We hereby report a child with transposition of great arteries and regressed ventricle who underwent arterial switch operation (ASO) with the aid of cardiopulmonary bypass and “integrated” extracorporeal membrane oxygenation (ECMO) circuit. The significance of lactate clearance as a guide to initiate and terminate veno-arterial ECMO in a post ASO child with regressed left ventricle is discussed.
Background: Fontan procedure and its modifications are established procedures for the treatment of anatomical defects with a single ventricle physiology.Methods: Thirty-two patients underwent extra-cardiac Fontan procedure between Feb 2004 and Oct 2005. Pre-operative cardiac catheterization was done in all patients. All cases were operated on cardiopulmonary bypass with beating heart. ePTFE conduit (Gore-Tex) was used to create an extra cardiac connection between inferior vena cava and the pulmonary artery. A fenestration was created between the conduit and right atrium in twenty-seven patients (91%) Results: The average age was 8.7 years (range 3-21yrs). Ten females underwent the operation. The pre-operative diagnosis was tricuspid atresia (n=15), DORV (n=8), DILV (n=3) and others (n=6). Three patients had PA banding and eight had a BT shunt prior to the bidirectional Glenn. The average pre-procedure pulmonary artery pressure was 11.9 mm Hg (range 7-16) and LVEDP was 10.6 mm Hg (range 7-18). The average branch PA size was 12.6 mm/m 2 (range 8.9-15). 20mm (n=10) or 22 mm (n=12) PTFE conduits were used. Twenty-nine patients (91%) survived the procedure. Postoperative complications were pleural effusion (n=9), renal failure (n=3) and bleeding (n=1). Technical problems during re-sternotomy (aortic injury in one and coronary artery injury in another) and poor PA anatomy were the causes for mortality. Arterial oxygen saturation increased from an average of 76.33% (pre-operative) to 94.5% (postoperative).Conclusions: Extra cardiac Fontan is a technically simple procedure that avoids an atrial suture line resulting in a theoretical reduction in the risk of atrial arrhythmias. However, careful selection of cases is mandatory to avoid early mortality.
Severe persistent hypertension is seen infrequently in newborns and infants, but we came across two infants who developed severe paradoxical hypertension after successful coarctation repair. Treatment of systemic hypertension following repair of coarctation of the aorta is always challenging particularly in infants. Dexmedetomidine was used successfully as an adjunct to the established anti-hypertensive drugs in the immediate postoperative period in our cases to treat postoperative paradoxical hypertension.
Objective: A retrospective comparison of clinical, echocardiographic and radiologic outcome following surgical correction of coarctation of the aorta by subclavian flap aortoplasty or resection end to end anastomosis at less than 3 months of age.Methods: 62 patients under 3 months of age with isolated coarctation of the aorta who underwent surgical correction between 1997 and 2002 (34 resections and 28 subclavian flap aortoplasties) were studied. Age at time of repair was comparable (p=0.54). Weight at time of repair was lower in the resection group (p=0.008). Follow up included clinical evaluation, echocardiographic estimation of residula gradient and left ventricular mass index in all patients and CT Aortography if there was evidence of recoarctation. Measurements of mid-arm circumference, acromion to-olecranon distance along with brachial artery flow velocity and flow pattern in both upper limbs were carried out in the flap aortoplasty group.Results: Mean follow-up was 33.21±14.78 months (range 12-65 months) which was similar in both groups (p=0.26). 12 in the resection group (35%) and 4 in the flap group (15%) had recoarctation. Left ventricular mass index was higher in the resection group (mean 76.50±11g/m 2 ) than the flap group (mean 58±4.77 g/m 2 ) p=0.00. There were no obvious upper limb ischaemic complications in the flap group, but the left arm was significantly shorter than the right.Conclusions: Subclavian flap procedure is superior in terms of lesser recurrence, and also lower left ventricular mass index. Minor differences in limb length were noted though none of the patients were symptomatic. 5Post-operative evaluation of arterial switch by 3D helical computed tomographic angiography
Introduction: Tetralogy of Fallot in adults is a surgical challenge owing to the long-standing hypoxic myocardium. Trans-annular patching (TAP) in comparison to an outflow-tract patch (OP) is speculated to cause progressive right ventricular dysfunction due to free pulmonary regurgitation. We present the results of objective assessment of surgical correction in an adult population at mid-tenn follow up.Methods: Ninety patients over the age of twelve years with a Tetralogy of Fallot operated between Jan 1995 and June 2004 at our institution, of which thirty-two patients underwent objective assessment of ventricular function by Tread Mill Testing (TMT) alongwith echocardiography at mid-term follow up, are included in this series. Mean age at surgery was 19.5±6.3 years. The male-to-female ratio was 2.2:1. Twenty-five patients I had undergone an intra-cardiac repair with TAP while seven had the repair with right ventricular OP.Results: Follow up ranged from 6 months to 9 years with a mean of 6.02 years. TMT showed good ventricular function in 31/32 (96.8%) patients with an average of 1 0.3 METS attained along with moderate pulmonary regurgitation on echocardiography. One patient (3.2%) with TAP had poor exercise tolerance with 5 METS achieved on TMT along with severe pulmonary regurgitation on echocardiography. Twenty-six patients were in NYHA class I, six in class II and only one in class III.Conclusions: Complete lntracardiac repair of Tetralogy of Fallot with TAP can be done with acceptable I morbidity. TAP does not appear to be significant risk factor for right ventricular failure at midterm follow up.
Objective: To minimize invasiveness for extended resection and end to end anastomosis of aortic coarctation.Methods: 27 consecutive patients (median age 8 days; median weight 3.3 kg) undergoing surgical repair for aortic coarctation from June 2002 to September 2003 were approached through a left posterior minithoracotomy with reduced invasiveness : 1) lattisimus dorsi was partially split (not at all in last 3 cases ), the serratus anterior was not divided 2) thorax was entered through a subperiosteal reflection of the intercostal muscles and 3) thoracic aorta was approached extrapleurally. Extended resection of stenotic isthmus and repair was performed in a standard manner. 4 patients were subjected to left subclavian arter T translocation for distal arch augmentation, while 6 underwent additional pulmonar Tarter T banding. Periosteum was readapted to the rib with continuous absorbable sutures. The median aortic clamp and operative times were 24 (range 14 35) and 90 (range 65 165) rains respectively.Results: All patients survived the operation without significant complications. One patient developed chylothorax needing exploration and suture closure of the lymphatic fistula. Postop echo showed no significant gradients across the neoisthmus.Conclusions: Reducing invasiveness (nondivision of muscles, subperisteal entr T and extrapleural appraoch) is feasible and safe and provides adequate exposure for isthmus resection and repair. It reduces postoperative morbidity related to division of muscles, handling of the lung and opening of the pleura. It produces good cosmetic result. It may prevent formation of systemic to pulmonar T parenchymal collaterals in patients with associated cyanotic diseases.A study of RVOT obstruction over eleven [----] years-JIPMER experience
Background: Bentall procedure and its modification is the standard surgical management option for aneurysmal diseases involving ascending aorta and the aotic valve. The progressive nature of the aortic disease and the development of early and late procedure ralated complications warrant a dedicated clinical and investigative follow up.Methods: One hundred and forty three patients underwent composite graft replacement of the aortic root between January 1992 and June 2003. Annulo aortic ectasia was the most common lesion seen in 94 (65.7%) patients and aortic dissection in 49 (34.3%0 patients. Inclusion technique was applied in 72 patients. From June 2000 onwards, coronary button technique with no wrap was employed and total of 71 patients were operated by this method. Forty two patients underwvent repeat angiographic study during follow up visit.Results: There were 9 (6.3%) early deaths and 8 (6%) late deaths. On angiographic study, one patient operated by inclusion technique was detected to have pseudoaneurysm at the distal suture line. In another patient in this group there was a perigraft hematoma compressing the graft. In 6 patients there was evidence of disease progression in the remaining aorta.Conclusions: The coronary button technique seems to be a superior procedure for the aortic root replacement. The angiographic follow up has substantiated this.successfully operated a female with a very large renal artery aneurysm and uncontrolled hypertension of 10 years duration.Methods: A 55 year old female presented with uncontrolled hypertension for 10 years and vague lumbar pain for one year. Angiography and CT abdomen revealed a 4.8x4.5x4.3 cm saccular aneurysm arising from right renal artery. Aorta was atherosclerotic and tortuous. Aneurysmectomy with aorto renal bypass was done using saphenous vein graft. Transverse right upper abdominal incision was used and aneurysm was exposed retroperitoneally. Adhesion between renal artery proximal to aneurysm and inferior vena cava were carefully separated after identifying and saving the ureter. Proximal aortosaphenous vein anastomosis was done first applying aortic partial clamp to relatively less atherosclerotic part of arota. Renal artery was clamped and aneurysmectomy done. Distal saphenous vein to renal artery anastomosis was then performed and the renal ischemia time was only 13 minutes.Results: The patient had an uneventful recovery and her renal functions were well preserved. Her blood pressure now is well controlled without any medication one year after surgery.Conclusions: Renovascular hypertension and large size of renal artery aneurysm are strong indications for elective renal artery aneurysmectomy. Construction of proximal aorto saphenous anastomosis before cross clamping the renal artery helps in decreasing the renal ischemia time during aorto renal bypass. [----] pseudoaneurysm of LVOT-rarest presentation of aorto arteritis. Cardiac tamponade due to leaking
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