Staged repair of tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries.

OBJECTIVE: To assess the results of a staged surgical approach for tetralogy of Fallot with pulmonary atresia, hypoplastic or absent pulmonary arteries, and major aortopulmonary collateral arteries. METHODS: We retrospectively reviewed a consecutive series of these patients from a single institution. RESULTS: From July 1993 to April 2001, 46 consecutive patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collateral arteries were treated with staged surgical repair. The operative sequence usually began with a central aortopulmonary shunt followed by unifocalization of aortopulmonary collateral arteries depending on the source and distribution of pulmonary blood flow. Twenty-eight patients (61%) subsequently underwent complete repair with ventricular septal defect closure and right ventricle to pulmonary artery connection. Those patients who underwent complete repair had a median of 3 total operations (range 1-6). The ratio of the mean pulmonary artery pressure to the mean systemic blood pressure at the time of complete repair was 0.36 (range 0.19-0.58). Two of the 28 repaired patients (7.1%) required subsequent fenestration of the ventricular septal defect closure due to later development of supersystemic right ventricular pressure and right ventricular failure. Eighteen patients (39%) have undergone 1 or more staging operations and are considered good candidates for eventual complete repair. There were no hospital deaths. There was 1 late death (2.2%; 95% CI 0.4-11.3%) in a patient born prematurely who developed severe bronchopulmonary dysplasia precluding complete repair. CONCLUSIONS: For tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries, a staged surgical approach yields low overall mortality and acceptable hemodynamics after complete repair.

Small intestine without mucosa as a growing vascular conduit: a porcine experimental study.

OBJECTIVE: This study was conducted to check the feasibility of using small intestine without mucosa as a growing vascular conduit. METHOD: Autologous proximal jejunum without mucosa after treatment with heparin bonding was used as a free inferior vena cava interpositional graft between the renal veins and bifurcation of inferior vena cava in 8 piglets. Intravenous ultrasonography was performed at 1 to 3 months after the operation and at autopsy. RESULTS: One intraoperative death was related to anesthesia. At a mean follow-up of 80 days for the 7 surviving pigs, the weight had increased by 201%, from a mean of 32 kg to a mean of 94 kg. The grafts had increased in length by 128%, from a mean of 2.3 cm at implantation to a mean of 5.1 cm (P <.018) at explantation. In 6 animals the diameter of the graft was equal to that of the adjacent inferior vena cava. At postmortem examination, 6 grafts were patent. The single blocked graft had been patent 1 month after surgery. One graft had extensive septae inside, 2 had minor septae, 2 had microscopic septae, and 2 had no septae at all. Normal appearing adventitia, fibrous tissue, and endothelium (factor VIII-related antigen positive) lined all the grafts. In all 7 grafts, scattered proliferating fibroblasts (MIB1 positive) were observed. CONCLUSIONS: Small intestine without mucosa remodels and acts like a live, growing, layered, endothelialized, nonthrombogenic (after re-endothelialization) vascular conduit in a growing pig. This graft material could have potential as a growing vascular conduit in children.