Liberal use of pericardium for closure of intra-cardiac defects results in a gap in the pericardial sac. Posterior thoracotomy approach for closure of atrial septal defect has a higher propensity for cardiac herniation owing to the small size and postero-lateral location of the pericardial defect. Recognition and early treatment of cardiac herniation is important since it can mimic cardiac tamponade. Cardiac herniation can be avoided either by enlarging the pericardial defect or by closing it with a prosthetic patch.
or triatriatum is an uncommon but surgically correctable cause of pulmonary venous hypertension and congestive cardiac failure, with a reported incidence of 0.1% among children with congenital heart diseases. Association with partial atrioventricular canal defect (PAVCD) is even rarer, with only anecdotal reports appearing in the literature. In the classic form, cor triatriatum is characterized by the presence of a fibromuscular diaphragm that subdivides the left atrium into a proximal accessory chamber and a distal true chamber. Clinical SummariesPATIENT 1. A 14-year-old boy was seen with class 2 exertional dyspnea. Clinical examination revealed fixed splitting of the second heart sound in the pulmonary area and short systolic murmur (grade 3/6) at the apex. Chest radiography showed right atrial enlargement and plethoric lung fields. Transthoracic echocardiography (TTE) demonstrated the presence of PAVCD with moderate left atrioventricular valve regurgitation and a dilated coronary sinus, suggestive of left superior vena cava. PAVCD was repaired under cardiopulmonary bypass. Postoperative TTE showed turbulence in the supramitral area with suspected membrane positioned obliquely and superiorly within the left atrium. Angiocardiography demonstrated an hourglass-shaped left atrium because of cor triatriatum (Figure 1, A and B). The pulmonary artery wedge pressure was elevated (16-22 mm Hg, mean 16 mm Hg), with a gradient of 11 mm Hg from the left ventricular end-diastolic pressure.PATIENT 2. A 4-year-old girl was evaluated for recurrent respiratory tract infection. TTE revealed PAVCD with mild left atrioventricular valve regurgitation and a patent ductus arteriosus. During surgery, a diaphragm separating the left atrium in to a proximal pulmonary venous chamber and a distal true chamber with a 7-mm central communication was identified. The left atrial appendage was arising from the distal chamber. The membrane was excised, and the PAVCD was repaired successfully.PATIENT 3. An 18-year-old woman had PAVCD with moderate left atrioventricular valve regurgitation diagnosed by TTE. During the operation, while the surgeon was checking for the orifices of pulmonary veins, a thin diaphragm partitioning the atrium with a central hole of 12 mm was found. The coronary sinus was unroofed. The proximal chamber was communicating to right atrium by a stretched foramen ovale. The appendage was arising from the distal true chamber. The membrane was excised, and the rest of the repair was carried out uneventfully. DiscussionThese cases illustrate the importance of looking for associated lesions while managing congenital cardiac defects. The clinical picture of cor triatriatum depends on the size of the communication in the obstructing membrane 1 and the associated intracardiac defects. Fea-From the Departments of Cardiology and
The ideal age for bidirectional Glenn shunt (BDGS) as the first stage of staged Fontan is still not clear. Because of the concerns regarding relatively high pulmonary vascular resistance during infancy, many centres would bridge through a systemic to pulmonary artery shunt in this age group. Patients and Methods:We did a retrospective analysis of 28 infants who had undergone bidirectional Glenn shunt at our institute from February 2001.Results: The mean age was 5 months (2.5-11) and the mean weight was 6.5 Kg (3.4-8.7). Boys dominated the group (25:3). 7 infants had previous procedures. In 3 patients, BDGS was done as a salvage procedure. Formal Cardiopulmonary bypass (CPB) was used in all but 4 patients, in whom a right heart bypass was used. Superior Vena Cava (SVC) or innominate vein was cannulated in 12 patients and the rest were managed with temporary occlusion of SVC under deep hypothermic low flow bypass. 9 infants had bilateral BDGS. The main pulmonary artery was interrupted in 12 and atrial septectomy was done in 10 patients. Additional procedures with BDGS included Patent Ductus Arterious (PDA) interruption, Blalock Taussig (BT) shunt interruption, Left pulmonary arterioplasty, Stansel procedure and redo TAPVC repair. The mean SVC pressure post operatively was 14 (10-24) and only 2 patients needed pulmonary vasodilators in the postoperative period. There is only one mortality in this series and the duration of chest tube drainage and Intensive Care Unit (ICU) stay is comparable with the older age group.Conclusion-BDGS can be performed safely in infants more than 2 months of age electively or as a salvage procedure. It helps to avoid one step in the form of aortopulmonary shunt and hence the ventricular volume overload associated with it. Further studies are required to establish the growth potential of pulmonary arteries following an early BDGS. (Ind J Thorac Cardiovasc Surg, 2004; 20: 159-163)
The spectrum of disorders involving the tracheobronchial tree is diverse, with some of the conditions unique to the pediatric population. Despite the "airway first" maxim, many such disorders are missed initially. Tracheal bronchus is one such condition that comes to notice by persistent right upper lobe atelectasis, pneumothorax, recurrent pneumonia, chronic bronchitis, and prolonged ventilation. This anatomic variant in a patient with cyanotic congenital heart disease is reported. For this patient, timely identification of tracheal bronchus allowed appropriate changes in airway management and was life saving.
Aim: To study the results of repair of Total Anomalous Pulmonary Venous Connection (TAPVC) in neonates Materials and Methods: Retrospective study of 27 neonates operated for TAPVC between January 2001 and October 2003. 27 neonates underwent TAPVC repair during the 2-year period. 21 were males and 6 were females.Results: Total hospital stay ranged from 10 days to 75 days. 9 supracardiac, 13 infracardiac, 3 cardiac and 2 mixed type comprised the group. Obstruction was seen in 24 patients. All the patients had severe pulmonary artery hypertension. Vertical vein was ligated in almost all cases either at the time of surgery or during the closure of sternum. Delayed sternum was closed in all cases but 7. Of 3 deaths, one died after permanent pacemaker implantation (about 1 month after the initial surgery of repair of cardiac TAPVC), one died due to pre-operative vascular access related accident and a third died due to post-operative low cardiac output. All survivors were thriving well at last follow-up.Conclusion: Repair of TAPVC in the neonatal age has been found to be rewarding with significant improvement in the well being of the child. Judicious use of pulmonary vasodilators like nitric oxide, Sildenafil and phenoxybenzamine and delayed sternal closure has improved the results in this study group.
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