Institutional experience with a protocol of early primary repair of double-outlet right ventricle

BACKGROUND

Our institution has adopted a protocol of primary repair for all patients with double-outlet right ventricle.

METHODS

Since May 1989, 24 consecutive neonates and infants with double-outlet right ventricle and atrioventricular concordance (median age, 4 months) underwent anatomic biventricular repair. One patient (4%) received prior pulmonary artery banding but was still repaired as a neonate at 22 days of age. Twelve patients had a subaortic ventricular septal defect (VSD), 5 patients a subpulmonary VSD, 3 patients doubly committed VSD, and 4 patients a noncommitted VSD. Sixty-nine of 72 associated lesions were repaired simultaneously. Four types of repairs were used: intraventricular rerouting in 16 patients, arterial switch operation with VSD closure into the pulmonary artery in 4 patients, Rastelli-type repair with extracardiac conduit in 3 patients, and the Damus-Kaye-Stansel repair with concomitant repair of aortic arch obstruction in 1 patient. Ventricular septal defect enlargement was necessary in 15 patients. Repair of subpulmonary stenosis and of subaortic stenosis was carried out in 13 and 4 patients, respectively. Three patients underwent simultaneous repair of aortic arch obstruction with no mortality. Two of the patients with noncommitted VSD had simultaneous repair of complete atrioventricular canal and repair of severe pulmonary venous obstruction.

RESULTS

The perioperative mortality was 8% (2 patients, and there was one late death (4%). Two patients (9%) underwent early successful reoperations (5 and 8 weeks postoperatively). The two reoperations were for residual VSD (1 patient) and severe mitral regurgitation (1 patient). All 21 survivors are alive at a mean follow-up of 40 months (range, 7 months to 6 years). The estimated 5-year actuarial survival is 88%, with no deaths after 2 months postoperatively. Ninety-five percent of long-term survivors have no restriction of physical activities because of cardiac status and are receiving no cardiac medications.

CONCLUSIONS

An institutional protocol of early anatomic biventricular repair of double-outlet right ventricle in infants and neonates achieves excellent survival, making palliative operations unnecessary. Associated lesions should be repaired simultaneously. The complexity of these malformations requires a highly individualized and flexible surgical approach.

Atrial myxomas in young children: an alternative surgical approach

A case report and a brief review of the literature on atrial myxomas in young children (5 years and younger) are presented. Right atrial myxomas are predominant in this age group in contrast to older children and adults. The echocardiogram alone can provide clear anatomic information for the operation. For large left atrial myxomas, wide exposure through a transverse biatrial incision is recommended to avoid tumor manipulation and facilitate en bloc resection.

Pericardial effusion after cardiac surgery in children and effects of aspirin for prevention

Seventy-four children aged 0.3 to 21.4 years (median 4.0) were followed echocardiographically on days 4, 7, 14 and 28 (+/- 2 days) after cardiac surgery to evaluate the incidence of postoperative pericardial effusion, to identify the patients at greatest risk of developing an effusion and to evaluate the use of aspirin as prophylaxis against pericardial effusion. Pericardial effusion was graded relative to the size of the aortic root from grade 0 (no effusion) to grade 5 (larger than the aortic root dimension). Patients were randomly divided into 2 groups: group 1 (32 patients) received aspirin 60 mg/kg/day for 7 days starting on the third postoperative day; group 2 (42 patients) received no aspirin. Forty-eight patients (65%) developed an effusion during the study period, 3 required pericardiocentesis and 1 died of tamponade. All patients with tamponade had a grade 4 effusion. Age or type of operation did not alter the cumulative incidence of significant effusion. No patient with a grade 0 effusion on the first echocardiogram developed a grade 4 or 5 effusion. Results in groups 1 and 2 were similar. Pericardial effusions are common in the first month after cardiac surgery. Patients with no effusion in the immediate postoperative period appear to be at lesser risk of developing a grade 4 effusion in the first month after operation. Finally, aspirin prophylaxis against postoperative pericardial effusions did not significantly alter the outcome in this small series of patients.

Transseptal catheterization of the left heart in infants and children: experience in a small volume catheterization laboratory

During a five-and-one-half year period, the transseptal technique was used for left heart catheterization in 37 patients with a variety of congenital heart disease. The age of the patients ranged from four months to 21 years and weights ranged from 6.6 to 65 kg. Access to the left heart cavities and ascending aorta was achieved in all but two patients. There were no complications. Even when used infrequently, the transseptal technique allows rapid and safe entry to the left heart cavities in infants and children.

Congenital valvular aortic stenosis: surgical management and long-term results

Case histories of 50 consecutive infants and children ith congenital valvular aortic stenosis treated at The Montreal Children's Hospital during the past 16 years were reviewed in order to determine the efficacy of the initial treatment as well as the long-term results. The operative technique employed was to incise fused commissures out almost to the anulus without causing aortic insufficiency, but often the accomplishment was limited by valve anatomy or cusp dysplasia. Six of the seven operative deaths occurred in infants. Eight to 16 year follow-up on the first 25 survivors revealed one late death, four "good" results, five aortic valve replacements, and three second valvotomies. Ten patients have recurrent aortic stenosis and two have moderate aortic insufficiency. Aortic valvotomy is a palliative operation, and about a third of the children operated upon will require a second operation within 10 years.

Prognosis of right bundle branch block and left anterior hemiblock after intracardiac repair of tetralogy of Fallot

One hundred and forty-one survivors of intracardiac repair of tetralogy of Fallot (TOF), operated on between 1958 and 1972, were studied in order to document the incidence of right bundle branch block and left anterior hemiblock (RBBB and LAH) and to definite the late prognosis. RBBB and LAH occurred in 31 patients (22 per cent), all of whom have had complete follow-up. Transient complete heart block (CHB) occurred postoperatively in 2 patients; there were no other significant arrhythmias. Two late deaths have occurred, neither from arrhythmia (one from progressive congestive heart failure, and the other from attempted reclosure of a ventricular septal defect). The remainder of the patients are well an average of 76 months postoperatively (range, 144 to 12 months). The absence of late-onset CHB or sudden death in this series contrasts with the relatively high incidence of these events in some studies of RBBB and LAH after intracardiac repair of TOF. However, in those reports a history of transient postoperative CHB (indicative of trifascicular disease in this setting) can be found in 75 per cent of those who developed late-onset CHB or died suddenly. We conclude that the occurrence of RBBB and LAH after intracardiac repair of TOF does not of itself carry a bad late prognosis. The critical factor in a bad late prognosis in patients with ECG evidence of RBBB and LAH may be with ECG evidence of RBBB and LAH may be the history of transient postoperative CHB.