Journal of the American College of Cardiology, 1997
Objectives. We sought to describe a large series of coronary artery obstructions after the arteri... more Objectives. We sought to describe a large series of coronary artery obstructions after the arterial switch operation for transposition of the great arteries and to discuss their clinical implications. Background. Aortic root angiography and myocardial perfusion imaging yield ambiguous results regarding the fate of the coronary artery anastomoses after the arterial switch operation. Late death related to coronary artery obstruction and growth of the translocated coronary arteries are of major concern in these patients. Methods. Selective coronary artery angiography was performed prospectively in a total of 165 children. Results. A total of 12 coronary occlusions, 8 major stenoses, 6 minor stenoses of the left ostium and 4 stretchings of one coronary artery were identified. Obstructions were more frequent in types D and E (p < 0.001) of the Yacoub and Radley-Smith classification. Coronary obstruction was documented in all patients with elec-trocardiographic and ultrasound evidence of myocardial ischemia at time of study. Early postoperative ischemia did not predict coronary artery lesion if the patient had fully recovered. Persistent or delayed myocardial ischemia was highly predictive of coronary artery lesions. The incidence of coronary artery obstruction was very high (11 of 35) in patients operated on by a rapidly abandoned technique of single-orifice reimplantation of both coronary artery ostia. Conclusions. Selective coronary angiography is the most accurate means to assess coronary artery obstruction after the arterial switch operation. Precise diagnosis of coronary artery lesions after this operation will help to elucidate the pathogenesis, develop adequate therapeutic strategies and might indicate how to prevent coronary complications after operation.
Transesophageal echocardiography, using a single plane (transverse axis) dedicated pediatric prob... more Transesophageal echocardiography, using a single plane (transverse axis) dedicated pediatric probe, was performed prospectively in 25 anesthetized children undergoing routine cardiac catheterization or intracardiac surgery, in order to assess any potential role it may have in the initial diagnosis, perioperative management and post operative follow-up of children with congenital heart disease. The age ranged from 1 year to 14 years 10 months (mean 6.1 years); the weight from 6.5 to 52 kilograms (mean weight 22.4 kg). Studies were successful in all patients; no complications were encountered. The results of the transesophageal studies (combined imaging, color flow mapping and pulsed wave Doppler) were correlated both with those of prior precordial studies and the information obtained at cardiac catheterization. Transesophageal echocardiography allowed a more detailed evaluation of the morphology and function of systemic and pulmonary venous return, both atria, interatrial baffles, both atrioventricular valves, and the left ventricular outflow tract. Additional information was obtained in 15 patients (60 %). Problem areas for single plane transesophageal imaging were the apical interventricular septum, the right ventricular outflow tract and the left pulmonary artery. The intraoperative use of transesophageal echocardiography allowed the assessment of the surgical repair and monitoring of ventricular function and volume status while the patient was weaned from cardia pulmonary bypass. Transesophageal echocardiography in pediatric patients is of additional value in three main areas a) in the morphologic diagnosis of congenital heart disease, b) for perioperative monitoring and c) for post surgical follow-up.
Cardiac catheterisation and surgery in Namibia population). The state billing system, incomplete ... more Cardiac catheterisation and surgery in Namibia population). The state billing system, incomplete and flawed, does not contribute to hospitals' revenue. National Health Insurance (NHI) proposals have led to futile results. Albeit with good future promise, healthcare is tainted by bureaucracy (policy and structural deficiencies) that warranted urgent addressing-before navigating new territories. HISTORY OF CARDIAC CARE IN NAMIBIA Fortunate patients were sent to South Africa for surgery. After independence, a SA cardiothoracic surgeon, Professor Johan Rossouw, started periodic visits. We pay special tribute to his work, as he was also instrumental in designing the unit we work in today. With an increasing burden, Namibia agreed with the Kenyan government in the early 2000s, to operate on RHD patients referred by physicians. The caveat; no longitudinal follow-up or structured Warfarin programme. The government opened its first unit at Windhoek Central
Journal of the American College of Cardiology, Apr 1, 1991
Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to... more Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to assess the immediate (5 patients) or intermediate (13 patients) results after a Fontan-type procedure. The findings were correlated with precordial echocardiographic (all patients) and cardiac catheterization (11 patients) data. Atrial shunting was documented by transesophageal studies in three patients (precordial in one patient). In two patients it was confirmed by cardiac catheterization; the third underwent reoperation based on the transesophageal study alone. Pulmonary artery obstruction was documented in three patients (precordial in one patient) and was confirmed by subsequent cardiac catheterization in all. Evaluation of anterior Fontan connections was successful in 5 of 8 patients (precordial in 6 of 8), and posterior connections in 10 of 10 patients (precordial in 5 of 10). A Glenn Several modifications of the original Fontan procedure (I) are widely applied for the treatment of a wide spectrum of complex congenital heart lesions (2-5). Although the early and late operative results have improved dramatically over the recent decade (6-8), a large proportion of patients have hemodynamic lesions (2-9). Such lesions may not always be clinically apparent, but may be the cause of impaired functional capacity (10-12). Whereas some lesions are residua of suboptimal surgical correction and require early reoperation (e.g., atrial shunting), others may develop during the late postoperative period (e.g., pulmonary artery obstruction), and may lead to either acute or gradually progressive clinical deterioration (13,14). Thus, a close follow-up of all patients after the Fontan procedure is required. Precordial ultrasound studies are used to assess the functional status of these patients (15,16), but they often yield limited information, particularly in adolescents and adults. Thus, to effect a complete evaluation of the Fontan procedure, the clinician must often perform cardiac catheterization.
The Journal of Thoracic and Cardiovascular Surgery, Nov 1, 2021
OBJECTIVE The most durable valved right ventricle to pulmonary artery conduit for the repair of c... more OBJECTIVE The most durable valved right ventricle to pulmonary artery conduit for the repair of congenital heart defects in patients of different ages, sizes, and anatomic substrate remains uncertain. METHODS We performed a retrospective analysis of 4 common right ventricle to pulmonary artery conduits used in a single institution over 30 years, using univariable and multivariable models of time-to-failure to analyse freedom from conduit dysfunction, reintervention, and replacement. RESULTS Between 1988 and 2018, 959 right ventricle to pulmonary artery conduits were implanted: 333 aortic homografts, 227 pulmonary homografts, 227 composite porcine valve conduits, and 172 bovine jugular vein conduits. Patients weighed 1.6 to 98.3 kg (median 15.3 kg), and median duration of follow-up was 11.4 years, with 505 (52.2%) conduits developing dysfunction, 165 (17.2%) requiring catheter intervention, and 415 (43.2%) being replaced. Greater patient weight, conduit z-score, type and position, as well as catheter intervention were predictors of freedom from replacement. Multivariable analysis demonstrated inferior durability for smaller composite porcine valve conduits, with excellent durability for larger diameter conduits of the same type. Bovine jugular vein conduit longevity was inferior to that of homografts in all but the smallest patients. Freedom from dysfunction at 8 years was 60.7% for aortic homografts, 72% for pulmonary homografts, 51.2% for composite porcine valve conduits, and 41.3% for bovine jugular vein conduits. Judicious oversizing of the conduit improved conduit durability in all patients, but to the greatest extent in patients weighing 5 to 20 kg. CONCLUSIONS Pulmonary and aortic homografts had greater durability than xenograft conduits, particularly in patients weighing 5 to 20 kg. Judicious oversizing was the most significant surgeon-modifiable factor affecting conduit longevity.
European Journal of Cardio-Thoracic Surgery, Mar 19, 2019
OBJECTIVES: We sought to define the early and late outcomes of unifocalization based on a classif... more OBJECTIVES: We sought to define the early and late outcomes of unifocalization based on a classification of the native pulmonary artery (nPA) system and major aortopulmonary collateral arteries (MAPCAs) with a policy of combined recruitment and rehabilitation and to analyse the role of unifocalization by leaving the ventricular septal defect (VSD) open with a limiting right ventricle-pulmonary artery (RV-PA) conduit in borderline cases. METHODS: An analysis of 271 consecutive patients assessed for unifocalization at a single institution between 1988 and 2016 was performed. Patients were classified according to the pulmonary blood supply: group A, unifocalization based on nPA only; group B, based on nPA and MAPCAs; group C, MAPCAs only (absent nPAs).
In a prospective study, atrial morphology was evaluated by both transoesophageal and precordial e... more In a prospective study, atrial morphology was evaluated by both transoesophageal and precordial echocardiography in 86 unoperated children with congenital heart disease (age range = 0.2 to 14.8 years, mean = 3.8 years) to determine what advantages, if any, might be inherent in the transoesophageal approach. The information derived from both ultrasound approaches was correlated and compared to information obtained during subsequent cardiac catheterization (78 patients) and, or, surgical inspection (53 patients). Atrial appendage morphology and hence atrial situs was determined by transoesophageal echocardiography in every case (82 solitus, two right atrial isomerism, two left atrial isomerism). In addition, the transoesophageal approach indicated left juxtaposition in four patients, compared to only one by precordial examination. Probe patency of the foramen ovale was correctly predicted in 21 patients by transoesophageal imaging, but in only 10 by precordial imaging. In two children significant secundum defects, undetected by the precordial route, were identified. Multiple atrial septal defects were correctly defined in four patients by transoesophageal study but in only one by precordial study. Sinus venosus defects were documented in four by the transoesophageal approach, but in only one by the precordial. Primum defects were equally well documented (nine patients) by either technique, but the associated valve leaflet morphology was better documented by transoesophageal study in 5/9. A subtotal cor triatriatum was diagnosed in one child only by transoesophageal investigation. Transoesophageal echocardiography allows a much more detailed evaluation of atrial morphology than precordial imaging even in infants. It provides direct diagnosis of atrial situs, detection of juxtaposed atrial appendages and improved demonstration or definitive exclusion of atrial septal defects.
The Journal of Thoracic and Cardiovascular Surgery, May 1, 1999
with hypoplasia or absence of the left ventricle. 1 Coarctation of the aorta is usually associate... more with hypoplasia or absence of the left ventricle. 1 Coarctation of the aorta is usually associated with the lesion 2 and may impede retrograde blood flow to a H ypoplastic left heart syndrome is a spectrum of underdevelopment of the left-sided heart structures, characterized by aortic valve atresia or severe stenosis Background: Classic first-stage Norwood repair of hypoplastic left heart syndrome uses a homograft patch enlargement to obtain an unobstructed aorta and coronary arteries. Because of possible disadvantages of the homograft, such as lack of growth, degeneration and calcification, and availability, we have tried to repair the aorta without patch supplementation. Methods: Between February 1993 and September 1997, 120 patients, aged birth to 47 days (median 4 days) and weighing 1.7 to 4.4 kg (median 3.1 kg), underwent first-stage palliation for hypoplastic left heart syndrome. The diameter of the ascending aorta ranged from 1.5 to 8.0 mm (median 3.0 mm). Eight patients had an aberrant right subclavian artery arising from the descending thoracic aorta. In 95 patients (group I), all duct tissue was excised and the descending aorta was anastomosed to the aortic arch, which had been opened back into the ascending aorta. Then to this confluence was anastomosed the proximal main pulmonary artery. In the remaining 25 patients (group II), continuity of the aortic arch was maintained and the repair was performed with a Damus-Kaye-Stansel anastomosis. The size of the systemic-to-pulmonary shunt was 3 mm in 48 patients, 3.5 mm in 70, and 4.0 mm in 2. Results: Circulatory arrest time ranged from 19 to 105 minutes (median 54 minutes). A homograft patch was necessary for the arch reconstruction in 18 patients (15%); 9 group I patients (10%) and 9 group II (36%) (P = .001). There were 82 hospital survivors (68%); 69 group I patients (73%) and 13 group II (52%) (P = .04), 71 patients without a patch (70%) and 11 with a patch (61%) (P > .2). By multiple logistic regression, the aberrant right subclavian artery was a significant risk factor for hospital death (P = .008). There were 6 late deaths. Sixteen of 71 patients (23%) who underwent second-stage palliation had a neoaortic arch obstruction develop, with a peak gradient greater than 10 mm Hg; 14 group I patients (23%) and 2 group II (22%) (P > .2), 15 without a patch (23%) and 1 with a patch (17%) (P > .2). Overall survivals were 57% at 1 year and 55% at 2 years. Conclusion: The modified Norwood procedure for first-stage palliation of hypoplastic left heart syndrome is possible in the majority of patients without the use of exogenous materials and does not result in an increased incidence of neoaortic arch obstruction. Repair of the aorta without patch supplementation may improve the potential for long-term growth of the new aorta. (
Trials must determine which neuroleptics are best in dementia Editor-Rupert McShane and colleague... more Trials must determine which neuroleptics are best in dementia Editor-Rupert McShane and colleagues conclude that neuroleptic drugs may worsen already poor cognitive function. 1 If confirmed in controlled trials, this is indeed an
Transesophageal echocardiography has gained an established role in the evaluation and management ... more Transesophageal echocardiography has gained an established role in the evaluation and management of the adult patient with acquired cardiac disease. Unlike the transthoracic approach, the transesophageal approach provides excellent imaging of posterior cardiac structures in virtually all patients.
Interdisciplinary CardioVascular and Thoracic Surgery
OBJECTIVES The aim of this study was to describe the early and late outcomes of the arterial swit... more OBJECTIVES The aim of this study was to describe the early and late outcomes of the arterial switch for transposition. METHODS A single-centre retrospective cohort study was conducted to assess the early and late outcomes of arterial switch performed during infancy using a standardized institutional approach between 1988 and 2018, compared by morphological groups. RESULTS A total of 749 consecutive patients undergoing arterial switch during infancy were included, 464 (61.9%) with intact septum, 163 (21.8%) with isolated ventricular septal defect and 122 (16.3%) with complex transposition with associated lesions, including 67 (8.9%) with Taussig–Bing anomaly. There were 34 early deaths [4.5%, 95% confidence interval (CI) 3.1–6.1] with only 10 (2.6%) early deaths since 2000. Complex morphology (odds ratio 11.44, 95% CI 4.76–27.43) and intramural coronary artery (odds ratio 5.17, 95% CI 1.61–15.91) were identified as the most important risk factors for 90-day mortality. Overall surviva...
Journal of the American College of Cardiology, 1997
Objectives. We sought to describe a large series of coronary artery obstructions after the arteri... more Objectives. We sought to describe a large series of coronary artery obstructions after the arterial switch operation for transposition of the great arteries and to discuss their clinical implications. Background. Aortic root angiography and myocardial perfusion imaging yield ambiguous results regarding the fate of the coronary artery anastomoses after the arterial switch operation. Late death related to coronary artery obstruction and growth of the translocated coronary arteries are of major concern in these patients. Methods. Selective coronary artery angiography was performed prospectively in a total of 165 children. Results. A total of 12 coronary occlusions, 8 major stenoses, 6 minor stenoses of the left ostium and 4 stretchings of one coronary artery were identified. Obstructions were more frequent in types D and E (p < 0.001) of the Yacoub and Radley-Smith classification. Coronary obstruction was documented in all patients with elec-trocardiographic and ultrasound evidence of myocardial ischemia at time of study. Early postoperative ischemia did not predict coronary artery lesion if the patient had fully recovered. Persistent or delayed myocardial ischemia was highly predictive of coronary artery lesions. The incidence of coronary artery obstruction was very high (11 of 35) in patients operated on by a rapidly abandoned technique of single-orifice reimplantation of both coronary artery ostia. Conclusions. Selective coronary angiography is the most accurate means to assess coronary artery obstruction after the arterial switch operation. Precise diagnosis of coronary artery lesions after this operation will help to elucidate the pathogenesis, develop adequate therapeutic strategies and might indicate how to prevent coronary complications after operation.
Transesophageal echocardiography, using a single plane (transverse axis) dedicated pediatric prob... more Transesophageal echocardiography, using a single plane (transverse axis) dedicated pediatric probe, was performed prospectively in 25 anesthetized children undergoing routine cardiac catheterization or intracardiac surgery, in order to assess any potential role it may have in the initial diagnosis, perioperative management and post operative follow-up of children with congenital heart disease. The age ranged from 1 year to 14 years 10 months (mean 6.1 years); the weight from 6.5 to 52 kilograms (mean weight 22.4 kg). Studies were successful in all patients; no complications were encountered. The results of the transesophageal studies (combined imaging, color flow mapping and pulsed wave Doppler) were correlated both with those of prior precordial studies and the information obtained at cardiac catheterization. Transesophageal echocardiography allowed a more detailed evaluation of the morphology and function of systemic and pulmonary venous return, both atria, interatrial baffles, both atrioventricular valves, and the left ventricular outflow tract. Additional information was obtained in 15 patients (60 %). Problem areas for single plane transesophageal imaging were the apical interventricular septum, the right ventricular outflow tract and the left pulmonary artery. The intraoperative use of transesophageal echocardiography allowed the assessment of the surgical repair and monitoring of ventricular function and volume status while the patient was weaned from cardia pulmonary bypass. Transesophageal echocardiography in pediatric patients is of additional value in three main areas a) in the morphologic diagnosis of congenital heart disease, b) for perioperative monitoring and c) for post surgical follow-up.
Cardiac catheterisation and surgery in Namibia population). The state billing system, incomplete ... more Cardiac catheterisation and surgery in Namibia population). The state billing system, incomplete and flawed, does not contribute to hospitals' revenue. National Health Insurance (NHI) proposals have led to futile results. Albeit with good future promise, healthcare is tainted by bureaucracy (policy and structural deficiencies) that warranted urgent addressing-before navigating new territories. HISTORY OF CARDIAC CARE IN NAMIBIA Fortunate patients were sent to South Africa for surgery. After independence, a SA cardiothoracic surgeon, Professor Johan Rossouw, started periodic visits. We pay special tribute to his work, as he was also instrumental in designing the unit we work in today. With an increasing burden, Namibia agreed with the Kenyan government in the early 2000s, to operate on RHD patients referred by physicians. The caveat; no longitudinal follow-up or structured Warfarin programme. The government opened its first unit at Windhoek Central
Journal of the American College of Cardiology, Apr 1, 1991
Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to... more Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to assess the immediate (5 patients) or intermediate (13 patients) results after a Fontan-type procedure. The findings were correlated with precordial echocardiographic (all patients) and cardiac catheterization (11 patients) data. Atrial shunting was documented by transesophageal studies in three patients (precordial in one patient). In two patients it was confirmed by cardiac catheterization; the third underwent reoperation based on the transesophageal study alone. Pulmonary artery obstruction was documented in three patients (precordial in one patient) and was confirmed by subsequent cardiac catheterization in all. Evaluation of anterior Fontan connections was successful in 5 of 8 patients (precordial in 6 of 8), and posterior connections in 10 of 10 patients (precordial in 5 of 10). A Glenn Several modifications of the original Fontan procedure (I) are widely applied for the treatment of a wide spectrum of complex congenital heart lesions (2-5). Although the early and late operative results have improved dramatically over the recent decade (6-8), a large proportion of patients have hemodynamic lesions (2-9). Such lesions may not always be clinically apparent, but may be the cause of impaired functional capacity (10-12). Whereas some lesions are residua of suboptimal surgical correction and require early reoperation (e.g., atrial shunting), others may develop during the late postoperative period (e.g., pulmonary artery obstruction), and may lead to either acute or gradually progressive clinical deterioration (13,14). Thus, a close follow-up of all patients after the Fontan procedure is required. Precordial ultrasound studies are used to assess the functional status of these patients (15,16), but they often yield limited information, particularly in adolescents and adults. Thus, to effect a complete evaluation of the Fontan procedure, the clinician must often perform cardiac catheterization.
The Journal of Thoracic and Cardiovascular Surgery, Nov 1, 2021
OBJECTIVE The most durable valved right ventricle to pulmonary artery conduit for the repair of c... more OBJECTIVE The most durable valved right ventricle to pulmonary artery conduit for the repair of congenital heart defects in patients of different ages, sizes, and anatomic substrate remains uncertain. METHODS We performed a retrospective analysis of 4 common right ventricle to pulmonary artery conduits used in a single institution over 30 years, using univariable and multivariable models of time-to-failure to analyse freedom from conduit dysfunction, reintervention, and replacement. RESULTS Between 1988 and 2018, 959 right ventricle to pulmonary artery conduits were implanted: 333 aortic homografts, 227 pulmonary homografts, 227 composite porcine valve conduits, and 172 bovine jugular vein conduits. Patients weighed 1.6 to 98.3 kg (median 15.3 kg), and median duration of follow-up was 11.4 years, with 505 (52.2%) conduits developing dysfunction, 165 (17.2%) requiring catheter intervention, and 415 (43.2%) being replaced. Greater patient weight, conduit z-score, type and position, as well as catheter intervention were predictors of freedom from replacement. Multivariable analysis demonstrated inferior durability for smaller composite porcine valve conduits, with excellent durability for larger diameter conduits of the same type. Bovine jugular vein conduit longevity was inferior to that of homografts in all but the smallest patients. Freedom from dysfunction at 8 years was 60.7% for aortic homografts, 72% for pulmonary homografts, 51.2% for composite porcine valve conduits, and 41.3% for bovine jugular vein conduits. Judicious oversizing of the conduit improved conduit durability in all patients, but to the greatest extent in patients weighing 5 to 20 kg. CONCLUSIONS Pulmonary and aortic homografts had greater durability than xenograft conduits, particularly in patients weighing 5 to 20 kg. Judicious oversizing was the most significant surgeon-modifiable factor affecting conduit longevity.
European Journal of Cardio-Thoracic Surgery, Mar 19, 2019
OBJECTIVES: We sought to define the early and late outcomes of unifocalization based on a classif... more OBJECTIVES: We sought to define the early and late outcomes of unifocalization based on a classification of the native pulmonary artery (nPA) system and major aortopulmonary collateral arteries (MAPCAs) with a policy of combined recruitment and rehabilitation and to analyse the role of unifocalization by leaving the ventricular septal defect (VSD) open with a limiting right ventricle-pulmonary artery (RV-PA) conduit in borderline cases. METHODS: An analysis of 271 consecutive patients assessed for unifocalization at a single institution between 1988 and 2016 was performed. Patients were classified according to the pulmonary blood supply: group A, unifocalization based on nPA only; group B, based on nPA and MAPCAs; group C, MAPCAs only (absent nPAs).
In a prospective study, atrial morphology was evaluated by both transoesophageal and precordial e... more In a prospective study, atrial morphology was evaluated by both transoesophageal and precordial echocardiography in 86 unoperated children with congenital heart disease (age range = 0.2 to 14.8 years, mean = 3.8 years) to determine what advantages, if any, might be inherent in the transoesophageal approach. The information derived from both ultrasound approaches was correlated and compared to information obtained during subsequent cardiac catheterization (78 patients) and, or, surgical inspection (53 patients). Atrial appendage morphology and hence atrial situs was determined by transoesophageal echocardiography in every case (82 solitus, two right atrial isomerism, two left atrial isomerism). In addition, the transoesophageal approach indicated left juxtaposition in four patients, compared to only one by precordial examination. Probe patency of the foramen ovale was correctly predicted in 21 patients by transoesophageal imaging, but in only 10 by precordial imaging. In two children significant secundum defects, undetected by the precordial route, were identified. Multiple atrial septal defects were correctly defined in four patients by transoesophageal study but in only one by precordial study. Sinus venosus defects were documented in four by the transoesophageal approach, but in only one by the precordial. Primum defects were equally well documented (nine patients) by either technique, but the associated valve leaflet morphology was better documented by transoesophageal study in 5/9. A subtotal cor triatriatum was diagnosed in one child only by transoesophageal investigation. Transoesophageal echocardiography allows a much more detailed evaluation of atrial morphology than precordial imaging even in infants. It provides direct diagnosis of atrial situs, detection of juxtaposed atrial appendages and improved demonstration or definitive exclusion of atrial septal defects.
The Journal of Thoracic and Cardiovascular Surgery, May 1, 1999
with hypoplasia or absence of the left ventricle. 1 Coarctation of the aorta is usually associate... more with hypoplasia or absence of the left ventricle. 1 Coarctation of the aorta is usually associated with the lesion 2 and may impede retrograde blood flow to a H ypoplastic left heart syndrome is a spectrum of underdevelopment of the left-sided heart structures, characterized by aortic valve atresia or severe stenosis Background: Classic first-stage Norwood repair of hypoplastic left heart syndrome uses a homograft patch enlargement to obtain an unobstructed aorta and coronary arteries. Because of possible disadvantages of the homograft, such as lack of growth, degeneration and calcification, and availability, we have tried to repair the aorta without patch supplementation. Methods: Between February 1993 and September 1997, 120 patients, aged birth to 47 days (median 4 days) and weighing 1.7 to 4.4 kg (median 3.1 kg), underwent first-stage palliation for hypoplastic left heart syndrome. The diameter of the ascending aorta ranged from 1.5 to 8.0 mm (median 3.0 mm). Eight patients had an aberrant right subclavian artery arising from the descending thoracic aorta. In 95 patients (group I), all duct tissue was excised and the descending aorta was anastomosed to the aortic arch, which had been opened back into the ascending aorta. Then to this confluence was anastomosed the proximal main pulmonary artery. In the remaining 25 patients (group II), continuity of the aortic arch was maintained and the repair was performed with a Damus-Kaye-Stansel anastomosis. The size of the systemic-to-pulmonary shunt was 3 mm in 48 patients, 3.5 mm in 70, and 4.0 mm in 2. Results: Circulatory arrest time ranged from 19 to 105 minutes (median 54 minutes). A homograft patch was necessary for the arch reconstruction in 18 patients (15%); 9 group I patients (10%) and 9 group II (36%) (P = .001). There were 82 hospital survivors (68%); 69 group I patients (73%) and 13 group II (52%) (P = .04), 71 patients without a patch (70%) and 11 with a patch (61%) (P > .2). By multiple logistic regression, the aberrant right subclavian artery was a significant risk factor for hospital death (P = .008). There were 6 late deaths. Sixteen of 71 patients (23%) who underwent second-stage palliation had a neoaortic arch obstruction develop, with a peak gradient greater than 10 mm Hg; 14 group I patients (23%) and 2 group II (22%) (P > .2), 15 without a patch (23%) and 1 with a patch (17%) (P > .2). Overall survivals were 57% at 1 year and 55% at 2 years. Conclusion: The modified Norwood procedure for first-stage palliation of hypoplastic left heart syndrome is possible in the majority of patients without the use of exogenous materials and does not result in an increased incidence of neoaortic arch obstruction. Repair of the aorta without patch supplementation may improve the potential for long-term growth of the new aorta. (
Trials must determine which neuroleptics are best in dementia Editor-Rupert McShane and colleague... more Trials must determine which neuroleptics are best in dementia Editor-Rupert McShane and colleagues conclude that neuroleptic drugs may worsen already poor cognitive function. 1 If confirmed in controlled trials, this is indeed an
Transesophageal echocardiography has gained an established role in the evaluation and management ... more Transesophageal echocardiography has gained an established role in the evaluation and management of the adult patient with acquired cardiac disease. Unlike the transthoracic approach, the transesophageal approach provides excellent imaging of posterior cardiac structures in virtually all patients.
Interdisciplinary CardioVascular and Thoracic Surgery
OBJECTIVES The aim of this study was to describe the early and late outcomes of the arterial swit... more OBJECTIVES The aim of this study was to describe the early and late outcomes of the arterial switch for transposition. METHODS A single-centre retrospective cohort study was conducted to assess the early and late outcomes of arterial switch performed during infancy using a standardized institutional approach between 1988 and 2018, compared by morphological groups. RESULTS A total of 749 consecutive patients undergoing arterial switch during infancy were included, 464 (61.9%) with intact septum, 163 (21.8%) with isolated ventricular septal defect and 122 (16.3%) with complex transposition with associated lesions, including 67 (8.9%) with Taussig–Bing anomaly. There were 34 early deaths [4.5%, 95% confidence interval (CI) 3.1–6.1] with only 10 (2.6%) early deaths since 2000. Complex morphology (odds ratio 11.44, 95% CI 4.76–27.43) and intramural coronary artery (odds ratio 5.17, 95% CI 1.61–15.91) were identified as the most important risk factors for 90-day mortality. Overall surviva...
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