Long-term results of apical aortic conduits in children with complex left ventricular outflow tract obstruction.

BACKGROUND: Apical aortic conduits were used in children with complex left ventricular outflow tract obstruction at our institution before we adopted the Ross and Ross-Konno procedures. The early results with apical aortic conduits were quite good when we used a porcine xenograft conduit and were less satisfactory when we converted to an aortic homograft valve as the conduit valve. This report summarizes our clinical experience with apical aortic conduits in children with an emphasis on hemodynamic results, reoperation, and long-term follow-up. METHODS: Records of 28 patients (age range, 2 weeks to 19 years) who underwent insertion of apical aortic conduit between September 1979 and June 1993 were reviewed. All patients had complex multilevel left ventricular outflow tract obstruction. All were symptomatic, and 22 (79%) had had one or two previous aortic valvotomies or left ventricular outflow tract operations, or both. RESULTS: Hospital mortality was 11% (3 of 28). Twenty-five children survived the perioperative period and improved, and 21 have had one or more cardiac catheterization from 6 to 18 months (mean, 1.2 years) after the initial operation. Reduction or resolution of resting mean left ventricular-to-aortic peak gradient in the early postoperative period from 81.8 +/- 24.0 to 15.4 +/- 8.9 mm Hg was demonstrated (p < 0.001). Overall 25-year survival was 57%. Fourteen surviving patients (56%) have undergone subsequent procedures (n = 18) from 5 months to 16 years postoperatively (mean, 6.9 years) because they developed a recurrent left ventricular-to-aortic gradient of 58 +/- 28 mm Hg (p < 0.002). One patient underwent heart transplantation. All other late survivors have normal left ventricular function as determined by serial echocardiography. CONCLUSIONS: Apical aortic conduit is effective in relieving complex left ventricular outflow tract obstruction and improving left ventricular performance with acceptable short-term and midterm results, but late complications caused primarily by conduit tissue valve dysfunction are frequent in children. Since the early 1990s, the apical aortic conduit procedure has been largely replaced with the Ross or Ross-Konno procedure in our pediatric practice.

Staged surgical repair of functional single ventricle in infants with unobstructed pulmonary blood flow.

OBJECTIVE: The infant with a functional single ventricle (SV) and unobstructed pulmonary blood flow (UPBF) requires early protection of the pulmonary vascular bed to ensure suitability for a subsequent Fontan procedure. Systemic obstruction by aortic arch obstruction, subaortic stenosis, or combination of both, has been widely recognized as an important risk factor for poor outcome in children with SV-UPBF who are palliated with pulmonary artery banding (PAB). We reviewed our experience with primary PAB in the subset of patients with SV-UPBF to identify risk factors for subsequent palliative procedures and Fontan completion. METHODS: Between January 1990 and May 2004, 80 patients (median age, 14 days) with functional SV and UPBF underwent PAB as their primary palliative procedure. Thirty-five neonates had concomitant aortic coarctation or interrupted aortic arch repair (44%). A Damus-Kaye-Stansel procedure was subsequently performed in 19 patients, and subaortic resection or ventricular septal defect or bulboventricular foramen enlargement was performed in five. RESULTS: There were 4 operative deaths, and 15 late deaths. The actuarial overall survival is 84% at 1 year, 76% at 5 and 15 years. Follow-up is complete in all but six children at a mean interval of 4.9+/-3.7 years (range, 2 months-15 years). Thirty-seven patients (49%; 37 of 76) have undergone the hemi-Fontan procedure (with three hospital deaths) and 40 patients (53%; 40 of 76; 12 children without previous hemi-Fontan) have undergone the completion Fontan procedure without mortality or Fontan takedown. CONCLUSION: In infants with single ventricle physiology with or without systemic outflow obstruction and unobstructed pulmonary blood flow, a strategy of pulmonary artery banding carries acceptable operative and mid-term mortality in a high-risk group of patients. Pulmonary artery banding does not compromise performance of subsequent Damus-Kaye-Stansel procedure or completion Fontan palliation.

Incidence, outcome, and risk factors for stroke after the Fontan procedure.

We reviewed records on patients who underwent hemi-Fontan and Fontan procedures over a 13-year period at a single institution to examine the incidence and outcome of stroke and to attempt to identify risk factors for stroke. A history of pulmonary artery banding was associated with an increased risk of stroke.