Pacemaker implantation in a premature low weight newborn with critical congenital atrioventricular block.

We describe a case of a preterm newborn with congenital complete atrioventricular block (CAVB), delivered for distress by cesarean section, and undergone, at 1295 grams of weight, to permanent pacemaker implantation. The pacemaker has been inserted between the upper left rectus abdominal muscle and the posterior rectus sheath and connected by two epicardial leads on the left ventricle wall. The procedure has been successfull.

Regression of pulmonary fistulas in congenital heart disease after redirection of hepatic venous flow to the lungs.

Although the etiology of pulmonary fistulas in congenital heart disease remains unknown, several hemodynamic factors are thought to play a role. Recently it was postulated that hepatic venous effluent might protect the pulmonary bed from development of pulmonary fistulas. However, there are no experimental data supporting this hypothesis. Here, we present the cases of 2 patients in whom pulmonary fistulas developed after unintentional surgical exclusion of the hepatic venous flow from the pulmonary circulation. In both patients, symptoms resolved after rerouting of the hepatic venous blood to the lungs.

Arterial switch operation: myocardial ischemia reversed by internal mammary artery graft.

We report a case in which an internal mammary artery graft to the left anterior descending coronary artery was successfully used in a newborn boy to reverse life-threatening myocardial ischemia 24 hours after arterial switch operation. One year later, angiography showed patency of both the graft and the transposed coronary ostium with normal left ventricular function. A brief review of the literature shows encouraging results of internal mammary artery grafts in pediatric patients.

Late left atrioventricular valve insufficiency after repair of partial atrioventricular septal defects: anatomical and surgical determinants.

Risk factors for late left atrioventricular (AV) valve insufficiency, which occurred in 16 (18%) of 90 patients evaluated after repair of partial AV septal defect, were examined. The operative findings in 9 patients undergoing reoperation were also examined. Preoperative left AV valve insufficiency was significantly more common in the group with late left AV valve incompetence, as were associated valvular malformations as a whole and fenestrations of valve leaflets in particular. Conversely, the higher incidence of malformed or malpositioned papillary muscles, accessory clefts, and double-orifice left AV valves in the group with late left AV valve insufficiency did not reach significance. The method of surgical treatment of the septal commissure was not a significant factor. In the group having reoperation, additional valvular malformations were found in association with inappropriate treatment of the septal commissure in 7 patients. The 2 remaining patients had either a directly sutured ostium primum or dilatation of the annulus. Three re-repairs were successful. Five patients required prosthetic valve replacement. Preoperative left AV valve insufficiency and associated valvular malformations are major determinants of late left AV valve insufficiency in partial AV septal defect.

Fontan repair for tricuspid atresia: experience with 50 consecutive patients.

From April, 1975, to October, 1985, 50 patients (mean age, 5.3 years; range, 2.5 to 14 years) underwent a Fontan repair for tricuspid atresia or severe tricuspid stenosis. Fifty-six palliative operations had been performed previously in 43 patients. Twenty-nine patients received an atriopulmonary connection by direct anastomosis [19], interposition of an aortic homograft [7], or a porcine heterograft [3]. An atrium-subpulmonary chamber connection was performed in 21 patients (Björk modification, 10; Dacron tube, 10; valved conduit, 1). Eleven patients (22%) died early, 6 of whom did not meet the established criteria for a Fontan operation. One patient died 6 months postoperatively of superior vena cava thrombosis. Four patients were reoperated on successfully. At a mean follow-up of 28.8 months, 28 patients are in New York Heart Association Functional Class I and 9 are in Class II; 1 patient was lost to follow-up. Thirteen patients underwent control catheterization fifteen days to four years postoperatively (median right atrial pressure, 14 mm Hg). Exercise testing in 9 asymptomatic patients, performed after a mean interval of 33 months, showed a moderate impairment of cardiac performance. We conclude that in select patients, a Fontan repair appears to be a reliable procedure at medium-term follow-up.

Palliative reconstruction of the right ventricular outflow tract in tricuspid atresia: a report of 5 patients.

Five patients with tricuspid atresia, normally related great arteries, and decreased pulmonary flow underwent reconstruction of the right ventricular outflow tract on enlargement of the ventricular septal defect (VSD) (outlet foramen) or both in order to increase pulmonary blood flow. The age of the patients ranged from 9 months to 4 years. All patients previously had had a systemic-pulmonary artery anastomosis. Preoperative mean arterial oxygen saturation was 67.2%. A restrictive outlet foramen was enlarged in 3 patients. Infundibulectomy and enlargement of the outlet chamber with a Dacron patch were performed in 4 patients. A pulmonary valve commissurotomy alone was done in 1 patient. There were no hospital or late deaths (mean follow-up, 16 months). Four patients out of 5 have obtained symptomatic and documented (increase in partial pressure of oxygen) benefit. In 1 patient, arterial oxygen saturation failed to rise to a satisfactory level.

Surgical repair of persistent truncus arteriosus in infancy.

Fourteen patients younger than two years of age with persistent truncus arteriosus underwent primary repair. Twelve of them were less than 1 year and 4 less than 3 months of age. Intractable heart failure was the indication for surgery in all patients but one who had increased pulmonary vascular resistance. There were 5 hospital and 2 late deaths. Six out of the 7 survivors (median follow-up: 29 months) were symptom-free. The remaining infant who preoperatively had significant truncal valve regurgitation was doing fairly well 2 1/2 years after repair. Our experience suggests that, although the mortality remains high, primary repair for infants with persistent truncus arteriosus is feasible and offers better overall results than does pulmonary artery banding followed by later intracardiac repair. We advise primary repair for all infants with intractable heart failure or increasing pulmonary vascular resistance with or without truncal valve regurgitation. Elective repair is recommended before the age of 2 years to minimize the risk of pulmonary vascular disease.

[Clinical use of a minicomputer in heart surgery intensive care units]. / Impiego clinico di un microcalcolatore in unitá' di terapia intensiva cardiochirurgica.

The Authors present three respiratory parameters useful to estimate the respiratory and hemodynamic conditions of a cardiac patients before these turn into obvious pathological clinical pictures. The parameters are: alveolar-arterial oxygen difference, respiratory index and arterial-venous pulmonary shunts. The sophisticated mathematic calculations necessary to calculate and to elaborate such data are made, in few seconds, by a minicomputer which is very easy to work with. A clinical example in which the above-mentioned data have been employed helps to demonstrate their extreme usefulness.

[Corrective surgery of double-outlet right ventricle and subaortic ventricular defect. Report of 12 cases surgically treated (author's transl)]. / Correzione chirurgica del ventricolo destro a doppia uscita con difetto interventricolare sottoaortico. A proposito di 23 casi operati.

Experience with corrective surgery in 23 pts with double outlet right ventricle (DORV) and subaortic VSD is presented. The overall hospital mortality was 17%. Patients were divided into two groups: Group I includes seven cases without pulmonic stenosis and Group II sixteen cases with pulmonic stenosis. Six of Group II required a sistemic to pulmonary artery shunt earlier in life. Anatomic and clinical aspects in both groups are described as well as indication for surgery. The importance of angiocardiography for a precise diagnosis is emphasized. Problems related to management and complications are discussed; in particular how to avoid LVOTO in case of restrictive VSD and RVOTO in patients with pulmonic stenosis.

[Results of palliative operations in infants with pseudotruncus arteriosus (author's transl)]. / Considerazioni sul trattamento chirurgico palliativo dell'atresia polmonare con difetto interventricolare (pseudotruncus)

A palliative procedure in patients with pulmonary atresia with VSD should improve arterial oxygen saturation, allow growth and development, and promotes a uniform dilatation of the pulmonary arteries. Thirty-three severely symptomatic patients, ranging from 5 days to 24 mths of age and from 2,4 to 11 kg of weight underwent a variety of palliative operations, including the ascending aorta-right pulmonary artery shunt (intrapericardial: 15 cases; extrapericardial: 14 cases), the Blalock shunt (4 cases). In two cases, both with absence of the left pulmonary artery, a Waterston shunt was performed using cardiopulmonary by-pass. The operative mortality was 20%. In two patients an additional shunt procedure was deemed necessary due to persistent cyanosis. All the survivors improved in terms of arterial oxygen saturation, growth and development. There were no late deaths (mean follow-up: 23 months).