Modified single patch: are we still worried about subaortic stenosis?

BACKGROUND: When the modified single-patch technique for atrioventricular septal defect (AVSD) repair was introduced by Dr Benson Wilcox, there was concern that these patients might be at risk for late subaortic stenosis and left ventricular outflow tract obstruction (LVOTO). This review evaluated our modified single-patch population for LVOTO in the postoperative period. METHODS: Between January 2000 and 2013, 77 infants underwent AVSD repair with a modified single-patch technique. Median age was 4.2 months, and median weight was 5 kg. Eight patients had a prior repair of coarctation of the aorta via left thoracotomy in the newborn period. RESULTS: The median hospital stay was 10 days. No patient required a pacemaker. The mean and median follow-up times were 4.6 and 3.7 years, respectively. Only 2 patients (2.5%) required reoperation for LVOTO; both had prior repair of coarctation of the aorta (2 of 8 vs 0 of 69, p = 0.01). A discrete fibrous subaortic membrane developed in the first patient that required resection at 3 and 7 years after repair. The other patient had LVOTO from accessory chordae of the left atrioventricular valve and required mitral valve replacement 5 months after repair. One early death occurred at 4 months postoperatively due to liver failure related to hyperalimentation. CONCLUSIONS: At intermediate term follow-up, LVOTO does not appear to be a significant postoperative issue after modified single-patch repair of AVSD. Coarctation of the aorta was the most significant predictor of late LVOTO after repair of AVSD with the modified single-patch technique.

Outcomes of surgical therapy for infective endocarditis in a pediatric population: a 21-year review.

BACKGROUND: Infective endocarditis is a rare disease in the pediatric population. We sought to define patient characteristics and outcomes of surgical therapy for endocarditis in children. METHODS: We performed a retrospective review of all patients with infective endocarditis who received surgical therapy between January 1, 1990, and March 1. 2011. We were interested in their congenital heart defect, prior surgical procedures, and outcome of the operation. RESULTS: We identified 35 cases of endocarditis in 34 patients requiring surgical intervention. Mean age was 10.7 ± 8.8 years. There was a bimodal age distribution at presentation: 11 (31%) were younger than 1 year and 15 (43%) were 10 to 21 years. Of the 34 patients, 22 (63%) had no history of prior cardiac operation. The infective organism was identified in 30 (86%), with Staphylococcus aureus (n = 8) and Streptococcus viridans (n = 6) predominating. Valve replacement was performed in 22 patients and valve repair in 10. All patients received 6 weeks of postoperative intravenous antimicrobial therapy. Operative mortality was 15% (5 of 34). The 5 deaths occurred in infants who were a mean age of 2.5 months, and 3 of the 5 infants (60%) were premature. Of 4 patients with fungal infection, 3 patients died. The Ross operation was performed successfully in 5 patients with severe aortic valve disease. Reoperations (n = 10 [28%]) included valve replacement in 5 and conduit replacement in 3, all but 1 due to somatic growth resulting in functional stenosis. CONCLUSIONS: The outcome of surgical therapy for endocarditis in children was similar to that reported for adults, with an overall mortality of 15%. The Ross operation was very effective in patients with aortic valve endocarditis. There is a significant incidence of late reoperation for valve and conduit replacement due to somatic growth. Age younger than 1 year, prematurity, and fungal organisms appear to be risk factors for death. Patients surviving to discharge had good outcomes, with no episodes of recurrent endocarditis.

Primary resection of Kommerell diverticulum and left subclavian artery transfer.

BACKGROUND: A Kommerell diverticulum (KD) is an aneurysmal remnant of the dorsal fourth aortic arch. This can be an independent cause of tracheoesophageal compression. We previously reported resection of the KD with left subclavian artery transfer to the left carotid artery for recurrent symptoms in patients with a right aortic arch, left ligamentum, and retroesophageal left subclavian artery after prior ligamentum division. In 2001 we began resecting the KD and transferring the left subclavian artery to the left carotid artery in selected patients as a primary operation. METHODS: From 2001 to 2011, 20 patients have had primary excision of a Kommerell diverticulum. Diagnosis was with computed tomographic scan (n = 14) or magnetic resonance imaging (n = 6) and bronchoscopy. Sixteen patients had a right aortic arch and 4 had a double aortic arch (right arch dominant). All patients were approached through a left thoracotomy. Fifteen patients had simultaneous division and reimplantation of the left subclavian artery into the left carotid artery. RESULTS: Mean age at operation was 9.1 ± 6.5 years (range 1.5 to 29.1 years). Symptoms included cough, wheezing, stridor, dysphagia, and dyspnea on exertion. Selection criteria included KD greater than 1.5 times the size of the left subclavian artery and posterior pulsatile compression of the trachea on bronchoscopy. There were no complications related to subclavian artery transfer. No patient required a blood transfusion. No patient had a recurrent laryngeal nerve injury or chylothorax. The mean hospital stay was 4.3 ± 2.5 days. All patients had resolution of their preoperative airway and esophageal symptoms. CONCLUSIONS: In selected patients with a vascular ring we now recommend resection of the associated Kommerell diverticulum and transfer of the retroesophageal left subclavian artery to the left carotid artery as a primary procedure. This strategy requires comprehensive and precise preoperative imaging with either computed tomography or magnetic resonance imaging.

Outcomes of radial incision of the tricuspid valve for ventricular septal defect closure.

BACKGROUND: Adequate exposure of a ventricular septal defect (VSD) is critically important to obtaining a satisfactory repair. Some surgeons have advocated a circumferential incision on the tricuspid valve. For 20 years we have used a radial incision of the tricuspid valve when added exposure is required. METHODS: All patients undergoing VSD repair at Children's Memorial Hospital (Chicago, IL) were identified from our database. Operative records were reviewed to determine details of exposure. Follow-up patient and echocardiography data were obtained from the medical record. RESULTS: Between January 1995 and March 2010, 366 isolated VSDs were repaired, including 341 perimembranous, 15 muscular, 5 inlet, and 5 inlet-muscular VSDs. A radial tricuspid valve incision was used in 230 patients (63%). Mean times (minutes) were 97±24 for cardiopulmonary bypass and 66±18 for cross-clamp, with no significant difference between groups (p=0.59 and p=0.96, respectively). No operative deaths occurred. Follow-up echocardiograms were available for 150 patients at a mean of 3.5 years. Tricuspid regurgitation was rated as none or trivial in 97 (65%), mild in 45 (30%), and moderate in 8 (5%). The degree of tricuspid regurgitation was similar between patients whose tricuspid valve was and was not incised. CONCLUSIONS: Radial incision of the tricuspid valve enhances exposure for safe VSD closure and adds little complexity to the case. Its use in our series did not lead to increased tricuspid valve dysfunction, and it was durable at midterm echocardiographic assessment.