Late outcome of Senning and Mustard procedures for correction of transposition of the great arteries.

OBJECTIVES: To evaluate late mortality and morbidity after an atrial switch procedure for correction of transposition of the great arteries (TGA) and to assess predictive factors for adverse outcome. SETTING: Tertiary referral centre. DESIGN AND PATIENTS: Retrospective follow up study of 137 patients surviving hospitalisation for TGA atrial switch procedure (Mustard or Senning) in a single institution and divided into two groups (simple and complex) depending on presurgical anatomy. Several surgical and follow up factors were evaluated during 16.7 (5.6) years' follow up. RESULTS: Late mortality was 5.1% (95% confidence interval 1.37% to 8.84%) with sudden death as the most common cause. No significant difference was found between Mustard and Senning procedures and between the complex and simple groups in terms of mortality. Independent predictive factors for late mortality were a history of supraventricular tachyarrhythmias and advanced New York Heart Association (NYHA) functional class during follow up. A very common finding was development of sinus node dysfunction (47.6%), which had no influence on mortality. There was little need for reintervention (5.1%) and relatively few cases of right ventricular systolic dysfunction (14.6%). During follow up, most patients (96.2%) were in NYHA functional class I-II. CONCLUSIONS: Overall long term outcomes of patients with atrial repair of TGA in the present era are encouraging in terms of late mortality and quality of life. Nevertheless, better outcomes may be offered through improved diagnostic methods for right ventricular function and better management of supraventricular tachyarrhythmias.

Long term results of mechanical prostheses for treatment of active infective endocarditis.

OBJECTIVE: To analyse the long term results of mechanical prostheses for treating active infective endocarditis. DESIGN: Prospective cohort study of a consecutive series of patients diagnosed with infective endocarditis and operated on in the active phase of the infection for insertion of a mechanical prosthesis. SETTING: Tertiary referral centre in a metropolitan area. RESULTS: Between 1975 and 1997, 637 cases of infective endocarditis were diagnosed in the centre. Of these, 436 were left sided (with overall mortality of 20.3%). Surgical treatment in the active phase of the infection was needed in 141 patients (72% native, 28% prosthetic infective endocarditis). Mechanical prostheses were used in 131 patients. Operative mortality was 30.5% (40 patients). Ninety one survivors were followed up prospectively for (mean (SD)) 5.4 (4.5) years. Thirteen patients developed prosthetic valve dysfunction. Nine patients suffered reinfection: four of these (4%) were early and five were late. The median time from surgery for late reinfection was 1.4 years. During follow up, 12 patients died. Excluding operative mortality, actuarial survival was 86.6% at five years and 83.7% at 10 years; actuarial survival free from death, reoperation, and reinfection was 73.1% at five years and 59.8% at 10 years. CONCLUSIONS: In patients surviving acute infective endocarditis and receiving mechanical prostheses, the rate of early reinfection compares well with reported results of homografts. In addition, prosthesis dysfunction rate is low and long term survival is good. These data should prove useful for comparison with long term studies, when available, using other types of valve surgery in active infective endocarditis.

Transient ischaemic attack: a common initial manifestation of cardiac myxomas.

BACKGROUND AND AIMS: Cardiac myxomas may present clinically with many different features. Since highly effective treatments exist, it is important that they are diagnosed quickly in order to avoid further complications. Our aim was to determine the influence of neurological presentation in diagnosis and prognosis of cardiac myxomas. METHODS: We have reviewed the clinical charts of 28 patients diagnosed with cardiac myxomas seen at our centre in the last 20 years. RESULTS: Mean age at diagnosis in patients with neurological events was 49.22 years and 60.84 years in those without neurological manifestations (p = 0.0325). Most frequent presentations were: cardiac manifestations (92.8%), general manifestations (71.4%) and embolic events (39.3%). Nine patients (32.1%) presented with cerebral embolism; 7 of whom presented with transient ischaemic attacks (TIA), which was the first manifestation in 6 of them; 3 of them later suffered complete cerebral infarction with sequelae. Echocardiography confirmed diagnosis in 26 out of 27 patients in which it was performed. None of the patients presented neurological symptoms after surgery. CONCLUSION: The most frequent initial neurological manifestation in our series was TIA. Nevertheless, none of the patients were diagnosed after the first neurological symptom. Although the contribution of cardiac myxomas to the total amount of TIA is low, since surgery is highly effective and of low risk, and patients with neurological manifestations are younger, it is vital to consider the possibility of cardiac myxoma after a TIA of unknown origin.

[Total anomalous pulmonary venous return in children: importance of echocardiographic diagnosis and early surgery]. / Retorno venoso pulmonar total anómalo en pediatría: importancia del diagnóstico ecocardiográfico y de la cirugía precoz.

OBJECTIVE: We studied patients who underwent surgical repair for total anomalous pulmonary venous return at our hospital. We report the importance of diagnosis by echocardiographic imaging before surgical treatment. METHODS: Within the period of 1990-1999, fourteen patients underwent surgical repair of this cardiopathy in our hospital. The type of anomalous drainage was supracardiac in 6 patients, infracardiac in 4, to the coronary sinus in 1, and mixed-type in 3 patients. Eleven cases were diagnosed with an echo-Doppler study, the findings being confirmed intraoperatively. RESULTS: There were 2 early deaths: one occurred in the operating room in a patient with a small left ventricle, and the second one was 35 days postoperatively as a result of a septic complication. Early in the postoperative period our primary goal has steadily been the control and treatment of pulmonary hypertension. After a mean follow-up time of 50 months, only 1 patient needed to be reoperated on and the remainder are symptomless. CONCLUSIONS: That sufficient diagnostic data on total anomalous pulmonary venous return can reliably be obtained by ultrasound scanning so that surgery can be promptly undertaken, and that its surgical risk is currently low and mid-term post-repair outcome is fairly good.

[Coronary endarterectomy]. / Endarterectomía coronaria.

The technique of coronary endarterectomy, in coronary artery surgery, has been controversial and alternatively indicated or contraindicated by different authors. In this paper coronary endarterectomy is reviewed, including its definition, history and development of different techniques. Early and late results of the main papers in the literature are commented on as well as our results. The surgical technique of endarterectomy in the different coronary artery territories is described with the primary indications and contraindications. Coronary endarterectomy is a valid and well established technique that can provide possibilities of revascularization in patients with extended and diffused coronary artery obstructions, which are unable to be treated with conventional coronary artery bypass grafts. Operative mortality and morbidity are slightly higher, but long-term results, as far as survival and functional class are concerned, are similar to standard coronary artery surgical procedures.

[Arterial switch: aortocoronary bypass with interposition of polytetrafluoroethylene (Gore-tex) vascular graft]. / Switch arterial: bypass aortocoronario con interposición de injerto vascular de politetrafluoroetileno (Gore-tex).

We report a case of an infant with transposition of the great arteries accompanied by an unusual coronary artery pattern, in whom an expanded polytetrafluorethylene (Gore-tex) graft to the right coronary artery was used during surgical correction (switch arterial), with a postsurgical follow-up time of 8 months.

[Double-outlet left ventricle with subaortic interventricular defect and pulmonary stenosis: surgical correction with cryopreserved aortic homograft]. / Doble salida ventricular izquierda con comunicación interventricular subaórtica y estenosis pulmonar: corrección quirúrgica con utilización de homoinjerto aórtico crioconservado.

Double outlet left ventricle with subaortic ventricular septal defect and pulmonary stenosis is a very rare congenital heart disease. We present a case of this cardiopathy which underwent correction consisting of ventricular septal defect closure and right ventricular outflow tract reconstruction using a cryopreserved aortic homograft, with a postsurgical follow-up time of 18 months.

[Pulmonary thromboendarterectomy in a patient with primary antiphospholipid syndrome]. / Tromboendarterectomía pulmonar en un paciente con síndrome antifosfolípido primario.

Pulmonary arterial hypertension (PAH) is an infrequent manifestation of the primary antiphospholipid syndrome (PAPS). It may appear due to different mechanisms although the most common cause is recurrent pulmonary embolisms. In some cases the thrombi do not dissolve and organize to form fibrous masses which occlude the pulmonary veins giving place to chronic thromboembolic pulmonary hypertension. When the thrombi are located in the proximal arteries, thromboendarterectomy may be curative. The first case of a patient with PAPS diagnosed with PAH secondary to chronic thrombosis of the proximal pulmonary arteries, in whom a successful pulmonary thromboendarterectomy was performed is herein reported.

[Doppler echocardiography in the postoperative assessment of the arterial switch in the repair of transposition of the great arteries and double outlet right ventricle]. / Ecocardiografía Doppler en la valoración posquirúrgica del switch arterial para la reparación de la transposición de las grandes arterias y la doble salida del ventrículo derecho.

OBJECTIVE: To evaluate the usefulness of Doppler-echocardiography in the follow-up of anatomical repair in transposition of great arteries and double outlet of right ventricle. PATIENTS AND METHODS: 108 Doppler-echo studies, in a follow-up protocol of the first 32 consecutive patients who successfully passed anatomical repair, were analyzed. The mean age for operation was 50 days (6-472 days) (25 patients before 21 days of age) with a mean follow-up time of 406 days (1 day-4.5 years). We studied subjective impression of left ventricular function and its quantification by systolic shortening fraction, the functioning of four heart valves; diagnosis and quantification of stenosis in arterial sutures of neoaorta and neopulmonary, the most useful windows and planes and, finally, the difficulties found during the examination. RESULTS: Thirteen patients (41%) showed a low left ventricular shortening fraction, though 85% of these patients had anomalous ventricular septal motion. Neoaortic valve insufficiency was detected in 12 patients (37%) (mild in 10 and moderate in 2) and neopulmonary valve regurgitation in 14 patients (44%) (mild in 11 and moderate in 3). Stenosis of arterial sutures was detected in: 2 (6%) patients at neopulmonary artery and 1 (3%) at neoaortic artery. The biggest technical difficulty was found in the neopulmonary artery evaluation. CONCLUSIONS: 1) Doppler echocardiography is an excellent method for anatomical and functional evaluation in these patients and is necessary in their follow-up evaluations; 2) Surgical results obtained in this series are good; 3) Left ventricle fractional shortening is misleading in the evaluation of ventricular function in these patients because of the high incidence of abnormal ventricular septal motion, and 4) The study of neopulmonary arteries is often very difficult.

[Left aorto-ventricular tunnel. Diagnosis with transthoracic and transesophageal echo-Doppler]. / Túnel aorto-ventricular izquierdo. Diagnóstico mediante eco-Doppler transtorácica y transesofágica.

Aortic-left ventricular tunnel is an infrequent congenital heart lesion consisting of an abnormal tubular-shaped communication between the aortic root and the left ventricle that bypasses the aortic valve. It is clinically undistinguishable from aortic insufficiency. Its prompt and precise diagnosis is crucial since early surgical treatment is definitely indicated, in contrast to aortic insufficiency. In our case, two-dimensional and pulsed color-flow Doppler imaging established the diagnosis, and the transesophageal approach was a great aid in detecting the aortic opening with its turbulent diastolic flow, and in tracing its intramyocardial course. This paper may be of interest not just as a new case-report but insofar as it stresses how importantly the transthoracic and transesophageal echocardiographic and Doppler scanning contributes to its diagnosis and therapeutic indication.

[Anatomical correction in transposition of the great arteries and double-outlet right ventricle. Our initial experience]. / Corrección anatómica en la transposición de grandes arterias y en la doble salida de ventrículo derecho. Experiencia inicial.

INTRODUCTION AND OBJECTIVES: Anatomical correction of transposition of great arteries and double outlet right ventricle with subpulmonary ventricular septal defect is a surgical approach that has not been generally adopted in our clinical environment. Our aim with this paper is reporting on our initial experience with this technique. METHODS: The clinical data and additional investigations are reviewed from 15 infants with transposition of the great arteries and 2 with double outlet right ventricle who underwent anatomical repair, with a postoperative follow-up of one year. RESULTS: The survival rate has been 76% (13 out of 17 cases). The 13 survivors are in good hemodynamic condition, with no treatment whatsoever. Thirteen patients are in sinus rhythm with normal repolarization patterns and 5 patients show a right bundle branch block. Neither aortic nor pulmonary gradients have been detected on Doppler examination, and slight valvular insufficiencies are found at aortic level in 4 patients, pulmonary in 2 and mitral in one. CONCLUSION: Anatomical correction is the method of choice for transposition of the great arteries and double outlet right ventricle with pulmonary-related ventricular septal defect.

[Primary cardiac hemangioma. A case report and review of the literature]. / Hemangioma cardíaco primario. Presentación de un caso y revisión de la literatura.

A 26-years-old woman, without symptoms, was diagnosed of cardiac tumor by means of two-dimensional echocardiography, magnetic resonance imaging and angiocardiography. The tumor was removed underwent open-heart operation and cardiopulmonary bypass. Histologic study was suggestive of a capillary hemangioma. We present our experience with this case and a review of the literature.

[Evaluation of DDD and VVIR pacemakers with gated radionuclide ventriculography]. / Valoración del marcapasos DDD y VVIR mediante la técnica de la ventriculografía isotópica en equilibrio.

Gated radionuclide ventriculography was performed in 53 patients, with 29 DDD and 24 VVIR pacemakers. Ejection fraction and regional contractility was studied in three conditions: a) At rest. b) With tachycardia after exercise. And c) With induced tachycardia at rest. At a rate similar to the one reached with the exercise. Stimulation in different parts of the right ventricule did not show any differences in the ejection fraction. Induced ventricular stimulation in comparison with natural ventricular contractions did not alter or change ejection fraction if the reached rate was the same an not too high in both cases. Induced stimulation at rest with a rate of 110-120/min, decreased the ejection fraction in 10% (p less than 0.001). Induced stimulation by exercise (VVIR. DDD) increased the ejection fraction in 10% (p less than 0.003) and if there were zones of dyskinesia they improved or disappeared. There were no statistical differences between VVIR and DDD pacemakers. It seems that a limited tachycardia is convenient for patients with rate response pacemakers (VVIR).

Endarterectomy of the LAD and internal mammary artery grafting. A reliable association.

Endarterectomy of the left anterior descending (LAD) coronary artery and concomitant myocardial revascularization with the internal mammary artery (IMA) were performed in five men aged 52-62 years. There was no perioperative myocardial infarction and no hospital mortality. Early postoperative angiography was performed in four cases and showed patent IMA grafts. The infrequent association of LAD endarterectomy and IMA grafting in the literature is commented on. The authors recommended myocardial revascularization with the IMA in all cases of LAD atherosclerosis, even though the condition is severe and diffuse, requiring endarterectomy.

Atherosclerosis of the internal mammary artery. Histopathological analysis and implications on its results in coronary artery bypass graft surgery.

To evaluate internal mammary artery (IMA) atherosclerosis in our population, 38 segments of IMA obtained at the time of coronary surgery and 20 segments of IMA obtained at postmortem studies were histologically studied. Hematoxilin-eosin, Masson trichromic, elastic fibers and reticulin fibers were the stain methods used. A total of 236 sections were studied. Atherosclerosis was graded from 0 to 4 according to Kay and co-workers. Severe disease, with more than 50% luminal narrowing was found in one necropsy case (5%) and in no surgical case. In the surgical group, only one case (2.36%) showed a degree 3 luminal narrowing (between 25% and 50% luminal reduction). The remaining sections were normal or minimally affected. It is concluded that the IMA shows minimal atherosclerotic changes, being considered a protected vessel.

Venous digital angio-radiography: an accurate and useful technique for assessing coronary bypass graft patency.

Digital angiography has been reported to be a valid technique for anatomical studies of the peripheral cardiovascular system and for dynamic studies of ventricular function. The purpose of the present study was to assess the usefulness and accuracy of venous digital angiography (2 images per second) for imaging coronary bypass grafts after coronary artery bypass surgery, comparing its results with those of selective angiography. Fifty-two patients with 108 grafts (101 venous grafts and 7 internal mammary artery grafts) were studied by venous digital angiography and selective angiography. Venous digital angiography correctly diagnosed 95 out of 97 patent grafts and the 11 occluded grafts visualized by selective angiography. These results are better than those obtained in the very few studies so far reported in the literature. We were not able to adequately visualize distal anastomoses in most patients although we could identify the distal portion of 7 out of 8 patent sequential bypass grafts. Thus, these results suggest that venous digital angiography is a useful and accurate technique for assessing coronary bypass graft patency.