Life-threatening arrhythmias and RV dysfunction after surgical repair of tetralogy of Fallot. Comparison between transventricular and transatrial approaches.

BACKGROUND: Late postoperative arrhythmias and right ventricular dysfunction may occur after classic repair of tetralogy of Fallot. METHODS AND RESULTS: During a mean follow-up of 8.9 years (range, 5 to 14 years), 24-hour ambulatory electrocardiographic studies were done in 107 patients after repair of tetralogy of Fallot. Radionuclide angiography was performed in 97, and 78 patients also underwent postoperative heart catheterization. The patients were divided into two groups: group A consisted of 71 patients aged 2 months to 61 years (mean, 6.8 years) in whom the right ventricular approach was used; group B included 36 patients aged 8 months to 39 years (mean, 7.9 years) whose repair was through the right atrium. A transannular patch was employed in 42 (59.2%) patients in group A and in 23 (63.9%) patients in group B. Eighteen patients were adults (> 18 years old) at the time of surgery: 13 (18.3%) in group A and 5 (13.8%) in group B. During a mean follow-up of 9.7 years, 57 (80.3%) group A patients were in New York Heart Association (NYHA) functional class I. Atrial flutter was present in 3 (4.2%) patients, and 28 (39.4%) had significant ventricular arrhythmias (> or = Lown grade 2). Postoperative heart catheterization showed good hemodynamic results in 36 of 54 group A patients studied (12 of whom had ventricular arrhythmias); moderate-to-severe pulmonary regurgitation was present in 14 (25.9%) patients; only 2 (3.7%) patients had right ventricular hypertension. On electrophysiological study, 8 of 28 (28.6%) patients in group A had inducible sustained ventricular tachycardia. Despite antiarrhythmic therapy, 2 of these patients died suddenly, presumably from ventricular arrhythmias. Two other late deaths in group A were caused by heart failure. During a mean follow-up of 7.2 years, 33 of 36 (91.7%) patients in group B were in NYHA functional class I. Atrial flutter was not found in any patient in this group. Only 1 (2.8%) patient, who had moderate-to-severe pulmonary regurgitation, had significant ventricular arrhythmias (> or = Lown grade 2). Postoperative catheterization showed good hemodynamic results in 20 of 24 patients; 3 (12.5%) had moderate-to-severe pulmonary regurgitation, and 1 (4.2%) patient had right ventricular hypertension. Sustained ventricular tachycardia could not be induced in any of the 5 adult patients who underwent electrophysiological studies. One late death (caused by endocarditis) occurred in group B. CONCLUSIONS: The right atrial approach significantly reduced the risk of life-threatening ventricular arrhythmias after repair of tetralogy of Fallot (P < .001) without increasing the incidence of supraventricular arrhythmias. Right ventricular dysfunction and severe pulmonary regurgitation were also more prevalent (P < .01) when the right ventricular approach was used.

Ventricular tumors: surgical options.

Primary cardiac tumors of the ventricles are very uncommon. During an 8-year period only, nine such patients were encountered: the tumor was primarily in the right ventricle in six, in the left ventricle in two and biventricular in one. There were seven children and two adults in this series. Histologically, the neoplasm was benign in all patients. The tumor was obstructive in six patients, five of whom underwent surgery (complete resection in three, partial excision in one and a Fontan-Kreutzer procedure in one); one neonate died before an operation could be performed. In addition, one patient with an epicardial tumor underwent complete resection. There were no early or late deaths among the six patients treated surgically. The tumor was small and non-obstructive in two patients, who were not operated on: one died suddenly, and the other was followed without intervention. In summary, complete or partial excision of ventricular neoplasms can usually be accomplished with good long-term results. If resection is not possible, effective palliation may be achieved with a Fontan-type operation, excluding the right ventricle from the circulation.

Laparoscopic cholecystectomy in heart transplant recipients.

To our knowledge these are the first three cases of laparoscopic cholecystectomy in heart transplant recipients. In one case the procedure was performed in the early posttransplant period. All three patients had uneventful postoperative outcomes and early hospital discharge. Laparoscopic cholecystectomy may be a safe alternative for elective cholecystectomy in heart transplant recipients.

Right submammarian thoracotomy in female patients with atrial septal defects and anomalous pulmonary venous connections. Comparison between the transpectoral and subpectoral approaches.

A right submammarian incision with anterior thoracotomy was performed in 89 female patients to repair simple and complex forms of atrial septal defects. Patients' ages ranged from 8 to 38 years (mean 21.5 years). Seventy-seven had secundum-type atrial septal defects, one had the primum type, and 11 had an associated partial anomalous pulmonary venous connection. The patients were divided into two groups: 57 patients in group A, in whom, after a breast flap was elevated, a transpectoral approach was used to enter the chest; 32 patients in group B, in whom the pectoral muscle was not divided and a subpectoral approach was used. Aortic cannulation was accomplished without difficulty in all 89 patients. There were no early or late deaths in either group. Follow-up ranged from 24 to 108 months (mean 63.7 months) and included 86 patients, who were free of symptoms. In group A, however, among 54 patients examined, the volume of the right breast and pectoral muscle was smaller than the left in four patients (7.4%), and 21 (38.8%) had persistent right periareolar numbness. In 32 patients evaluated in group B, no difference was noted in the size of the breasts, and persistent numbness was present in four patients (12.5%). In summary, atrial septal defects or anomalous pulmonary venous connections can be safely repaired through a right submammarian thoracotomy in female patients. The subpectoral approach offers better results because breast asymmetry and paresthesias are significantly less prevalent (p less than 0.01).

Risk of recoarctation in neonates and infants after repair with patch aortoplasty, subclavian flap, and the combined resection-flap procedure.

Between September 1980 and August 1988, 47 patients younger than 12 months (27 neonates and 20 infants) underwent repair of aortic coarctation. Three surgical techniques were used: patch aortoplasty (group A: 5 neonates and 3 infants, mean age 4.5 months), subclavian flap (group B: 11 neonates and 8 infants, mean age 3.1 months), and the combined resection-flap procedure (group C: 11 neonates and 9 infants, mean age 2.7 months). There were 8 early deaths (3 in group A, 3 in group B, and 2 in group C) and 2 late deaths (both in group B), all of which occurred in patients with complex coexisting anomalies. Follow-up included 37 patients (5 in group A, 14 in group B, and 18 in group C) and ranged from 28 to 108 months (mean 68.0, 60.8, and 51.7 months, respectively). Residual arm-leg pressure gradients greater than 10 mm Hg were detected in 4 of 5 patients in group A, 11 of 14 patients in group B, and 1 of 18 patients in group C (p less than 0.005). There were no reoperations in any infant operated on after 1 month of age in any group (0% risk). However, 4 patients who underwent repair during their neonatal period, with recurrent gradients greater than 20 mm Hg, have required reoperation: in group A, 1 of 5 patients (20% risk) (1 of 2 neonates or 50% risk); in group B, 3 of 14 patients (21% risk) (3 of 9 neonates or 33% risk); and none in group C (0% risk in infants and neonates) (p less than 0.001). In summary, residual gradients and risk of recoarctation are significantly higher when a patch or a subclavian flap had been used for repair. The combined resection-flap procedure (an end-to-end anastomosis enlarged with a subclavian flap) is more effective in avoiding gradients and preventing recoarctation, especially in neonates.

Surgical treatment of acute type A dissecting aneurysm, with preservation of the native aortic valve and use of biologic glue. Follow-up to 6 years.

We present an analysis of 59 patients operated on between 1983 and 1987 for acute type A dissecting aneurysm with aortic valve insufficiency. The ascending aorta was replaced with a Dacron tube, the layers of the dissection were unified with gelatin-resorcine-formaldehyde glue, and the natural aortic valve was preserved. Follow-up every 6 months was subject to actuarial analysis. The hospital mortality rate was 22%. The survivors were studied for 35.9 +/- 18.6 months (mean +/- standard deviation). Eight patients died (six of cardiovascular causes, one of cancer of the colon, and one of an unknown cause). Seventeen (36.9%) had aortic insufficiency, eight mild and nine moderate to severe. Four patients with severe insufficiency had reoperation with valve replacement. Excluding patients who have died or undergone reoperation, 29 of the remainder (90.6%) are free of symptoms. The follow-up survival rate is 61% +/- 6.93% (standard error) including hospital mortality. It is 55.4% +/- 7% (standard error) excluding reoperation and 44.2% +/- 7.1% (standard error) additionally excluding modest or severe aortic insufficiency. The use of gelatin-resorcine-formal glue allowed preservation of the native aortic valve, obviating the need for anticoagulants, and no embolic or hemorrhagic episodes were registered.

Comparison of two levels of anticoagulant therapy in patients with substitute heart valves.

After cardiac valve replacement patients were blindly randomized into two groups, both receiving aspirin (330 mg) and dipyridamole (75 mg) twice daily and the oral anticoagulant acenocoumarol (Sintrom). An international normalized ratio of 2.0 to 2.99 was assigned to group A and 3.0 to 4.5 to group B; both groups were subsequently analyzed for thromboembolic and hemorrhagic complications. Final evaluation included 51 and 48 patients, respectively. The follow-up was 626 months for group A (12.3 months/patient) and 486 months for group B (10.1 months/patient). The frequency of thromboembolism was equal in both groups: one transient ischemic attack in group A (a rate of 1.92/100 patient-years) and two transient ischemic attacks in group B (a rate of 4.94/100 patient-years). There was, however, a statistical difference in bleeding complications between the two groups (p less than 0.02). Two patients bled in group A, a rate of 3.9% (3.8/100 patient-years), which represents an incidence of one episode each 25.6 years of treatment; 10 patients bled in group B, a rate of 20.8% (24.7/100 patient-years) representing an incidence of one episode each 4 years of treatment. We conclude that an international normalized ratio of 2 to 3 is safer than a ratio of 3 to 4.5 and confers good protection from thromboembolism when oral anticoagulant therapy is used conjointly with platelet function-inhibiting drugs in patients with mechanical substitute heart valves.

Computerized tabulation of cine coronary angiograms. Its implication for results of randomized trials.

The quality of cine angiography is excellent in our days, and as a consequence some of the pitfalls encountered in previous randomized trials are not currently present. An example can be found in the CASS analysis of the reproducibility of coronary arteriographic reading by the Quality Control Committee Sessions: "There is an indication that different clinics" involved in the CASS trial "can reduce the variability between their readings by concerted effort to improve both the quality and the completeness of the angiographic examination." The introduction of electronic calipers to judge the severity of the obstruction can eliminate human errors. The computerized protocol has the disadvantage that it takes longer to tabulate cine coronary angiography and it will depend on its pattern, but it certainly will not be as long as filling in the CASS protocol. However, this effort is justified because it will enrich our knowledge of coronary arteriosclerosis. As a result, patients will be divided into proximal (1, 2, 12, 13, and 19), middle (mainly, 3, 14, and 20), and distal (remainder) segments. Sometimes midsegments can be important. For example, in the report from CASS related to the left main equivalent lesions, the 5-year survival rate was 48% if the obstruction on the left anterior descending was proximal and increased to 71% if it was more distal. Several randomized studies to compare PTCA with CABG as suggested by Gruentzig et al in 1979 are underway, and it is hoped that the data will be properly analyzed. However, if cine coronary angiography and the status of the left ventricle are not carefully tabulated (classification of patients into left main trunk or one-, two-, or three-vessel disease is not sufficient), the results of the randomized trials comparing PTCA with CABG will add more confusion instead of clarifying proper therapeutic implications.

Deep hypothermia and circulatory arrest as an elective technique in the treatment of type B dissecting aneurysm of the aorta.

The combination of deep hypothermia and circulatory arrest has been used in a variety of cardiovascular surgical techniques and is presented in this article as an elective method in the treatment of type B dissecting aneurysms that may or may not involve the distal aortic arch. Out of 190 patients operated on with acute aortic dissection, 10 patients with type B underwent surgical procedures, between January 1985 and December 1987, four with acute dissection (less than 14 days evolution), and six with chronic dissection (more than 14 days evolution). The approach was by left posterolateral thoracotomy with cardiopulmonary bypass using femoro-femoral cannulation, deep hypothermia, and circulatory arrest. The duration of circulatory arrest was between 27 and 58 minutes, mean 37 minutes. Extracorporeal circulation (ECC) lasted between 68 and 142 minutes, with a mean perfusion time of 83.7 minutes, and temperature fell to 14 degrees C and 16 degrees C. Intrahospital mortality was 20% (two patients). No long-term mortality has been recorded. Eighty percent of the patients (eight patients) are alive and showed good evolution between 10 and 44 months following surgery, with a long-term mean survival of 24 months and 23 days. The only neurological complication was a single case of right unilateral blindness followed by complete visual recuperation. Myocardial and spinal cord protection are excellent, without any incidence of postoperative infarct or paraplegia. Postsurgical blood loss ranged from 200 to 650 mL with a mean of 385 mL. Acute renal insufficiency was not detected. We believe that the combined techniques of deep hypothermia and circulatory arrest used electively, and not just out of occasional necessity, is a viable choice that allows easier surgical manipulation of type B dissection aneurysms and complete resolution of those involving retrograde dissection to the aortic arch. In addition. this combined technique does not increase postoperative mortality in this critically dangerous disease.

Right atrial approach for surgical correction of tetralogy of Fallot.

Total correction of tetralogy of Fallot was performed without a ventriculotomy in 39 patients aged 8 months to 39 years (mean age, 9.1 years) between May 1984 and July 1988. A transatrial approach was used to resect the obstructed infundibulum and to close the ventricular septal defect. In 14 patients, the pulmonary annulus was not enlarged (group 1). Twenty-five patients required a transannular patch (group 2), placed by extending the pulmonary artery incision 1 cm into the right ventricular infundibulum. Eleven patients had repair of pulmonary artery branch stenosis, and associated intracardiac anomalies were simultaneously corrected in 10 patients. After repair, the right ventricular to left ventricular systolic pressure ratios ranged from 0.36 to 0.59 (mean ratio, 0.45) in group 1 and 0.33 to 0.70 (mean ratio, 0.51) in group 2. There were no hospital or late deaths in group 1. Two patients in group 2 with a small left ventricle died shortly after operation. The 37 survivors were followed for 2 to 51 months. Postoperative catheterization in 7 patients detected no residual ventricular septal defects, mild pulmonary regurgitation in 2 patients (group 2), and right ventricular to left ventricular pressure ratios ranging from 0.25 to 0.42 (mean ratio, 0.34). Only 1 patient with a previous total repair by ventriculotomy is symptomatic and requires antiarrhythmic agents and diuretics. The other 36 patients are asymptomatic. In conclusion, tetralogy of Fallot can be safely repaired at any age without a ventriculotomy. The results indicate a minimal incidence of postoperative arrhythmias and pulmonary regurgitation, as well as improved right ventricular function.

Successful pregnancy and vaginal delivery after heart transplantation.

Successful pregnancy and delivery in women with serious cardiovascular diseases have been reported. We describe here a patient with a transplanted heart, treated with cyclosporine and prednisone, who underwent pregnancy and vaginal delivery with good outcomes for mother and infant.