Tricuspid atresia presenting in infancy. Survival and suitability for the Fontan operation

27 years of experience with the Fontan procedure: characteristics and clinical outcomes of children in a tertiary referral hospital

BACKGROUND

The Fontan operation has improved the survival of children born with congenital heart disease with single ventricle physiology. The most widely adopted variations of the Fontan procedure are the extracardiac conduit, the lateral tunnel ve the intra/extracardiac conduit with fenestration. Despite advances in the treatment and prevention of early and late complications that may develop after Fontan surgery, morbidity still remains an important problem.

METHODS

304 patients who underwent Fontan surgery in our center between 1995 and 2022 were included in our study. The complications that developed in patients who underwent primary Fontan or lateral tunnel surgery and extracardiac conduit Fontan application were compared.

RESULTS

Classic Fontan surgery and lateral tunnel surgery were performed in 26 of the patients, and extracardiac Fontan surgery was performed in 278 patients. 218 of 304 cases were patients with single ventricular pathology. 86 cases were patients with two ventricular morphologies but complex cardiac pathology. Fenestration was performed in only 6 patients, other patients did not require fenestration. The mean follow-up period of our patients was 12 years (3 months-27 years). When the complications between Fontan procedures were compared in our study, it was found that the length of hospital stay and mortality were statistically significantly reduced in patients who underwent extracardiac Fontan surgery. There was no significant difference in terms of complications that can be seen after Fontan surgery and the length of stay in the intensive care unit.

CONCLUSION

Fontan complex is a palliative surgery for children with complex heart disease. Palliative surgical operations aimed at the preparation of the Fontan circulation lead to the preparation of the pulmonary vascular bed and the preservation of ventricular function. The techniques applied in Fontan surgery affect the early and long-term complications and the survival of the patients. In our study, when we examined the patients who extracardiac conduit Fontan procedure for the non-cardiac route, we found that mortality and morbidity were minimal.

Tissue engineering: Relevance to neonatal congenital heart disease

Congenital heart disease (CHD) represents a large clinical burden, representing the most common cause of birth defect-related death in the newborn. The mainstay of treatment for CHD remains palliative surgery using prosthetic vascular grafts and valves. These devices have limited effectiveness in pediatric patients due to thrombosis, infection, limited endothelialization, and a lack of growth potential. Tissue engineering has shown promise in providing new solutions for pediatric CHD patients through the development of tissue engineered vascular grafts, heart patches, and heart valves. In this review, we examine the current surgical treatments for congenital heart disease and the research being conducted to create tissue engineered products for these patients. While much research remains to be done before tissue engineering becomes a mainstay of clinical treatment for CHD patients, developments have been progressing rapidly towards translation of tissue engineering devices to the clinic.

Global Leadership in Paediatric and Congenital Cardiac Care: "Coding our way to improved care: an interview with Rodney C. G. Franklin, MBBS, MD, FRCP, FRCPCH"

Dr Rodney Franklin is the focus of our third in a planned series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care." Dr Franklin was born in London, England, spending the early part of his childhood in the United States of America before coming back to England. He then attended University College London Medical School and University College Hospital in London, England, graduating in 1979. Dr Franklin would then go on to complete his general and neonatal paediatrics training in 1983 at Northwick Park Hospital and University College Hospital in London, England, followed by completing his paediatric cardiology training in 1989 at Great Ormond Street Hospital for Children in London, England. During this training, he additionally would hold the position of British Heart Foundation Junior Research Fellow from 1987 to 1989. Dr Franklin would then complete his training in 1990 as a Senior Registrar and subsequent Consultant in Paediatric and Fetal Cardiology at Wilhelmina Sick Children's Hospital in Utrecht, the Netherlands. He subsequently obtained his research doctorate at University of London in 1997, consisting of a retrospective audit of 428 infants with functionally univentricular hearts.Dr Franklin has spent his entire career as a Consultant Paediatric Cardiologist at the Royal Brompton & Harefield Hospital NHS Foundation Trust, being appointed in 1991. He additionally holds honorary Consultant Paediatric Cardiology positions at Hillingdon Hospital, Northwick Park Hospital, and Lister Hospital in the United Kingdom, and Honorary Senior Lecturer at Imperial College, London. He has been the Clinical Lead of the National Congenital Heart Disease Audit (2013-2020), which promotes data collection within specialist paediatric centres. Dr Franklin has been a leading figure in the efforts towards creating international, pan European, and national coding systems within the multidisciplinary field of congenital cardiac care. These initiatives include but are not limited to the development and maintenance of The International Paediatric & Congenital Cardiac Code and the related International Classification of Diseases 11th Revision for CHD and related acquired terms and definitions. This article presents our interview with Dr Franklin, an interview that covers his experience in developing these important coding systems and consensus nomenclature to both improve communication and the outcomes of patients. We additionally discuss his experience in the development and implementation of strategies to assess the quality of paediatric and congenital cardiac care and publicly report outcomes.

Effect of race on the timing of the Glenn and Fontan procedures for single-ventricle congenital heart disease

OBJECTIVE

Disparities in health care have been documented between different racial groups in the United States. We hypothesize that there will be racial variance in the timing of the Glenn and Fontan procedures for children with single-ventricle physiology.

DESIGN AND SETTING

We performed a retrospective review of a national pediatric intensive care unit database (Virtual PICU Performance System, LLC).

PATIENTS

Children with hypoplastic left heart syndrome, tricuspid atresia, and common ventricle, admitted from January 2006 to July 2008, were included. Data included race, weight, age, medical length of stay, Paediatric Index of Mortality 2 score, and survival.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 423 patients from 29 hospitals. The study population was 7.6% black, 13.0% Hispanic, 59.8% white, 9.2% "other," and 11.6% had missing racial/ethnic information. Diagnoses included 255 patients with hypoplastic left heart syndrome, 91 with tricuspid atresia, and 77 with common ventricle. The median age for the Glenn procedure (n = 205) was 5.5 months (interquartile range, 4.6-7.0 months) and 39.7 months (interquartile range, 32.4-50.6 months) for the Fontan procedure (n = 218). There was no difference between the median age at the time of the Glenn or Fontan procedures between the different racial/ethnic groups (p = .65 and p = .16, respectively). The medical length of intensive care unit stay for patients receiving the Glenn and Fontan procedures was 3.7 days (interquartile range, 1.9-6.1 days) and 3.7 days (interquartile range, 1.9-6.8 days), respectively. There were no differences in medical length of intensive care unit stay for the Glenn procedure between the different racial/ethnic groups (p = .21). Hispanic patients had a longer medical length of intensive care unit stay (6.3 days; interquartile range, 3.1-9.9 days) than white patients (2.9 days; interquartile range, 1.8-5.3 days) for the Fontan procedure (p = .008).

CONCLUSION

The timing of single-ventricle palliative procedures was not affected by race/ethnicity.

Survival and prognostic factors in patients with an absent atrioventricular connection

INTRODUCTION AND OBJECTIVES

To identify anatomical and functional characteristics associated with survival in adult patients with an absent atrioventricular connection and to highlight the diagnostic importance of echocardiography.

METHODS

The clinical histories and echocardiographic and hemodynamic test results of 24 patients were recorded.

RESULTS

Some 87.5% of patients were in New York Heart Association (NYHA) functional class I/II. In 92%, the ECG demonstrated sinus rhythm and left ventricular dilatation. Chest X-ray showed grade-II cardiomegaly in 83%. Situs solitus and an absent right atrioventricular connection were found on echocardiography in 92%. The ventriculoarterial connection was most frequently concordant (in 71%). All patients had an atrial septal defect, 21 had a ventricular septal defect and 21 had decreased pulmonary flow. The ejection fraction of the main ventricle in the whole patient group was 55% +/- 10%; 52% +/- 12% in those who did not undergo surgery and 58% +/- 8% in those who did (P=NS). Factors associated with poor survival were an ostium secundum atrial septal defect, hemoglobin <16 g/dL and a main ventricle ejection fraction <50%. Of the 54% of patients who underwent surgery, 85% are alive and the majority are in NYHA functional class I/II. Among those who did not, 82% are alive and 73% are in NYHA functional class I/II.

CONCLUSIONS

The presence of a wide atrial septal defect, a normal hemoglobin level and a normal main ventricle ejection fraction were associated with the survival of these patients into adulthood. Echocardiography can provide clinicians and surgeons with information that is valuable for selecting treatment and monitoring follow-up.

Pulmonary artery banding before the Damus-Kaye-Stansel procedure

Subaortic stenosis (SAS) in a single ventricle leads to myocardial hypertrophy and compromises Fontan results. Moreover, controversy exists concerning the optimal surgical strategy for relieving SAS. We have applied pulmonary artery banding (PAB) before the Damus-Kaye-Stansel procedure (DKS), and here we analyze factors that influence systemic ventricular compliance. Thirteen patients underwent PAB before DKS. Median PAB duration was 5.5 months (range, 20 days to 17.7 months). Procedures administered concomitantly with DKS were Blalock-Taussig shunt (n = 6), bidirectional cavopulmonary shunt (n = 5), and Fontan operation (n = 2). All survived and were doing well after a median follow-up 2.7 years. Cardiac catheterization before DKS showed that the mean pressure gradient across the systemic ventricular outflow tract and PAB were 20.6 +/- 10.1 and 67.4 +/- 10.2 mmHg, respectively. After DKS, systemic ventricular end diastolic pressure (SVEDP) was significantly correlated with PAB duration (r = 0.65, p = 0.022), but not with PAB or systemic ventricle outflow tract pressure gradients. After DKS, SVEDP decreased or fell to within the range in patients with PAB duration less than 7 months (p < 0.05). Seven patients had a successful Fontan operation, and 6 without risk factors are waiting operation. SVEDP was found to be correlated with PAB duration, and our findings indicate that short-term PAB can be considered a safe option in patients with a single ventricle and SAS.

Matching procedure to morphology improves outcomes in neonates with tricuspid atresia

OBJECTIVE

This study was undertaken to characterize morphologic substrate of tricuspid atresia with ventriculoarterial concordance and discriminate management strategies that lead to successful definitive repair.

METHODS

From 1999 to 2004, a total of 150 babies with type I tricuspid atresia were enrolled from first diagnosis at 26 institutions. Antegrade pulmonary blood flow was absent in 19%, restricted in 54%, and unrestricted in 28%. Competing-risk methodology determined the time-related prevalence and risk factors for death versus cavopulmonary anastomosis and subsequent death versus Fontan completion.

RESULTS

Overall 5-year survival was 86%. Initial palliation included systemic-pulmonary arterial shunt in 64%, pulmonary artery banding in 11%, and cavopulmonary anastomosis in 24%. Median age at cavopulmonary anastomosis was 6 months, with 83% undergoing bidirectional Glenn shunt and 17% undergoing hemi-Fontan procedure. By the age of 2 years, 89% had cavopulmonary anastomosis, 6% were dead, and 4% remained alive without cavopulmonary anastomosis. Risk factors for death without cavopulmonary anastomosis included presence of mitral regurgitation (P = .03) and palliation with systemic-pulmonary arterial shunts not originating from the innominate artery (P = .04). Factors associated with decreased transition rate to cavopulmonary connection included patient variables (younger admission age to a participating institution, noncardiac anomalies) and procedural variables (larger systemic-pulmonary arterial shunt diameter, previous palliation). Of patients undergoing cavopulmonary anastomosis, 75% had undergone a Fontan operation within 3 years.

CONCLUSION

Smaller shunt size and decreased pulmonary blood flow decrease mortality after initial palliation and increase the rate of successful transition to cavopulmonary anastomosis. Outcomes can be improved by placing smaller shunts from the innominate artery, especially in patients with any mitral regurgitation.

Designing therapeutic strategies for patients with a dominant left ventricle, discordant ventriculo-arterial connections, and unobstructed flow of blood to the lungs

The palliation of the cyanotic child with a dominant morphologically left ventricle, discordant ventriculo-arterial connections, and obstruction to the pulmonary outflow tract has continued to evolve and mature. The evolution began in the early days of surgical palliation with the Blalock-Taussig shunt, extended to construction of cavopulmonary shunts, if required, and then to the Fontan procedure and its subsequent modifications. This journey took nearly 30 years to complete. There is increasing clinical data to document the beneficial effects of this approach, with ever-improving outcomes. Some aspects of the history of the cavopulmonary shunt have been previously reviewed in this journal and elsewhere, as have analysis of outcomes for some groups of patients considered for surgical completion of the Fontan circulation. While there has been some ongoing interest in ventricular septation since the early success of Sakakibara et al., this approach has largely been abandoned. Considerably more challenges and debate resonate in the surgical algorithms defined for patients whose hearts are characterized by a dominant left ventricle, discordant ventriculo-arterial connections, and unobstructed flow of blood to the lungs. This latter group will be the focus of this review, as will the aetiology of the myocardial hypertrophy that is particularly frequent in this group of patients, its clinical recognition, indeed its anticipation, and the multiple surgical strategies designed to prevent or treat it. All these manoeuvres are considered to optimise suitability for, and outcome from, creation of the Fontan circulation.

Outcomes of tricuspid atresia in the Fontan era

BACKGROUND

Whereas indications expand and results improve with increasing refinements to the Fontan procedure the overall impact on outcomes related to tricuspid atresia remains suboptimally defined.

METHODS

We reviewed 225 consecutive patients presenting between 1971 and 1999. All patients had classic tricuspid atresia with absent right atrioventricular connection and with D-transposition of the great arteries in 21%, pulmonary outflow obstruction in 75%, and aortic outflow obstruction in 11%.

RESULTS

Ten patients died before any intervention and 3 patients were lost to follow-up. Palliative procedures (includes 151 with systemic shunt, 27 pulmonary artery banding, 60 venous shunt) were performed in 203 patients, with 44 deaths, 8 patients awaiting Fontan, 12 patients Fontan contraindicated, and 11 patients lost-to-follow-up. A total of 137 patients had the Fontan procedure (9 patients without previous procedures) with 7 early deaths, 11 late deaths, and 3 patients progressing to heart transplantation. Total survival for the cohort was 90% at the age of 1 month, 81% at 1 year, 70% at 10 years, and 60% at 20 years with no significant change over the time period. Independent factors associated with ineligibility or death without Fontan (n = 68, 30%) included earlier birth date, lower birth weight, presence of aortic arch anomaly and greater right ventricular hypoplasia, and no palliative procedure. There were no significant changes in mortality with Fontan over the study time period with survival of 95% at 1 month, 93% at 1year, and 82% at 10 years.

CONCLUSIONS

Improvements in outcomes with tricuspid atresia will require attention to management and risk factors before Fontan.

Effects of therapeutic beta blockade on myocardial function and cardiac remodelling in congenital cardiac disease

BACKGROUND

Cardiac remodelling is now recognised as an important aspect of cardiovascular disease progression and is, therefore, emerging as a therapeutic target in cardiac failure due to different etiologies. Little is known about the influence of different therapies for cardiac failure on the remodelling seen in infants with congenital cardiac disease.

METHODS

During follow-up of a prospective and randomized trial, we investigated therapeutic effects on neurohormonal activation, ventricular function, and myocardial gene expression. We compared the data from 8 infants with severe congestive heart failure due to left-to-right shunts, who received digoxin and diuretics alone, to 9 infants who received additional treatment with propranolol.

RESULTS

In these infants, beta-adrenergic blockade significantly reduced highly elevated levels of renin, from 284 +/- 319 microU/ml compared to 1061 +/- 769 microU/ml. Systolic ventricular function was normal in both groups, but diastolic ventricular function was improved in those receiving propranolol, indicated by significantly lower left atrial pressures, lower end-diastolic pressures, and less pronounced ventricular hypertrophy, the latter estimated by lower ratios of myocardial wall to ventricular cavity areas on average of 42%. Further hemodynamic parameters showed no significant differences between the groups, except for the lower heart rate in infants treated with propranolol. In those treated with digoxin and diuretics, there was a significant downregulation of beta2-receptor and angiotensin-2 receptor genes, and up-regulation of endothelin A receptor and connective tissue growth factor genes, that were partially prevented by additional treatment with propranolol.

CONCLUSIONS

Beta-blockade is a new therapeutic approach for congestive heart failure in infants with congenital cardiac disease, producing with significant benefits on neurohormonal activation, diastolic ventricular function, and cardiac remodelling.

Nonobstructive ASD creation to qualify patients for the Fontan operation: effects on pulmonary hypertension due to restrictive left atrioventricular valve and interatrial communication

Pulmonary hypertension (PH) due to elevated left atrial pressure (LAp) caused by restrictive left atrioventricular valve and interatrial communication sometimes precludes patients with univentricular heart from undergoing the Fontan operation. We have created atrial septal defect (ASD) for such patients to reduce LAp and then pulmonary arterial pressure (PAp) and pulmonary vascular resistance (Rp) in an attempt to qualify the patients for the Fontan repair. This study was performed to clarify the efficacy and limitation of this approach. Twelve patients with PH (mean PAp > 20 mm Hg and/or Rp > 3.0 Wood's unit/m(2)) due to obstruction at the LA exit underwent ASD creation at the age of 4.0 +/- 4.0 (mean +/- SD) years. Follow-up catheterization 14.9 +/- 15.6 months after the ASD creation demonstrated marked reductions in mean LAp (from 21 +/- 5 to 8 +/- 2 mm Hg), mean PAp (from 39 +/- 13 to 17 +/- 4 mm Hg), and Rp (from 6.2 +/- 4.5 to 2.7 +/- 1.4 Wood's unit/m(2)) compared with those before the procedure (all P < 0.0001). Seven of the 12 patients (58%) qualified for the Fontan operation (mean PAp < 20 mm Hg, Rp < 3.0 Wood's unit/m(2), and Nakata's PA index > or = 250) after the ASD creation. Final surgical outcomes of the seven patients included successful Fontan operation in five and biventricular repair in two. Patients with severe PH [mean PAp > or = 45 mm Hg (n = 6) or Rp > or = 4.5 Wood's unit/m(2) (n = 5)] before the ASD creation qualified less frequently for the Fontan repair than those with mild PH [mean PAp < 45 mm Hg (n = 6; 17% vs. 100%; P = 0.008) or Rp < 4.5 Wood's unit/m(2) (n = 7; 20 vs. 86%; P = 0.045)]. Patients with PA banded after 6 months of age (n = 3) qualified less frequently for the Fontan operation than those banded before 6 months of age (n = 6; 0 vs. 83%; P = 0.048). These data suggest that ASD creation is an effective approach to qualify patients for the Fontan operation in the presence of restrictive left atrioventricular valve and interatrial obstruction, except those with longstanding severe PH following delayed PA banding.

Sudden death in patients with right isomerism (asplenism) after palliation

OBJECTIVE

To define the risk of sudden death in patients with right isomerism (asplenia) after palliation.

STUDY DESIGN

A total of 154 patients with right isomerism was identified from 1980 to 1999. Sudden death was defined as acute cardiovascular collapse from which death occurred within 24 hours.

RESULTS

A total of 620 patient-years were evaluated. The 1-year and 5-year survival was 72% and 50%, respectively. There were 22 sudden unexpected deaths (14%, 35 events/1000 patient-years). Sudden death tended to occur in infancy or early childhood (12 +/- 9 months; median, 9 months). The mechanisms were classified as sudden tachyarrhythmic in 2 (9%), sudden cardiac but nontachyarrrhythmic (sudden onset severe cyanosis) in 15 (68%), and sudden noncardiac in 5 (23%)(fulminant sepsis with positive blood culture: streptococcus pneumonia (3), Escherichia coli (1), and yeast-like organism (1)). The incidence of sudden death steadily decreased with age until the age of 3 years.

CONCLUSION

The incidence of sudden death in patients with right isomerism after initial palliation remained high. Sudden death was related to complex cardiac anomalies, a susceptibility to fulminant infection, and arrhythmia.

Single ventricle with systemic obstruction in early life: comparison of initial pulmonary artery banding versus the Norwood operation

OBJECTIVES

The outcomes of initial pulmonary artery banding (PAB)+/-coarctation repair are compared with the Norwood operation in newborns with single ventricle (SV) and systemic obstruction (SO).

METHODS

Between January 1987 and July 2000, 22 patients (median age, 12 days) with SV and aortic arch obstruction (AAO), subaortic stenosis (SAS), or both underwent surgery. Two initial surgical approaches were used: PAB+/-coarctation repair (group I, seven patients); Norwood type operation (group II, 15 patients).

RESULTS

The overall mortality was 32% (seven of 22 patients). There was no late mortality. The mortality in group I was 43% versus 27% in group II. Recently, there has been no mortality following the Norwood operation in the last eight patients operated since 1995. Of the survivors, nine patients have undergone the Fontan operation and four patients have had the bidirectional Glenn (BDG) with no deaths. There was one repair of supravalvar aortic stenosis at the time of BDG in group II as opposed to eight reinterventions for SAS and/or AAO in four patients in group I (P=0.01).

CONCLUSIONS

PAB+/-coarctation repair for SV and SO is associated with a high mortality and a high reoperation rate for SAS or recurrent AAO. Although the Norwood operation was also associated with a high mortality early on, it can now be performed with excellent outcome. This improvement, combined with a low reintervention rate for SAS or AAO, suggests that the Norwood operation is likely to emerge as the procedure of choice for SV and SO.

The Fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients

OBJECTIVES

We assessed the operative and late mortality and the present clinical status of 216 patients with tricuspid atresia who had a nonfenestrated Fontan procedure performed at the Mayo Clinic in the 25-year period 1973 to 1998.

BACKGROUND

The Fontan operation eliminates the systemic hypoxemia and ventricular volume overload characteristic of prior forms of palliation. However, it originally did so at the cost of systemic venous and right atrial hypertension, and the long-term effects of this "price" were unknown when the procedure was initially proposed.

METHODS

We reviewed the clinical records of the 216 patients retrospectively. These were arbitrarily grouped into early (1973 through 1980), middle (1981 through 1987) and late (1988 through 1997) surgical eras. Patient outcome was also analyzed according to age at surgery. Operative and late mortality rates were determined and present clinical status was ascertained in 167 of 171 surviving patients.

RESULTS

Overall survival was 79%. Operative mortality steadily declined and was 2% (one of 58 patients) during the most recent decade. Late survival also continues to improve. Age at operation had no effect on operative mortality, and late mortality was significantly increased only in patients who were operated on at age 18 years or older. Eighty-nine percent of surviving patients are currently in New York Heart Association class I or II.

CONCLUSIONS

The initial 25-year experience with the nonfenestrated Fontan procedure for tricuspid atresia has been gratifying, with most survivors now leading lives of good quality into adulthood. These results justify continued application of this procedure for children born with tricuspid atresia.

Treatment and outcome of serious structural congenital heart disease

Serious structural congenital heart disease usually presents to the neonatal paediatrician, although increasingly these conditions are being diagnosed before birth. It is, therefore, important that those dealing with these fetuses and infants have some knowledge of their natural and modified history. The vast majority of lesions can either be corrected or given symptomatic palliation and this review discusses treatment options and provides up-to-date outcome information to enable fetal and neonatal staff to anticipate and to complement information given to families by paediatric cardiologists.

Absorbable pulmonary artery banding in tricuspid atresia

A child with tricuspid atresia, concordant ventriculoarterial connections, large ventricular septal defect, and elevated pulmonary artery pressure underwent pulmonary artery banding with a polydioxanone ribbon. This procedure was successful in this patient as the ventricular septal defect became restrictive while the banding was fully absorbed after 5 months. This technique could be included in the panel of surgical strategies for patients with single ventricle physiology and potential but insufficient subpulmonary stenosis in early infancy.

Effectiveness of low dose captopril versus propranolol therapy in infants with severe congestive failure due to left-to-right shunts

To evaluate the therapeutical effects of the angiotensin converting enzyme inhibitor Captopril to the beta-blocker Propranolol in infants with congestive failure due to pulmonary overcirculation, we retrospectively analysed clinical, neurohormonal and hemodynamic data in 22 infants, 11 of whom were treated with Captopril (Group 1), 11 with Propranolol (Group 2). Age, weight, number of palliative operations, plasma renin activities and pulmonary to systemic flow ratios (3.5 vs. 3.5) were not significantly different prior to Captopril or Propranolol therapy. If treatment with digoxin and diuretics did not succeed, the infants were additionally treated with Captopril (1 mg/kg) for a mean of 7.4 months, or with 1.9 mg/kg Propranolol for 9.2 months.

RESULTS

1 mg/kg Captopril did not effectively suppress angiotensin converting enzyme in the steady state at trough level (92+/-52 vs. 87+/-50 nmol/min/ml). In the Propranolol group, the clinical heart failure score (2.6+/-1.5 vs. 7. 4+/-2.5) and plasma renin activities (14+/-10 vs. 101+/-70 ng/ml/h) were significantly lower, compared to the Captopril group. Length of hospital stay (23+/-9 vs. 52+/-24 days) was lower and weight gain (126+/-38 vs. 86+/-84 g/week) was higher within 3 months after starting Propranolol therapy. Significantly lower left atrial pressures (6.2+/-2.2 vs. 13.4+/-9.2 mmHg) and lower endiastolic ventricular pressures (7.6+/-2.5 vs. 12.6+/-4.0 mmHg) during pre-operative cardiac catheterization indicated a better diastolic ventricular function under chronic Propranolol treatment.

CONCLUSION

Although high dose Captopril was not evaluated in this study, when compared to patients on low Captopril dosages, infants who received Propranolol treatment showed improvement in heart failure scores, shorter lengths of hospital stay, lower plasma renin activities and better diastolic ventricular functions.

Subaortic obstruction and the Fontan operation

Systemic outflow tract obstruction in the heart with a functional single ventricle promotes myocardial hypertrophy, and this has been shown to be an unequivocal risk factor for poor outcome at Fontan procedure. Such systemic outflow tract obstruction may be congenital or acquired. Those factors contributing to acquired systemic outflow tract obstruction in those patients with a double-inlet left ventricle, a rudimentary right ventricle, and a discordant ventriculoarterial connection include the size of the ventricular septal defect, previous pulmonary artery banding, and other volume unloading surgical procedures. Staging with a bidirectional cavopulmonary connection and construction of a proximal pulmonary artery-aortic connection or ventricular septal defect enlargement has neutralized this factor.

Beta-blocker therapy of severe congestive heart failure in infants with left to right shunts

We report on the clinical and neurohumoral effects of adding low-dose propranolol to conventional therapy with digoxin and diuretics in 6 infants with severe congestive heart failure due to large left-to-right shunts. A significant decrease in heart failure scores and a decrease of the highly activated renin-angiotensin-1 aldosterone system by approximately 70% strongly suggests a beneficial effect of this new therapeutic approach.

A congenitally "poor" pulmonary artery is a major reason for exclusion from Fontan operation

We reviewed the clinical records of 185 patients who were possible candidates for Fontan operation. We did this to clarify whether all patients with suitable anomalies ultimately underwent a Fontan operation. Of the 152 patients with decreased pulmonary blood flow, 38 (26%) did not fulfill the criteria for Fontan operation, and 17 of the 33 patients (52%) with increased pulmonary blood flow (P < 0.01) were excluded as candidates. Of 48 non-candidate survivors, 19 had high pulmonary artery (PA) pressure or resistance and small PA (which we term "poor PA"), 17 had pulmonary hypertension, 6 had a markedly distorted PA, and 6 had severe ventricular dysfunction. A significant proportion of possible candidates with a suitable anomaly ultimately did not undergo a Fontan operation, because of "poor PA", a congenital condition that precluded Fontan operation.

Factors influencing survival in patients undergoing the bidirectional Glenn anastomosis

The bidirectional Glenn anastomosis (BGA) has long been used as a surgical intervention for patients with single ventricle physiology. Initially, this procedure was the final stage in palliation and was performed in older children. Eventually, as the Fontan procedure came to be used as a method to separate circulations, the Glenn procedure was performed as an intermediate step. Over time, the BGA was performed as an alternative for patients who were considered to be at high risk with the Fontan procedure. Between January 1, 1988, and January 1, 1994, 129 patients underwent BGA at the University of California-Los Angeles. These patients were reviewed retrospectively, including clinic visits, catheterization, and echocardiographic information. The overall survival rate was 87% (112 of 129 patients). The average length of follow-up was 27 months. This information was then analyzed by univariate and multivariate analysis. Several factors were related to failure in patients who underwent BGA including pulmonary artery pressure, systemic right ventricle, and presence of anomolous pulmonary venous drainage and heterotaxy syndrome.