Pediatric cardiac retransplantation: intermediate-term results.

BACKGROUND: Cardiac retransplantation (re-CTx) in children is a controversial therapy, yet it remains the best treatment option to recipients with failing grafts. Our objective was to determine the incidence of re-CTx in a large pediatric population of recipients and evaluate the outcome of such therapy. METHODS: Between November 1985 and November 1999, 347 children underwent cardiac transplantation at the Loma Linda University Medical Center. Of these, 32 children were listed for re-CTx. Ten patients died while waiting, and 22 recipients underwent re-CTx. Median age at re-CTx was 7.1 years (range, 52 days to 20.1 years). RESULTS: Indications for re-CTx were allograft vasculopathy (n = 16), primary graft failure (n = 5), and acute rejection (n = 1). Two patients with primary graft failure underwent retransplantation within 24 hours of the first transplantation procedure while on extracorporeal membrane oxygenation support. Median time interval to re-CTx for the others was 7.2 years (range, 32 days to 9.4 years). Operative mortality for all cardiac re-CTx procedures was 13.6%. Causes of hospital mortality were pulmonary hypertension with graft failure (n = 2) and multiorgan failure (n = 1). Median hospital stay after re-CTx was 14.1 days (range, 6 to 45 days). There was one late death from severe rejection. Actuarial survival at 3 years for re-CTx was 81.9% +/- 8.9% compared with 77.3% +/- 2.6% for primary cardiac transplantation recipients (p = 0.70). CONCLUSIONS: Elective re-CTx can be performed with acceptable mortality. Although the number of patients undergoing retransplantation in this report is small and their long-term outcome is unknown, the intermediate-term survival after re-CTx is similar to that of children undergoing primary cardiac transplantation.

Right ventricular outflow tract reconstruction using a Goretex membrane monocusp valve in infant animals.

We examined the feasibility of using a polytetrafluoroethylene membrane (goretex) valve and transannular patch (TAP) for right ventricular outflow tract (RVOT) reconstruction in growing animal models. Eleven infant goats (Group A) and 12 infant sheep (Group B) underwent RVOT reconstruction under cardiopulmonary bypass. In Group A, a monocusp valve was constructed of goretex, and the RVOT was roofed over utilizing a TAP of bovine pericardium. In Group B, both a monocusp valve and a TAP were constructed of goretex. Animals were sacrificed at 6 or 12 postoperative months. Two goats in Group A died at 9 days and 4 months postoperatively due to RVOT obstruction caused by thrombus formation. Seven goats in Group A and 11 in Group B showed no pressure gradient across the valve. All animals in Group B revealed mild to moderate valvular insufficiency, but no ventricular deterioration. In contrast to the bovine pericardium, which showed a prominent fibroinflammatory reaction with calcified areas causing TAP shrinkage and RVOT stenosis, there was minimal calcification and inflammatory reaction directed against the goretex valve and TAP. We conclude that goretex can be used as a material from which to create both a monocusp valve and TAP for long-term RVOT reconstruction.

Emergency implantation of a left ventricular assist device in adolescents with biventricular failure.

Adolescents with congestive cardiomyopathy who present with intractable arrhythmia or progressive ventricular failure have a very poor prognosis and often die awaiting cardiac transplantation (CTx). We present our recent experience with a pneumatically powered left ventricular assist device (LVAD) implanted emergently to salvage adolescents with severe biventricular failure. Four patients, aged 15-17 years, body surface areas of 1.5-1.7 m2, with dilated cardiomyopathy (LV diastolic dimension, 7.1-8.3 cm); two presented with cardiovascular collapse, one with refractory ventricular tachycardia, and one with cardiac arrest. Hemodynamic and biochemical data before and 1 week after LVAD placement are expressed as mean and range values. None of the patients required right ventricular assist, and all patients achieved functional recovery while on LVAD support (8-71 days). Currently, all four patients are alive (11-22 months) after successful CTx. We conclude that emergency implantation of an LVAD in adolescents with biventricular heart failure can be life saving. As has been shown in the adult population, such a ventricular assist system restores normal circulatory hemodynamics, reverses multi-organ dysfunction, and provides a "safe" bridge to transplantation.

Sutureless coronary artery bypass with biologic glued anastomoses: preliminary in vivo and in vitro results.

OBJECTIVE: As heart surgery becomes increasingly focused on minimally invasive techniques, it has become apparent that conventional techniques of anastomosis will need to be severely altered or abandoned. Toward that end, we developed and tested in vitro and in vivo coronary artery bypass graft anastomoses using a biologic glue formulated from bovine albumin and glutaraldehyde. We used a double-balloon catheter as a temporary internal stent to create and seal the anastomosis during gluing. METHODS: Initially, anastomoses were made between cryopreserved human saphenous vein segments and coronary arteries in vitro on 12 intact bovine hearts. A total of 42 anastomoses were created with the catheter system introduced into the distal end of the graft, exiting the back wall, and entering the anterior wall of the coronary artery. Two balloons (one in the graft and one in the coronary artery) held the anastomosis stable while the biologic glue was applied externally and allowed to set for 2 minutes. The balloon catheter was then removed from the end of the graft simulating a side-to-side internal thoracic artery anastomosis. After the graft had been flushed to assure distal end patency, the open end of the graft was clipped, turning the anastomosis into an end-to-side graft. A pressure transducer was then attached to the graft and saline solution forcefully infused. RESULTS: All grafts easily held a pressure of 300 mm Hg; 10 grafts were tested up to 560 mm Hg without leaks. Distal and proximal coronary artery patency was checked by examining flow out of the coronary ostia and by cutting arteries distal to the grafts. All anastomoses were patent on being opened and no glue was seen intraluminally. Subsequently, 3 anastomoses of the left internal thoracic artery to the left anterior descending artery have been constructed in goats, with autopsies at 24 hours, 10 months, and 1 year revealing patent anastomoses. CONCLUSION: A biologic glue and catheter system has been developed that allows a coronary anastomosis with a high bursting strength to be performed. When the system has been further developed and tested, truly minimally invasive heart surgery may be possible.

How to construct a monocusp valve.

Construction of a monocusp is an easy procedure that adds little, if any time to routine transannular patching of the right ventricular outflow tract. It also adds little cost to the operation when constructed from autologous pericardium. The monocusp's utility in preventing or lessening the impact of pulmonary regurgitation in the early postoperative period has been demonstrated. Its utility as a long-term pulmonary valve substitute will need to await longer-term clinical follow-up currently underway at our institution and others.

Repair of traumatic aortic rupture: a 25-year experience.

BACKGROUND: Surgical management of traumatic aortic rupture (TAR) is controversial, specifically whether distal aortic perfusion modifies the outcome. HYPOTHESIS: The outcome of patients who undergo repair of TAR is not dependent on the technique of repair. DESIGN: Retrospective review. SETTING: Tertiary care teaching hospital, level I regional trauma center. PATIENTS: One hundred fifteen victims (aged 5-81 years) of blunt chest trauma with aortic tear, presenting between January 1, 1974, and June 30, 1999. METHODS: Medical records were reviewed for prehospital and emergency department data, operative findings, and outcome. Statistical comparison was made using a paired 2-tailed t test. INTERVENTION: Surgical repair of TAR with (group 1) or without (group 2) distal aortic perfusion. RESULTS: Thirty-two patients in group 1 had TAR repair using active bypass (n = 18) or Gott shunt (n = 14). The clamp-and-sew technique was used in 83 patients (group 2). Primary repair was possible in 14 patients (44%) in group 1 and 69 patients (83%) in group 2. The average aortic cross-clamp time was 48 minutes for group 1 (range, 25-113 minutes) and 20 minutes for group 2 (range, 5-40 minutes) (P<.03). There was no significant difference in hospital mortality (6 [18.7%] of 32 vs 15 [18.1%] of 83) or the incidence of paraplegia (2 [6%] of 32 vs 5 [6%] of 83) between groups 1 and 2. During the last 15 years, 78 patients (73 in group 2) had repair of TAR with an operative mortality rate of 19.2%. CONCLUSIONS: Acute TAR remains a highly lethal injury with no change in prognosis during the last 2(1/2) decades. Repair of TAR using simple aortic cross-clamping alone is feasible in the majority of patients without increased mortality or spinal cord injury.

Successful myocardial volume reduction in a 9-month-old infant.

Left ventricular reduction has shown promise as a treatment for end-stage dilated cardiomyopathy, with restoration of the physiologic ratio between myocardial mass and left ventricular diameter. We present a case of successful partial left ventriculectomy utilizing both lateral and septal wall excision as treatment of dilated cardiomyopathy in a 9-month-old patient.

Ultra fast track in elective congenital cardiac surgery.

BACKGROUND: Changes in healthcare delivery have affected the practice of congenital cardiac surgery. We recently developed a strategy of limited sternotomy, early extubation, and very early discharge, and reviewed the perioperative course of 198 pediatric patients undergoing elective cardiovascular surgical procedures, to assess the efficacy and safety of this approach. METHODS: One hundred ninety-eight patients aged 0 to 18 years (median 3.2 years) underwent 201 elective cardiovascular surgical procedures over a 1-year period. All patients were admitted on the day of surgery. Patients were divided into six diagnostic groups: group 1, complex left-to-right shunts (n = 14, 7.0%); group 2, simple left-to-right shunts (n = 83, 41.3%); group 3, right-to-left shunts with pulmonary obstruction (n = 33, 16.4%); group 4, isolated, nonvalvular obstructive lesions (n = 30, 14.9%); group 5, isolated valvular anomalies (n = 20, 10.0%); and group 6, miscellaneous (n = 21, 10.4%). RESULTS: After 201 procedures, 175 patients (87.1%) were extubated in the operating room and 188 (93.6%) within 4 hours from operation. Four patients (2.0%) were extubated more than 24 hours from completion of the procedure, and 2 (1.0%) died while on respiratory support (never weaned). Five patients (2.6%) failed early extubation (<4 hours). Early discharge was achieved for the vast majority of patients. Overall median length of stay (LOS, including day of surgery as day 1) was 2.0 days, with a median LOS of 3.0 days for those patients requiring circulatory arrest duration exceeding 20 minutes. Of 195 patients, 43 (24.6%), 121 (74.0%), and 159 (81.5%) were discharged, respectively, at <24, <48, <72 hours from admission. Longest and shortest mean postoperative LOS were in group 6 (9.9+/-14.5 days) and group 2 (1.6 = 0.7 days), respectively. Six patients (2.9%) died, and 11 (5.5%) suffered in-hospital complications. Thirty patients (15.4%) were either treated as outpatients (n = 11, 5.7%) or readmitted (n = 19, 9.7%) within 30 days from the time of surgery. Only 8 of 195 patients (4.1%) were readmitted with true surgical complications requiring invasive therapeutic procedures. CONCLUSIONS: Selected patients with a broad spectrum of congenital heart disease may enjoy same-day admission, limited sternotomy, immediate extubation, and very early discharge with excellent outcomes and acceptable morbidity.

Minimally invasive approach for aortic arch branch vessel reconstruction.

Minimally invasive aortic arch branch vessel reconstruction was successfully accomplished in four patients over the past 3 years. There were no operative complications. Three patients had an uneventful hospital course, ranging from 3 to 5 days. The fourth patient with multiple medical problems and severe peripheral vascular disease had a prolonged hospital course for reasons unrelated to the surgical procedure. This minimally invasive surgical exposure can be used to effectively and safely repair innominate and left common carotid artery lesions.

Repair of acute descending aortic dissection complicated by visceral ischemia.

Visceral ischemia is a rare but lethal complication of type III aortic dissection. We report a Marfan patient with such a complication who had a complete resolution of profound visceral ischemia despite a delay in repair of over 48 hours.

Pulmonary Rhizopus rhizopodiformis cavitary abscess in a cardiac allograft recipient.

Pulmonary mucormycosis is rare in solid organ transplant recipients. Only one case has been reported previously in a cardiac allograft recipient. However, the Rhizopus species in that study was not identified. We report a case of successful surgical treatment of pulmonary cavitary mucormycosis due to Rhizopus rhizopodiformis in a cardiac allograft transplant recipient. A review of the literature on pulmonary mucormycosis occurring in solid organ transplant recipients is also presented.

Posttransplant recoarctation of the aorta: a twelve year experience.

OBJECTIVES: This study was undertaken to investigate the incidence of posttransplant recoarctation of the aorta, delineate the mode of presentation, identify risk factors that predict recoarctation and examine the results of intervention for posttransplant recoarctation. BACKGROUND: Patients with aortic arch hypoplasia require extended arch reconstruction at transplant, with an inherent possibility of subsequent recoarctation of the aorta. METHODS: This was a retrospective review of all children (age <18 years) who underwent cardiac transplantation over a 10-year period. Collected data included pretransplant diagnosis, details of the transplant procedure and posttransplant data including development of recoarctation of the aorta, interventions for recoarctation and the most recent follow-up assessment of the aortic arch. RESULTS: Two hundred eighty-eight transplants were performed on 279 children (follow-up = 1,075 patient-years; range 0 to 133 months, median 43.7). Thirty-two of 152 patients (21%) who underwent extended aortic arch reconstruction subsequently developed recoarctation. All but one patient developed recoarctation within 2 years after transplant; 87% were hypertensive at presentation. Of 30 patients who underwent intervention for recoarctation (balloon angioplasty [n = 26] and surgical repair of recoarctation [n = 4]), 26 (87%) have remained recurrence-free (follow-up = 133 patient-years; range 8 to 106 months, median 47). CONCLUSIONS: The high frequency of recoarctation after cardiac transplantation with extended aortic arch reconstruction mandates serial echocardiographic evaluation of the aortic arch. Patients typically present with systemic hypertension within the first two years after transplantation. Balloon angioplasty is a safe, effective and durable method of treatment.

Cardiac retransplantation for graft vasculopathy in children: should we continue to do it?

BACKGROUND: Cardiac transplantation (CTx) has been established as an effective therapy for a variety of inoperable cardiac conditions in infants and children. However, graft vasculopathy (GV) has emerged as the main limiting factor to long-term survival of CTx recipients. The only treatment of severe GV is cardiac retransplantation (re-Tx). Controversy exists regarding the use of scarce donor organs for cardiac re-Tx. OBJECTIVE: To compare the outcome of cardiac re-Tx for GV with that of primary CTx in children. DESIGN: A 12-year retrospective cohort review. SETTING: A university-affiliated children's hospital. PATIENTS: All infants and children who underwent CTx (group 1, n = 322) had complete follow-up of 1389.7 patient-years. Graft vasculopathy was confirmed in 32 recipients (1.1-8.2 years after undergoing CTx). Thirteen patients died suddenly, 3 died waiting for cardiac re-Tx (1-17 days after relisting), 4 are pending cardiac re-Tx, and 12 (group 2) underwent cardiac re-Tx. INTERVENTION: Cardiac re-Tx at a mean (+/- SD) interval from the first CTx of 6.3 +/- 1.8 years (range, 2.2-9.4 years). Two patients required additional aortic arch aneurysm repair with cardiac re-Tx. RESULTS: When group 1 was compared with group 2, there was no significant difference in operative mortality (9.0% vs 8.3%; P = .9), rejection rate (0.98 vs 0.86; P = .1), and hospital stay (23.0 +/- 18.8 days vs 20.5 +/- 11.6 days; P = .65). Actuarial survival for groups 1 and 2 at 1 and 4 years was 84.3% vs 83.3% (P = .59) and 74.4% vs 83.3% (P = .85), respectively. CONCLUSIONS: The surgical outcome and intermediate survival of cardiac re-Tx for GV and primary CTx are similar. Children with severe cardiac GV are at risk of sudden death and can benefit from early cardiac re-Tx.

Heart transplantation in infants and children with situs inversus.

BACKGROUND: Recipient situs inversus has always represented a technical challenge during heart transplantation. OBJECTIVE: A simplified operative strategy for heart transplantation in a recipient with atrial situs inversus is described. METHODS: Fifteen pediatric recipients with situs inversus accompanying other complex congenital heart disease or dilated cardiomyopathy having "orthotopic" heart allotransplantation in one center, between 1985 and 1997, were reviewed retrospectively. A nearly uniform, simplified technical approach to transplantation was used and is described. RESULTS: Fourteen of these recipients with complex malformations survived the transplantation. Morbidity relating to surgical technique has been limited to partial (n = 2) or complete (n = 1) late obstruction of superior vena caval drainage; each case was managed successfully by interventional cardiologic techniques. Actuarial survival after transplantation compares favorably with that among 290 infants and children with atrial situs solitus who underwent heart transplantation. CONCLUSIONS: Systemic atrial malposition, including situs inversus, does not limit successful heart transplantation by the simplified method described.