The Role of Surgery in the Treatment of Transposition of the Great Vessels

In 28 infants and children with complete transposition of the great vessels, atrial septal defects were created utilizing an open technique with inflow caval occlusion and moderate hypothermia. Of the 12 infants for whom operation was necessary during the first two weeks of life only two survived, suggesting that this technique is not adequate for infants at this age. Only four of the 16 children operated on between the ages of two weeks and three years failed to survive. Two of these died because of pre-existing non-cardiac conditions. Seven children with associated systemic-to-pulmonary shunts survived; the open technique may be preferable in this particular group. Despite the initial improvement afforded by this procedure, three sudden late deaths occurred. For this reason, and because of the danger of early development of pulmonary vascular disease, total operative correction of the malformation should be performed early.     

Communication interventriculaire avec défaillance cardiaque chez le nouveau-né et le nourrisson: Evaluation du traitement médical

Twenty-seven infants with ventricular septal defects and in cardiac failure were followed regularly under medical treatment for an average period of 17 months. The diagnosis was proved in all cases by cardiac catheterization.At the end of the follow-up period, the patients could be classified as follows: Sixteen patients showed no change in their cardiovascular status, and six had signs of pulmonary infundibular stenosis. One child had died from bronchopneumonia. Another was classified as having probable functional closure of the defect. Finally, three other children, because of failure of medical treatment, underwent banding of the pulmonary artery. One died during the operation.It is concluded that the great majority of patients with ventricular septal defects and cardiac failure can be carried successfully under medical management until the age at which corrective surgery is feasible. Palliative procedures which in themselves carry a fairly high mortality risk should be used only as a last resort.     

CORRECTION OF ANOMALOUS VENOUS RETURN FROM THE RIGHT LUNG TO THE INFERIOR VENA CAVA (SCIMITAR DEFORMITY)

Anomalous pulmonary venous drainage to the inferior vena cava is a rare congenital cardiac defect. Oxygenated blood from the right lung enters the right atrium resulting in a left-to-right shunt. Because the radiographic shadow of the anomalous vein resembles a curved saber, this defect has been called the "scimitar" deformity. From 1958 through June 30, 1975, 11 patients underwent surgical correction of this anomaly at our institution with 10 survivors. Diagnosis was made by routine roentgenography of the chest in all but one patient. Eight patients had total correction which consisted of implanting the anomalous vein into the right atrium, opening the interatrial septum and applying a patch graft as a baffle to direct pulmonary venous blood into the left atrium. Five patients had associated cardiac defects which were also repaired. Three patients underwent pneumonectomy and all survived. The only operative death occurred in a 5-year-old female with an atrial septal defect and endocardial cushion defect. We believe the existence of a large left-to-right shunt justifies surgical intervention. The prognosis appears to depend upon the presence of other cardiac or pulmonary anomalies.     

Evaluation of late results of surgical treatment of congenital heart disease.

Operative mortality from surgical treatment of congenital heart disease has been steadily reduced over the past 20 years. During the same period it has become clear that a proportion of survivors have residual clinical problems. Some of these are due to imperfect repair, a number being due to factors beyond present surgical control, and some are the consequence of associated cardiovascular defects. The chief problems can be elucidated by an analysis of the results of surgical treatment of six cardiac malformations: simple pulmonary valve stenosis, coarctation of the aorta, secundum atrial septal defect, isolated ventricular septal defect, tetralogy of Fallot and transposition of the great arteries. Recognition of the sequelae of preoperative hemodynamic strain and apparently minor associated malformations is important, and it is possible to anticipate such factors. Long-term follow-up of patients after operation is particularly important.     

RESULTS OF MEDICAL AND SURGICAL MANAGEMENT IN TEN CASES OF CONGENITAL MEGACOLON

Of 20 patients under 15 years of age with proven diagnoses of megacolon, ten were treated surgically with either partial colectomy or resection of the entire colon down to the rectosigmoid junction after thorough trial of medical management. Follow-up shows five of these patients as 100 per cent relieved, one as 75 per cent relieved. Three were entirely well a few months after operation but have not been heard from since. One died of peritonitis on the 16th postoperative day.In four cases in which lumbar sympathectomy was done, the result was partial, temporary or no improvement.Of the patients not operated upon, several have been lost to follow-up, some are doing well on medical treatment, one died in early infancy, and resection is being considered for two.For children with congenital megacolon the authors recommend first a thorough trial of medical treatment consisting of diet, vitamins, drugs and enemas. This should be started as soon as possible after the diagnosis is made, in an attempt to prevent the distention and hypertrophy of the bowel from progressing. If distention remains after a reasonable trial period and the child is not gaining weight adequately, requires repeated hospitalization, and is three years of age or more, then resection of the affected portion of the colon is indicated. The risk of operation has been somewhat reduced with better supportive measures and chemotherapy now available. Since infants and extremely young children do not stand operation on the colon as well as older children, decision to operate should take into consideration the age of the patient. In the reported series, the patient who died following operation was the youngest—2½ years of age.     

The Results of Open-Heart Operations Performed on Children

From December 1, 1959, to January 1, 1965, a total of 166 children have undergone 168 open-heart operations at The Children''s Hospital in Winnipeg, Manitoba.While this series is not a large one, the defects encountered include most of those cardiac abnormalities which are amenable to open-heart correction in children.For all operations a Kay-Cross disc oxygenator was employed. In 42 of the 168 operations, hypothermia (25-30° C.) was also used and was obtained by a Brown-Harrison heat exchanger incorporated into the arterial line.The smallest infant survivor in this series of patients weighed 8 lb. 14 oz. at the time of her operation.Of the 166 children operated upon 149 have survived, an overall survival rate of 89.8%.     

Secundum atrial septal defect in adults: a practical review and recent developments

Secundum atrial septal defect (ASDII) is a common congenital heart defect that causes shunting of blood between the systemic and pulmonary circulations. Patients with an isolated ASDII often remain asymptomatic during childhood and adolescence. If the defect remains untreated, however, the rates of exercise intolerance, supraventricular arrhythmias, right ventricular dysfunction and pulmonary arterial hypertension (PAH) increase with patient age, and life expectancy is reduced. Transcatheter and surgical techniques both provide valid options for ASDII closure, the former being the preferred method. With the exception of those with severe and irreversible PAH, closure is beneficial to, and thus indicated in all patients with significant shunts, regardless of age and symptoms. The symptomatic and survival benefits conferred by defect closure are inversely related to patient age and the presence of PAH, supporting timely closure after diagnosis. In this paper we review the management of adult patients with an isolated ASDII, with a focus on aspects of importance to the decision regarding defect closure and medical follow-up.     

Cardiac arrhythmias during rewarming of patients with accidental hypothermia.

Accidental hypothermia has a high mortality and is associated with cardiac arrhythmias. To determine the incidence of arrhythmias and their importance 22 patients with accidental hypothermia (core temperature less than 35 degrees C) were studied by 12 lead electrocardiography and continuous recording of cardiac rhythm. Although 14 of the patients died (64%), only six died while hypothermic. Prolongation of the Q-T interval and the presence of J waves were related to the severity of the hypothermia. Supraventricular arrhythmias, including atrial fibrillation, were common (nine cases) and benign. Ventricular extrasystoles were also common (10 cases), but ventricular tachycardia or fibrillation did not occur during rewarming. In eight patients who died while being monitored the terminal rhythm was asystole. There was no correlation between the severity of hypothermia or the rate of rewarming and the clinical outcome. In the absence of malignant arrhythmias there is no indication for using prophylactic antiarrhythmic treatment in patients with accidental hypothermia. The presence or absence of severe underlying disease is the main determinant of prognosis.     

80岁以上老年人冠状动脉旁路移植术合并瓣膜置换手术的临床分析

目的：总结老年患者行冠状动脉旁路移植术（CABG）合并瓣膜置换（VR）手术的特点及经验。方法：上海交通大学附属第一人民医院心血管外科2001年11月至2010年3月对60例年龄大于80的患者施行冠状动脉搭桥＋瓣膜置换手术,男33例,女27例。年龄80-87岁,平均年龄（83.77±2.45）岁。均为冠心病合并瓣膜病变患者。其中36例患者行冠状动脉旁路移植＋二尖瓣置换手术,15例患者行冠状动脉旁路移植＋主动脉瓣置换手术,9例患者行冠状动脉旁路移植＋双瓣置换手术,同时8例患者行三尖瓣成形手术,3例患者行射频消融手术,1例升主动开成形术。置换生物瓣膜者51例,置换机械瓣膜者9例。CABG平均搭桥（2.13±0.75）根,搭桥材料为左乳内动脉与大隐静脉。结果：全组早期死亡9例（15%）,1例死于术后出血,1例死于多器官功能衰竭,7例死于术后心衰。早期生存51例（85%）,出现术后并发症10例,其中2例发生胸腔积液,1例心包填塞,3例肺部感染,1例心房扑动后发生室颤,3例二次开胸止血。给予相应对症治疗后痊愈出院。门诊随访49例,随访时间1～60个月,心功能I级2例、Ⅱ级29例、Ⅲ级18例、Ⅳ级0例（NYHA分级）。结论：对老年患者行冠脉搭桥＋瓣膜置换手术,只要掌握手术适应证,充分作好术前准备、术中及术后处理,手术治疗可以取得良好效果。     

Observations on the Value of Mitral Commissurotomy: An Analysis of Long-Term Results

Long-term follow-up of patients subjected to mitral commissurotomy permits evaluation of the late efficacy of this operation and the causes of subsequent deterioration in some cases.Three hundred and eighty-nine patients operated upon for mitral stenosis from 1950 to 1957 were studied. Of these, 89 died, 38 were lost to follow-up and 262 were re-examined.Results for the postoperative period of five to 12 years were satisfactory in 204 patients (77%) and unsatisfactory in 58 (22%). The possible causes of deterioration were studied separately.A second commissurotomy was performed on 23 patients (8.7%), because of re-stenosis thought to be due to a rheumatic process in one and to fibrotic scarring in nine, and because of an inadequate opening in 13.Mitral commissurotomy is a palliative operation, but is definitely useful in cases of tight mitral stenosis.The duration of improvement in patients with a functionally adequate opening is related to the state of the myocardium and to the possibility of rheumatic fever recurrences. Because of the risk of fibrotic restenosis, the possibility that a second commissurotomy might be required should be considered in each patient subjected to this operation.     

Gender Differences and Role of Pregnancy in the History of Post-Surgical Women Affected by Tetralogy of Fallot

Background

The aim of this study was to describe gender differences in patients operated on for TOF and to define the impact of pregnancy in late post-surgical follow-up in women.

Methods

In this research, we studied 145 patients after correction of TOF: 66 male, 79 women, 41 of which reported history of 68 pregnancies, means age 37±10 years, age at operation 7±8 years, mean duration of post-surgical follow-up 30±7 years. Selected variables were compared according to sex and according to history of pregnancy with statistical tests.

Results

Men had more severe hemodynamic impairment and a higher number of cardiac reoperations than females. 41% of patients had at least one complication during pregnancy; there were 16 (67%) abortions and 39 (74%) Caesarian delivers; the recurrence of congenital heart defect was 10%. After pregnancy, there was a shift from first to second functional class: unique pregnancy determined no differences in term of morpho-functional ventricular features compared to nulliparous, but they complained fatigue and palpitation and echocardiographyc dysfunction. Left ventricular dysfunction and QRS duration at ECG were independent predictors of ventricular arrhythmias in all patients.

Conclusions

There were no gender-specific differences in patients operated on for TOF using ventriculotomy. Pregnancy is an event in these patients at risk for the newborn, in terms of miscarriage, prematurity, and recurrence of birth defects, and for the mother in terms of ventricular dysfunction and electrical instability. At least a single pregnancy does not appear to significantly modify the natural history of post-surgical patients operated on for TOF.     

CARDIAC OPERATIONS WITH EXTRACORPOREAL CIRCULATION

In a series of 50 patients for whom a heart-lung machine was used for periods as long as 70 minutes during operations to correct structural defects of the heart, there were no deaths attributable to the machine. Seven patients died. Two of them had high pressure ventricular septal defects with bidirectional shunts; a third patient with the same lesion recovered after repair. One patient died of cardiac tamponade when a large blood clot formed about the entire heart in a loosely closed pericardial sac. Others died of various causes. The development of subacute bacterial endocarditis in one patient led to a change in sterilization of apparatus.     

Treatment of accidental hypothermia: a prospective clinical study.

A 15-year prospective study was carried out of 44 patients with accidental hypothermia (mean age 60 years) admitted to an intensive therapy unit. The lowest core temperature recorded in each patient ranged from 20.0 to 34.3 degrees C. The precipitating factors were poisoning (by drugs, alcohol, or coal gas) in 25 cases and various illnesses in 19. Rewarming was achieved in 42 patients by applying a radiant heat cradle over the torso, and in two patients by mediastinal irrigation with warmed fluids. Twelve patients died, but only two during the period of rewarming. Thus rewarming may be consistently and safely achieved irrespective of the cause of hypothermia, and normal body temperature may be regained as rapidly as is compatible with adequate tissue perfusion and oxygenation. Surface rewarming of the torso is perhaps the simplest technique available, but internal rewarming procedures may be desirable or essential in the presence of, for example, profound hypothermia, severe hypotension, or ventricular fibrillation. Mortality was attributable to underlying factors or disease and not to hypothermia.     

An unusual case of recurrent left atrial myxoma.

In a patient who had a calcified left atrial myxoma resected, recurrence developed 31 months later. Although complete radical resection of the recurrent tumour presented a special problem, the patient survived the second operation. The tumour recurred again and the patient had two episodes of cerebral embolism 1 1/2 and 2 years later, respectively, and died 3 1/2 years after the second operation. The erythrocyte sedimentation rate correlated with the size of the tumor, and the recurrent tumour seemed to grow more rapidly than the primary tumour. Experience with this case and a review of the nine reported cases of recurrent left atrial myxoma suggest that a radical approach is necessary at the primary operation.     

Progress in larynx-sparing surgery for glottic cancer through tracheal transplantation.

The current surgical treatment for unilateral, advanced glottic cancer is a total laryngectomy. Usually, the noninvolved hemilarynx needs resection because the resulting laryngeal defect cannot be reconstructed after adequate tumor resection. Experimental findings suggest that segments of autologous trachea may restore extended laryngeal defects. The authors used tracheal transplantation to save laryngeal function after the removal of advanced glottic cancer. In this case series review, 10 patients were treated during a 1.5-year period, with an average follow-up of 8 months. Evaluated factors included survival of the tracheal transplant and functional outcome with regard to the onset and quality of the airway, speech, and deglutition. The authors showed that segments of cervical trachea may restore extended laryngeal defects after initial revascularization by a radial forearm fascial flap. The fascial flap served as a vascular carrier for the transplanted trachea. Follow-up showed the stability of the reconstruction. Compared with a total laryngectomy, a striking improvement in patient comfort and function was noticed. Transplantation of the trachea is a technique that may save laryngeal function after the treatment of advanced-stage glottic cancer. These findings may improve laryngeal preservation strategies in treating laryngeal cancer.     

Risks and benefits of aortocoronary bypass surgery in patients aged 65 years or more.

Between January 1970 and July 1978, 85 patients aged 65 years or more underwent aortocoronary bypass surgery at the Montreal Heart Institute. The mortality during the operation and the first 29 days thereafter was 12% overall, but was only 5% when the myocardium was protected by the use of cold cardioplegic solutions. Of the 75 patients who survived this period 7 (9%) had a perioperative transmural myocardial infarction. Nonfatal noncardiac complications were more common in these patients than in younger patients, but did not lead to permanent deficits. Three patients died after discharge from hospital, two of cardiac causes. Only one patient had a nonfatal myocardial infarction after discharge. The actuarial 5-year survival rate for all the patients was 80%. After a mean follow-up period of 30 months the condition of 94% of the patients was improved by at least one class of the New York Heart Association functional classification, and 68% were asymptomatic. It is concluded that aortocoronary bypass surgery can be performed in selected older patients with a relatively low in-hospital mortality and morbidity. Symptomatic improvement occurs in almost all such patients. Cardiac catheterization and aortocoronary bypass surgery should therefore be performed in selected older patients with severe angina that is refractory to optimum medical therapy.     

Transcatheter device closure of atrial septal defects in patients aged 40 years and older

Objective. To evaluate the safety and effect of transcatheter device closure in ostium secundum atrial septal defects (ASD II) in patients aged 40 years and older.Methods. Retrospective single-centre study concerning 47 consecutive ASD transcatheter occlusion procedures performed between January 1999 and December 2008. Electrocardiography, echocardiography and clinical assessments of the patients were conducted pre- and post-intervention and at follow-up.Results. Of the 130 patients who were referred for interventional ASD closure, 47 were 40 years and older and all of them actually had the device inserted. There were no major complications during the intervention. Mean follow-up time was 15±15 months. During follow-up, three patients needed surgical reintervention because of device embolisation (n=2) or dislocation (n=1). Of the patients with severe right ventricular (RV) dilatation, more than half (58%) had no or mild dilatation at last follow-up. Reduction of RV dilatation was not related to age. Pulmonary hypertension was present in 63% before the procedure and was reduced to 38% at follow-up. NYHA class improved in all age groups, also in patients over 60 years of age. In two of the three patients who died during follow-up, no cause of death could be established, but both had responded well to treatment regarding the echocardiographic and clinical findings.Conclusion. Transcatheter device closure of ASD is a successful and effective treatment, also for patients aged 40 years and older. Patients showed regression of right ventricular enlargement and an improvement in functional class. (Neth Heart J 2010;18:537–42.)     

Differences between atrial and ventricular protein profiling in children with congenital heart disease

The purpose of the present study was to compare protein profiling of atria and ventricles in children operated for congenital heart disease. Tissue samples were obtained during surgery from patients with normoxemic (ventricular and atrial septal defects) and hypoxemic (tetralogy of Fallot) diseases. Protein fractions were isolated by stepwise extraction from both fight ventricular and atrial musculature. The concentration of total atrial protein in the normoxemic patients exceeded the ventricular value (110±2.1 vs 99.9±4.0mg.g^–1 wet weight, respectively); in the hypoxemic group this atrio-ventricular difference disappeared. The concentration of contractile proteins in all cardiac samples was significantly higher in the ventricles as compared with atria, while the concentration of collagenous proteins was significantly higher in the atria (due to a higher amount of the insoluble collagenous fraction). The concentration of sarcoplasmic proteins (containing predominantly enzyme systems for aerobic and anaerobic substrate utilization), however did not differ between ventricles and atria. Furthermore, ventricular contractile fractions obtained from both normoxemic and hypoxemic patients were contaminated with the myosin light chain of atrial origin. Soluble collagenous fractions (containing newly synthesized collagenous proteins, predominantly collagen I and III), derived from all ventricular samples, were contaminated by low molecular weight fragments (mol. weight 29–35 kDa). The proportion of the soluble collagenous fraction was significantly higher in atrial but not in ventricular myocardium of hypoxemic children as compared with the normoxemic group. It seems, therefore, that lower oxygen saturation affects the svnthesis of collagen preferentially in atrial tissue.     

Functional reconstruction using a depressor anguli oris musculocutaneous flap for large lower lip defects, especially for elderly patients

Described here is a new technique to reconstruct large lower lip defects using one or two musculocutaneous island flaps, which includes an innervated depressor anguli oris muscle and has a facial artery in its pedicle. Vermilion is simultaneously reconstructed using a mucosal transposition flap. Three patients who had a total lower lip defect and five patients who had a defect larger than one-half of the lower lip were treated by our procedure. All the flaps survived completely without any signs of vascular stasis. In six patients, sphincter function and sensation appeared within 3 months after surgery. In one patient who needed a total lower lip reconstruction, the depressor anguli oris muscle was atrophic and the motor nerve could not be found. This patient could not regain motion. One other patient complained of a sialorrhea accompanied by sensory loss; however, his sensation improved within 6 months after surgery. All of the reconstructed lower lips were large enough to enable the patient to wear dentures and were of a cosmetically acceptable appearance 1 year after surgery.