Delated Senning Procedure for Transposition of the Great Arteries with Severe Pulmonary Hypertension / 日本心臓血管外科学会雑誌

We report a case of transposition of the great arteries (TGA) with severe pulmonary hypertension from the right to left shunt in the right modified Blalock-Taussig shunt. The patient was diagnosed with TGA with a small ventricular septal defect, restrictive patent foramen ovale, and patent ductus arteriosus. Balloon atrial septostomy was performed, and an arterial switch operation (ASO) was planned. However, ASO was delayed during the neonatal period due to cerebral bleeding. Moreover, left outflow tract obstruction was noted ; hence, the surgical strategy was shifted to an atrial switch operation or Rastelli type operation. The patient was palliated at the age of 5 months with a right 4-mm Gore-Tex modified Blalock-Taussig shunt. After this procedure, he was followed up at the outpatient clinic with good saturation level. However, at 9 months, he revisited the hospital due to septic shock. His SpO2 was 60% in the upper right limbs and 40% in the upper left and lower limbs. Nitric oxide inhalation and 100% oxygen were administered to improve pulmonary hypertension and subsequent differential cyanosis. Pulmonary hypertension decreased from over-systemic to 70% of the systemic arterial pressure. The Senning procedure with a fenestration in an atrial baffle was successfully performed at the age of 1 year.

Clinical Applications and Pitfalls of Hypothermia in Patients after Fontan's Operation / 日本心臓血管外科学会雑誌

This study was designed to clarify the usefulness and pitfalls of hypothermic management after Fontan's operation. Twenty-five patients who underwent Fontan's operation and received hypothermic management in an acute postoperative phase from 1974 to 1991 were divided into two groups; the alive (S) group and the dead (D) group. The lowest rectal temperature during the procedure was 32°C on average. There were no significant differences in preoperative indices of pulmonary circulation and renal function. After rewarming, PaO₂ and daily urinary output were increased and central venous pressure decreased significantly in the S group. In all S group patients, urinary output was increased during hypothermia irrespective of peritoneal dialysis. Anuria occurred 2 days on average after induction of hypothermia in D group. Urinary output in D group decreased significantly for 4 days compared to S group. On the other hand, it was possible to save two patients who underwent take-down of Fontan's operation within 6 hours after the onset of anuria. We conclude that hypothermic management is useful in serious cases after Fontan's operation and that daily urinary output in relation to body weight during hypothermia is most important as an index of post operative circulation.

Experiences of Absorbable Suture Material in Pediatric Cardiovascular Surgery / 日本心臓血管外科学会雑誌

We have used absorbable suture material for the repair of pediatric cardiovascular anomalies where subsequent growth of the suture line was requied since 1986. We reviewed long-term results of three groups of patients using absorbable suture (1. cardiovascular surgery in the high-pressure areas, 2. semicircular annuloplasty for mitral regurgitation, 3. cardiovascular surgery in the low pressure areas). In group 1, six patients after Jatene procedure using PDS^® were examined. Subsequent growth of the neo-aortic anastomotis were well preserved without formation of pseudoaneurysm 6-56 (average 18.6) months after the operation. In group 2, seven patients with mitral regurgitation (mitral valve regurgitation 4, endocardial cushion defect 3) were examined. The semicircular annuloplasty was applied using Vicryl^® and Dexon^® and mitral regurgitation was improved and in two patients normal growth of the mitral annulus was recognized 4 and half years after the operation. In group 3, sixteen patients in the repair of total anomalous pulmonary venous drainage (Darling type I, III) using PDS^® were examined. Pulmonary venous obstruction were encountered 1 and 5 months after the anastomotis between common pulmonary vein and left atrium in two patients and anastomotic stenosis was thought to be induced by tissue overgrowth. On the basis of our clinical experiences, we believe that application of absorbable suture in pediatric cardiovascular surgery in the high-pressure areas could be recommended as an alternative treatment, but that should be avoided in the neonatal small low-pressure areas on the assumption that anastomotic stenosis might be induced by tissue overgrowth.