Clinical anatomy of the meniscus in animal models: pros and cons.

Nowadays, despite the possibility to use in vitro or computer models in research, animal models are still essential. Different animal models are available for meniscal repair investigation. Although a unique perfect model for the structure of the human's knee does not exist, the choice of the proper animal model is crucial for a correct research. The principal animal models in the meniscal repair are sheep, goats, pigs and dogs. Each of these has pros and cons for their utilization. Analysing each pro and con is essential for optimizing the choice of the animal model, which depends on the experimental question, avoiding unnecessary waste of resources and minimizing the animal suffering, according to the Russell and Burch's three "Rs" principles (Reduce, Refine and Recycle). In this concise review, we resume the meniscus anatomical features of the main large animals, to help choose the most suitable animal model for subsequent studies on meniscal repair.

Effect of chronotype on motor skills specific to soccer in adolescent players.

Circadian rhythms influence daily behavior, psychological and physiological functions, as well as physical performance. Three chronotypes are distinguished according to the preferences people typically display for activity at certain times of day: Morning, Neither, and Evening types (M-, N- and E-types). The chronotype changes with age: eveningness tends to be stronger in youth and morningness in older age. The progressive shift toward eveningness during adolescence creates misalignment with morning society schedules and can lead to a deterioration in intellectual and physical performance. Soccer is one of the world's most popular sports practiced by adolescents and soccer workouts are usually held after school in the afternoon or evening. Performance in soccer is related to a host of factors, including physiological variables and motor skills that have a circadian variation. The aim of this study was to determine the effect of chronotype on motor skills specific to soccer, specifically whether agility, aerobic endurance, and explosive power differ among the three chronotypes in relation to the time of day. For this study 141 adolescent soccer players filled in the Morningness-Eveningness Questionnaire (MEQ) for the assessment of chronotype. A subsample of 75 subjects, subdivided in M-types (n= 25), E-types (n= 25), and N-types (n= 25), performed three tests (Sargent Jump Test - SJT, Illinois Agility Test - IAT, and 6-Minutes Run Test - 6MRT) at a morning and an evening training session (9:00 am and 6:00 pm). Mixed ANOVA was used to test the interactions between chronotypes, physical performance, and time. On all tests, better performance during the morning than the evening session was observed for the M-types (p< .05), whereas the E-types performed better in the evening than in the morning session (p< .05), and no differences in test performance were detected for the N-types. These findings underline the importance of a correct chronobiological approach to sports training. Scheduling training sessions according to an athlete's circadian preferences could be a valid strategy to enhance performance.

Comparison of early functional outcomes between two different surgical approaches for total hip arthroplasty.

Total Hip Arthroplasty (THA) is considered the most successful treatment for advanced hip osteoarthritis. Different surgical approaches for THA are available and they have shown excellent outcomes in the long-term follow-ups. However, few studies have analyzed the functional outcomes in the first days after a THA surgery. The purpose of this study was to compare the early functional outcomes between two different surgical techniques: a minimally invasive direct anterior approach (mini-DAA) and a postero-lateral approach (PL). Twelve patients for each group were analyzed. Pre- and postoperative (3, 10, 30 and 90 days after surgery) Patient-Reported Outcome Measures (PROMs) were administered: HOOS, HHS, VAS and SF-12-v2 scores. Moreover, comparison between surgical operation time and blood loss were examined. PROMs showed a significant improvement in the SF-12-v2 in the mini-DAA group compared to the PL group at 3 days after surgery: this difference was maintained also after 10 and 30 days. In addition, HOOS and HHS were significantly ameliorated in the mini-DAA group starting 10 days from surgery. In both groups, a physiological pain reduction was observed in the first days after surgery; comparing it to the pre-surgical VAS values, we found a significant improvement in the scores for the mini-DAA group after 30 days. Moreover, we demonstrated a significant reduction in blood loss for the mini-DAA group. Surgical operation times were similar in the two groups; however, the duration of the mini-DAA procedure was shorter compared with the known literature. In this preliminary study, we demonstrated that the minimally invasive direct anterior approach for THA may lead to benefits in the early postoperative time, as it allows for an improvement in functional outcomes, a reduction of postoperative pain, a reduction of hospitalization time and consequent reduction of postoperative complications; therefore, this surgical approach may consent an early return to work and daily activities.

Ventricular assist devices as a bridge to heart transplantation or as destination therapy in pediatric patients.

PURPOSE: Despite the remarkable advances with the use of ventricular assist devices (VAD) in adults, pneumatic pulsatile support in children is still limited. We report on our experience in the pediatric population. METHODS: Retrospective review of 27 consecutive children offered mechanical support with Berlin Heart as a bridge to heart transplant, and Jarvik 2000 as a destination therapy from February 2002 to October 2011. RESULTS: The median patient age was 4.8 years (range = 75 days to 20.5 years). The median patient weight was 18.6 kg (range = 2.9-63 kg). We divided the patients in two groups, including in group I patients assisted for bridging to heart transplantation and in group II patients with Duchenne's dystrophy assisted as destination therapy. In the group I, 11 patients required biventricular mechanical support (BVAD), but in all other cases, a single left VAD proved sufficient (56%). The median duration of VAD support was 48 days (1 to 192 days). The median pre-VAD pulmonary vascular resistance index (Rpi) was 5.7 WU/m(2) (3.5 to 14.4 WU/m(2)). Twelve patients (48%) were successfully bridged to heart transplantation after a median duration of mechanical support of 63 days (range = 2-168 days). Ten deaths occurred (40%), three for neurological complications, two for sepsis, two for multiorgan failure, and three other for device malfunctioning. Since 2007, the survival rate of our patients has increased from 33% to 75%, and the need for BVAD has decreased from 89% to 23%. In the group II, two patients with mean age of 15.3 years were assisted with Jarvik 2000, and both of them are alive in a follow-up of 10.4 months. In two patients with Rpi > 10 WU/m(2), unresponsive to pulmonary vasodilatator therapy, Rpi dropped to 2.2 and 2 WU/m(2) after 40 and 23 days of BVAD support, respectively. Six patients (32%) required at least one pump change. Of 12 patients undergoing heart transplantation, five developed an extremely elevated (>60%) panel-reactive antibody by enzyme-linked immunosorbent assay, confirmed by Luminex. All of them experienced at least one acute episode of rejection in the first month after heart transplant, needing plasmapheresis. The survival rate after heart transplantation was 100% with a median follow-up of 34.4 months (45 days to 8.7 years). CONCLUSIONS: Mechanical support in children with end-stage heart failure is an effective strategy as a bridge to heart transplantation with a reasonable morbidity and mortality. BVAD support may offer an additional means to reverse extremely elevated pulmonary vascular resistance. The total implantable system opens a future scenarios for patients not eligible for heart transplantation.

Role of tricuspid regurgitation in fetal echocardiographic diagnosis of pulmonary atresia with intact ventricular septum.

OBJECTIVE: Pulmonary atresia with intact ventricular septum (PAIVS) is a rare cardiac malformation with a broad spectrum of anatomical manifestations, varying from types suitable for biventricular repair to those with diminutive right ventricle and primitive ventriculocoronary connections (VCC), more suitable for single-ventricle palliation or heart transplantation. We sought to test whether tricuspid regurgitation is an easily detectable prenatal criterion with which to identify PAIVS patients at lower risk of needing postnatal single-ventricle palliation. METHOD: We identified retrospectively patients with both fetal diagnosis and postnatal confirmation of PAIVS who were seen at Bambino Gesù Hospital between January 2000 and December 2006. Tricuspid valve/mitral valve (TV/MV) ratio, presence and severity of tricuspid regurgitation and direct visualization of VCC were evaluated by echocardiography both pre- and postnatally. RESULTS: We identified 22 patients with a prenatal diagnosis of PAIVS. Four pregnancies were terminated and one fetus was lost to follow-up, leaving 17 patients for the analysis. Based on postnatal cardiac catheterization and/or echocardiography we divided our population in two groups: Group 1 included 10 patients with VCC; Group 2 included seven patients without VCC. At fetal echocardiography, tricuspid regurgitation was absent in all ten Group 1 patients and present in all seven Group 2 patients. VCC were seen directly in 6/10 Group 1 patients and in no Group 2 patients. A cut-off value of 0.56 for the TV/MV ratio was highly predictive of VCC during fetal life, with a sensitivity of 100% and a specificity of 90%. CONCLUSIONS: The absence of tricuspid regurgitation in fetuses affected by PAIVS is a strong prenatal echocardiographic predictor of VCC, as is a TV/MV ratio < 0.56. Fetuses presenting with tricuspid regurgitation and relatively large right ventricle are at lower risk of needing single-ventricle palliation postnatally. This inforation could be helpful for appropriate prenatal counseling and postnatal decision-making.

Antiphospholipid antibodies and intracardiac thrombosis. A case report.

The antiphospholipid syndrome (APS) has been associated with multiple cardiac abnormalities. The present report describes a case of right ventricle thrombus in a 51-year-old woman with a history of autoimmune haemolytic anemia and antiphospholipid antibodies. Transthoracic echocardiography demonstrated the presence of a right ventricle mass, mimicking a myxoma. She underwent open heart removal of the mass and was started on indefinitely anticoagulant therapy. At 2 years follow-up she was free of symptoms.

Transient complete atrioventricular block during transcatheter ablation of a left inferoparaseptal anomalous pathway in a patient with a history of previous surgical repair of ventricular septal defect.

This case describes a young woman with a manifest left inferoparaseptal accessory pathway and previous history of surgical repair of a defect of the ventricular inlet septum in whom a transient complete AV block occurred during radiofrequency ablation performed from the coronary sinus. The presence of a preexisting surgery related AV block unmasked by anomalous pathway ablation is the more reliable explanation for this case.

Modified button-Bentall operation for aortic root replacement: the miniskirt technique.

BACKGROUND: The aim of this study was to evaluate the midterm results of a modified button-Bentall operation (modified-bB) specifically designed to incorporate any type of prosthetic valve in composite conduit aortic root replacement. METHODS: Between 1991 and 2000, a total of 135 patients underwent modified-bB for annuloaortic ectasia (74 patients), type A dissection (31), or aortic aneurysm without dissection (30). Of these, 34 were emergencies (25.2%). A total of 50 bioprostheses (study group 1) and 85 bileaflet mechanical prostheses (study group 2) were implanted. Group 1 mean age was 66.9 +/- 7.4 years versus 51.5 +/- 12.1 years in group 2 (p < 0.001). Composite-conduit creation occurred during proximal suture line construction as a single-step maneuver. Interrupted extracardiac polyester mattress sutures sequentially entered the aortic annulus, the prosthetic valve ring, and the vascular graft 7 mm from its free edge (miniskirt). Running monofilament suture line secured proximal hemostasis, buttressing aortic remnants and graft edge. Coronary reimplantation was accomplished in all cases by the button technique. Concomitant procedures were performed in 51 patients (37.8%). RESULTS: The 30-day mortality was 5.18% (7/135 patients). Eight patients (5.9%) required revision for proximal (1 patient), coronary button (3), or distal (4) anastomosis leakage. Three patients (2.2%) perioperatively developed nonfatal inferior myocardial infarction. Kaplan-Meier 9-year survival is 91.8% +/- 0.026 SE with 88.1% (95% confidence limits 71.7% to 95.5%) reoperation freedom. According to the Cox proportional hazard method, stratification of the risk for death according to prosthesis type indicates previous operation (p = 0.001) and emergency (p = 0.0465) as independent predictors of hospital mortality. Associated procedures to modified-bB increased risk of reoperation (p = 0.031). CONCLUSIONS: Modified-bB was associated with low mortality, excellent midterm survival, and freedom from reoperation. Absence of valve-to-graft tapering, reduced coronary button anastomosis tension, and prosthesis selection according to patient profile, are apparent advantages of modified-bB.

Morphological variation analysis of the repeatability of soccer offensive schemes.

A landmark-based statistical method, morphological variation analysis, for the quantification of the repeatability in the arrangement of body segments during the execution of sport actions has recently been developed. A two-dimensional shape is produced and its morphology is studied. The method was used to measure the within-team variability of the relative positions of players during the execution of offensive schemes in soccer. Two junior soccer teams of different technical abilities (semi-professional vs. amateur), each playing two standardized offensive schemes of different difficulty (easier: throw-in; more difficult: wing attack) were filmed. Each scheme was repeated 25 (semi-professionals) or 10 (amateurs) times. For each repetition, the position of the players in a single significant frame was analysed using morphological variation analysis. The reproducibility of both schemes was higher among the semi-professionals than among the amateurs (two-way analysis of variance, P<0.005). The repeatability of the players' relative positions was related to the difficulty of the scheme and the technical level of the team. Among the amateurs, the throw-in was more reproducible than the wing attack (Student's t-test, P<0.005). The method not only allows the quantification of collective (team) coordination, but also the separation of the influence of individual players.

Repair of aortico-left ventricular tunnel originating from the left aortic sinus.

We report on a case of an 11-year-old asymptomatic child with aortico-left ventricular tunnel arising from the left aortic sinus. Preoperative transesophageal echocardiography showed a dilated aortic root with mild aortic valve incompetence and demonstrated the course of the tunnel, which originated from the left coronary sinus entering the outlet portion of the left ventricular outflow tract. Patch closure of the aortic end of the tunnel eliminated left ventricular volume overload with immediate marked reduction of cardiomegaly. At 10-month follow-up the child is asymptomatic and receiving no oral medications. Control two-dimensional Doppler echocardiography shows trivial central aortic valve incompetence.

Foot asymmetry in healthy adults: elliptic fourier analysis of standardized footprints.

The size and shape of paired structures differ in the left and right sides of the body. Shape characteristics should be analyzed separately from size to supply information about the normal variations of human organs. In the present study, the within-subject normal symmetry of footprint shape and size was analyzed from a mathematical standpoint. On the standardized left and right footprints of 46 healthy adults (23 women and 23 men; 19-26 years old), the outline of each foot excluding the toes was identified and its shape was quantified independently from size by the elliptic Fourier analysis. The symmetry in shape was quantified on an intra-subject basis by calculating a morphologic distance D between the mathematical reconstructions of the left and right footprints of each subject. Symmetry in size was assessed by the right-to-left area ratio and found to be very good for all subjects; it ranged from 0.948 to 1.049. The subjects were also grouped by sex, and mean values were calculated. Within-subject symmetry in the footprint shape appeared high, with morphologic distances ranging between 8.94 and 2.66 in men and between 7.15 and 3.09 in women. No consistent associations between footprint symmetry and age, body height and weight, or shoe size were found. On average, women had more symmetric size-standardized footprints than did men (women: mean 4.57, SD 1.14; men: mean 5.46, SD 1.7; p < 0.05). Mean size-independent shapes of male and female left and right footprints were also calculated. Together with the analysis of individual asymmetry, they could be used for the quantitative diagnosis of borderline patients.

Repair of complete common atrioventricular canal defects in patients younger than four months of age.

BACKGROUND: The purpose of this study was to evaluate the impact of age at repair and atrioventricular (AV) valve anatomy on preoperative and postoperative AV valve incompetence (AVVR) was done to test the hypothesis that early repair (less than 4 months of life) can be safely accomplished and not only control heart failure but also improve surgical results on AV valve reconstruction. METHODS AND RESULTS: One hundred patients, median age 6.1 months, underwent repair of the complete common AV canal defect (CAVC) between 1981 and 1996. Surgery was performed in 37 patients (37%) less than 4 months of age (Group 1) and in 63 patients (63%) more than 4 months of age (Group 2). Surgical correction included double patch septal reconstruction in all. Trifoliate reconstruction of the left AV valve was selected in 93 patients (93%). Parametric time-related predicted survival was 92.9% at 14 years in Group 1 (70% confidence limits, 87.6% to 96.1%) and 75.9% at 15.4 years in Group 2 (70% confidence limits, 70.08% to 81.02%) (P=.038). Multivariate analysis in hazard function domain shows early repair as a negative risk factor for death (P=.038). Ordinal logistic regression equation indicates a higher probability of preoperative AVVR with older age at operation (P=.019). Regression analysis demonstrates good correlation between annular size and age at repair (r=.87, P < .01) and between annular size and AVVR (r=0.68, P < .01). Parametric time-related predicted freedom from reoperation was 82.7% at 15.4 years (70% confidence limits, 76.9% to 88.5%). Multivariate analysis in hazard function domain demonstrated Down's syndrome as a negative risk factor for reoperation (P=.05), whereas annular dilation increased the risk of this event (P=.027). CONCLUSIONS: Early correction of CAVCs is safe and beneficial not only in controlling chronic heart failure, but also in preventing annular dilation secondary to large QP/QS, as a potential mechanism of preoperative AVVR. Annular dilation is an incremental risk factor for reoperation. Early correction according to the double patch technique and trifoliate approach to the left AV valve reconstruction allows respect of valvar and subvalvar apparatus architecture, with a low incidence of postoperative AVVR, excellent survival rate, and low reoperative rate for residual AVVR.

Repair of tetralogy of Fallot in the first six months of life: transatrial versus transventricular approach.

BACKGROUND: This report describes our experience with primary correction of tetralogy of Fallot in infants. METHODS: Fifty-one consecutive infants younger than 6 months underwent primary correction of tetralogy of Fallot between January 1978 and October 1994. Mean age at repair was 4.2 months. Four were neonates. Correction was accomplished through a right ventriculotomy in the first consecutive 22 patients (43%; group A); since 1991, a combined transatrial-transpulmonary approach was used in 29 consecutive patients (57%; group B). A transannular patch was necessary in 33 infants (65%) 16 of group A (73%) and 17 of group B (59%). RESULTS: There was one early death from possible left anterior descending coronary artery distortion in group A and no deaths in group B. Two patients required early reoperation for systemic-to-pulmonary artery collateral ligation (postoperative day 6) and permanent pacemaker implantation (postoperative day 30). There were no late deaths. All 50 survivors are currently asymptomatic and in New York Heart Association class I. Three patients required late reoperations 36 months, 30 months, and 13 months after repair for (1) subaortic stenosis and dysfunctioning dysplastic mitral valve, (2) residual pulmonary artery branch stenosis, and (3) residual right ventricular outflow obstruction. Four patients underwent balloon dilation and stent insertion (1 patient) for peripheral pulmonary artery stenosis 1.5 year to 12 years (mean, 5 years) after initial repair. Actuarial freedom from need for reintervention at 4 years was 78.4% in group A and 85.7% in group B. Two-dimensional and Doppler echocardiographic follow-up studies showed a residual mild to moderate pulmonary artery branch stenosis in 4 patients in group A, and a recurrent subaortic stenosis in 1 patient in group A. Right ventricular peak systolic pressure was less than 40 mm hg in all but 3 asymptomatic patients who had a residual pulmonary artery branch stenosis. Right ventricular end-systolic and end-diastolic volumes showed larger volumes and reduced ejection fraction in group A compared with group B. CONCLUSIONS: This limited experience with repair of tetralogy of Fallot in patients less than 6 months of age demonstrates that the transatrial-transventricular approach is possible in neonates and young infants with a very low mortality and morbidity and also a low incidence of residual lesions. Follow-up echocardiographic data suggest that right ventricular function is better preserved in those patients who underwent the transatrial-transpulmonary repair.

Left atrioventricular valve incompetence after repair of common atrioventricular canal defects.

BACKGROUND: Reoperation rate for residual atrioventricular (AV) valve regurgitation after repair of common atrioventricular canal defect (AVCD) is currently between 5% and 10%. This retrospective analysis evaluates the impact of AV valve anatomy, age at repair, and surgical technique on postoperative AV valve incompetence. METHODS: Between January 1982 and July 1994, 205 patients with common AVCD underwent surgical repair at our institution. A complete form with common atrioventricular orifice (CCAVCD) was present in 81 patients. One hundred twenty-four had separate AV valves and orifices; 22 of these had a restrictive ventricular septal defect component. Preoperative moderate to severe AV valve regurgitation (AVVR) was present in 74 (36%), with a lower incidence in the CCAVCD group (20/81, 25%) versus the transitional (8/22, 36%) or the partial forms (46/102, 45%) (p = 0.02). The incidence was 12.5% (3/24) for CCAVCD patients less than 4 months of age (p = 0.02). Repair of the left AV valve was performed according to the trifoliate approach in most cases (142/205, 70%). Follow-up was 98% complete. RESULTS: By Kaplan-Meier analysis, survival at 12.3 years was 97.8% +/- 1% in partial AVCD, 95.4% +/- 4% in transitional AVCD, and 73.2% +/- 5% in CCAVCD (median follow-up, 60 months). Freedom from reoperation at 12.3 years was 93.5% +/- 2% for partial AVCD, 76.9 +/- 9% for the transitional form, and 68.3% +/- 5% for CCAVCD: Postoperative moderate to severe AVVR occurred in 42 patients (21%), with lower incidence for CCAVCD (10/81, 12.5%) versus transitional AVCD (8/22, 36%) and partial AVCD (24/102, 24%) (p = 0.02). Postoperative moderate AVVR was found in only 1 patient with CCAVCD less than 4 months of age (p < 0.01). Nine patients (5%) underwent reoperation for residual postoperative AVVR Valve repair was performed in all with no operative death. By Cox proportional risk multivariate analysis, preoperative AVVR and double orifice "mitral" valve were associated with increased risk of postoperative left AVVR (p < 0.01), whereas a bifoliate approach appeared to reduce the risk of this event in partial AVCD (p = 0.03). CONCLUSIONS: Postoperative AVVR is related to the type of anatomy of the AV valve, to the age at repair, and to the surgical technique employed. Residual AVVR can still be corrected with conservative techniques at low mortality rates. Early repair of common AVCD is associated with a lower incidence of preoperative and postoperative AVVR in CCAVCD and seems to prevent progression of annular dilation and preoperative AVVR in partial AVCD.

New television technique for natural head and body posture analysis.

A new television technique that proved to be faster than conventional photographic analysis has been developed and applied to the evaluation of the head and body natural standing posture in 303 healthy children, ages 6 to 11, and in 186 healthy young adults. In the lateral plane all subjects had extended head (soft tissue Frankfurt plane), with parallel Camper's and occlusal planes. The neck was halfway between the horizontal and vertical planes. Most angles significantly correlated with each other. The occlusal and neck angles showed a significant effect of age, being larger in children than in adults. In children the neck was more flexed, and the occlusal plane was more inclined downward. The results were in accord with previous photographic evaluations showing that the applied method was reliable and could be usefully employed in postural investigations. The results also confirmed that in healthy subjects, regardless of age, the soft tissue Frankfurt plane is extended, not horizontal.

Video-assisted cardioscopy in congenital heart operations.

Recent advances in fiberoptics and endoscopic imaging technology have extended the applications of video assistance in surgical procedures. Video-assisted thoracoscopic surgical techniques have been employed to improve anatomic visualization within the pleural space and to reduce chest wall trauma. Open heart operations for congenital heart disease in neonates and infants also require clear visualization of small structures within confined spaces. By adapting pediatric thoracoscopic instrumentation, we have developed a technique for video-assisted cardioscopy. This technique was used in 4 patients with complex congenital heart disease to expose remote intracardiac structures and facilitate surgical repair. The patients ranged in weight from 4.6 to 17 kilograms, and visualization of the intended structures was achieved in each case within 12 minutes. There were no complications associated with the videoscope. Further experience with video-assisted cardioscopy might broaden its role as an adjunct to the surgical repair of complex congenital heart defects.

Aortic valve prosthesis obstruction after aortoventriculoplasty: reconstruction with aortic allograft.

An aortoventriculoplasty (Konno procedure) operation was performed for relief of tunnel-type subaortic stenosis using a Bjork-Shiley valve aortic prosthesis. The mechanical prosthesis thrombosed and cerebral embolism occurred when anticoagulant medication was stopped. The aortic root was successfully reconstructed with a cryopreserved aortic allograft using freehand implant technique. The cryopreserved aortic allograft is an excellent replacement device in the young adult patient in cases of failed prostheses, even in the presence of complex left ventricular outflow tract morphology or previous reconstruction operations.

Hypothermic circulatory arrest for cardiac valve replacement reoperations.

Three patients had cardiac valve replacement using hypothermic circulatory arrest. The patients had multiple previous operations via median sternotomy, and 1 had functioning coronary bypass grafts. This technique provided simple and safe reentry to the heart without necessity of control of the aorta or venae cavae, adequate myocardial and cerebral protection from ischemia, and excellent operating conditions for the valve replacement.

Modified Fontan operation in the presence of anomalies of systemic and pulmonary venous connection.

BACKGROUND: The purpose of this report is to outline technical maneuvers dictated by anomalies of systemic and/or pulmonary venous connection in the performance of the Fontan procedure. METHODS AND RESULTS: Between 1975 and 1990, 104 patients (60 male, 44 female) with anomalies of systemic and/or pulmonary venous connection underwent a modified Fontan procedure at the Mayo Clinic. Mean age was 9.7 +/- 5.7 years. Isolated anomalies of the systemic venous connection were identified in 46 patients, isolated anomalous pulmonary venous connections in 4, and a combination of the two in 54. Previous palliative operations had been performed in 93 patients. Surgical repair was accomplished by atrial septation or placement of an intra-atrial conduit combined with cavopulmonary anastomosis if required. Survival by Kaplan-Meier, including operative mortality, was 55.7% at 10.3 years, not significantly different from the overall survival of the Fontan population. By the proportional hazards general linear model procedure, insufficiency of the systemic atrioventricular valve, preoperative mean pulmonary pressure greater than 15 mm Hg, and pulmonary artery resistance index greater than 4 U.m2 were associated with higher mortality. Five patients required reoperation for pulmonary venous obstruction (1 patient), revision of the atrial baffle (1 patient), revision of the intra-atrial conduit (2 patients), and replacement of the systemic atrioventricular valve (1 patient). CONCLUSIONS: We conclude that the modified Fontan operation can be successfully performed in this subset of patients, with long-term results comparable to those obtained in patients with normal systemic and pulmonary venous connection.

Replacement of the aortic valve with cryopreserved aortic allograft.

Replacement of the aortic valve with cryopreserved aortic allograft was performed in 88 patients during the period from July 1985 until January 1993. Age of patients ranged from 15 to 75 years (mean, 44 years). The cause of aortic valve disease was congenital in 39 (44%), rheumatic in 9 (10%), degenerative in 14 (16%), endocarditis in 11 (13%), and failed prosthesis in 15 (17%). The operation was performed by freehand allograft technique in 71 patients (81%). There were no perioperative deaths. Two patients died later at 4 months and 5 years after operation (actuarial survival = 94% at 7.5 years). Follow-up extending to 7.5 years shows 87% of patients are in New York Heart Association functional class I. No thromboembolism has been detected in any patient. Infection was cured in all patients with endocarditis. Mild aortic valve incompetence was detected by diastolic murmur in 45% of patients. Only three valves have been removed at reoperation: one was removed early for technical reasons, and two valves were removed for structural degeneration at 33 and 55 months; the latter was infected. Actuarial freedom from reoperation for any reason was 89%; for structural deterioration it was 93% at 7.5 years. Aortic valve replacement with cryopreserved aortic allograft can be safely performed in adult patients. Medium-term results show excellent freedom from thromboembolism and cure of bacterial endocarditis. Mild aortic valve incompetence is often present, but reoperation for progressive incompetence is unusual.