The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Nov 1997
Comparative StudyOne-stage midline unifocalization and complete repair in infancy versus multiple-stage unifocalization followed by repair for complex heart disease with major aortopulmonary collaterals.
Patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries have traditionally required multiple unifocalization staging operations before undergoing complete repair. Recently, the feasibility of a single-stage unifocalization and repair was demonstrated by Hanley. In this report, we describe our experience with each approach. ⋯ Early intervention with both surgical approaches can lead to complete biventricular repair in most patients. Because the single-stage midline unifocalization and repair can achieve a completely repaired heart in infancy with one operation, it is currently our approach of choice.
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J. Thorac. Cardiovasc. Surg. · Nov 1997
Benefit of neurophysiologic monitoring for pediatric cardiac surgery.
Pediatric patients undergoing repair of congenital cardiac abnormalities have a significant risk of an adverse neurologic event. Therefore this retrospective cohort study examined the potential benefit of interventions based on intraoperative neurophysiologic monitoring in decreasing both postoperative neurologic sequelae and length of hospital stay as a cost proxy. ⋯ Interventions based on neurophysiologic monitoring appear to decrease the incidence of postoperative neurologic sequelae and reduce the length of stay. Inasmuch as the break-even cost for neurophysiologic monitoring is more than four times the actual average charge, both patients and hospital may profit from this service. Because this study was not a truly randomized clinical trial, unintentional statistical bias may have occurred and caution is urged in interpreting the magnitude of apparent intergroup outcome differences.
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J. Thorac. Cardiovasc. Surg. · Nov 1997
Extending the concept of the autograft for complete repair of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: a report of ten cases of a modified procedure.
In most cases of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction, a Lecompte procedure (réparation à l'étage ventriculaire) is possible without interposition of a conduit between the right ventricle and pulmonary artery. However, the anterior location of the pulmonary arteries after the Lecompte maneuver may be a potential cause for right ventricular outflow obstruction, which continues to be reported in 5% to 25% of cases. We have used a tubular segment of aortic autograft to connect the pulmonary artery, left in the orthotopic posterior position (without the Lecompte maneuver), to the right ventricle in 10 consecutive patients with transposition, ventricular septal defect, and left ventricular outflow tract obstruction. ⋯ This modification of the Lecompte operation using a segment of autograft allows an excellent early and late result, with no danger of compression of anteriorly placed pulmonary arteries, no significant right ventricular outflow obstruction, and normal appearance of the tubular autograft. In view of laboratory and clinical evidence, normal growth of the autograft can be anticipated. It allows an elective correction of transposition, ventricular septal defect, and left ventricular outflow tract obstruction without a previous Blalock-Taussig shunt (three patients) and correction at a young age (three patients younger than 1 year).
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J. Thorac. Cardiovasc. Surg. · Nov 1997
Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body.
The intervalvular fibrous body between the aortic and mitral valves can be damaged by infective endocarditis, degenerative calcification, or multiple previous heart valve operations, making double valve replacement difficult. We have managed this problem by approaching the aortic and mitral valves through the aortic root and the dome of the left atrium. After excising the aortic valve, the diseased fibrous body, and the mitral valve, we suture a properly tailored patch of Dacron fabric or bovine pericardium to the lateral and medial fibrous trigones and to the aortic root, reestablishing the aortic and mitral anuli. A prosthetic mitral valve is implanted and a separate patch is used to close the left atriotomy before implantation of a prosthetic aortic valve. This study was undertaken to determine the efficacy of this operation. ⋯ Reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement is a satisfactory operative approach in patients with complex valve annular pathology.
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J. Thorac. Cardiovasc. Surg. · Oct 1997
The limits of detectable cerebral perfusion by transcranial Doppler sonography in neonates undergoing deep hypothermic low-flow cardiopulmonary bypass.
Neurologic morbidity including seizures, abnormal neurologic function, and delayed psychomotor development continue to be significant problems for some patients undergoing operations for congenital heart disease, particularly for those subjected to deep hypothermic circulatory arrest. The technique of low-flow cardiopulmonary bypass has been advocated to decrease the incidence of neurologic sequelae. Our study examined the limits of detectable blood flow in the middle cerebral artery during low-flow cardiopulmonary bypass in 28 neonates undergoing the arterial switch procedure. ⋯ Our data show that cerebral perfusion can be detected by transcranial Doppler sonography in the middle cerebral artery in some neonates at bypass pump flows as low as 10 ml/kg per minute. However, when transcranial Doppler sonography was used in our patient population, a minimum bypass flow rate of 30 ml/kg per minute was needed to detect cerebral perfusion in all neonates.