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Biomedical subjects

C I Tchervenkov

Publications and source records attributed to C I Tchervenkov.

At least 37 records · Page 2Linked to original sources
PubMed1997

Single-stage arterial switch with aortic arch enlargement for transposition complexes with aortic arch obstruction.

BACKGROUND: Patients with transposition complexes and aortic arch obstruction are a surgical challenge with significant mortality. We have adopted an aggressive approach of concurrent aortic arch repair and arterial switch operation with excellent results. METHODS: Since 1989, 12 of 13 patients with aortic arch obstruction and transposition of the great arteries or double-outlet right ventricle with subpulmonary ventricular septal defect have undergone complete single-stage repair. One patient underwent a two-stage repair because of hemodynamic instability. The median age of repair was 27 days and the median weight was 3.5 kg. Surgical technique involved the arterial switch operation and ventricular septal defect closure when present in 12 patients. One patient with severe subaortic stenosis underwent a modified Damus-Kaye-Stansel operation with concomitant aortic arch enlargement. The aortic arch was enlarged in 12 of 13 patients with a pulmonary homograft patch. RESULTS: There have been no early deaths and only one late death at 39 months postoperatively from hepatoblastoma. The mean follow-up is 42 months. There have been no reoperations for recurrent aortic arch obstruction. All survivors are currently well from a cardiac point of view. CONCLUSIONS: Concomitant single-stage repair for transposition complexes with aortic arch obstruction achieves excellent survival and should be the surgical procedure of choice.

Aorta, Thoracic↗
PubMed1997

One-stage midline unifocalization and complete repair in infancy versus multiple-stage unifocalization followed by repair for complex heart disease with major aortopulmonary collaterals.

BACKGROUND: Patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries have traditionally required multiple unifocalization staging operations before undergoing complete repair. Recently, the feasibility of a single-stage unifocalization and repair was demonstrated by Hanley. In this report, we describe our experience with each approach. METHODS AND RESULTS: Since 1989, 11 of 12 patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries have undergone complete surgical correction. The first seven patients were subjected to staged bilateral unifocalizations, with repair being achieved in six (group I). The last five patients have undergone a single-stage midline unifocalization and repair via a sternotomy (group II). Four of these were infants (2 weeks to 9 months) and one was 13 years old. All patients in group I had tetralogy of Fallot, whereas in group II three patients had tetralogy of Fallot, one patient had double-outlet right ventricle, and one patient had complete atrioventricular canal and transposition. In group I, the median age at the first operation was 43 weeks. Complete repair was performed at a median age of 3.5 years, with a mean number of 3.3 operations required. In group II, only one operation was required to achieve complete repair at a median age of 28 weeks. The postoperative right ventricular/left ventricular pressure ratio was 0.49 in group I and 0.45 in group II. One intraoperative death and one late death occurred in group I and no early or late deaths in group II. Currently, four patients in group I and all five patients in group II are alive and well. CONCLUSIONS: Early intervention with both surgical approaches can lead to complete biventricular repair in most patients. Because the single-stage midline unifocalization and repair can achieve a completely repaired heart in infancy with one operation, it is currently our approach of choice.

Aorta, Thoracic↗
PubMed1995

Institutional experience with a protocol of early primary repair of double-outlet right ventricle.

BACKGROUND: Our institution has adopted a protocol of primary repair for all patients with double-outlet right ventricle. METHODS: Since May 1989, 24 consecutive neonates and infants with double-outlet right ventricle and atrioventricular concordance (median age, 4 months) underwent anatomic biventricular repair. One patient (4%) received prior pulmonary artery banding but was still repaired as a neonate at 22 days of age. Twelve patients had a subaortic ventricular septal defect (VSD), 5 patients a subpulmonary VSD, 3 patients doubly committed VSD, and 4 patients a noncommitted VSD. Sixty-nine of 72 associated lesions were repaired simultaneously. Four types of repairs were used: intraventricular rerouting in 16 patients, arterial switch operation with VSD closure into the pulmonary artery in 4 patients, Rastelli-type repair with extracardiac conduit in 3 patients, and the Damus-Kaye-Stansel repair with concomitant repair of aortic arch obstruction in 1 patient. Ventricular septal defect enlargement was necessary in 15 patients. Repair of subpulmonary stenosis and of subaortic stenosis was carried out in 13 and 4 patients, respectively. Three patients underwent simultaneous repair of aortic arch obstruction with no mortality. Two of the patients with noncommitted VSD had simultaneous repair of complete atrioventricular canal and repair of severe pulmonary venous obstruction. RESULTS: The perioperative mortality was 8% (2 patients, and there was one late death (4%). Two patients (9%) underwent early successful reoperations (5 and 8 weeks postoperatively). The two reoperations were for residual VSD (1 patient) and severe mitral regurgitation (1 patient). All 21 survivors are alive at a mean follow-up of 40 months (range, 7 months to 6 years). The estimated 5-year actuarial survival is 88%, with no deaths after 2 months postoperatively. Ninety-five percent of long-term survivors have no restriction of physical activities because of cardiac status and are receiving no cardiac medications. CONCLUSIONS: An institutional protocol of early anatomic biventricular repair of double-outlet right ventricle in infants and neonates achieves excellent survival, making palliative operations unnecessary. Associated lesions should be repaired simultaneously. The complexity of these malformations requires a highly individualized and flexible surgical approach.

Double Outlet Right Ventricle↗
PubMed1995

The management of chylothorax/chylopericardium following pediatric cardiac surgery: a 10-year experience.

We reviewed the management of 25 cases of chylothorax/chylopericardium (CT/CP) in 24 patients (9 females, 15 male; 3 days to 11-years-old) following 1605 cardiothoracic procedures (incidence of 1.5%) between January 1984 and December 1993 at our institution. The surgical procedures preceding the occurrence of lymph leak included ligation of patent ductus arteriosus (6 patients), coarctation/double aortic arch repairs (3), complex intracardiac repairs (11), and systemic to pulmonary shunts (5). There were 3 CPs and 22 CTs. All of the patients were initially treated nonsurgically with diet modification using either total parenteral nutrition (TPN) or enteral low fat solid food or enteral elemental diet supplemented with intravenous lipid emulsion. Twenty-one cases (84%) responded to conservative therapy. Of those, 15 had TPN as the initial treatment; the average duration of lymph leak was 13.7 (range 7 to 30) days and the average maximal lymph leak was 39.4 (range 15 to 130) mL/kg per day. The other six cases had low-fat enteral diet as the initial treatment, four resolved completely. Two with high-central venous pressure had to be switched to TPN prior to complete resolution. The average duration of lymph leak in this subgroup was 30 (range 12 to 56) days with the average maximal lymph leak was 30.1 (range 8.5 to 59) mL/kg per day. Excluding these two cases, the average lymph leak of the rest of the group was very compatible to the TPN group of 15 days. Lymphocytopenia and hyponatremia were frequently seen during CT/CP (47.6% and 43%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Surgical Procedures↗
PubMed1994

Newborn myocardial protection after prolonged prearrest cooling: a calcium overload phenomenon?

Prolonged cold perfusion of the nonarrested newborn heart has been shown to induce stunning and subsequent contracture when followed by ischemia. The underlying mechanism remains unknown. To test whether this phenomenon is due to cytosolic calcium (Ca2+) overload, a Ca(2+)-channel blocker (verapamil hydrochloride) was used to pretreat the newborn heart immediately before prolonged cold perfusion. Twenty-eight newborn piglets were studied in an isolated, Krebs-Henseleit-perfused Langendorff cardiac model. Group I control hearts (n = 8) were subjected to 90 minutes of cold perfusion at 15 degrees C, followed by 90 minutes of global ischemia and then 30 minutes of normothermic reperfusion. Group II hearts (n = 6) were pretreated with verapamil (0.2 x 10(-7) mol/L) for 3 minutes prior to similar experimentation. Groups III (control, n = 8) and IV (verapamil pretreatment, n = 6) underwent the same protocol without ischemia. Baseline functional measurements were obtained with left ventricular balloon inflated at baseline pressure of 10 to 15 mm Hg prior to cold perfusion and after 30 minutes of normothermic reperfusion. Perfusate creatine kinase level was analyzed, and electron microscopic examination was performed at the conclusion of each experiment. Fifty percent of group I control hearts had no postischemic recovery, and ultrastructural study revealed marked contraction bands.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1994

Successful management of postoperative chylothorax with fibrin glue in a premature neonate.

Chylothorax is a potentially serious condition that may complicate a variety of thoracic operations, particularly cardiothoracic procedures for congenital heart disease. Conservative therapy with chest tube drainage of the chyle fluid and dietary manipulations is frequently effective. When conservative treatment fails, surgery may be necessary. In this report, the authors discuss their recent experience with fibrin glue in the management of a 600-g premature neonate who had a postoperative chylothorax. Recent trends in the management of this difficult problem are also discussed.

Chest Tubes↗
PubMed1993

Double-lung transplantation in mechanically ventilated patients with cystic fibrosis.

Many lung transplant programs consider ventilator dependence as a contraindication for transplantation. Among 54 patients in whom bilateral lung transplantations for cystic fibrosis were performed by the Joint Marseille-Montreal Lung Transplant Program, 10 were ventilator dependent. Three of them died in the early postoperative period (30%): 2 as a result of cerebral anoxia and sepsis, 1 of Pseudomonas cepacia pneumonia. Two patients died at 15 and 19 months after transplantation of obliterative bronchiolitis and secondary bacterial pneumonitis. Another 2 patients in whom obliterative bronchiolitis developed underwent retransplantation with a heart-lung block; 1 of those was operated on at 12 months and is well at 29 months after his initial transplantation; the second was operated on at 34 months and died of primary graft failure. Three other patients are alive and well at 3, 11, and 14 months after transplantation. Actuarial survival at 1 year was 70%. The postoperative course and the infectious and rejection complications were no different from those in patients who underwent transplantation while spontaneously breathing. Obliterative bronchiolitis developed in 66% of patients at risk (2 of 6 patients surviving more than 6 months). We conclude that transplantation in mechanically ventilated patients with cystic fibrosis is not associated with an increase in morbidity or mortality after bilateral lung transplantation. Long-term survival, as in patients who undergo transplantation while spontaneously breathing, is limited by the development of obliterative bronchiolitis.

Adolescent↗
PubMed1993

Atrial myxomas in young children: an alternative surgical approach.

A case report and a brief review of the literature on atrial myxomas in young children (5 years and younger) are presented. Right atrial myxomas are predominant in this age group in contrast to older children and adults. The echocardiogram alone can provide clear anatomic information for the operation. For large left atrial myxomas, wide exposure through a transverse biatrial incision is recommended to avoid tumor manipulation and facilitate en bloc resection.

Cardiac Surgical Procedures↗
PubMed1993

Contracture of the newborn myocardium after prolonged prearrest cooling.

Profound hypothermic circulatory arrest is frequently used to facilitate the surgical repair of congenital heart defects in neonates. Deep hypothermia is achieved by a period of core systemic cooling during cardiopulmonary bypass before cardioplegic arrest. There have been conflicting reports with respect to the consequence of perfusing a nonarrested newborn heart under hypothermic conditions. This in vitro study was designed to prolong the clinically simulated hypothermic perfusion sequence into an extreme condition and to test the hypothesis that prolonged cold perfusion of the nonarrested newborn myocardium could, in fact, be detrimental. Twenty-four newborn piglets (5 to 7 days old) were randomly assigned to four groups and studied in a crystalloid perfused Langendorff heart model. The first two groups of hearts (n = 6 per group) were subjected to either 30 minutes (group I) or 90 minutes (group II) of cold perfusion at 15 degrees C, followed by 90 minutes of ischemia and then 30 minutes of normothermic reperfusion. In a second experiment, group III hearts subjected to 30 minutes of cold perfusion were compared with group IV (90 minutes of cold perfusion) without ischemic insult in either case. Postischemic recovery of isovolumetric developed pressure was significantly impaired in group II (16.1% +/- 7.4% [II] versus 65.5% +/- 4.8% [I], p < 0.05), and 50% of the hearts had no spontaneous cardiac activity on reperfusion. End-diastolic pressure showed significant contracture with prolonged cold perfusion: group II 57.3 +/- 13.9 mm Hg versus group I 14.8 +/- 1.8 mm Hg, p < 0.05. In the absence of ischemia, a similar relationship was observed between groups IV and III (left ventricular developed pressure 68.5% +/- 3.6% versus 82.4% +/- 4.2%, p < 0.05, and left ventricular end-diastolic pressure 23.5 +/- 6.2 mm Hg versus 13.3 +/- 2.6 mm Hg, p = not significant. Ultrastructural examination revealed severe damage to the myocardial cells and contraction band necrosis in group II (prolonged cooling and ischemia). These results suggest that prolonged cold perfusion of the nonarrested newborn heart impairs functional recovery and is therefore detrimental. When followed by a period of ischemic arrest, it further potentiates the myocardial injury and induces severe contracture. This preceding adverse effect of prolonged myocardial cold perfusion before cardiac arrest may, in part, explain the suboptimal protective effect of cardioplegia in neonates.

Animals↗
PubMed1992

Adverse effect of prearrest hypothermia in immature hearts: rate versus duration of cooling.

It has been suggested that rapid cooling before the induction of arrest may be harmful to the newborn myocardium. The objective of this study was twofold: (1) to evaluate whether prearrest rapid cooling is indeed detrimental to myocardial recovery and (2) if so, to evaluate whether the adverse effect of prearrest hypothermia is dependent on the rate of cooling or the total duration of cold perfusion. After an initial stabilization period isolated Langendorff hearts (n = 5 per group) from neonatal piglets (5 to 7 days old) were randomized to four groups: group 1, 5 minutes of rapid cooling to 15 degrees C; group 2, 20 minutes of slow cooling to 15 degrees C; group 3 and group 4, rapid and slow cooling, respectively, with the addition of St. Thomas cardioplegic solution. All groups were then subjected to 2 hours of ischemia at 15 degrees C followed by 30 minutes of reperfusion at 38.5 degrees C. Post-ischemic recovery of left ventricular developed pressure was significantly greater in group 1 versus group 2 (80% +/- 3% versus 61% +/- 2%; p less than 0.05) and in the presence of cardioplegia, group 3 versus group 4 (72% +/- 3% versus 57% +/- 3%; p less than 0.05). The increase in left ventricular end-diastolic pressure was significantly less in group 1 versus group 2 (8% +/- 5% versus 33% +/- 7%; p less than 0.01). Myocardial adenosine triphosphate content recovery correlated with ventricular recovery.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosine Triphosphate↗
PubMed1992

Clinical outcomes after the arterial switch operation for transposition. Patient, support, procedural, and institutional risk factors. Congenital Heart Surgeons Society.

BACKGROUND: As the probability increases that the arterial switch operation is optimal treatment for transposition, detailed information about outcomes and the circumstances in which they are suboptimal becomes important. METHODS AND RESULTS: A multi-institutional prospective study with annual detailed follow-up included 513 neonates with simple transposition or transposition and ventricular septal defect entering for diagnosis and treatment at < 15 days of age and undergoing an arterial switch repair. The 1-month and 1- and 5-year survivals were 84%, 82%, and 82%, respectively. The hazard function for death had a rapidly declining single phase that approached zero by 12 months after surgery. Among the eight patients who died > or = 3 months after the operation, four had severe ventricular dysfunction, probably related to imperfect coronary arterial transfer. Coexisting single ventricular septal defect was not a risk factor for death. Origin of the left main coronary artery or only the left anterior descending or the circumflex artery from the right posterior sinus (sinus 2) was a risk factor that was even stronger when an intramural course was present; multiplicity of ventricular septal defects was a risk factor. Longer global myocardial ischemic time and total circulatory arrest time were risk factors. Certain institutions were shown to be risk factors for death; the results in some improved with increasing experience, in some they did not, and in some they worsened. CONCLUSIONS: Good early and intermediate-term clinical outcomes can be obtained in neonates with simple transposition and transposition and ventricular septal defect by use of the arterial switch operation. Certain coronary artery patterns and certain institutions lessen the goodness of outcome.

Coronary Vessel Anomalies↗
PubMed1992

Oral vitamin E prophylaxis in the protection of newborn myocardium from global ischemia.

BACKGROUND: Oxygen-derived free radicals have been implicated in the pathophysiology of myocardial reperfusion injury after ischemic insult. Recent studies have demonstrated that free radical scavengers could afford protection to the mature myocardium from these injuries. The purpose of this study was to investigate whether oral vitamin E pretreatment could improve the tolerance of newborn hearts to ischemia. METHODS: Two groups of six newborn piglet hearts were randomly studied in an isolated, perfused Langendorff heart model. Group I control hearts were subjected to 30 minutes of cold perfusion at 15 degrees C, in which profound hypothermia was achieved over a period of 10 minutes. This was followed by 90 minutes of global ischemia arrest and 30 minutes of normothermic reperfusion. Group II piglets were pretreated with d-alpha-tocopherol (vitamin E) given by oral gavage for 4 days before similar experimentation. Baseline functional parameters were recorded before cold perfusion by a left intraventricular balloon inflated to a diastolic pressure of 11 to 14 mm Hg and repeated at the end of 30 minutes of normothermic reperfusion. Creatine phosphokinase leakage in the perfusate was analyzed immediately after reperfusion and the pressure/volume ratio was obtained at the conclusion of each experiment. RESULTS: Postischemic functional recovery of vitamin E-pretreated group II hearts was improved significantly compared with the control hearts (group I). Left ventricular diastolic pressure was 87.5% +/- 2.3% versus 66.1% +/- 2.3%, +dp/dt was 94.5% +/- 2.2% versus 68.0% +/- 5.6%, -dp/dt was 93.0% +/- 2.4% versus 69.6% +/- 6.0%, mean left ventricular end-diastolic pressure was 13.0 +/- 0.8 versus 22.0 +/- 3.5 mm Hg, and pressure/volume ratio was 29.2 +/- 2.3 versus 41.8 +/- 4.3 mm Hg/ml, respectively (p less than 0.05). Perfusate creatine phosphokinase leakage was also reduced significantly from 112.5 +/- 17.9 to 56.2 +/- 4.0 IU/L (p less than 0.05) in group II. CONCLUSIONS: Oral vitamin E pretreatment improved the ischemic tolerance of newborn myocardium and therefore might be considered a valuable, effective, and inexpensive method of myocardial protection.

Administration, Oral↗
PubMed1990

Pericardial effusion after cardiac surgery in children and effects of aspirin for prevention.

Seventy-four children aged 0.3 to 21.4 years (median 4.0) were followed echocardiographically on days 4, 7, 14 and 28 (+/- 2 days) after cardiac surgery to evaluate the incidence of postoperative pericardial effusion, to identify the patients at greatest risk of developing an effusion and to evaluate the use of aspirin as prophylaxis against pericardial effusion. Pericardial effusion was graded relative to the size of the aortic root from grade 0 (no effusion) to grade 5 (larger than the aortic root dimension). Patients were randomly divided into 2 groups: group 1 (32 patients) received aspirin 60 mg/kg/day for 7 days starting on the third postoperative day; group 2 (42 patients) received no aspirin. Forty-eight patients (65%) developed an effusion during the study period, 3 required pericardiocentesis and 1 died of tamponade. All patients with tamponade had a grade 4 effusion. Age or type of operation did not alter the cumulative incidence of significant effusion. No patient with a grade 0 effusion on the first echocardiogram developed a grade 4 or 5 effusion. Results in groups 1 and 2 were similar. Pericardial effusions are common in the first month after cardiac surgery. Patients with no effusion in the immediate postoperative period appear to be at lesser risk of developing a grade 4 effusion in the first month after operation. Finally, aspirin prophylaxis against postoperative pericardial effusions did not significantly alter the outcome in this small series of patients.

Adolescent↗
PubMed1990

Norwood operation for univentricular heart with subaortic stenosis in the neonate.

In the setting of a single ventricle, subaortic stenosis may be enhanced by pulmonary artery banding and may later contraindicate a Fontan operation. The Norwood operation may prove a preferable alternative in some infants as a preparatory procedure. We have successfully used this procedure as the initial operation to palliate a newborn with tricuspid atresia, transposition of the great arteries, coarctation, and severe arch hypoplasia secondary to a restrictive bulboventricular foramen.

Abnormalities, Multiple↗
PubMed1990

Sternotomy after muscle flap repair of sternal osteomyelitis and mediastinitis.

A 61-year-old man who had undergone aortocoronary bypass developed sternal osteomyelitis and mediastinitis which required sternal debridement and muscle flap interposition. Two years later the midline incision was used for an orthotopic heart transplantation. No major technical difficulties were encountered at the time of transplantation.

Coronary Artery Bypass↗