Aortic implantation is possible in all cases of anomalous origin of the left coronary artery from the pulmonary artery.

BACKGROUND: Anomalous origin of the left coronary artery from the pulmonary artery (PA) optimally is treated by creation of a multiple coronary system. This study explores the use of aortic implantation employing alternative methods to achieve coronary transfer in all patients, regardless of the site of origin of the anomalous coronary artery, avoiding the problems of bypass grafts and tunnel procedures. METHODS: During the period 1986 to 1994, 11 patients aged 6 months to 8 years (mean age, 2.6 years) underwent repair. Coronary artery origin from the PA included left sinus in 3, posterior in 2, right sinus in 2, intramural aorta with its orifice at the bifurcation of the main and right PA in 1, high left main PA in 1, high at the bifurcation of main and right PA in 1, and anterior in 1. Findings included angina in 4, prior infarctions in 3, ischemia in 7, left ventricular dysfunction in 6, mitral regurgitation in 5, atrial septal defect in 2, and echocardiograms suggestive of endocardial fibrosis in 4. One patient had prior ligation with ventricular dysfunction and collateralization and recanalization. A single patient was asymptomatic. Repair was accomplished by direct transfer using the PA sinus of Valsalva as a button in only 6; tubular reconstruction was used in 4 when the distance was too great to avoid tension; 2 short tubes were constructed with PA wall in 2 of the 3 left sinus origins, whereas 2 long tubes of PA wall were used (1 high on the left side of the main PA and 1 with left anterior descending origin from the anterior sinus of Valsalva in a patient with malrotation [end neo-artery to side aortic reconstruction]); finally, in situ transfer and intraaortic reconstruction (unroofing and anastomosis) was performed in 1 intramural coronary artery. Division of the PA, mobilization of the distal PA, division of the ductus, and direct reanastomosis of the PA was performed in 3 tubular reconstructions, as well as all 6 direct coronary transfers. RESULTS: There were no operative or late deaths. Follow-up of 2 to 100 months (mean, 46 months) revealed no new angina or infarctions, improved function and decreased mitral regurgitation. Echocardiographic and angiographic studies demonstrated patency and prograde flow in the new coronary systems. CONCLUSIONS: Aortic implantation is the treatment of choice for anomalous origin of the left coronary artery. Methods such as direct transfer, tubular reconstruction, and in situ transfer make such implantation possible in all patients regardless of the site of coronary origin, distance from the aorta, or coronary artery configuration.

Use of pericardium to control bleeding after ascending aortic graft replacement.

We present the case of a patient who required replacement of an ascending aortic composite graft for endocarditis complicated by uncontrollable bleeding from the proximal anastomotic site. A new method of creating a right atrial-to-periprosthetic space fistula with autologous pericardium was used with a favorable result.

Origin of both coronary arteries from the pulmonary trunk associated with hypoplasia of the aortic tract complex: a new entity.

The first case of origin of both coronary arteries from the pulmonary trunk, associated with hypoplasia of the aortic tract complex is reported. Although this is a lethal anomaly, as both coronary arteries originate from the pulmonary artery, it is conceivable that surgical intervention could make this unusual entity a viable one. Possible surgical techniques are discussed.

Cardiac valve replacement in systemic lupus erythematosus. A review.

Three cases of cardiac valve replacement for Libman-Sacks endocarditis and their long-term follow-up are described. From the review of the literature, an additional nine patients who required cardiac valve replacement are studied. Steroids probably increase the incidence of valve incompetence, but most patients presumably die of other associated organ involvement before undergoing a cardiac operation. Operation is indicated because of change in the intensity or character of the murmur, and a new murmur with resultant, resistant congestive cardiac failure. Both the aortic and mitral valves should be explored. Valve reconstruction in these young patients, with the expectation of avoiding prosthetic valve dysfunction and repeat operation, is not possible. Bioprosthetic valve replacement may be preferable, since it eliminates the need for anticoagulation during steroid treatment. Overall mortality was 25%.

Risk-benefit analysis of warfarin therapy in Hancock mitral valve replacement.

The purpose of this investigation was to analyze the thromboembolic and/or major bleeding complications of 124 consecutive but nonrandomized patients who had only mitral valve replacement with the Hancock porcine xenograft between September, 1974 and June, 1979. These patients were treated either with or without anticoagulants. Four basic study groups were created: Group 1, warfarin; Group 2, aspirin; Group 3, no anticoagulants; and Group 4, warfarin and aspirin. Group 5 combined Groups 1 and 4 (warfarin and warfarin plus aspirin) and Group 6 combined Groups 2 and 3 (aspirin and no anticoagulants). The cardiac rhythm, history of embolism, and intraoperative findings of a thrombus in the left atrium were examined as risk factors for later thromboembolism . Follow-up time was 3.03 years (range 2.0 to 4.2 years). The embolic rate was not significantly different in any group (n = NS). In Groups 5 and 6 the embolic rate was 2.97 and 3.25 embolisms per 100 patient-years, respectively. Warfarin therapy resulted in significant major bleeding episodes, including two deaths (p less than 0.05). The number of patients with a history of a previous embolism, the finding of an intraoperative left atrial thrombus, or abnormal cardiac rhythm was insufficient to test embolic risk in the four treatment groups. We conclude that long-term warfarin therapy increases the risk of bleeding complications but may not significantly influence the incidence of thromboembolism arising from the Hancock porcine xenograft mitral valve. Other and larger studies are needed to confirm this last point.

Preoperative management of proximal lesions of the left coronary artery system: surgical implications.

Between January 1975 and December 1978, a total of 67 consecutive patients with left main coronary disease had coronary bypass operations at Pacific Medical Center in San Francisco. Of these, 54 were men and 13 women. The mean age was 59 years (range 44 to 77 years). Three groups were identified retrospectively. Sex ratio, age, symptoms, and coronary pathology and hemodynamics were comparable in all groups. Group 1 (24 patients) received no propranolol or had it discontinued at least two weeks preoperatively. Group 2 (28 patients) received propranolol up until two days before the operation. Group 3 (15 patients) received propranolol until the morning of the bypass operation. The overall mortality was 2.9 percent (2 patients). In Group 1, 33 percent (8 patients) had unstable angina preoperatively, while 50 percent (14 patients) in group 2 and 40 percent (6 patients) in group 3 had unstable angina. Perioperative infarction occurred in 12.5 percent (3 patients) in group 1, 25 percent (7 patients) in group 2 and 13 percent (2 patients) in group 3. Creatine phosphokinase myocardial band fractions in the postoperative period were lowest in group 3 but were notably elevated in group 2. Postoperative inotropic support was required in one patient (4 percent) in group 1, four patients (14 percent) in group 2, while none required support in group 3. The decreased incidence of perioperative infarction and reduced need for postoperative inotropic support in group 3 suggests that if propranolol is to be part of the pharmacological preoperative regimen, it can and should be continued up to the time of operation. Propranolol should not be discontinued in the immediate preoperative period.

Infradiaphragmatic total anomalous pulmonary venous drainage: surgical treatment and long-term results.

Since 1971, 20 infants (1 day to 3 months old) with infradiaphragmatic total anomalous pulmonary venous drainage (TAPVD) have undergone repair at The Hospital for Sick Children, Great Ormond Street, London. All patients were seen with severe cyanosis (mean partial pressure of arterial oxygen, 35.8 mm Hg) and pulmonary edema. All had a persistent ductus arteriosus. Right-sided pressures were equal to or greater than systemic in 17 patients. During surgical repair, the confluence of the pulmonary veins was anastomosed to the left atrium. The descending vein was ligated in 11, divided in 4, and left open in 5 patients. Atrial septal defects were closed with a patch in 6 and sutured in 14. Eight patients died (40%). Acidosis on admission was significantly greater among nonsurvivors (mean pH, 7.29 +/- 0.02) than survivors (mean ph, 7.37 +/- 0.02) (p less than 0.05). Twelve survivors are well four months to 8 years after operation. All are asymptomatic and none requires cardiac medication. Six have undergone repeat catheterization, demonstrating normal pressures and no shunts. We conclude that the mortality of patients with infradiaphragmatic TAPVD depends mainly on the condition of the child on admission.

Calcified left ventricular aneurysm in a 6-year-old Caucasian boy.

A 6-year-old Caucasian boy presented with a calcified left ventricular aneurysm of unknown aetiology. Aneurysmectomy was carried out uneventfully. A review of the English language papers reveals that this is the first reported case of a calcified left ventricular aneurysm occurring in a Caucasian child.

Management of ascending suture line sepsis by excision on the ascending aorta and insertion of a left ventricular apex to aorta conduit.

A new technique used in the management of infection of an aortic suture line following aortic valve replacement and subsequent episodes of severe hemorrhage resulting from suture line disruption is described. In a planned, staged procedure, a left-ventricular-apex-to-aorta conduit was inserted followed by excision of the supracoronary aortic root and ascending aorta, incorporating all infected tissue. This technique demonstrates that near total excision of the ascending aorta is possible and coronary artery flow can be maintained with only a minimal supravalvular aortic chamber.

Aortic stenosis complicated by severe calcification of the wall of the ascending and transverse aorta: management by use of left ventricular to aortic composite conduit. Report of two cases.

The use of left ventricular aortic composite conduits in 2 patients with severe intramural calcification of both the ascending and the transverse aorta is reported. This method is felt to be superior to conventional aortic valve replacement, when the texture of the aortic wall does not allow cross clamping or secure closure.

A guideline to the management of patent ductus arteriosus in infants and children.

Experience with multiple ligation of the patent ductus arteriosus (PDA) at the Hospital for Sick Children, Great Ormond Street, London, is presented. One hundred and sixty-one consecutive cases between January 1971 and December 1974 have been reviewed. Fifty-four children (33%) were less than one year of age. In the majority of cases the diagnosis was made on clinical grounds. Cardiac catheterization and angiography were carried out when associated intracardiac lesions were suspected. The overall mortality was 2.5%. All the deaths occurred in infants less than six months of age who had associated cardiac lesions. There were no deaths in patients who had an uncomplicated PDA or who were more than one year of age. Multiple ligation of the PDA is a simple and safe operation. The risk of operative treatment is affected more by the presence of associated cardiac lesions and the age of the patient than by the surgical technique employed.

Reoperation for complictions after inflow correction of transposition of the great arteries: technical considerations.

A right anterolateral thoracotomy through the fifth or sixth intercostal space is described as an easier approach for reoperations after the Mustard procedure for transportation of the great arteries. Advantages of this approach compared with repeated sternotomy include easier cannulation of the superior and inferior vena cava; less extensive dissection of adhesions, resulting in decreased postoperative bleeding; reduced risk of injury to the coronary asteries and the right phrenic nerve; and improved exposure of intracardiac pathways and the tricuspid valve.