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Biomedical subjects

J Bruniaux

Publications and source records attributed to J Bruniaux.

At least 55 records · Page 3Linked to original sources
PubMed1994

Conventional cardiopulmonary bypass in neonates. A physiological approach--10 years of experience at Marie-Lannelongue Hospital.

There is still controversy about the optimal method of venoarterial cardiopulmonary bypass (CPB) for correction of congenital heart disease in neonates and young infants. High rates of CPB-related morbidity and mortality are still reported. Since 1980, conventional CPB with double caval cannulation with right-angled cannulae has been used in the high majority of neonates at Marie-Lannelongue Hospital. The extracorporeal circuit was miniaturized to be primed with a volume as small as possible. Priming (500 ml) was done with packed red cells and fresh frozen plasma. CPB was conducted at 30% haematocrit and normal ranges of flow rate, arterial pressure, systemic vascular resistances and oxygen delivery. These normal physiological parameters were also maintained during hypothermia. During the last two years, 151 neonates below 15 days old who underwent open-heart surgery were reviewed. The overall hospital mortality was 7.24%. None of the survivors had postoperative complications related to CPB. All physiological and biological values remained within normal ranges during the postoperative course.

Cardiopulmonary Bypass↗
PubMed1994

Surgery for tetralogy of Fallot at less than six months of age.

Absence of consensus persists regarding the optimal procedure and timing for the surgical treatment of young infants with symptomatic tetralogy of Fallot. From 1987 through 1992, 56 patients with tetralogy of Fallot were operated on at less than 6 months of age. Forty-one patients (median age 2.9 months) underwent primary repair and 15 (median age 2.4 months) underwent initial palliation. Mean follow-up was 24.2 +/- 16.4 months. No strict protocol was used but patients who received initial palliation were younger, had a smaller pulmonary arterial tree, or had anomalous coronary artery. Two patients died (overall mortality 3.6%; 95% confidence limits 0% to 11%), one after initial palliation (6.7%), and one after primary repair (2.4%) (P = 0.47). Eight of the 15 patients who received initial palliation underwent repair and had an increase in pulmonary anulus size at the time of definitive repair (mean difference Z-value = 2.2 +/- 1.6 standard deviation; p = 0.006). Transannular patch was required in 50% of patients who underwent repair (56% among patients having primary repair versus 13% for patients having initial palliation; P = 0.03). Five patients underwent reoperation. Early primary repair of symptomatic tetralogy of Fallot was achieved with a low mortality rate and is the preferred protocol. Initial palliation remains indicated in case of associated cardiac anomaly, very low weight, or severely hypoplastic pulmonary artery tree.

Age Factors↗
PubMed1993

Aortic arch thrombosis in the neonate.

Two cases of neonatal aortic arch thrombosis are reported. One patient, who had ascending aortic thrombosis, died preoperatively. The other had reoperation and is alive and well at 6 months' follow-up. No obvious cause was found.

Adult↗
PubMed1993

Anatomic correction of transposition of the great arteries in neonates.

OBJECTIVES: This retrospective study attempts to assess the results of the neonatal anatomic repair of transposition of the great arteries by a single institution. BACKGROUND: Anatomic correction of transposition of the great arteries by means of the arterial switch operation is now widely accepted as the therapeutic method of choice. METHODS: Four hundred thirty-two consecutive neonates underwent an arterial switch operation for various forms of transposition of the great arteries. There were 362 neonates with transposition and intact ventricular septum, 47 with a ventricular septal defect, 6 with intact ventricular septum and coarctation of the aorta and 17 with ventricular septal defect and coarctation. Among patients with coarctation, 18 underwent a single-stage repair through median sternotomy. The mean age was 13.1 +/- 4.2 days. Coronary artery distribution was described according to the origin and initial course of the arteries. RESULTS: Overall in-hospital mortality was 7.8% (34 patients) and was 7.6% for transposition with intact ventricular septum, 8.5% for transposition with ventricular septal defect and 13.3% for transposition with ventricular septal defect and coarctation. Univariate analysis of risk factors revealed that coronary anatomy was the main determinant for operative survival. A mean follow-up time of 44 +/- 19 months was achieved in all but five survivors. More than 95% were in New York Heart Association functional class I, without medication and with normal left ventricular function. Reoperation was performed in 20 patients: early reoperation (< 30 days) in 4 and late reoperation in 16. Actuarial survival rates at 5 years were 91.3% (transposition with intact ventricular septum) and 81.06% (transposition with ventricular septal defect). As well, freedom from reoperation at 5 years was 96.8% (transposition with intact ventricular septum) and 84.6% (transposition with ventricular septal defect). CONCLUSIONS: The arterial switch operation is feasible in almost all forms of transposition of the great arteries in neonates as primary and definitive repair. Palliative surgery is recommended in cases with complex intracardiac anatomy not amenable to early repair.

Aorta↗
PubMed1993

Subaortic obstruction in double outlet right ventricles. Surgical considerations for anatomic repair.

BACKGROUND: Subaortic obstruction is one of the risk factors for anatomic repair of double outlet right ventricles (DORV). A comprehensive approach to such lesions has been developed in our institution since 1981. This retrospective work analyzes the results of this approach. METHODS AND RESULTS: Between January 1981 and September 1992, 30 patients aged 15 days to 15 years (mean, 44.8 months) underwent repair of a DORV associated with subaortic obstruction. Eighteen patients had a palliative procedure before complete repair. The ventricular septal defect (VSD) was subaortic in 15 patients, doubly committed in 1, noncommitted in 9, and subpulmonary in 5. The subaortic obstruction was a result of restrictive VSD in 29 patients and of double straddling of mitral and tricuspid valves once. The preoperative peak systolic pressure gradient between the left ventricle and the aorta (LV-Ao) was 68.7 +/- 23 mm Hg. Reconstruction of the left ventricular outflow tract comprised a ventral enlargement of the VSD in subaortic, doubly committed, and those subpulmonary VSDs scheduled for an arterial switch operation or a conal resection in noncommitted and other subpulmonary forms. Reconstruction of the right ventricular outflow tract included primary closure of the right ventricle in 12 patients, an infundibular patch in 9, a transannular patch in 4, and insertion of a right ventricular pulmonary valved conduit in 5. There were two early (6.6%) and two late (7.1%) deaths. Three patients required reoperation. A mean follow-up of 60.5 +/- 46.8 months was achieved in all the survivors. They were all in New York Heart Association class I or II, in sinus rhythm. At last follow-up, the mean LV-Ao gradient was 7.5 +/- 6.2 mm Hg, and LV function indices were within normal ranges. Actuarial survival and freedom from reoperation rates at 8 years were 86.6% and 87.0%, respectively. CONCLUSIONS: Surgical relief of subaortic obstruction in DORV has to be adapted to VSD location and spatial arrangement of atrioventricular valves and great vessels.

Aortic Stenosis, Subvalvular↗
PubMed1993

[Atresia or congenital stenosis of the left coronary ostium. Myocardial revascularization in 5 children].

Five patients, 3 months to 13 year old with atresia (4) or stenosis (1) of the left coronary artery underwent myocardial revascularisation at Marie Lannelongue Hospital. The preoperative symptoms were dominated in one case by cardiac failure due to myocardial infarction and in the other cases by effort angina with syncope. The operative technique of revascularisation in one case was angioplasty with enlargement of the left main coronary artery with a patch and, in the others, bypass graft of the left coronary artery with the left internal mammary artery. All 5 patients survived surgery and are asymptomatic with a follow-up of 6 months to 7 years. Control coronary angiography confirmed the patency of the different procedures of myocardial revascularisation. In 3 children, exercise electrocardiography was normal. Myocardial revascularisation of a child with a congenital stenotic abnormality of the left coronary network is possible, the technique of which depends on the diameter of the left main stenosis when the vessel is absent or atresic, left internal mammary artery bypass graft is the only solution. When the left main coronary is stenosed but patent, direct reconstructive surgery is an interesting alternative.

Adolescent↗
PubMed1993

[Comparison of long-term results of arterial switch and Senning procedure in transposition of great vessels with intact ventricular septum].

One hundred and five survivors after the 30th day of complete cure of transposition of the great arteries with intact ventricular septum between 1980 and 1985 were followed up. Fifty-four had an arterial switch (AS) in a single stage at an average age of 10 +/- 9 days and 51 had Senning's procedure (S) at an average age of 4 +/- 2.5 months. The average follow-up (97% of patients) was 5.8 +/- 1.1 years for the AS group and 9.3 +/- 2.3 years for the S group. The actuarial survival at 5 years was 100% in the AS group and 85.8% in the S group (p < 0.01) (8 late deaths). In the AS group, 3 patients were reoperated for stenosis of the pulmonary artery and, in the S group, 4 patients underwent 6 reoperations. All but 3 patients in the S group and all but 1 patient in the AS group are in functional Class I of the NYHA classification. Doppler echocardiographic studies have shown mild to severe dysfunction of the systemic ventricle in 2% of the AS group and 26% of the S group (p < 0.001). Holter monitoring, performed in 70% of patients in the S group showed sinus node dysfunction in 60% and sinus rhythm in 40% of cases. In conclusion, good functional results were observed at over 5 years in both groups. However, the absence of late mortality and the minimal incidence of systemic ventricular dysfunction in the AS group confirm the authors' choice of indication of arterial switch for the treatment of transposition of the great arteries with intact ventricular septum.

Actuarial Analysis↗
PubMed1993

[Taussig-Bing malformation with straddling of both atrioventricular valves. Echocardiographic description of a case].

The authors report the case of an infant with the Taussig-Bing malformation and straddling of the two atrioventricular valves, the diagnosis of which was made by echocardiography and confirmed at surgery. Anatomic repair of the transposed great arteries was preceded by reconstruction of the interventricular septum which left the abnormal tricuspid subvalvular apparatus in the right ventricle and the abnormal mitral subvalvular apparatus in the left ventricle. Postoperative Doppler echocardiography confirmed the absence of left ventricular outflow obstruction.

Double Outlet Right Ventricle↗
PubMed1993

Anatomic repair of transposition of great arteries with ventricular septal defect and aortic arch obstruction. One-stage versus two-stage procedure.

Between September 1, 1982, and March 1, 1992, 40 patients underwent anatomic repair of transposition of the great arteries, ventricular septal defect, and aortic arch obstruction. In group I, 26 patients (65%) underwent repair in a two-stage procedure, phases A and B. Phase A included repair of the aortic arch obstruction with (16 patients) or without (10 patients) pulmonary artery banding through a left thoracotomy (mean age 18.7 +/- 23.4 days). There were three deaths and three reoperations. Phase B included an arterial switch operation with closure of the ventricular septal defect (mean age 95.5 +/- 122 days). There were five early deaths and two late deaths. Eight patients required reoperation. Mean delay between phase A and phase B was 77.5 +/- 109 days. In group I, there were eight early and two late deaths, and 11 patients required reoperation. The mean stay in the intensive care unit was 24.7 +/- 20 days. Mean follow-up of 59.6 +/- 21.4 months was completed in all survivors. All but one were in New York Heart Association class I without medication. Actuarial survival rate and rate of freedom from reoperation at 5 years were 57.5% and 49.9%, respectively. In group II, 14 patients (35%) had a one-stage procedure through midsternotomy: an arterial switch operation with closure of the ventricular septal defect and repair of the aortic arch obstruction (mean age 10.2 +/- 5.5 days). There were two early deaths (14.2%) and one late death after reoperation for overlooked multiple ventricular septal defects. Two patients required reoperation. The mean stay in the intensive care unit was 11.7 +/- 2.5 days. Mean follow-up of 22.4 +/- 16.7 months was achieved in all survivors. They were all in New York Heart Association class I without medication. Actuarial survival rate and rate of freedom from reoperation at 3 years were 78.5% and 81.5%, respectively. The one-stage procedure allowed complete repair in neonates without the need for multiple operations. We believe that it may decrease early mortality rates (14.2% versus 30.7%), reduce the reoperation rate and cumulative stay in the intensive care unit (11.7 days versus 24.7 days, p = Not significant), and significantly decrease the overall rate of morbidity (p < 0.01). However, requirements for surgical intervention with a one-stage or a two-stage procedure must include accurate assessments of intracardiac and aortic arch anatomy.

Actuarial Analysis↗
PubMed1992

[Neonatal heart transplantation. First results].

Two 5- and 17-days old neonates with hypoplastic left heart syndrome respectively underwent orthotopic heart transplantation. The donor-recipient weight ratio was +58 percent and +88 percent; ischemic time was 144 and 167 min. The immunosuppressive protocol included thymoglobulin during the induction period and a classical 3-drug therapy, with a rapid tapering off of prednisone over 3 weeks. No infectious complication was observed; each infant experimented one episode of acute rejection, successfully treated with prednisolone. Forty-three months and 10 months later, the 2 children are doing well, with normal renal function and normal growth. No late rejection episode was observed. Heart transplantation in neonates is feasible, the short-term and mid-term results are good. Despite important ethical problems, heart transplantation represents a great hope for neonates with inoperable congenital heart defects.

Graft Rejection↗
PubMed1992

Neonatal anatomic repair of transposition of the great arteries and ventricular septal defect.

From January 1985 to March 1992, 64 consecutive neonates with transposition of the great arteries (TGA) and ventricular septal defect (VSD) underwent an arterial switch operation and VSD closure. The mean age at operation was 18.5 +/- 12 days and the mean weight was 3.3 kg. Seventeen patients had an associated aortic coarctation, of whom 15 underwent single-stage repair through median sternotomy. Coronary artery distribution was: type A: 45 patients; type B: 2; type D: 11 and type E: 6 patients. The location of the VSD was perimembranous in 42 patients, trabecular in 13, infundibular in 5, and 4 presented with the Taussig Bing heart anomaly. The hospital mortality was 9.3% (n = 6). There were four late deaths (one TGA-VSD and three TGA-VSD and coarctation). Nine patients required reoperation. The mean follow-up of all survivors was 36 +/- 19 months. They were in NYHA class I without medication. Six patients developed mild-to-moderate aortic insufficiency. The actuarial survival and freedom from reoperation at 5 years were 81.06% and 84.6%, respectively. We conclude that neonatal anatomic repair of TGA and VSD offers good medium-term results and avoids iterative operations.

Actuarial Analysis↗
PubMed1992

Early palliation of univentricular hearts with subaortic stenosis and ventriculoarterial discordance. The arterial switch option.

The optimal Fontan-type operation greatly depends on appropriate initial palliation. Several surgical techniques have been used in infancy to palliate patients with univentricular hearts, ventriculoarterial discordance, and subaortic stenosis. The two most common are pulmonary artery banding and Damus-Norwood procedures. Palliative arterial switch operation is another surgical option that was used in this early series of seven infants. The principle of this operation is to "switch" the subaortic obstruction into a subpulmonary obstruction; the coronary artery relocation on the large pulmonary trunk creates a harmonious aortic root and the connection of the rudimentary ventricular chamber to the pulmonary artery trunk creates a natural protection of the pulmonary vascular bed through the restrictive bulboventricular foramen. Seven infants with univentricular hearts, ventriculoarterial discordance, and subaortic stenosis underwent a palliative arterial switch operation. All infants had an associated aortic arch obstruction of various degrees, including one with interrupted aortic arch, five with coarctation with severe arch hypoplasia, and one with isolated arch hypoplasia. There were three with double-inlet left ventricle, three with tricuspid atresia, and one with transposition of the great arteries with ventricular septal defect and severe right ventricular hypoplasia. The subaortic obstruction was patent at birth in five patients who underwent a palliative switch operation in the first 2 months of life, and rapidly occurred following a previous neonatal pulmonary artery banding associated with arch repair in two patients who underwent a switch operation at 5 and 8 months of age, respectively. The operation includes aortic arch repair without prosthetic material, an atrial septectomy, and the arterial switch. An associated pulmonary shunt was required in five patients and a pulmonary artery banding in one. There was one early death in a patient with [S,L,L] anatomy and congenital atrioventricular block, leading to an early mortality of 14% (95% confidence limits: 1% to 28%). There was one late death. Four survivors are waiting for a Fontan-type procedure, and one survivor had satisfactory right ventricular growth. Early palliative arterial switch operation offers several advantages: reconstruction of a harmonious aortic root, natural protection of the pulmonary bed through the restrictive bulboventricular foramen, prevention of deleterious myocardial hypertrophy, and arch reconstruction without the introduction of a foreign material. This aggressive technique may provide a satisfactory palliation in infants with univentricular hearts and ventriculoarterial discordance, when the bulboventricular foramen/aortic anulus ratio is less than 0.8 or when the subaortic stenosis is severe enough to be associated with an arch obstruction.(ABSTRACT TRUNCATED AT 400 WORDS)

Abnormalities, Multiple↗
PubMed1992

[Immediate and mid-term results of surgery of aortic valve stenosis in the newborn infant].

Between January 1980 and June 1990, 47 consecutive neonates with severe aortic stenosis underwent surgical aortic commissurotomy at Marie-Lannelongue Hospital. The average age at operation was 5 days. Other cardiac abnormalities were present in 27 children and left ventricular fibroelastosis in 11 children. Closed heart aortic valvotomy via the apex of the left ventricle was performed in 26 patients and open heart commissurotomy in 21 patients. Immediate per- or postoperative death was observed in 14 cases (29.8%). Six patients died after open heart valvulotomy (29%) and 8 after closed heart valvulotomy (31%). The mortality was higher in children with a critical preoperative status: 60% versus 22% (p less than 0.05); in cases with an associated cardiac malformation: 45% versus 6% (p less than 0.01) or fibroelastosis: 91% versus 11% (p less than 0.001). None of the patients was lost to follow-up which lasted an average of 47 +/- 41 months. Ten secondary deaths were observed, of which 4 were sudden, 4 after reoperation and 2 due to mitral stenosis with pulmonary hypertension. The overall one year survival was 57% (IC 70%: 40-64); the 5 year survival was 46% (IC 70%; 30-60). Reoperation was necessary in 12 children. Survival without reoperation at 1 and 5 years was 49% (IC 70%: 41-56) and 43% (IC 70%: 29-59) respectively. At the last follow-up examination, 97% of the 23 survivors had good left ventricular function; the systolic pressure gradient was less than 50 mmHg in two thirds of patients and aortic regurgitation was minimal or absent in three quarters of patients. In critical aortic stenosis in neonates, surgery is associated with a high immediate and secondary mortality. The results at medium term in the survivors are good with respect to symptoms, left ventricular function and obstruction to left ventricular ejection.

Aortic Valve Stenosis↗
PubMed1992

[Peroperative evaluation of pulmonary vascular resistance by cavo-pulmonary bypass. Value of atrio- and cavo-pulmonary diversions].

Immediate and long-term results of the Fontan procedure depend on the value of the pulmonary vascular resistance. This parameter cannot always be quantified accurately during preoperative evaluation. Cavo-pulmonary bypass using an extra corporeal circulation allowed simulation a Fontan procedure in 5 patients, and prediction of the pressure changes in the pulmonary artery and the systemic atrium according to the pulmonary to systemic resistances ratio. This technique could be valuable in border line cases for deciding on the optimal therapeutic solution.

Anastomosis, Surgical↗
PubMed1992

[Total cavo-pulmonary bypass. Short-term results].

In order to reduce the complications of the Fontan procedure, 2 techniques of total cavopulmonary connection using a right intra-atrial baffle (Pugas' technique, 19 patients), and a modified de Kreutzer (19 patients) were assessed in 38 consecutive patients operated between November 1980 and November 1991. All patients had complex cyanotic congenital heart disease: tricuspid atresia (13), single ventricle (12), hypoplasia of one of the two ventricles (8), pulmonary atresia with an intact septum (5). The average age was 5.8 +/- 5.6 years (range 1 to 30 years), the weight was 18 +/- 11.7 kg (range 8 to 59.7 kg). Six patients (15.8%) died, 4 of whom (10.5%) in the operative period. Five of these deaths were related to extremely high right heart pressures without any technical fault, and the other to thrombosis of the conduit in a patient not taking anticoagulants. Two immediate and 10 secondary reoperations were necessary. All 3 patients who had disconnection of the anastomosis because of high right heart pressures died. The postoperative course was often difficult: right heart failure (63%), pleural effusion (57%), and pericardium effusion (13%). Of the risk factors analysed, age had no influence on postoperative outcome. The two poor prognostic factors were: presence of atresia or hypoplasia of the systemic atrioventricular valve (mortality 42.8% versus 6.5%, p = 0.05 and prolongation of the hospital period: 39.5 +/- 32 days versus 21 +/- 11 days, p less than 0.05) and previous banding (reoperation rate 62.5% versus 16.6%, p less than 0.05, and longer stay in the intensive care unit and hospital period).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

[Pulmonary valve atresia with intact interventricular septum. Mid-term results of the surgical treatment. Apropos of 45 cases].

Between 1980 and 1991, 45 patients with pulmonary atresia with intact interventricular septum (38 cases) or critical pulmonary stenosis (7 cases), underwent surgery. The right ventricle was tripartite in 23 children, bipartite in 12 and unipartite in 10. Sinusoid vessels were present in 20 cases. They reinjected a native coronary trunk in 10 cases (major sinusoids). During the initial operation performed in the neonatal period in 41 cases and later in 4 cases, 26 children had an isolated systemic-pulmonary shunt (3 deaths) and 19 had connection of the right ventricle and pulmonary artery (6 deaths). Perioperative mortality was 20% (9/45). Global actuarial survival at 5 years was 47%. Of the 22 patients referred later for univentricular repair, 8 (36%) died (6 perioperative and 2 sudden deaths). The actuarial survival for this group was 49% at 4 years. Of the 23 patients referred for biventricular repair, 11 (47%) died (9 perioperative and 2 sudden deaths) and 2 attained complete cure status. The actuarial survival is 43% at 4 years in this group. Children with intermediate forms (type II or tricuspid less than 8 mm) were orientated to univentricular repair, partly due to the high incidence of major sinusoids. None of the children with major sinusoids survived to over 3 years of age. When the anatomic form is favorable, the present strategy is to perform transpulmonary valvotomy under cardiopulmonary bypass associated with the implantation of a Gore-Tex tube between the innominate artery and right pulmonary artery during the neonatal period. The risk of secondary pulmonary regurgitation would seem to be less than the immediate risk of low pulmonary flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1992

Surgical management of isolated multiple ventricular septal defects. Logical approach in 130 cases.

From January 1980 through September 1990, 130 children underwent surgical closure of isolated multiple ventricular septal defects (mean age 14 +/- 18 months, mean weight 7.0 +/- 4.4 kg). Sixty-one were less than 1 year of age. Sixty-one children had pulmonary protection, 51 had pulmonary artery banding, and 10 had pulmonary valve stenosis. All other patients had severe pulmonary hypertension (mean systolic pressure 75.7 +/- 20.5 mm Hg and already disabling heart failure (New York Heart Association classes III and IV). The surgical management was based on the location of the defects and the ventricular dominance that were assessed preoperatively and intraoperatively. Midtrabecular ventricular septal defects were always centered by the moderator band and were therefore divided into low trabecular, midtrabecular, and high trabecular defects. The perimembranous septum was involved in 102 patients, the trabecular in 121, the inlet septum in 12, and the infundibular septum in 9. Fifty patients had the "Swiss cheese" form of the lesion. Closure of the ventricular septal defects included Dacron patch and mattress sutures. They were always first approached through a right atriotomy, which was sufficient for complete repair in 82 patients. In midtrabecular ventricular septal defects, section of the moderator band (n = 24) allowed closure of all the defects with a single Dacron patch. In 48 patients a right atriotomy and a right (n = 32) or left (n = 14) (particularly for low trabecular ventricular septal defects) or both right and left (n = 2) ventriculotomies were necessary to secure the repair. The hospital mortality rate was 7.7% (10 patients). The causes of deaths were residual ventricular septal defect (n = 5), pulmonary hypertension (n = 2), hypoplastic right ventricle (n = 1) and left ventricle (n = 1), and myocardial infarction (n = 1). Among eighteen survivors with residual ventricular septal defect, six were reoperated on; there were two deaths. A permanent pacemaker was necessary in four patients. Low trabecular ventricular septal defects and left ventriculotomy were significant risk factors for morbidity (death, residual ventricular septal defect), p less than 0.01. At 7 years of follow-up, 90% of survivors were in New York Heart Association class I. Actuarial survival and freedom from reoperation at 7 years were 89.6% and 87.5%, respectively.

Abnormalities, Multiple↗