RESUMEN
PURPOSE: To predict persistent type II endoleaks (pT2Es) following endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms, we examined factors related to post-EVAR pT2Es. METHODS: Eighty-four cases of EVAR were analyzed. T2Es that persisted for ≥6 months were defined as pT2Es. pT2Es flowing from an inferior mesenteric artery (IMA) and lumbar artery (LA) were termed pIMA-T2Es and pLA-T2Es, respectively. The anatomical factors concerning the aneurysm, IMA and LAs were assessed in the preoperative CT angiography images. A statistical analysis was performed on the factors associated with pT2Es. RESULTS: The incidence of pT2Es was 25 %. pT2Es were associated with postoperative changes in the aneurysm diameter. A univariate analysis showed that a sac thrombus and the number of patent side branches arising from an aneurysm were significant factors associated with pT2Es. The IMA diameters were significantly larger in cases of pIMA-T2Es. The significant factors associated with pLA-T2Es were a circumferential thrombus, the number of patent LAs and the mean LA diameter. Multivariate analyses indicated that a circumferential thrombus was a protective factor for pT2Es, whereas an IMA ≥2.6 mm and each additional LA branch ≥1.9 mm were powerful risk factors for a pT2E. CONCLUSION: Significant anatomical factors associated with pT2E were found in this study. These factors may be useful in selecting patients for perioperative intervention.
RESUMEN
The radial artery is increasingly used as a second arterial conduit for myocardial revascularization. However, the radial artery is susceptible to vasospasm, which is thought to be the principal cause of graft failure. The radial artery is harvested as a skeletonized or a non-skeletonized graft, but the effect of different harvesting technique remains unknown. In this study, we compared the early- and mid-term angiographic findings to elucidate its influence on the graft luminal diameter. We harvested 39 radial arteries either as a skeletonized (n = 18) or a non-skeletonized graft (n = 21) using an ultrasonic scalpel. We constructed a composite straight graft by combining a right internal thoracic artery and a radial artery. All the radial artery grafts were sequentially anastomosed to coronary arteries. We measured the diameters of the radial arteries before the operation, within 1 month and 1 year after the operation. At early postoperative period, graft diameter was significantly larger in skeletonized grafts. Graft diameter at the point before the first and the second anastomosis was similar in skeletonized grafts, although that was significantly smaller before the second anastomosis in non-skeletonized grafts. However, 1 year after the operation, the graft diameter was comparable and equally reduced after the first anastomosis in both groups. Skeletonization with an ultrasonic scalpel increases the luminal diameter of the radial artery graft at early postoperative period, which, however, reduces possibly as adaptation to graft flow 1 year after the operation.
Asunto(s)
Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/cirugía , Arterias Mamarias/trasplante , Arteria Radial/trasplante , Grado de Desobstrucción Vascular/fisiología , Anciano , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/fisiopatología , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Arterias Mamarias/diagnóstico por imagen , Arterias Mamarias/fisiopatología , Tomografía Computarizada Multidetector , Arteria Radial/diagnóstico por imagen , Arteria Radial/fisiopatología , Estudios Retrospectivos , Factores de Tiempo , Recolección de Tejidos y Órganos , Vasoconstricción/fisiologíaRESUMEN
We describe surgical treatment for a patient with chronic thromboembolic pulmonary hypertension who developed acute type A aortic dissection. Acute aortic dissection is a life-threatening disease and must be operated emergently, and chronic thromboembolic pulmonary hypertension can be treated only by pulmonary endarterectomy. We performed a staged procedure consisting of hemiarch replacement with antegrade cerebral perfusion first and pulmonary endareterectomy with periods of deep hypothermic circulatory arrest a week later. We used extracorporeal membrane oxygenation after aortic surgery as a bridge to pulmonary endarterectomy. Our strategy was useful for patients with chronic thromboembolic pulmonary hypertension who require complicated aortic surgery.
Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Hipertensión Pulmonar/cirugía , Embolia Pulmonar/cirugía , Anciano , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico por imagen , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico por imagen , Paro Circulatorio Inducido por Hipotermia Profunda , Endarterectomía , Femenino , Humanos , Hipertensión Pulmonar/complicaciones , Embolia Pulmonar/complicaciones , Embolia Pulmonar/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Functional tricuspid regurgitation (TR) often develops secondary to left heart disease. Tricuspid annuloplasty (TAP) is usually the treatment of choice for significant TRs, but recurrence of TR after surgery can occur. Previous studies have not clearly demonstrated the cause of the recurrent TR after TAP. By using an electrocardiogram-gated 320-detector-row multislice computed tomography (CT), we sought to delineate the morphologic cause of the incompetent tricuspid valve and identify the risk factors for recurrent TR. METHODS: From August 2010 to September 2011, 35 patients underwent preoperative CT of the tricuspid valve. The distance between each commissure, the tethering angle of each leaflet, and the tethering height were measured. TAP using a rigid annuloplasty ring was performed in 22 patients. Risk factors for recurrent TR were determined by multivariate analyses. RESULTS: End-diastolic and end-systolic tricuspid valve annular diameters (TVAD) correlated significantly with preoperative TR severity (R(2), 0.2734-0.4287; P < .05). However, compared with TVAD, tethering angles and height showed stronger correlation with preoperative TR severity (R(2): tethering angles, 0.5769-0.6810; tethering height, 0.6854). Multivariate analysis revealed that tethering height was an independent risk factor of postoperative recurrent TR (P = .0069). CONCLUSIONS: TVAD, tethering angles, and tethering height correlated significantly with preoperative TR severity. The tethering height of the tricuspid valve showed significant correlation with recurrent TR.
Asunto(s)
Anuloplastia de la Válvula Cardíaca/efectos adversos , Técnicas de Imagen Sincronizada Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Tomografía Computarizada Multidetector , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/cirugía , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Electrocardiografía , Femenino , Humanos , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Válvula Tricúspide/fisiopatología , Insuficiencia de la Válvula Tricúspide/etiología , Insuficiencia de la Válvula Tricúspide/fisiopatologíaRESUMEN
BACKGROUND: Autonomic ganglionated plexi (GPs) play a significant role in the initiation and maintenance of atrial fibrillation (AF). GPs are key targets for a maze procedure. The purpose of this study was to identify the location of the left atrial GPs based on dense epicardial mapping during a maze procedure in patients with concomitant AF. METHODS: Sixteen patients (age, 68 ± 10 years; 11 males, 69%) with heart failure and concomitant AF (duration 55 ± 86 months) underwent intraoperative epicardial electrophysiological mapping and a GP ablation using the maze procedure at our institution. Twenty-four-site, high-frequency stimulation (1,000/min; output, 18 V; pulse width, 0.75 ms) was performed by placing tweezers directly onto the potential GP sites on the left atrial epicardium. RESULTS: Active GPs were found in 13 (81%) of the 16 patients, and 12 (92%) of 13 patients had active GPs between the right pulmonary veins (PVs) and the interatrial groove. For those patients with active locations, a 7-day event-loop recording demonstrated that 12 (92%) of 13 patients were maintained in sinus rhythm 3 months after the operation. CONCLUSION: Dense epicardial mapping in the potential GP areas identified active GP locations in a high percentage of patients. GPs between the PVs and interatrial groove have a high potential as ablation targets for treatment of concomitant AF.
Asunto(s)
Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Mapeo del Potencial de Superficie Corporal/métodos , Ablación por Catéter/métodos , Ganglios Autónomos/cirugía , Sistema de Conducción Cardíaco/cirugía , Adolescente , Adulto , Anciano , Fibrilación Atrial/fisiopatología , Femenino , Atrios Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Cirugía Asistida por Computador/métodos , Resultado del TratamientoRESUMEN
We report a rare case of a 58-year-old male with accidental occlusion of left main trunk (LMT) artery by injured aortic valve during percutaneous coronary intervention (PCI). Although we successfully bailed out this complication by urgent LMT stenting, aortic regurgitation developed immediately after PCI. Echocardiography detected a filamentous structure attached to the aortic valve. An elective aortic valve replacement surgery revealed that his right coronary cusp was torn into two filamentous strips. One strip accidentally plunged into LMT and was fixed by the intracoronary stent. Another strip floated in the aortic root and appeared as though vegetation attached to the aortic valve in case of acute infective endocarditis. Guiding catheters probably injured the aortic valve during PCI. This report reminded us of the importance of meticulous manipulation of a guiding catheter.
Asunto(s)
Angioplastia Coronaria con Balón/efectos adversos , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/lesiones , Cateterismo Cardíaco/efectos adversos , Oclusión Coronaria/terapia , Implantación de Prótesis de Válvulas Cardíacas/métodos , Angioplastia Coronaria con Balón/métodos , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/cirugía , Cateterismo Cardíaco/métodos , Angiografía Coronaria/efectos adversos , Angiografía Coronaria/métodos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/etiología , Ecocardiografía Transesofágica/métodos , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Standard full median sternotomy for total arch replacement in tracheostomy patients may lead to mediastinitis and graft infection. Several approaches for typical cardiac surgery, including a T-shaped sternotomy, have been used in patients with both terminal and transient tracheostomas; however, these procedures offer inadequate surgical exposure of the arch vessels. We herein report the case of a 67-year-old man with a subacute type A aortic dissection with a terminal tracheostoma after total laryngectomy, who successfully underwent total arch replacement by a fourth intercostal thoracotomy performed using an anterior bilateral approach and the arch-first technique. To our knowledge, this is the first report of a case of total arch replacement in a patient with subacute aortic dissection and a terminal tracheostoma.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Laringectomía , Toracotomía/métodos , Traqueostomía , Injerto Vascular/métodos , Anciano , Humanos , MasculinoRESUMEN
BACKGROUND: Treatment of complex aortic pathologies involving the transverse arch with extensive involvement of the descending aorta remains a surgical challenge. Since clamshell incision provides superior exposure of the entire thoracic aorta, we evaluated the use of this technique for single-stage total arch replacement by arch vessel reconstruction. METHODS: The arch-first technique combined with clamshell incision was used in 38 cases of aneurysm and aortic disease in 2008 and 2009. Extensive total arch replacement was used with clamshell incision for reconstruction of arch vessels under deep hypothermic circulatory arrest. RESULTS: Overall 30-day mortality was 13%. The mean operating time was approximately 8 hours. Deep hypothermia resulted in mean CPB time exceeding 4.5 hours and mean duration of circulatory arrest was 25 minutes. The overall postoperative temporary and permanent neurologic dysfunction rates were 3% and 3% for elective and 3% and 0% for emergency surgery, respectively. All patients except the five who died in hospital were discharged without nursing care after an average post-operative hospital stay of 35 days. CONCLUSIONS: The arch-first technique, combined with clamshell incision, provides expeditious replacement of the thoracic aorta with an acceptable duration of hypothermic circulatory arrest and minimizes the risk of retrograde atheroembolism by using antegrade perfusion.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Torácica/mortalidad , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Paro Circulatorio Inducido por Hipotermia Profunda , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Resultado del TratamientoRESUMEN
Cardiac myxoma is the most common primary cardiac tumour, but infected cardiac myxoma is relatively rare. Infected cardiac myxoma is very fragile, and has a potential to lead to catastrophic disorder with systemic bacteremia, systemic mycotic embolism, and disseminated intravascular coagulation (DIC).We present here the successful surgical treatment of a case of infected left atrial myxoma with septic shock, DIC and cerebral infarction without hemorrahage. Collective review of 58 reported cases with infected cardiac myxoma revealed that surgical treatment for it were still challenging and its result was poor. Until date, only one successful surgical treatment for a case complicated by DIC and cerebral infarctions has been reported, and our report describes second such case of successful resection. Even though this report is limited to a case, only aggressive and prompt surgical intervention could relieve the intractable conditions in such a patient with extremely high risk.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Infarto Cerebral/etiología , Coagulación Intravascular Diseminada/etiología , Neoplasias Cardíacas/cirugía , Mixoma/cirugía , Choque Séptico/terapia , Infecciones Estafilocócicas/terapia , Antibacterianos/uso terapéutico , Infarto Cerebral/diagnóstico , Infarto Cerebral/terapia , Diagnóstico Diferencial , Coagulación Intravascular Diseminada/diagnóstico , Coagulación Intravascular Diseminada/terapia , Quimioterapia Combinada , Ecocardiografía , Estudios de Seguimiento , Atrios Cardíacos , Neoplasias Cardíacas/complicaciones , Neoplasias Cardíacas/diagnóstico , Humanos , Inmunoglobulinas Intravenosas/uso terapéutico , Factores Inmunológicos/uso terapéutico , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Mixoma/complicaciones , Mixoma/diagnóstico , Choque Séptico/complicaciones , Choque Séptico/diagnóstico , Infecciones Estafilocócicas/complicaciones , Infecciones Estafilocócicas/diagnóstico , Staphylococcus aureus/aislamiento & purificaciónRESUMEN
A 75-year-old man developed persistent dysphagia 2 months after successful total arch replacement with a long elephant trunk (ET) for a distal arch aneurysm. Enhanced computed tomography revealed not only complete thrombosis of the distal arch aneurysm, but also rapid expansion of another downstream aortic aneurysm with esophageal compression. Thoracic endovascular aortic repair was undertaken for this symptomatic aortic aneurysm, which was totally thrombo-excluded. ET might produce turbulent or jet-like blood flow from its tip in some situations and have a potential to accelerate the expansion of the downstream aneurysm. Additional endovascular ET completion is simple, effective, and less invasive.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aortografía/métodos , Afasia/etiología , Implantación de Prótesis Vascular/efectos adversos , Estenosis Esofágica/etiología , Humanos , Masculino , Diseño de Prótesis , Recurrencia , Reoperación , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
We present a new, less-invasive technique for a re-do for perivalvular leakage after aortic mechanical valve replacement. Only the carbon ring of the previously implanted St. Jude prosthesis was excised, the sewing cuff being preserved. The locations of the perivalvular defects were clearly identified by pulling the sewing cuff inward. They were securely closed by placing pledgeted sutures at the preserved cuff through the full thickness of the aortic wall or through the annulus by a deep bite from the left ventricular side. A new mechanical prosthesis was then sewn onto the preserved sewing cuff.
Asunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Falla de Prótesis , Técnicas de Sutura , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Reoperación , Resultado del TratamientoRESUMEN
Popliteal artery entrapment syndrome (PAES) is a rare cause of acute limb ischemia in adult patients but commonly demonstrates as claudication in young patients. The most significant, although rare, complication associated with PAES is aneurysm formation. We present the case of an elderly patient with a unilateral popliteal artery aneurysm owing to symptomatic anatomic entrapment. This report presents the oldest patient ever reported with this syndrome and highlights the advantage of multimodal treatment. As multidetector computed tomography highly contributed to the rapid diagnostic confirmation and choice of treatment in the popliteal fossa, limb salvage was achieved in this patient.
Asunto(s)
Aneurisma/etiología , Arteriopatías Oclusivas/complicaciones , Isquemia/etiología , Extremidad Inferior/irrigación sanguínea , Arteria Poplítea , Trombosis/complicaciones , Enfermedad Aguda , Anciano , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/cirugía , Humanos , Isquemia/diagnóstico por imagen , Isquemia/cirugía , Recuperación del Miembro , Masculino , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/cirugía , Vena Safena/trasplante , Trombectomía , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Early surgical intervention for complete atrioventricular septal defect (AVSD) has contributed to a decline in postoperative mortality. METHODS: We retrospectively evaluated outcomes in 116 complete AVSD patients undergoing definitive repair from February 1997 through October 2002. Patients with an unbalanced AVSD not suitable for biventricular repair, tetralogy of Fallot, or double-outlet right ventricle were excluded. RESULTS: Median age at operation was 4.8 months (range, 9 days to 5.4 years); weight was 4.8 kg (range, 2.1 to 23 kg). Follow-up was 93% complete (mean, 27 months; range, 1 to 73 months). Early definitive repairs were performed in 98% (110 of 112) of patients initially presenting to our institution. Ninety-two patients (79%) underwent repair before 6 months of age, including 25 (22%) before 3 months. Actuarial survival at 1, 3, and 5 years was 98%, 95%, and 95%, respectively. Seventy-five patients (68%) had trivial to mild left AV valve regurgitation at discharge; moderate or severe left AV valve stenosis developed in 3 (3%). Actuarial freedom from reoperation for left AV valve dysfunction at 1, 3, and 5 years was 94%, 89%, and 89%, respectively. Actuarial freedom from reoperation for left ventricular outflow tract obstruction at 1, 3, and 5 years was 100%, 93%, and 90%, respectively. CONCLUSIONS: Definitive repair for complete AVSD can be performed in early infancy with excellent results. The two-patch technique is a safe and reproducible surgical method that can achieve low mortality and good midterm outcomes even in very young infants.
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Defectos del Tabique Interatrial/cirugía , Defectos del Tabique Interventricular/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Ecocardiografía Doppler , Femenino , Defectos del Tabique Interatrial/mortalidad , Defectos del Tabique Interventricular/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Lactante , Recién Nacido , Masculino , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia , Resultado del Tratamiento , Obstrucción del Flujo Ventricular Externo/cirugíaRESUMEN
We report an operative case of the anomalous origin of the left coronary artery from the right pulmonary artery with aortic intramural course. This particular anatomy was clearly identified with a preoperative angiogram. The restoration of the two-coronary system was accomplished by unroofing the intramural segment into the left sinus of Valsalva with encouraging midterm results. The details of this anatomical correction are described with a review of the literature.
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Anomalías de los Vasos Coronarios/cirugía , Arteria Pulmonar/anomalías , Procedimientos Quirúrgicos Vasculares/métodos , Anomalías Múltiples/diagnóstico , Anomalías Múltiples/cirugía , Angiografía Coronaria , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Estudios de Seguimiento , Humanos , Lactante , Masculino , Arteria Pulmonar/cirugía , Medición de Riesgo , Resultado del TratamientoRESUMEN
One patient with major aorto-pulmonary collateral arteries and heterotaxy underwent staged unifocalizations, and eventually the staged Fontan completion. Subsequent to the bidirectional Glenn procedure, the left pulmonary artery was once thrombozed, but successfully treated. The progressively regurgitant common atrioventricular valve needed repair twice during the course. Pulmonary arterial pressure was 11 mm Hg 1 year after the Fontan procedure.
Asunto(s)
Anomalías Múltiples/cirugía , Circulación Colateral , Procedimiento de Fontan , Cardiopatías Congénitas/cirugía , Atresia Pulmonar/cirugía , Anomalías Múltiples/diagnóstico por imagen , Niño , Preescolar , Cardiopatías Congénitas/diagnóstico por imagen , Humanos , Masculino , Atresia Pulmonar/diagnóstico por imagen , RadiografíaRESUMEN
OBJECTIVE: It was well discussed, in the primary Fontan era, that small pulmonary arterial size could affect the results immediately after the Fontan procedure. The objective of the present study is to determine whether this feature remains as a risk factor in the era of the staged Fontan completion and poses functional impediments in the longer terms. METHODS: Between June 1991 and November 2004, the staged Fontan completion was carried out subsequent to the bidirectional Glenn procedure in consecutive 57 patients with a preoperative pulmonary artery index less than 250 mm2/m2 (Group-S; minimum index 104 mm2/m2). Clinical data were reviewed retrospectively. As background and reference information, similar data were collected in another consecutive 64 patients with larger pulmonary arteries who underwent the staged Fontan completion during the same period (Group-L; maximum index 697 mm2/m2). RESULTS: No patients died after the Fontan procedure in Group-S, while six early deaths in Group-L. No takedown of the Fontan circulation was carried out in either group. The latest catheterizations, at 2.8+/-2.7 years postoperatively, showed a pulmonary artery index significantly lower than the preoperative index (Group-S: 198+/-37-176+/-49 mm2/m2; P=0.0082, Group-L: 360+/-94-266+/-89 mm2/m2; P<0.0001). Hemodynamics in Group-S during the intermediate term were identical with those in Group-L in mean pulmonary arterial pressure (10+/-2 in Group-S and 10+/-3 mmHg in Group-L), mean atrial pressure for the systemic chambers (5+/-2 and 6+/-3 mmHg, respectively), mean transpulmonary gradient (5+/-2 and 4+/-2 mmHg, respectively), cardiac index (3.0+/-0.7 and 3.0+/-0.6l/min/m2, respectively), and arterial oxygen saturation (93+/-3% and 94+/-2%, respectively). Similarly, brain natriuretic peptides concentration in the serum (19.4+/-15.6 in Group-S and 28.3+/-37.2 pg/ml in Group-L) and peak oxygen consumption on exercise testing (24.8+/-4.5 and 24.0+/-6.3 ml/kg/min, respectively) were not inferior in Group-S to those in Group-L. CONCLUSIONS: The outcome after the Fontan completion, including functional ones in the intermediate term, was acceptable in patients having a preoperative PA index smaller than 250 mm2/m2. Pulmonary artery index decreased still further postoperatively, but did not obviously militate against functional efficacy of the Fontan circulation.
Asunto(s)
Procedimiento de Fontan/métodos , Cardiopatías Congénitas/patología , Arteria Pulmonar/patología , Adolescente , Adulto , Presión Sanguínea , Cateterismo Cardíaco , Puente Cardiopulmonar/métodos , Niño , Preescolar , Métodos Epidemiológicos , Cardiopatías Congénitas/cirugía , Humanos , Lactante , Pronóstico , Arteria Pulmonar/fisiopatología , Resultado del TratamientoRESUMEN
OBJECTIVES: Atrial tachyarrhythmia is a common complication late after the atriopulmonary connection Fontan procedure. The P-wave duration and dispersion have been regarded as useful markers for its prediction. The purpose of this study was to analyze change in the P-wave characteristics over time after the atriopulmonary connection Fontan procedure, with a special emphasis on the timing of the Fontan conversion. METHODS: We reviewed clinical and electrocardiographic data in 18 patients with classic tricuspid atresia who underwent the atriopulmonary connection Fontan procedure. Their median age at operation was 4.1 years (range, 1.1-22 years), and the median follow-up period was 18.1 years (range, 10-25 years). We measured the P-wave duration, dispersion, and axis from consecutive 12-lead electrocardiograms in each patient. RESULTS: There was a significant increase in the maximum P-wave duration as well as the P-wave dispersion over time. Transient ectopic atrial rhythm was observed in 16 patients during follow-up. Atrial tachyarrhythmia developed subsequent to transient ectopic atrial rhythm in 8 patients. Ten patients underwent the conversion. Atrial tachyarrhythmia recurred in 2 patients who had sustained arrhythmia (6.0 and 8.0 years) before the conversion. In contrast, the other 8 patients with transient ectopic atrial rhythm alone or nonsustained atrial tachyarrhythmia have been free from arrhythmia after the conversion. CONCLUSIONS: Patients commonly and increasingly had prolonged P-wave duration, larger P-wave dispersion, and ectopic atrial rhythm, along with an atrial tachyarrhythmia propensity, late after the atriopulmonary connection Fontan procedure. These P-wave characteristics were informative when considering the Fontan conversion before a sustained atrial tachyarrhythmia ensued.
Asunto(s)
Electrocardiografía , Procedimiento de Fontan , Taquicardia Atrial Ectópica/diagnóstico , Taquicardia Atrial Ectópica/etiología , Preescolar , Femenino , Estudios de Seguimiento , Procedimiento de Fontan/efectos adversos , Cardiopatías Congénitas/cirugía , Humanos , Lactante , Masculino , Reoperación , Factores de Tiempo , Atresia Tricúspide/cirugíaRESUMEN
BACKGROUND: Repair of partial anomalous pulmonary venous connection (PAPVC) to the high portion of the superior vena cava (SVC) may be complicated by atrial arrhythmia and obstruction of the pulmonary veins or SVC. We reviewed our experience with the modified Warden technique, in which the SVC was transected and anastomosed to the right atrial appendage with anterior augmentation of pedicled autologous pericardial flap, and the atrial septum was directly displaced to the SVC orifice. METHODS: Twenty of 51 patients with PAPVC underwent this technique. Mean age was 11.9 years. Follow-up averaged 6.5 years. To quantify the height of insertion of anomalous pulmonary veins, the distance between the highest anomalous pulmonary venous orifice and SVC-right atrial junction was indexed by thoracic vertebral body height (height index). RESULTS: All patients are alive in sinus rhythm. No patients exhibited pulmonary venous obstruction, and mean flow was 0.61 mL. Mean flow of SVC return was 0.79 mL. The SVC occlusion occurred in 2 patients who had persistent left SVC with a good communicating vein. Three patients whose height index exceeded 2.5 successfully underwent catheter intervention at the SVC channel. CONCLUSIONS: Midterm results with the modified Warden technique were satisfactory. Patients with particularly high insertion of anomalous pulmonary veins should be treated and followed with specific caution for preserving an unobstructed caval pathway.
Asunto(s)
Venas Pulmonares/anomalías , Vena Cava Superior/anomalías , Adolescente , Adulto , Anastomosis Quirúrgica , Antropometría , Apéndice Atrial/cirugía , Bradicardia/etiología , Bradicardia/terapia , Estimulación Cardíaca Artificial , Puente Cardiopulmonar , Niño , Preescolar , Femenino , Estudios de Seguimiento , Defectos del Tabique Interatrial/cirugía , Tabiques Cardíacos/cirugía , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Circulación Pulmonar , Venas Pulmonares/cirugía , Estudios Retrospectivos , Colgajos Quirúrgicos , Resultado del Tratamiento , Vena Cava Superior/cirugíaRESUMEN
BACKGROUND: Biventricular repair is often difficult to accomplish in patients with right atrial isomerism because of complex anomalous structures. METHODS: Ten patients with right atrial isomerism underwent biventricular repair. Their ages ranged from 15 months to 21 years. The follow-up period ranged from 1 month to 21 years. The Fontan procedure was unsuitable in 7 patients. The atrioventricular valves were separated in 5 patients and common in 5. One patient who had severe right-sided atrioventricular valvular regurgitation required concomitant prosthetic valve replacement. Another patient with a hypoplastic intraventricular septum underwent ventricular septation. Nine patients had two balanced ventricles. A ventricular septal defect was enlarged for rerouting in 3 patients. All patients had anomalous venoatrial connections and required intra-atrial baffle rerouting. One with major aortopulmonary collateral arteries underwent staged unifocalization. Three had extracardiac conduit repair. The outcomes were compared with 97 patients who underwent the Fontan procedure. RESULTS: There were 3 early deaths and 1 late death. Six survivors are in New York Heart Association functional class I or II. Two are free from medications. Two required reoperation owing to infection or prosthetic valve failure. At 1 year, cardiac index and systemic venous pressure were 3.2 +/- 0.9 L.min(-1).m(-2) and 6.6 +/- 1.6 mm Hg, respectively. There were no significant differences in survival, freedom from arrhythmia, freedom from reoperation, or exercise tolerance between biventricular repair and the Fontan procedure. CONCLUSIONS: Biventricular repair provided good long-term outcomes in patients with right atrial isomerism. In selected circumstances, biventricular repair is an acceptable alternative to the Fontan procedure.