[Interrupted aortic arch with aortopulmonary window. Total primary correction without extracorporeal circulation in the newborn]

This report describes the unusual association between the interruption of the aortic arch type B and aortopulmonary window type II in a neonate. When the patient was 20 days old, a one-stage surgical repair was done through left side thoracotomy without circulatory by-pass, making a left carotid artery to descending aorta anastomosis, closing the window with a hemaclip, respectively. A routine 2-D Doppler color echocardiography performed in the immediate postoperative period showed the absence of blood flow in the right pulmonary artery. The patient required a new intervention, changing the position of the clip in order to restore the normal pulmonary blood flow. Eight months after surgery, the "neoaortic arch" grows in harmony with the body surface area, without signs of cerebral circulatory deficiency or significant gradient at any level.

[The role of the stent in non-coronary cardiopathies]

INTRODUCTION

The stent has demonstrated to be a useful device in the prevention of postangioplasty coronary restenosis and it is expected to have a favourable effect as an alternative or complementary treatment of stenotic lesions in arteries or veins associated with congenital defects. The aim of this study is to analyze our experience in this setting.

MATERIAL AND METHODS

From February 1992 to March 1996, 28 stenting procedures were performed in 26 patients (mean age: 8.6 +/- 0.7 years; mean weight: 26.2 +/- 3 kg). In 12 patients, stenting was single, and a iliac Palmaz stents were always used. Stenting location was: pulmonary artery branches in 17 patients, right ventricular outflow in 2 patients, in the junction of right atrium with pulmonary artery in 2 patients, systemic veins in 2 patients and in post Mustard intratrial channel stenosis in 2 patients. 25 patients had previously undergone at least one surgical procedure.

RESULTS

The stenotic diameter of the treated lesions increased significantly after the procedure (4.4 +/- 0.3 mm before stenting vs 11.6 +/- 0.3 mm after stenting, p < 0.0001) and the transtenotic gradient decreased from 38.1 +/- 5 to 12 +/- 3.8 mmHg. Those changes were associated with a diminution of right ventricular pressure (81.6 +/- 3 vs 56.7 +/- 6 mmHg, p < 0.0001) in patients with pulmonary branch stenosis without septal defects. There was no mortality among the percutaneously treated patients and only one patient needed surgery. Nevertheless, one patient died after bilateral intraoperative stenting.

CONCLUSION

The treatment of proximal or distal stenotic lesions in the pulmonary tree, systemic veins, and obstructed intraatrial channels with stents, can replace or complement conventional balloon angioplasty. It also offers a useful and effective alternative to surgery, when it is impossible or carries a risk.

[Complete atrioventricular canal and tetralogy of Fallot: surgical considerations]

Nine patients with complete atrioventricular canal and tetralogy of Fallot underwent intracardiac repair of both anomalies between 1982 and 1989. The ages of the patients ranged from 6 months to 7 years. Six of the 9 had one or more previous systemic-pulmonary artery shunts. Two-dimensional echocardiography showed diagnostic characteristics of both malformations in all patients. The diagnosis was confirmed by cardiac catheterization and cineangiography. The ventricular septal defect was repaired by a combined right atrial and ventricular approach in every patient. Outflow tract reconstruction was performed with the use of a transannular patch (4), infundibular patch (4), and a valved conduit (1). There were no hospital deaths. Meningitis was responsible for the death of a patient 2 years after repair. We recommend early palliation, complete repair in those older than 4 or 5 years, surgical technique depending on the anatomical findings, combined atrial and ventricular approach, 2 separate patches to close the ventricular septal defect in required cases, adjusted correction of the right ventricular outflow tract, and careful postoperative care.

Complete atrioventricular canal and tetralogy of Fallot: surgical management

Between 1982 and 1989, nine patients with complete atrioventricular (AV) canal and tetralogy of Fallot underwent successful repair of both anomalies. Seven patients had Down's syndrome. One or more previous palliative shunts had been used in six patients. Associated cardiovascular lesions included persistent left superior vena cava (two patients), patent ductus arteriosus with marked stenosis of the left pulmonary artery (one patient). The diagnosis was confirmed by cardiac catheterization and cineangiography. Closure of the ventricular septal defect was performed through a combined right atrial and ventricular approach in each patient. The right ventricular outflow obstruction was relieved with the use of a transannular patch (4), right ventricular infundibular patch (4) or a valved external conduit (1). There were no hospital deaths. One patient died as a result of meningitis 2 years after repair. Progressive left AV valve incompetence developed in one patient requiring valve replacement. A single atrial approach may not provide the best exposure of the subaortic end of the defect. In this regard, we recommend an additional right ventriculotomy in order to ensure safe closure of the septal defect. Although an adequately shaped isolated patch could be sufficient to close the anterior VSD, we favour a separate patch to minimize the possibility of producing subaortic obstruction. A further method to avoid this subaortic stenosis consists of dividing the common anterior leaflet to the right towards the lateral extent of the infundibular septum.

[Systemic-pulmonary fistula. Percentage of children attaining corrective surgery]

Because of the lack of information on definitive long term results of the systemic pulmonary fistulae (SPF) we decided to review our experience. From 1978/1980, SPF was carried out on 91 children with a minimal follow-up period of 53 months, 80 (88%) survive the immediate postoperative period, 65 (71%) the late period, although only 48 (53%) reached corrective surgery. 14 (50%) of the 28 newborn children died and only 9 (32%) had corrective surgery. 12 (19%) of the 63 children of two months or older died and 39 (62 por 100) had definitive surgery. 72% with Fallot syndrome, 58% with TGA and pulmonary stenosis and less than 40% of other pathologies also reached definitive corrective surgery. Frequently the SPF is the only alternative to achieve total correction although there may be a high mortality and morbidity rate. The age (newborn children) and the complex pathology are unfavourable in the end results.

[Surgical management of aortic coarctation in the newborn infant]

Between 1978 and 1983, 35 neonates with coarctation of the aorta (from a group of 200 cases with the same pathology) underwent coarctation relief. Indications for operation were persistent heart failure and/or hypertension. Three surgical techniques were employed: Aortoplasty with prosthetic patch (politetrafluoroethylen) in 23 cases. Repair with subclavian flap in 11 cases, and resection of coarctate segment with and-to-end anastomosis in only one case. It is an important fact the high incidence of congenital cardiac malformations associated with coarctation of the aorta in neonates. There were 8 deaths (six of them with associated cardiac malformations, and other with miocardiophaty). There were 8 late deaths and 5 cases with restenosis, and no hypertension cases. All others are well in the follow-up. Some of them are waiting for definitive correction of their major cardiac malformation. The high risk of mortality in this group, mark again the importance of adequate medical treatment previous to surgical correction in optimal conditions and as early as possible.

Tetralogy of Fallot associated with total anomalous pulmonary venous drainage

We present a case of tetralogy of Fallot associated with total anomalous pulmonary venous return, with successful surgical correction. This association presents problems as regards surgical indications and technique.

[Aortic coarctation in childhood. Surgical experience in 120 cases]

112 cases of coarctation of the aorta and 8 cases of tubular hypoplasia of the aortic isthmus operated upon in the Children's Hospital "La Paz" from Madrid, are reviewed. All children were under 7 years of age. 64.2% of the cases of aortic coarctation were in the first year of life, 47.3% of them had associated lesions, being the most frequently present persistent ductus arteriosus and ventricular septal defect. Hospital mortality was 14.2%, what is considered as very acceptable. All the children operated upon for the correction of tubular hypoplasia of the aortic isthmus were in the first year of age. 75% of them had associated ductus arteriosus and ventricular septal defect, being hospital mortality of 62.5%. Most frequent postoperative complications and cause of death were due to broncopulmonary disorders secondary to the existence of a previous pulmonary hypertension.

Ascending aorta-right pulmonary artery anastomosis: Waterston's operation

The results of 180 cases of congenital heart disease with diminished pulmonary flow operated upon with Waterston's technique are presented.

It is considered that Waterston's operation is to be preferred in children under 2 years of age and in older children who have had a previous thrombotic or insufficient Blalock operation and in whom total correction is not indicated.

The problem of pseudotruncus with hypoplastic pulmonary arteries is discussed. The convenience of the Waterston operation in these cases, and the importance of creating an anastomosis at the pulmonary bifurcation and as far back as possible in the aorta, is emphasized.

The need to perform this technique in the correct way is stressed. This will avoid the kinking and pulling of the right pulmonary artery, which are causes of preferential blood flow to the right lung, as we have demonstrated experimentally.

The possible complications caused by such a technical failure are discussed. The necessity for previous angiocardiographic study, in order properly to repair the defect during total correction, is also considered.