[Pulmonary artery banding in the treatment of univentricular heart. Results and therapeutic implications for cavopulmonary derivations]. / Cerclage de l'artère pulmonaire dans le traitement des coeurs univentriculaires. Résultats et implications thérapeutiques pour les dérivations cavopulmonaires.

Eighty-six children under one year of age with univentricular hearts associated with increased pulmonary flow underwent pulmonary artery banding as the first stage of palliative therapy. Fifteen patients also had treatment of coarctation of the aorta at the same time and an atrial septal defect was treated in 13 patients. Twenty-seven patients underwent a Fontan procedure secondarily. The mean follow-up was 42.6 +/- 45.5 months; 8 patients were lost to follow-up. Twenty-three patients died during the whole of the study period. The global actuarial survival rate was 69.6 +/- 5% at 5 years. The 3 year survival rate was 56 +/- 12% in patients with anatomical right ventricles compared with 74.4 +/- 5.7% and 69.5 +/- 7.3% at 3 and 5 years respectively in those with anatomical left ventricles (p < 0.01). The presence of coarctation of the aorta reduced the 5 year actuarial survival rate to 25.4 +/- 12.8% (p < 0.01). Subaortic stenosis either at the time of initial presentation or occurring during pulmonary banding was associated with a 5 year survival of 58.3 +/- 13.7% (p < 0.01). Uni- and multivariate analysis demonstrated poor prognostic risk factors. On univariate analysis, they were the residual mean pulmonary pressures after banding, coarctation of the aorta, subaortic stenosis and a restrictive atrial septal defect. Independent risk factors on multivariate analysis were the residual pulmonary pressures after banding, coarctation of the aorta, the necessity of operation in the neonatal period and the need for reoperation for reason other than for a cavopulmonary connection. The feasibility of a Fontan procedure was reduced when subaortic stenosis was observed at any time. Only 17.5% of patients were free of reoperation during this study for whom banding remained the only palliative procedure. In conclusion, a programme of cavopulmonary connection should be envisaged from the initial presentation of these patients. The different stages of treatment with this objective in mind should aim to preserve myocardial function and keep pulmonary resistances low. Therefore, pulmonary artery banding should be rejected in cases with coarctation of the aorta and/or subaortic stenosis. Similarly, early conversion with a Glenn type bidirectional anastomosis allows adaptation of myocardial function for a secondary total cavopulmonary connection.

Aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia: results of surgical management.

Between January 1977 and December 1990, eight patients underwent surgical correction of aneurysms of the extracranial internal carotid artery due to fibromuscular dysplasia. Mean age of patients was 50 years (range 31 to 70 years). Five patients presented with neurologic hemispheric symptoms. Most aneurysms were saccular and occurred preferentially at the level of C2 or C3. All of these patients underwent operation through conventional cervicotomy. Resection-anastomosis was performed in three cases whereas resection-graft was performed in five. Histopathological examination of the eight specimens was consistent with fibromuscular dysplasia of the media. There was no central nervous system-related mortality and morbidity. Seven patients were alive and free of new neurological manifestations at mean follow-up of 156 months (18 to 180 months). One patient died of myocardial infarction at 96 months. All patients had postoperative duplex scanning or arteriograms. These revealed that carotid restorations were patent in seven whereas one patient had asymptomatic occlusion at 18 months.