Hybrid pediatric cardiac surgery

Minimally invasive strategies can be expanded by combining standard surgical and interventional techniques. We performed a longitudinal prospective study of all pediatric patients who have undergone hybrid cardiac surgery at the University of Chicago Children's Hospital. Hybrid cardiac surgery was defined as combined catheter-based and surgical interventions in either one setting or in a planned sequential fashion within 24 hours. Between June 2000 and June 2003, 25 patients were treated with hybrid approaches. Seventeen patients with muscular ventricular septal defects (mVSDs) (mean age, 4 months; range, 2 weeks-4 years) underwent either sequential Amplatzer device closure in the catheterization laboratory followed by surgical completion (group 1A, n = 9) or one-stage intraoperative off-pump device closure (group IB, n = 8) with subsequent repair of any concomitant heart lesions. Eight patients with branch pulmonary artery (PA) stenoses (group 2) underwent intraoperative PA stenting or stent balloon dilatation along with concomitant surgical procedures. All patients survived hospitalization. Complications from the hybrid approach were mostly confined to groups 1A and 2. At a mean follow-up of 18 months, 2 group 1A patients died suddenly several months after discharge. All other patients are doing well. Hybrid pediatric cardiac surgery performed in tandem by surgeons and cardiologists is safe and effective in reducing or eliminating cardiopulmonary bypass. Patients with mVSDs who are small, have poor vascular access, or have concomitant cardiac lesions are currently treated in one setting with the perventricular approach.

Intracardiac lymphoma in a child: successful treatment with chemotherapy alone

A 5-year-old female child with history of non-Hodgkin's lymphoma presented with cough and palpitation. On physical examination a cardiac tumor plop was heard. Paroxysmal supraventricular tachycardia was noted on the electrocardiogram. Transthoracic echocardiogram revealed multiple large tumor masses within the right and the left atrium. The right atrial tumor was flopping back and forth at the tricuspid valve orifice. The tumor resolved completely with chemotherapy without any surgical intervention.

Congestive heart failure caused by Wilms' tumor

A 2-year-old child with unilateral Wilms' tumor presented with congestive heart failure (CHF). The heart failure was secondary to severe hypertension from hyperreninemia. After surgical removal of the tumor the CHF disappeared. This case is the first one reported of a child presenting with CHF due to unilateral Wilms' tumor.

Congenital complete heart block

Congenital complete heart block in utero has become diagnosed more frequently with the clinical use of fetal echocardiography. The fetus with complete heart block may remain asymptomatic or may develop congestive heart failure. Congenital complete heart block is more frequently seen in infants of mothers with systemic lupus erythematosus, both clinically manifested and subclinical systemic lupus erythematosus with positive antibodies (SS-A and SS-B antibodies). At birth, the neonate with complete heart block may remain asymptomatic and may not require a pacemaker to increase the heart rate. The indications for a pacemaker in neonates with complete heart block have been discussed. Both in-utero and neonatal management of congenital complete heart block are discussed to manage congestive heart failure in a fetus. Four patients with congenital complete heart block are presented covering a broad spectrum of clinical presentation, diagnosis, and management both in the fetal and neonatal period.

Spontaneous acquisition of discontinuous pulmonary arteries

BACKGROUND

Discontinuous pulmonary arteries have been considered a rare complication of systemic-to-pulmonary shunt operations. We report a series of children who spontaneously acquired pulmonary artery discontinuity.

METHODS

All children from 1989 through 1995 with congenital pulmonary atresia were reviewed.

RESULTS

Pulmonary artery discontinuity developed in 29% (15 patients), none related to shunt operation. In 6 of 15 patients, the neonatal angiogram showed a pattern that seemed to predict subsequent discontinuity; in 9 of 15, pulmonary arteriography was normal at birth. Two clinical patterns were identified: an early rapid acquisition of discontinuity within hours to days, and a delayed, more subtle development that occurred over months. Eight of 15 have died. Pathologic studies in 6 children showed ductal tissue extending along and into the pulmonary artery wall as well as intimal hypertrophic reaction and maladaptive remodeling.

CONCLUSIONS

Children with congenital pulmonary atresia may experience spontaneous acquisition of pulmonary artery discontinuity. Ductal tissue is responsible for local pulmonary artery distortion and discontinuity; this may be exacerbated by previous prostaglandin E1 administration. Clinical algorithms are suggested for patients with pulmonary atresia.

Tricuspid valve closure in pulmonary atresia and important RV-to-coronary artery connections

Mortality is high for children with pulmonary atresia, intact ventricular septum, and important connections between the right ventricle and the coronary arteries because of myocardial ischemia: in systole, suprasystemic right ventricular pressure delivers deoxygenated blood to the coronary artery (or arteries) and in diastole, the right ventricle provides a lower resistance alternative to coronary perfusion of the myocardium. Tricuspid valve closure was performed in 10 such children. None had stenosis of native coronary arteries. A trial of tricuspid valve closure (by balloon) was performed in the cardiac catheterization laboratory in 5 of 10 patients. Seven of 10 children survived surgical closure of the tricuspid valve plus concurrent procedures; none had heart block. Two of the 3 nonsurvivors were probably in inoperable condition due to preoperative myocardial ischemia. Before operation, 4 patients had ischemic changes on electrocardiograms; these changes were abolished after operation. Three of 10 patients have had a Fontan operation with 2 survivors. We conclude that children with pulmonary atresia, intact ventricular septum, important connections between the right ventricle and the coronary arteries, and normal native coronary arteries should have surgical closure of the tricuspid valve within the first year of life and treated thereafter as patients with "tricuspid atresia."

Aortic origin of the RPA: immediate resolution of severe pulmonary artery hypertension by surgical repair

Aortic origin of the right pulmonary artery (AORPA) is a rare condition requiring a high index of suspicion for diagnosis as the usual signs of structural heart disease are often absent. Ultrasound examination can strongly suggest the condition but can easily be misinterpreted. Infants should be considered "operable" even when the resistance calculations predict otherwise as there appears to be a large component of immediately reversible pulmonary artery hypertension. With technical skills learned from arterial switch operations (for transposition of the great arteries), surgical repositioning of the RPA should be possible in nearly all cases without the use of a tube graft.

Why does a child with a normal heart undergo cardiac catheterization?

Children who have no heart disease at cardiac catheterization have usually been referred because of signs or symptoms on the background of a basal flow murmur. The ECG and chest x-ray are sometimes spurious and may lead to catheterization. Advances in noninvasive testing are helping to screen this population. Only in rare instances should the risks involved with catheterization be taken in a child with a basal flow murmur and no other evidence of heart disease.