A 6-month-old baby boy had undergone the Jatene procedure at 4 days. Four months later, catheter intervention (balloon angioplasty) was performed because of severe stenosis at the bifurcation of the pulmonary arteries. Twenty days later, several episodes of cyanosis occurred and he was readmitted. The existence of shunt flow between the sinus of valsalva and the pulmonary bifurcation was detected by echocardiography and examination by 16-row MDCT revealed 2 holes at this site. Under a diagnosis of aortopulmonary (AP) window, the patient was placed on cardiopulmonary bypass and the pulmonary artery was opened after aortic clamping. There was a ridge between the bifurcation of the pulmonary arteries. After removing it, 2 holes were visualized that resembled the findings on 16-row MDCT. These holes were closed with Xenomedica patches and the main pulmonary artery was also extended with a Xenomedica patch. AP window is a rare complication after balloon angioplasty for pulmonary stenosis, but we must take great care to prevent this complication.
A Successful Surgical Treatment of Ebsteinʼs Anomaly by Hetzerʼs Procedure in an AdultMitsutaka Nakao, Kiyozou Morita, Yoshihiro Ko, Takayuki Abe and Kazuhiro Hashimoto(Department of Cardiac Surgery, Jikei University School of Medicine, Tokyo, Japan) A 29-year-old woman, who had been diagnosed with Ebsteinʼs anomaly associated with paroxysmal supraventricular tachycardia due to Wolff-Parkinson-White(WPW)syndrome, was referred to our hospital for treatment of congestive heart failure and tachycardia. She had undergone a catheter ablation for WPW syndrome at the age of 28 years. Subsequently, surgical treatment for Ebsteinʼs anomaly was indicated because of persistent symptoms of heart failure due to tricuspid regurgitation(TR). The echocardiogram and pathologic findings corresponded to Ebsteinʼs anomaly of the Carpentier type B classification, with severe displacement of the septal and posterior leaflets resulting in moderate TR. A mobile anterior leaflet of sufficient size without a cleft enabled us to successfully perform Hetzerʼs procedure. In this procedure, the large mobile anterior leaflet was approximated to the opposing true tricuspid annulus with a mattress suture of 3-0 polypropylene passed from the anterior leaflet annulus to the true tricuspid annulus at the site of atrialized right ventricle near the coronary sinus. The postoperative course was uneventful, and the cardiothoracic ratio reduced from 56% to 48% with mild TR. In this adult case of Carpentierʼs type B adult Ebsteinʼs anomaly, Hetzerʼs procedure allowed reconstruction of the tricuspid valve mechanism of "leaflet-to-septum" coaptation at the level of the true annulus by approximating the anterior leaflet. This was, effective in reducing the patientʼs moderate TR. We conclude that this procedure is a simple and reproducible method for repairing the tricuspid valve in Ebsteinʼs anomaly, especially for cases with a large mobile anterior leaflet.
We have studied potential for pulmonary circulational assist by the dynamic Fontan model with a skeletal muscle ventricle (SMV) constructed using the latissimus dorsi muscles of 5 dogs. After 2 weeks of vascular delay, the SMV was electrically preconditioned for 8 weeks. Under cardiopulmonary bypass (CPB), the right heart (RV) bypass model was established with the SMV anastomosed between the right atrium and pulmonary trunk. The SMV was paced at a burst frequency of 25 Hz, 60/min, with an asynchronization ratio. The aortic pressure (AoP), pulmonary arterial pressure (PAP), central venous pressure (CVP), and pulmonary flow (PAF) were measured. Just after on-SMV, PAP and PAF increased, CVP decreased. CVP decreased Fontan procedure. On this Rp, under off-SMV the CVP was 18 mmHg and severe RV failure was recognized as PAF was 35% of the preoperative value. Under on-SMV, CVP decreased and PAF was almost the same as the preoperative value. On physiological CVP, an RV bypass model with intrathoracic SMV maintained PAF at the preoperative value under high Rp. We concluded that this model may be a viable surgical option for univentricular heart with high Rp, which may not be Fontan candidates.
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