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Biomedical subjects

F M Lupinetti

Publications and source records attributed to F M Lupinetti.

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

Procollagen production in fresh and cryopreserved aortic valve grafts.

Long-term durability of aortic valve allografts may be enhanced by cellular capacities for regeneration and repair. To evaluate aortic valve graft production of an important structural protein, rat aortic roots were implanted heterotopically into the abdominal aorta of recipient rats. Grafts were either syngeneic or strongly allogeneic, were implanted either fresh or after cryopreservation, and were left in place 2 to 21 days after implantation. A total of 80 aortic valve grafts and the corresponding native aortic valves were examined. The grafts were retrieved and immunocytochemically stained for the presence of procollagen, a precursor to collagen. Regardless of histocompatibility or preservation, grafts exhibited consistent procollagen presence that equaled or exceeded that seen in the corresponding native valves. Positive procollagen staining was predominantly in the aortic wall. The most prominent staining was near the hinge point of the valve leaflets, with no staining in the free portion of the leaflets. Staining with alpha-actin demonstrated vascular smooth muscle in sites remote from the areas positive for procollagen, which suggests that vascular smooth muscle was not responsible for the procollagen production. These findings indicate that cryopreservation is compatible with persistent fibroblast viability and in vivo protein synthesis by both syngeneic and allogeneic aortic valve grafts.

Animals↗
PubMed1996

Stent redilation in canine models of congenital heart disease: pulmonary artery stenosis and coarctation of the aorta.

In a canine puppy model, pulmonary artery stenosis was created by banding the left pulmonary artery to 30-40% of its original diameter. Animals underwent right heart catheterization and angiography 1-2 mo later, and Palmaz P308 stents were implanted. Stent redilation was performed 3-5 mo later. One mo postredilation, the animals were restudied and sacrificed. Coarctations of the aorta were created by transverse aortic incision and longitudinal repair. P308 stent implantation was performed 2-3 mo later. Stent redilation was performed after 6-10 mo, and the animals were restudied and sacrificed 1-2 mo later. Stent implantation was performed in 6 puppies with pulmonary artery stenosis, as 2 animals developed postoperative pulmonary arterial hypoplasia, precluding stenting. The stenosis diameter increased from 4.8 +/- 0.5 mm to 7.4 +/- 0.6 mm (mean +/- SE) following stenting (P = 0.005), and increased further to 9.2 +/- 0.7 mm following redilation (P < 0.001). There were no significant vessel tears or ruptures. Coarctation stenting was performed in 8 animals. The coarctation was dilated from 5.8 +/- 0.9 mm to 9.8 +/- 0.6 mm (P < 0.001), and to 13.5 +/- 0.5 mm at redilation (P = 0.002). Redilation could not be performed in 1 animal. Aortic rupture and death occurred in 2 of 7 animals at redilation. Stent implantation and redilation in experimental pulmonary artery stenosis appears safe and effective. Though stent implantation for coarctation of the aorta appears safe, there was a 28% aortic rupture rate at stent redilation in this model.

Angioplasty, Balloon↗
PubMed1995

The effects of cyanosis on myocardial blood flow, oxygen utilization, and lactate production in dogs.

To elucidate differences in myocardial blood flow and metabolism between cyanotic and normal hearts, a model of chronic cyanosis was created in five adult mongrel dogs by anastomosing the inferior vena cava to the left atrium. After 6 to 9 months, myocardial blood flow, the ratio of subendocardial to subepicardial flow, oxygen consumption, oxygen extraction ratio, and lactate consumption in these cyanotic dogs and five control dogs were determined under baseline conditions and during pharmacologic stress with isoproterenol (0.2 micrograms/kg/min). Radioactive microspheres were used to determine left and right ventricular blood flow rates, and arterial and coronary sinus differences in oxygen and lactate levels were measured. At baseline and during stress, oxygen consumption and oxygen extraction ratios were identical in control and cyanotic hearts. Total myocardial blood flow was increased with stress and did not differ between cyanotic and control hearts. Left ventricular muscle from cyanotic hearts did exhibit lower endocardial/epicardial blood flow ratios than those of control hearts at rest, and the relative subendocardial flow decreased further with stress. During isoproterenol infusion, myocardial lactate production, indicative of anaerobic metabolism, was evident in two of five cyanotic animals and none of the control dogs. The relative subendocardial ischemia and its further aggravation by stress in cyanotic hearts may contribute to the pathophysiologic basis of myocardial dysfunction in cyanotic heart disease.

Animals↗
PubMed1994

Comparison of a low osmolarity nonionic radiographic contrast agent with a standard medium on renal function in cyanotic and normal dogs.

Renal dysfunction may follow administration of iodinated radiographic contrast agents. This complication may be less common when low osmolarity nonionic agents are used. Although potential benefits from the use of low osmolarity nonionic contrast may be minimal in individuals with normal physiology, a greater benefit has been postulated in the presence of chronic cyanosis. To test this hypothesis, six adult mongrel dogs underwent anastomosis of the inferior vena cava to the left atrium. This produced chronic cyanosis with a mean pO2 of 48 +/- 4 mm Hg and polycythemia with a mean hematocrit of 56 +/- 2 gm%. Three to 5 months after preparation, these cyanotic dogs and five control dogs each received diatrizoate (a high osmolarity ionic agent) or ioversol (a low osmolarity nonionic agent), 465 mg iodine/kg body weight, by intravenous bolus injection. One month later, each animal received the other agent. The order of administration was randomized. Renal function studies, including serum creatinine and creatinine clearance, were performed precontrast, after 60 min, and 24 hr postcontrast. Neither agent adversely affected renal function in either the cyanotic or the normal group. We conclude that at the doses that are commonly used in clinical practice, high osmolarity ionic contrast agents do not create a greater risk of renal injury than do low osmolarity nonionic agents in this model of cyanosis.

Angiocardiography↗
PubMed1994

Selective lung or heart-lung transplantation for pulmonary hypertension associated with congenital cardiac anomalies.

Fixed pulmonary hypertension has been a contraindication to correction of congenital heart defects. Beginning in February 1991, we pursued a policy of performing single-lung transplantation with intracardiac repair for selected patients with this physiology, reserving heart-lung transplantation for those with unreconstructable heart disease. Of 7 patients treated under this protocol, 5 underwent single-lung transplantation and intracardiac repair. The cardiac anomalies included complete atrioventricular canal (1), aortopulmonary window (1), atrial septal defect (1), and ventricular septal defect (2). One patient died perioperatively. All 4 patients surviving operation remained alive through the first postoperative year, but 3 died 13, 17, and 22 months after operation. Two other patients with pulmonary hypertension (1 with tricuspid atresia, 1 after failed Mustard procedure) received a heart-lung transplant and are well 15 and 18 months after operation. This experience demonstrates that selected patients with major intracardiac defects and pulmonary hypertension may have good early results after cardiac repair and single-lung transplantation, but that long-term results are considerably less favorable.

Adolescent↗
PubMed1994

Regulation of pulmonary vascular resistance by endogenous and exogenous nitric oxide.

Inhaled nitric oxide (NO) causes selective pulmonary vasodilation under conditions of hypoxia or pulmonary vascular dysfunction. We have observed that NO affects canine pulmonary vascular resistance minimally under normal conditions. We hypothesized that endogenous NO is partly responsible for pulmonary vasomotor regulation in normoxic and hypoxic states. Dogs were studied before and after pulmonary endothelial injury with monocrotaline and N-omega-nitro-L-arginine (LNNA). Systemic vascular resistance was unaffected by NO. Under normal conditions, exogenous NO had little effect on pulmonary vascular resistance. After monocrotaline administration, baseline pulmonary vascular resistance was unchanged but decreased further in response to NO. After LNNA administration, pulmonary vascular resistance increased and there was an exaggerated increase with hypoxia that was reduced by NO. The effect of monocrotaline on in vitro endothelial function was evaluated with isolated pulmonary arteries, which showed a decreased relaxation response to bradykinin (an endothelial-dependent vasodilator) and a normal response to nitroprusside (an endothelial-independent vasodilator). These results support the hypothesis that endogenous NO is an important regulator of pulmonary vasomotor tone and is of even greater importance during hypoxia.

Animals↗
PubMed1994

Systemic ventricular outflow obstruction progresses after the Fontan operation.

To evaluate the course of systemic ventricular outflow obstruction after the Fontan operation, the records of 57 hospital survivors of that procedure were reviewed. Ventricular outflow obstruction was identified in 7 patients (group 1) and was absent in 50 patients (group 2). Overall, the ventricular outflow gradient in group 1 was 6.3 +/- 2.9 mm Hg (mean +/- standard error) before the Fontan operation and 7.6 +/- 3.9 mm Hg at hospital discharge. Ventricular outflow obstruction subsequently progressed to 80.1 +/- 17.3 mm Hg (range, 33 to 165 mm Hg; p < 0.02) a mean of 28 months postoperatively. One patient died of severe progressive ventricular outflow obstruction. Group 1 did not differ from group 2 in age, ventricular morphology, presence of a subaortic outflow chamber, prior shunt, or length of follow-up. Compared with group 2, however, patients in group 1 more commonly had an aorta arising from a hypoplastic ventricle (p < 0.001) and had undergone prior pulmonary artery banding (p = 0.005). We conclude that systemic ventricular outflow obstruction occurs commonly after a Fontan procedure (incidence, 12%; 70% confidence interval, 9% to 18%) and is a progressive lesion.

Child, Preschool↗
PubMed1994

Improving results with first-stage palliation for hypoplastic left heart syndrome.

Between January 1990 and February 1993, 73 patients underwent first-stage reconstruction for hypoplastic left heart syndrome at the University of Michigan Medical Center. During this period, surgical reconstruction remained essentially constant and consisted of a pulmonary artery-to-aorta anastomosis with allograft augmentation of the ascending, transverse, and proximal descending aorta, restriction of pulmonary blood flow with a polytetrafluoroethylene shunt from the innominate artery to the central pulmonary artery confluence, and atrial septectomy. Hospital survival was 62 of 73 patients, 85% (70% confidence limits: 80% to 89%). These results stand in marked contrast to those obtained during the earlier years of our experience from 1986 to 1989 when only 21 of 50 patients (42%, 70% confidence limits: 35% to 49%) survived (p = 0.001). Among the most recent group of patients, only 2 of 7 patients older than 1 month of age at operation survived, whereas 60 of 66 (91%, 70% confidence limits: 87% to 94%) patients younger than 1 month of age survived (p = 0.0001). Anatomic subtype and ascending aortic diameter were not predictive of survival. Actuarial survivals for those patients younger than 1 month of age at the first-stage operation, including hospital deaths and subsequent operative procedures, were 81%, 74%, and 74% at 6 months, 1 year, and 2 years, respectively. These results indicate that survival for patients after first-stage reconstruction for hypoplastic left heart syndrome has significantly improved in recent years. Older age was a strong risk factor, with a hospital survival of 91% for those patients undergoing first-stage palliation within the first month of life. These data have important implications for the type of operative intervention and its timing.

Actuarial Analysis↗
PubMed1994

Effects of preservation techniques on in vivo expression of adhesion molecules by aortic valve allografts.

Methods of sterilization and preservation of aortic valve allografts influence graft longevity. The effect of storage techniques on valve durability may be mediated by alterations in the immunologic properties of the allograft, which are reflected by expression of leukocyte adhesion molecules. Rat aortic valve grafts were transplanted in the fresh state, after cryopreservation (-196 degrees C), or after storage at 4 degrees C for 1 to 21 days. Syngeneic and strongly allogeneic valves were transplanted for 4 hours to 21 days and were retrieved for immunohistochemical staining for expression of leukocyte adhesion molecules. Unimplanted valves and transplanted syngeneic valves, regardless of storage methods, exhibited little or no expression of leukocyte adhesion molecules. Fresh allogeneic valves expressed all molecules, indicating up-regulation, at all time intervals studied. Cryopreserved allogeneic valves demonstrated no leukocyte adhesion molecules at 4 hours or 2 days and weak reactivity at 10 and 21 days. Allogeneic valves stored at 4 degrees C, regardless of the duration of storage, demonstrated weak expression of all molecules at 10 days and strong expression at 21 days. Expression of leukocyte adhesion molecules requires an allogeneic environment and may precede immune-mediated injury. Reduced expression of leukocyte adhesion molecules resulting from storage may predict a diminished immunologic response. Cryopreservation (-196 degrees C) causes the greatest delay and diminution of expression of leukocyte adhesion molecules.

Animals↗
PubMed1994

Central pulmonary artery growth patterns after the bidirectional Glenn procedure.

The changes in pulmonary artery size and hemodynamics in 30 patients with univentricular cardiac anatomy were examined before and after bidirectional Glenn procedures done between October 1989 and February 1992. Serial angiographic and hemodynamic examinations before and 17.6 +/- 1.6 months after bidirectional Glenn procedures were compared. At the follow-up study there was no significant change in diameter of the pulmonary artery ipsilateral to the bidirectional Glenn shunt, however, a significant decrease was noted in the diameter of the pulmonary artery contralateral to the bidirectional Glenn shunt (p = 0.04). There was also a 32% decrease in the Nakata index of total cross-sectional pulmonary artery area after the bidirectional Glenn procedure (p = 0.004). Total pulmonary blood flow and mean pulmonary artery pressure had decreased, and arterial oxygen saturation had increased at follow-up. These changes, however, did not correlate with the observed changes in pulmonary artery size. By linear regression analysis, a significant relationship was identified between the Nakata index before the bidirectional Glenn procedure and the absolute change in Nakata index (r = 0.83). A significant decrease in Nakata index occurred only in patients with a bidirectional Glenn shunt in place more than 15 months. Sixteen of the 30 patients subsequently underwent total cavo-pulmonary anastomosis with 7 requiring concurrent surgical pulmonary artery reconstruction. Changes in pulmonary artery size observed more than 15 months after the bidirectional Glenn procedure may have implications for subsequent Fontan repair in children with univentricular anatomy.

Arteriovenous Shunt, Surgical↗
PubMed1994

Pulmonary function in single lung transplantation for chronic obstructive pulmonary disease.

The primary determinants of pulmonary function after heart-lung or double lung transplantation are the volume and compliance of the recipient's thoracic cage. This study evaluated the influence of recipient chest wall factors on static and dynamic lung volumes after single lung transplantation for chronic obstructive pulmonary disease. Fourteen patients with chronic obstructive pulmonary disease received 15 single lung transplants (one retransplant). Posttransplantation follow-up data at 3 and 6 months, in the absence of infection or rejection, were available in nine patients. Overall pulmonary function at 6 months improved from preoperative levels to 55% to 65% of predicted values (forced vital capacity 38% to 55%, forced expiratory volume at 1 second 18% to 55%, maximum voluntary ventilation 21% to 65%), and allograft-specific pulmonary function improved to nearly normal predicted single-lung values (forced vital capacity 89%, forced expiratory volume at 1 second 90%, maximum voluntary ventilation 105%). Postoperative pulmonary function in these patients correlated significantly with preoperative thoracic volume measured by planimetry of chest radiographs. No correlation between postoperative pulmonary function was demonstrated with either the estimated volume of donated lung tissue or relative donor-to-recipient size matching. These findings support the concept that recipient chest wall factors determine postoperative pulmonary function in patients undergoing single lung transplantation for chronic obstructive pulmonary disease. Furthermore, the allograft lung functions at a normal level for the recipient and does not appear to be constrained by hyperinflation of the contralateral lung.

Adult↗
PubMed1994

Developmental differences in myocardial protection in response to 5'-nucleotidase inhibition.

Age-related differences in the activity of 5'-nucleotidase, an enzyme responsible for conversion of high-energy phosphates to their the diffusible precursors, may help to explain age-related differences in tolerance of global myocardial ischemia. Postischemic function and high-energy phosphate content were measured in the hearts of rabbits 7 to 10 days old (neonate), 30 to 40 days old (1 month), and 6 to 12 months old (adult). Hearts in each age group were subjected to 60 minutes of ischemia at 34 degrees C either with no cardioplegia, with unmodified St. Thomas' Hospital cardioplegic solution, or with St. Thomas' Hospital cardioplegic solution with pentoxifylline, a 5'-nucleotidase inhibitor. These groups were compared with one another and with control hearts that were continuously perfused for 1 hour. In adults, addition of pentoxifylline to St. Thomas' Hospital cardioplegic solution restored adenosine triphosphate and total nondiffusible nucleotide levels to control values and improved recovery of cardiac output and developed pressure compared with results with unmodified St. Thomas' Hospital cardioplegic solution. In contrast, biochemical and functional parameters in neonatal hearts were not affected by either unmodified St. Thomas' Hospital cardioplegic solution cardioplegia or St. Thomas' Hospital cardioplegic solution with pentoxifylline. Functional recovery in neonatal hearts subjected to unprotected ischemia was superior to that in the older age groups. In 1-month-old hearts, St. Thomas' Hospital cardioplegia improved recovery compared with recovery after unprotected ischemia, but no incremental improvement in function or high-energy stores was seen with addition of pentoxifylline. The lack of effect of pentoxifylline on neonatal hearts suggest that there is a relative deficiency of 5'-nucleotidase in this age group. This may contribute to the improved functional recovery observed in unprotected hearts. Furthermore, addition of pentoxifylline to adult hearts appears to confer the benefits of low 5'-nucleotidase activity occurring naturally in the neonate.

5'-Nucleotidase↗
PubMed1993

Usefulness of the bidirectional Glenn procedure as staged reconstruction for the functional single ventricle.

The bidirectional Glenn operation may be particularly useful as an intermediate procedure before Fontan correction in high-risk patients. From October 1989 through February 1992, 50 patients 1 to 60 months old (median 12) have undergone a bidirectional Glenn operation. Diagnoses included hypoplastic left heart syndrome in 21 patients, pulmonary atresia with intact ventricular septum in 10, tricuspid valve atresia in 9, other complex univentricular heart defects in 9, and Ebstein's anomaly in 1. Mean pulmonary vascular resistance was 2.2 +/- 0.2 Wood U (range 0.5 to 7.3) and mean pulmonary artery area Nakata index was 318 +/- mm2/m2 (range 80 to 821). Additional procedures were performed in 17 patients, including pulmonary artery reconstruction in 15 (29%) and bilateral caval anastomoses in 5 (10%). There were 4 hospital deaths (8%). Two deaths resulted from myocardial infarction in patients with pulmonary atresia with intact ventricular septum and sinusoids and 1 from severe pulmonary vascular disease in a patient with hypoplastic left heart syndrome. There was 1 late death from pneumonia. Actuarial survival is 92 +/- 4% at 1 month and beyond, with a mean follow-up of 13.4 +/- 1 months. Risk factor analysis showed that pulmonary vascular resistance > 3 Wood U and pulmonary artery distortion were associated with increased mortality. Twelve patients have undergone a Fontan procedure at a mean duration after bidirectional Glenn of 18 months with 1 death (8%). The bidirectional Glenn procedure provides excellent palliation in high-risk patients and appears useful as a staging procedure before Fontan correction.

Anastomosis, Surgical↗
PubMed1993

Endothelial cell replication in an in vivo model of aortic allografts.

Previous studies of aortic valve allograft viability have used in vitro assessments that may not reflect in vivo properties. This study evaluated in vivo endothelial cell replication in experimental valved aortic grafts and examined the consequences of histoincompatibility and cryopreservation. Valved aortic conduits were heterotopically transplanted into syngeneic or allogeneic rats. Tritiated thymidine was administered to graft recipients and control rats. After 72 hours, monolayers from the native aortas and the aortic portion of the grafts were prepared for autoradiography, with six or more silver grains per nucleus considered evidence of replication. Percentages of replicating cells in native aortas ranged from 0.3% to 2.3% (p = not significant). Percentages of replicating cells in the fresh isografts (12.4%) and allografts (12.2%) were not significantly different from each other, although each was significantly greater than the percentage in its native aorta (p < 0.04). Cryopreserved allografts and isografts displayed a few endothelial cells, none of which was replicating. Immunologic differences do not affect endothelial cell replication in this early period after fresh graft transplantation. Cryopreservation, however, results in the absence of replicating endothelium.

Animals↗
PubMed1993

Balloon-expandable stent treatment of experimental coarctation of the aorta: early hemodynamic and pathological evaluation.

The present study was intended to evaluate the acute and short-term hemodynamic, angiographic, and pathological response to balloon-expandable stent treatment of experimental coarctation of the aorta. A discrete thoracic coarctation was surgically created in six mongrel dogs (two adults, four puppies). Two months postoperatively all six dogs (8.9-30 kg) underwent left heart catheterization and coarctation stenting performed through a femoral artery cutdown. A Palmaz PS-30 stent was advanced to the coarctation through a 10 French sheath, and expanded with an angioplasty balloon chosen to equal the diameter of the proximal aorta (9-12 mm). Stent implantation was successful in each dog. The systolic pressure gradient decreased from 26.3 +/- 9.1 mmHg (mean +/- SE) to 0.5 +/- 0.5 mmHg (P = 0.04), and the coarctation diameter improved from 50 +/- 6% to 82 +/- 6% of the diameter of the proximal descending aorta (P less than 0.01). Follow-up catheterization 4-7 weeks after stenting documented no stent migration, early restenosis, thrombosis, obstruction of arterial side branches, or aneurysm formation. Pathological evaluation of the explanted segments of stented aorta documented that by 6-7 weeks the stents are covered by a neointima composed of intimal proliferation and fibrosis with an endothelial cell surface. These data suggest that balloon-expandable stainless steel stents provide excellent acute and short-term relief of coarctation in this experimental model. Larger and longer-term studies are needed to better assess the incidence of restenosis or aneurysm formation following stenting of coarctation of the aorta.

Angiography↗
PubMed1993

Intraoperative and percutaneous stenting of congenital pulmonary artery and vein stenosis.

BACKGROUND: Conventional surgical or balloon dilation therapy for pulmonary artery or vein stenosis has been unsatisfactory in many patients. Balloon-expandable stents offer a new form of treatment for these vascular stenoses and can be implanted percutaneously or intraoperatively. METHODS AND RESULTS: Between July 1991 and October 1992, 20 balloon-expandable Palmaz stents (Johnson & Johnson) were implanted in 16 children at median age and weight of 3.0 years and 12.8 kg, respectively. Stent implantation was performed intraoperatively (n = 15) if the patient was less than 1 year of age or less than 10 kg in weight, in cases where limited vascular access precluded percutaneous implantation, or as an adjunct to other intracardiac surgery. Otherwise, percutaneous stenting was performed (n = 5). Vessels were tested for distensibility by dilation with balloon catheters or vascular sounds. Stents were implanted using angioplasty catheter balloons chosen to achieve desired vessel diameter and inflated to 4 to 17 atm. Acute hemodynamic and cineangiographic studies were performed in all patients immediately after the procedure to 2 months after stenting. After pulmonary artery stent implantation, mean pulmonary artery diameter increased from 5.6 to 11.5 mm (P = .001), with a decrease in mean systolic pressure gradients from 43 to 8.0 mm Hg (P = .005). Follow-up cardiac catheterization (mean, 8.7 months) in 3 patients revealed no restenosis, thrombosis, or aneurysm formation. In patients in whom pulmonary vein stents were implanted, mean pressure gradients fell from 11 to 0.3 mm Hg (P = .03), and mean pulmonary capillary wedge pressure fell from 17 to 6.3 mm Hg (P = .03) immediately after stenting. At 2- to 6-month follow-up, cardiac catheterization documented restenosis within the stent in 2 of 3 patients. The third patient died 2 months after stenting from presumed vein reocclusion. CONCLUSIONS: When implanted intraoperatively or percutaneously, balloon-expandable endovascular stents have been efficacious in the treatment of pulmonary artery stenosis. Longer follow-up will be necessary to document the long-term effectiveness of pulmonary artery stenting. Preliminary data suggest that early restenosis is common after pulmonary vein stenting. The intraoperative approach extends stenting therapy to smaller children and to patients who have limited percutaneous access.

Angioplasty, Balloon↗
PubMed1993

Correction of total anomalous pulmonary venous connection in infancy.

From January 1985 through January 1993, 41 patients less than 1 year of age underwent operative correction of isolated total anomalous pulmonary venous connection. There were 24 boys and 17 girls. The median age at operation was 13 days (range 1 to 282 days) and weight was 3.6 kg (2.5 to 5.2 kg). Locations of the connections were supracardiac in 19, cardiac in 9, infracardiac in 11, and mixed supracardiac and cardiac in 2. Obstruction of the pulmonary veins was severe in 24, mild in 3, and absent in 14. Preoperative stabilization included mechanical ventilation for 15 patients for a mean duration of 2 1/2 days and extracorporeal membrane oxygenation for 1 patient for 1 day. All operations were performed with deep hypothermia and circulatory arrest (mean arrest time 34 minutes). Supracardiac connections were repaired by performing a side-to-side anastomosis between the pulmonary venous confluence and the dome of the left atrium through a superior approach between the superior vena cava and the aorta. Coronary sinus connections were repaired by enlarging the atrial septal defect and the coronary sinus communication with the left atrium and closing the atrial defect with a large patch. Infracardiac repairs included elevation and rotation of the heart to the right and an elongated side-to-side anastomosis between the common venous confluence and the left atrium. One patient died 1 week postoperatively of persistent pulmonary hypertension. Another patient, who was supported by extracorporeal membrane oxygenation before the operation, died 3 months after the operation as a consequence of pulmonary lymphangiectasia. All other patients are alive and well with a mean follow-up of 26 months (range 3 to 77 months). One patient required two subsequent reoperations for persistent pulmonary venous obstruction, and another patient had superior vena cava obstruction necessitating reoperation. Operative treatment of total anomalous pulmonary venous connection in infants can be performed with low mortality and an infrequent need for reoperations.

Cardiac Surgical Procedures↗