surgery populations. The aim of this study was to characterize the risk-adjusted occurrence of postoperative complications and mortality in relation to intraoperative blood product transfusion in our pediatric cardiac surgery population. METHODS: A retrospective review was performed on 1,631 consecutive cardiopulmonary bypass cases to determine the effects of intraoperative blood product transfusion on selected outcomes. After adjusting for patient and operative risk factors, multivariate analysis was performed to determine the association between blood product transfusion and postoperative complications. Cox proportional hazards model was used to examine the relationship of packed red blood cell transfusion to hospital length of stay. RESULTS: Red blood cell and fresh frozen plasma transfusion was associated with pulmonary complications (adjusted odds ratio, 1.55; 95% confidence interval, 1.05 to 2.28; p=0.03). Red blood cell transfusion also correlated with prolonged hospital stay (p<0.01). Cryoprecipate transfusion was associated with postoperative pulmonary complications (adjusted odds ratio, 1.79; 95% confidence interval, 1.13 to 2.55; p=0.01), but decreased incidence of 30-day mortality (adjusted odds ratio, 0.44; 95% confidence interval, 0.23 to 0.85; p=0.02). Platelet transfusion was associated with decreased 30-day mortality (adjusted odds ratio, 0.51; 95% confidence interval, 0.28 to 0.93; p=0.04), but not overall mortality. CONCLUSIONS: Blood product transfusion was associated with an increased incidence of postoperative pulmonary complications and prolonged hospital length of stay, but not overall mortality. These findings suggest that minimizing blood product transfusion would be beneficial in the pediatric cardiopulmonary bypass surgery patient population.


Assuntos
Ponte Cardiopulmonar/métodos , Transfusão de Eritrócitos/efeitos adversos , Mortalidade Hospitalar/tendências , Complicações Pós-Operatórias/mortalidade , Adolescente , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/efeitos adversos , Causas de Morte , Criança , Pré-Escolar , Estudos de Coortes , Intervalos de Confiança , Transfusão de Eritrócitos/métodos , Feminino , Seguimentos , Humanos , Incidência , Lactente , Cuidados Intraoperatórios/métodos , Masculino , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias/fisiopatologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
13.
Eur J Cardiothorac Surg ; 43(4): 743-51, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23024233

RESUMO

OBJECTIVES: The absence of a pulmonary valve (PV) after tetralogy of Fallot (TOF) repair has been shown to impact postoperative right ventricular (RV) function. The purposes of this study were to (i) compare early outcomes after PV-sparing vs transannular patching (TAP) with monocusp valve reconstruction or TAP alone and (b) assess the mid-term results after polytetrafluoroethylene (PTFE) membrane monocusp reconstruction. METHODS: From 2003 to 2009, 163 patients underwent TOF repair. Sixty-nine patients (42.3%) underwent a PV-sparing procedure (Group A), 74 (45.4%) underwent PTFE membrane monocusp valve reconstruction (Group B) and 20 (12.3%) underwent TAP only (Group C). Early outcomes were evaluated by the right-to-left ventricular pressure ratio, RV outflow tract gradient, tricuspid and PV function, intensive care unit (ICU) parameters and need for reintervention. Group B patients were also evaluated at intermediate term for clinical and echocardiographic parameters, including tricuspid and monocusp valve function and mobility. RESULTS: The median age, weight and PV Z-value of Group B patients were significantly lower; 20.5 months, 9.3 kg and -4, respectively. Postoperatively, the right-to-left ventricular pressure ratio was <0.5 in all groups. Mechanical ventilation time, fluid drainage duration and total ICU stay showed no significant difference between Groups A and B, while Group C was significantly longer (P < 0.01). There were five (3%) early deaths: three from Group A and two from Group B. The incidences of moderate or severe pulmonary insufficiency (PI) on discharge were 8.2% in Group A, 9% in Group B and 50% in Group C (P < 0.001). Among Group B patients, 85% of the evaluated patients had less than moderate PI in the intermediate-term follow-up, QRS duration <140 ms in 83.3% and right-to-left ventricular diameter ratio of 0.6 ± 0.2. Two (2.6%) patients underwent reoperation for monocusp replacement. There were two (2.7%) mid-term deaths. CONCLUSIONS: The use of a PTFE membrane monocusp valve and a valve-sparing strategy prevents immediate PI and improves short-term clinical outcomes. PTFE membrane monocusp appears advantageous in preventing severe intermediate-term PI and facilitates the preservation of RV function.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Valva Pulmonar/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Tetralogia de Fallot/cirurgia , Obstrução do Fluxo Ventricular Externo/cirurgia , Adolescente , Criança , Pré-Escolar , Ecocardiografia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estatísticas não Paramétricas , Adulto Jovem
14.
Pediatr Cardiol ; 34(4): 999-1005, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23179430

RESUMO

Transient complete heart block (TCHB) is defined as complete interruption of atrioventricular conduction (AVC) after cardiac surgery followed by return of conduction. This study aimed to assess the risk for the development of late complete heart block (LCHB) after recovery of TCHB and to examine the electrocardiographic and electrophysiologic properties of the AVC system after TCHB. Of the 44 patients in this study who experienced TCHB, 37 recovered completely. Seven patients progressed from TCHB to intermittent CHB or LCHB requiring pacemaker implantation. Preoperative, early postoperative, and late postoperative electrocardiograms as well as postoperative atrial stimulation were obtained. The results showed that the median duration of TCHB was 5 days in the TCHB group compared with 9 days in the LCHB group (p = 0.01). All 37 subjects with TCHB recovered AVC within 12 days, but only two with LCHB did so (p = 0.02). The risk of LCHB for the patients with 7 days of postoperative TCHB or longer was 13 times greater than for the patients with fewer than 7 days of TCHB (p = 0.01). The median late postoperative PR interval was slightly but significantly longer in the LCHB group than in the TCHB group (p = 0.02). In contrast, the electrophysiologic properties between the two groups did not differ significantly. From those findings, we concluded that delayed recovery of AVC after surgical TCHB (≥7 days), but not electrophysiologic properties of recovered AVC assessed early in the postoperative period strongly, predicts risk of LCHB. Follow-up evaluation of AVC is particularly indicated for the delayed recovery group.


Assuntos
Bloqueio Cardíaco/fisiopatologia , Bloqueio Cardíaco/cirurgia , Cardiopatias Congênitas/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Cardíacos , Criança , Pré-Escolar , Eletrocardiografia , Feminino , Humanos , Lactente , Modelos Logísticos , Masculino , Marca-Passo Artificial , Curva ROC , Recuperação de Função Fisiológica , Estatísticas não Paramétricas , Resultado do Tratamento
15.
Ann Thorac Surg ; 93(4): 1274-8; discussion 1278-9, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22381450

RESUMO

BACKGROUND: The optimal surgical procedure for repair of supravalvar aortic stenosis (SVAS) remains uncertain. Proponents of multisinus repair techniques suggest improved outcomes compared with the single-patch technique. We evaluated the outcomes after an extended single-patch technique for relief of SVAS. METHODS: A cross-sectional retrospective analysis was performed of all SVAS patients who underwent repair from 1996 to 2009. Patient, procedural, and hospital course data were obtained through a review of the medical records. At follow-up, patients were evaluated for residual SVAS gradient, valvar aortic stenosis, aortic insufficiency, and need for reintervention. RESULTS: Twenty-two patients (mean age, 2.4 ± 2.4 years) underwent repair of SVAS (discrete form, 59%). Mean preoperative peak gradient was 77 ± 27 mm Hg (range, 20 to 139 mm Hg). There were no hospital deaths. Median postoperative length of stay was 5 days (range, 3 to 68 days). Mean follow-up was 4.1 ± 3.5 years (range, 0.7 to 13 years). Follow-up Doppler echocardiography revealed a peak left ventricular outflow tract gradient of 10 ± 12 mm Hg (range, 0 to 41 mm Hg). No patient had significant valvar aortic stenosis or insufficiency. Two patients (9%) required catheter-based reintervention that was unrelated to the SVAS repair. CONCLUSIONS: This study demonstrates that a simple, extended single-patch technique for repair of SVAS provides excellent medium-term results. A durable reduction in gradient with low complication and recurrence rates can be achieved without the need for more complicated multisinus patch repairs.


Assuntos
Estenose Aórtica Supravalvular/cirurgia , Aorta/cirurgia , Estenose Aórtica Supravalvular/diagnóstico , Aortografia , Prótese Vascular , Criança , Pré-Escolar , Estudos Transversais , Ecocardiografia , Feminino , Seguimentos , Humanos , Lactente , Masculino , Estudos Retrospectivos , Resultado do Tratamento
16.
J Thorac Cardiovasc Surg ; 144(3): 553-6, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22325326

RESUMO

OBJECTIVES: The placement of a pulmonary artery band to retrain the left ventricle often requires reoperation for band adjustment. We describe an effective technique for the placement of a transcutaneously adjustable pulmonary artery band that allows adjustments to be made without the need for repeat sternotomy. METHODS: Using standard catheters, an adjustable band was fashioned and placed around the pulmonary artery with the control end positioned in the subcutaneous tissue of the anterior chest wall. Tightening or loosening of the band can be subsequently performed by exposing the control end without the need for reopening the chest. RESULTS: From 1995 to 2011, 11 patients underwent placement of a transcutaneously adjustable pulmonary artery band for the purpose of retraining the morphologic left ventricle for a subsequent arterial switch operation. One or more band adjustments were required in 6 patients (1 loosened and 5 tightened, 55%) at a mean of 281 days (median, 98; range, 0-917) after initial band placement. All were accomplished successfully by exposing the band in the subcutaneous tissue of the anterior chest wall and performing the adjustment under Doppler echocardiographic guidance. CONCLUSIONS: This technique affords the operating surgeon the freedom to apply the band very gradually, erring on the side of safety, and facilitates a gradual increase in ventricular afterload that can be performed as a minor procedure.


Assuntos
Artéria Pulmonar/cirurgia , Transposição dos Grandes Vasos/cirurgia , Função Ventricular Esquerda , Adolescente , Pressão Sanguínea , Cateterismo Cardíaco , Procedimentos Cirúrgicos Cardíacos/instrumentação , Cateteres , Criança , Pré-Escolar , Dissecação , Ecocardiografia Doppler , Desenho de Equipamento , Humanos , Lactente , Ligadura , Michigan , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/fisiopatologia , Recuperação de Função Fisiológica , Esternotomia , Fatores de Tempo , Transposição dos Grandes Vasos/diagnóstico por imagem , Transposição dos Grandes Vasos/fisiopatologia , Resultado do Tratamento
17.
Ann Thorac Surg ; 93(2): 614-8; discussion 619, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22197533

RESUMO

BACKGROUND: Single ventricle hearts can be surgically palliated by a series of operations culminating in the Fontan procedure, which establishes a total cavopulmonary connection. The second-stage procedure creates a physiologic connection between the superior vena cava and the pulmonary artery. METHODS: From 1998 to 2010, 557 patients with single ventricle heart disease underwent second-stage surgical palliation. This cohort was retrospectively analyzed to assess patient outcome by a number of anatomic, physiologic, and procedural factors. The analysis excluded patients undergoing hybrid first-stage procedures. RESULTS: The median age at operation was 165 days (range, 59 days to 49 years). The most common anatomic subtypes were hypoplastic left heart syndrome (52%), tricuspid atresia (12%), unbalanced atrioventricular septal defect (10%), double inlet left ventricle (9%), or other (17%). Left ventricular hypoplasia was present in 70%. A hemi-Fontan procedure was done in 89%, and 11% received a bidirectional Glenn. Concomitant atrioventricular valve repair was necessary in 9%. Early mortality was 4.7%, and 5.9% died after discharge but before Fontan. No early or late deaths occurred in patients with tricuspid atresia and double inlet left ventricle. Multivariate analysis demonstrated ventricular dysfunction, atrioventricular valve regurgitation, and unbalanced atrioventricular septal defect were significant adverse risk factors for survival to Fontan. CONCLUSIONS: Second-stage palliation can be performed at low risk for patients with left ventricular dominance, but significant risk remains for patients with left ventricular hypoplasia and unbalanced atrioventricular septal defect. Atrioventricular valve insufficiency is a persistent problem that has not been neutralized by repair strategies.


Assuntos
Técnica de Fontan , Ventrículos do Coração/anormalidades , Cuidados Paliativos , Artéria Pulmonar/cirurgia , Veia Cava Superior/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Técnica de Fontan/estatística & dados numéricos , Defeitos dos Septos Cardíacos/epidemiologia , Defeitos dos Septos Cardíacos/cirurgia , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Ventrículos do Coração/cirurgia , Síndrome de Heterotaxia/epidemiologia , Síndrome de Heterotaxia/cirurgia , Humanos , Síndrome do Coração Esquerdo Hipoplásico/epidemiologia , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Hipóxia/etiologia , Hipóxia/cirurgia , Lactente , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/cirurgia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Atresia Tricúspide/epidemiologia , Atresia Tricúspide/cirurgia , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/cirurgia , Adulto Jovem
18.
Pediatr Cardiol ; 32(5): 599-606, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21347834

RESUMO

Tricuspid valve regurgitation (TR) remains an obstacle for staged palliation of hypoplastic left heart syndrome (HLHS). Because previous results from our institution suggested that posterior leaflet obliteration (PLO) is effective in tricuspid valve repair (TVR), we preferentially used this method. This report analyzes the effect of this preference on repair success and patient survival. All HLHS patients with 3-4+ preoperative TR undergoing TVR between 2002 and 2007 were retrospectively analyzed. Clinical and echocardiographic data were used to determine outcomes. Seventy-one percent (17 of 24) of patients had success at early outcome; the remaining 29% experienced early failure. Sixty-three percent (15 of 24) of patients demonstrated success at late outcome. Early outcome status was found to be a predictor of late outcome status (OR 22.9, P = 0.0037). Overall survival was 71% (17 of 24). Survival could not be shown to be associated with early or late outcome status (odds ratio = 0.96). A preference for PLO was found to give improved, long-lasting results for HLHS patients. Success at immediate outcome was predictive of success with time. PLO has the advantage of being simple and reproducible and produces good outcomes in this challenging group. Continued follow-up will be necessary to confirm long-term outcomes.


Assuntos
Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Insuficiência da Valva Tricúspide/cirurgia , Valva Tricúspide/cirurgia , Pré-Escolar , Feminino , Seguimentos , Técnica de Fontan , Mortalidade Hospitalar , Humanos , Síndrome do Coração Esquerdo Hipoplásico/mortalidade , Lactente , Masculino , Estudos Retrospectivos , Taxa de Sobrevida , Técnicas de Sutura , Insuficiência da Valva Tricúspide/mortalidade , Função Ventricular Direita/fisiologia
19.
J Thorac Cardiovasc Surg ; 142(1): 136-41, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21277589

RESUMO

OBJECTIVE: The study's objectives were to survey the quality of life in patients with congenitally corrected transposition of the great arteries and to compare the responses of those who have undergone anatomic repair with those who have a systemic right ventricle. METHODS: Thirty-eight patients who underwent anatomic repair and 13 patients after either conventional repair or no surgical procedure were enrolled. Subjects completed the PedsQL 4.0 Generic and 3.0 Cardiac Modules. Scores were also compared with those of patients from the literature with at least moderately severe cardiovascular disease. Mean differences between groups were compared, and the association between clinical variables and score in the anatomic repair subgroup was measured. RESULTS: Caregivers of patients in the anatomic repair group reported similar scores compared with the non-anatomic repair group in all functional domains The anatomic repair group self-reported lower school function (63 vs 81, P = .02). On the Cardiac Module, patients in the anatomic repair group self-reported fewer problems related to residual heart disease (75 vs 63), appearance (81 vs 68), and treatment anxiety (74 vs 59), although the differences were not significant. Compared with patients with other heart disease, the anatomic repair group scored lower, with the largest differences in cognition and communication. Prolonged hospital stay and need for a pacemaker were associated with lower quality of life after anatomic repair. CONCLUSIONS: Patients in the anatomic repair group had similar quality of life compared with patients in the non-anatomic group, except in the domain of school functioning. Prolonged hospital stay and need for a pacemaker after anatomic repair may be risk factors for lower quality of life.


Assuntos
Qualidade de Vida , Procedimentos Cirúrgicos Vasculares/psicologia , Adolescente , Adulto , Ansiedade/etiologia , Imagem Corporal , Estimulação Cardíaca Artificial/psicologia , Criança , Pré-Escolar , Cognição , Comunicação , Escolaridade , Feminino , Humanos , Tempo de Internação , Masculino , Saúde Mental , Michigan , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Inquéritos e Questionários , Transposição dos Grandes Vasos/fisiopatologia , Transposição dos Grandes Vasos/psicologia , Transposição dos Grandes Vasos/cirurgia , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Adulto Jovem
20.
J Thorac Cardiovasc Surg ; 141(2): 419-24, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20709336

RESUMO

OBJECTIVE: As outcomes for the Fontan procedure have improved, it has become more difficult to select between a single-ventricle repair or biventricular repair for patients with complex anatomy and 2 ventricles. However, late complications after the Fontan procedure remain a concern. Our strategy, which has favored an aggressive preferential approach for biventricular repair in these patients, has also been applied to patients initially treated on a single-ventricle track elsewhere. METHODS: Nine patients (4 male patients) who had previously undergone the Fontan procedure (n=3) or bidirectional cavopulmonary shunting (n=6) with intent for a later Fontan procedure were referred to our center for complex 1½- or 2-ventricle repair over the last 10 years. Indications for conversion in these patients were protein-losing enteropathy (n=2), pulmonary arteriovenous malformation (n=1), and preference for biventricular anatomy (n=6). The conversion mainly consisted of takedown of the Fontan procedure or bidirectional cavopulmonary shunt connection, reconstruction of 1 or both of venae cavae, creation of an intraventricular pathway for left ventricular output, and placement of a right ventricle-pulmonary artery conduit (Rastelli-type operation). RESULTS: Five patients underwent 1½-ventricle repair, and 4 had complete biventricular repair. Median cardiopulmonary bypass and aortic crossclamp times were 202 minutes (range, 169-352 minutes) and 129 minutes (range, 100-168 minutes), respectively. There were 2 early deaths and 1 late death. At a median follow-up of 27 months (range, 3.3-99.8 months), all survivors are in New York Heart Association class I. CONCLUSIONS: Patients initially treated with intent to perform single-ventricle palliation can be converted to 1½- or 2-ventricle physiology with acceptable outcomes.


Assuntos
Técnica de Fontan , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/cirurgia , Ponte Cardiopulmonar , Constrição , Feminino , Técnica de Fontan/efeitos adversos , Técnica de Fontan/mortalidade , Cardiopatias Congênitas/mortalidade , Ventrículos do Coração/anormalidades , Humanos , Masculino , Michigan , Cuidados Paliativos , Seleção de Pacientes , Fatores de Tempo , Resultado do Tratamento
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