[Functional mitral regurgitation. Physiopathology and impact of medical therapy and surgical techniques for left ventricle reduction]

Lessons learned from a series of patients with missed aortopulmonary windows

OBJECTIVES

To identify factors contributing to missed diagnosis of aortopulmonary windows on initial echocardiographic examination; and to analyze lesions associated with these malformations.

DESIGN

Retrospective study where echocardiographic findings and per-operative findings of patients were correlated by reviewing records.

SETTING

Tertiary-care paediatric cardiac centre.

PATIENTS

From May 2002 to September 2007, we diagnosed 50 patients with aortopulmonary windows. The group included 31 boys and 19 girls. Mean age at intervention was 1.7 years, with a range from 3 months to 17 years.

RESULTS

The diagnosis of aortopulmonary window was made correctly by echocardiography during initial evaluation in 46 of 50 patients (92%). The remaining 4 patients were diagnosed either during repeat echocardiographic evaluation, cardiac catheterization, or per-operatively. We describe the details of these patients. Of the 50 patients, 23 had associated malformations, including ventricular septal defects in 10 patients, patent arterial ducts in 9, atrial septal defects or patent oval foramens in 5, 3 of whom also had patent arterial ducts, interruption of the aortic arch at the isthmus in 4, or between the left subclavian and common carotid arteries in 2, tetralogy of Fallot in 2, double-outlet right ventricle in 2, discordant ventriculo-arterial connections in 2, 1 of whom also had anomalous origin of the left coronary artery from the pulmonary trunk, and superior-inferior ventricles in 1 patient.

CONCLUSIONS

Even meticulous echocardiography may result in a false negative diagnosis of an aortopulmonary window. A high index of suspicion for this lesion is warranted in cases of unexplained severe pulmonary arterial hypertension, and/or unexplained cardiac dilation.

[Aortopulmonary window: clinical assessment and surgical results]

INTRODUCTION AND OBJECTIVES

Aortopulmonary septal defect is an uncommon congenital cardiac anomaly. To date, approximately 300 cases have been reported. We present our experience, emphasizing the importance of early correction to avoid irreversible pulmonary hypertension.

PATIENTS AND METHOD

Between 1979 and 2000, seven patients underwent surgical repair of this heart defect in our hospital. Two had type I (proximal), 4 had type II (distal) and 1 had type III (complete). Complex associated cardiac anomalies were present in 4 cases: type A interruption of the aortic arch in 2 cases, hypoplastic aortic arch in 1 and transposition of great arteries with ventricular septal defect in 1. Four cases (57%) were diagnosed by echocardiography. In all patients diagnoses were confirmed by cardiac catheterization. Patient records were reviewed retrospectively, with special attention to clinical, echocardiographic and hemodynamic data as well as surgical characteristics.

RESULTS

No intraoperative deaths occurred. The patient with associated transposition of great arteries died 22 days after surgery as a result of severe pulmonary hypertension. The remaining patients are asymptomatic without treatment after a mean follow-up period of 69 months.

CONCLUSIONS

Even though aortopulmonary septal defect is a rare anomaly, it should be considered whenever the course of complex congenital heart disease includes early cardiac failure and pulmonary hypertension. Repair before 6 months will prevent irreversible damage of pulmonary vessels.

[Risk assessment of mitral valve surgery combined with myocardial revascularization]

INTRODUCTION AND OBJECTIVES

Patients with combined mitral valve operation and coronary artery surgery represent a high risk group. The aim of this retrospective study was to evaluate which factors affect early and late postoperative results in this particular group of considered high risk patients. PATIENTS AND METHOD. Between 1984 and 1997, 264 patients (mean age: 63 +/- 7.3 years) underwent mitral valve surgery (199 patients; 75% mitral valve replacement, 25% mitral valve repair) in combination with coronary revascularization (mean 2.4 +/- 1.3 grafts). Follow-up comprised a mean of 69 +/- 42 months and was 98.3% complete.

RESULTS

Early mortality was 10.6% (28/264). Ischemic mitral regurgitation operated on in emergent status, moderate to severe reduced left ventricular function and advanced age (> 60 years) were independently associated with early hospital mortality (p < 0.05). Ischemic etiology of mitral valve disease (emergency and elective operations), severity of mitral regurgitation and New York Heart Association (NYHA) functional class IV were related to early hospital mortality, only with univariate statistics. Actuarial survival was 86, 69 and 48% at 1, 5 and 10 years, respectively. The preoperative NYHA functional class was the only variable independently related to late survival. Eighty-five percent of the surviving patients were in NYHA functional class I and II.

CONCLUSIONS

Mitral valve operation combined with coronary artery bypass grafting is associated with a high early hospital mortality. Independent risk factors of early mortality are emergency operation of ischemic mitral valve disease, reduced left ventricular function and advanced age. Long term survival is independently influenced only by preoperative NYHA functional class IV.

[Hemodynamic benefits of left ventricular pacing in two pacemakers syndromes with refractory heart failure]

We describe two cases in which right ventricular pacing produced severe hemodynamic deterioration and in which changing the pacing from the right to the left ventricle sharply corrected these alterations, while simultaneous biventricular pacing did not. Chronic left ventricular pacing can solve hemodynamic alterations in severe pacemaker syndromes, thereby avoiding the need for mitral prosthesis implantation in some cases. The use of this procedure today should be individualized, including acute hemodynamic and echocardiographic studies, because the width of the QRS complex during pacing is not a significant predictor of hemodynamic efficiency.