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Biomedical subjects

M J Béland

Publications and source records attributed to M J Béland.

17 recordsLinked to original sources
PubMed2001

Single ventricle with systemic obstruction in early life: comparison of initial pulmonary artery banding versus the Norwood operation.

OBJECTIVES: The outcomes of initial pulmonary artery banding (PAB)+/-coarctation repair are compared with the Norwood operation in newborns with single ventricle (SV) and systemic obstruction (SO). METHODS: Between January 1987 and July 2000, 22 patients (median age, 12 days) with SV and aortic arch obstruction (AAO), subaortic stenosis (SAS), or both underwent surgery. Two initial surgical approaches were used: PAB+/-coarctation repair (group I, seven patients); Norwood type operation (group II, 15 patients). RESULTS: The overall mortality was 32% (seven of 22 patients). There was no late mortality. The mortality in group I was 43% versus 27% in group II. Recently, there has been no mortality following the Norwood operation in the last eight patients operated since 1995. Of the survivors, nine patients have undergone the Fontan operation and four patients have had the bidirectional Glenn (BDG) with no deaths. There was one repair of supravalvar aortic stenosis at the time of BDG in group II as opposed to eight reinterventions for SAS and/or AAO in four patients in group I (P=0.01). CONCLUSIONS: PAB+/-coarctation repair for SV and SO is associated with a high mortality and a high reoperation rate for SAS or recurrent AAO. Although the Norwood operation was also associated with a high mortality early on, it can now be performed with excellent outcome. This improvement, combined with a low reintervention rate for SAS or AAO, suggests that the Norwood operation is likely to emerge as the procedure of choice for SV and SO.

Aortic Coarctation↗
PubMed2000

Primary repair minimizing the use of conduits in neonates and infants with tetralogy or double-outlet right ventricle and anomalous coronary arteries.

OBJECTIVE: The purpose of this study was to review our results with an approach of early primary repair for tetralogy of Fallot or double-outlet right ventricle with anomalous coronary arteries, using several techniques to minimize the use of a conduit. METHODS: Twenty consecutive neonates and infants with anomalous coronary arteries crossing an obstructed right ventricular outflow tract underwent primary repair. Median age was 5.5 months and mean weight 6.22 kg. The anomalous coronary arteries included the left anterior descending from the right coronary artery (n = 10), the right coronary artery from the left anterior descending (n = 1), the left anterior descending from the right sinus (n = 1), and a significant conal branch from the right coronary artery (n = 7) or left anterior descending (n = 1). Two neonates had pulmonary atresia. The right ventricular outflow tract was reconstructed without a conduit in 18 patients, including those with pulmonary atresia. Surgical techniques included main pulmonary artery translocation in 4 patients, transannular repair under a mobilized left anterior descending coronary artery in 2 patients, and displaced ventriculotomy with subcoronary suture lines in 8 patients. In 4 patients the right ventricular outflow tract was repaired via the ventriculotomy and/or pulmonary arteriotomy. A homograft was used as the sole right ventricle-pulmonary artery connection in 1 patient and in another a homograft was added to a hypoplastic native pathway. RESULTS: There have been no early or late deaths. The right ventricular/left ventricular pressure ratio within 48 hours of the operation was 0.47 +/- 0.10. There were 2 reoperations at 8 and 11 years after the operation, during a mean follow-up of 5.2 years (1-11.3 years). CONCLUSIONS: Primary repair of tetralogy of Fallot or double-outlet right ventricle with anomalous coronary arteries can be done in neonates and infants with excellent results. Alternative surgical techniques for right ventricular outflow tract reconstruction, such as main pulmonary artery translocation, can avoid the use of a conduit in most patients.

Angiography↗
PubMed1998

Biventricular repair in neonates with hypoplastic left heart complex.

BACKGROUND: Multiple obstructions in the left heart-aorta complex have been associated with poor survival. No consensus exists as to whether these patients will have a favorable outcome with biventricular repair where most advocate a univentricular approach. METHODS: Since late 1988, all 11 neonates seen with hypoplastic left heart complex, which includes aortic arch obstruction, underwent biventricular repair. All patients had antegrade aortic flow and no intrinsic aortic or mitral stenosis. Elimination of the extracardiac afterload was achieved by extensive ascending aorta and aortic arch reconstruction with a pulmonary homograft patch. All intracardiac shunts were eliminated to fully preload the left heart. The median age at first operation was 7 days and the mean weight, 3.59+/-0.49 kg. The echocardiographic variables used to evaluate the left heart-aorta complex were reviewed, and the preoperative and postoperative measurements were compared. RESULTS: There were two early deaths. Four patients had six reoperations for left ventricular outflow tract obstruction, 2 of whom have required prosthetic valve replacement (1, aortic and mitral; 1, aortic), and 2 patients had three reoperations for recurrent coarctation. There was one late death at 3 years from pulmonary hypertension. Mean follow-up was 44+/-35 months. The 8 current survivors are all in New York Heart Association class I or II. The actuarial survival rate at 8 years is 63%, and the freedom from reoperation at 3 years is 25%. CONCLUSIONS: We have successfully achieved biventricular repair in most of the patients with hypoplastic left heart complex, a subset of patients with hypoplastic left heart syndrome. Some growth of the left ventricular structures was already observed at the time of hospital discharge. However, reoperation, particularly for left ventricular outflow tract obstruction, appears likely. Increasing experience will more accurately define predictive criteria for the feasibility of biventricular repair.

Female↗
PubMed1998

Single-stage repair of aortic arch obstruction and associated intracardiac defects with pulmonary homograft patch aortoplasty.

OBJECTIVE: Intracardiac malformations associated with coarctation and aortic arch hypoplasia have traditionally been repaired in 2 stages, with a high mortality rate. We review our experience with single-stage biventricular repair of intracardiac defects associated with aortic arch hypoplasia by means of pulmonary homograft patch aortoplasty. METHODS: Between October 1988 and October 1997, 39 of 40 consecutive patients underwent single-stage biventricular repair for aortic arch obstruction and associated intracardiac defects. The median age at operation was 17 days and the mean weight was 3.71 +/- 1.09 kg. Nineteen patients had either dextrotransposition of the great arteries or the Taussig-Bing anomaly. Sixteen patients had multiple left-sided obstructive lesions (2 cases of critical aortic stenosis, 3 of subaortic stenosis and ventricular septal defect, and 11 of hypoplastic left heart complex). One patient had an associated complete atrioventricular septal defect. Four patients had only an associated ventricular septal defect. Through a median sternotomy, the hypoplastic aortic arch was enlarged with a pulmonary homograft patch in 36 patients. In 4 patients an extended end-to-end anastomosis was performed. RESULTS: There were 2 early deaths (5%) and 2 late deaths (5%). One late death was not cardiac related. The mean follow-up time was 36 months (range 1 month-9 years). The recoarctation rate after pulmonary homograft patch aortoplasty was 8. 3%, but after exclusion of those patients with associated left-sided obstructive lesions this decreased to 0%. No aneurysm formation in the aorta has occurred. The actuarial survival at 8 years is 89% +/- 10%. CONCLUSIONS: Single-stage biventricular repair of aortic arch obstruction and associated intracardiac defects can achieve excellent survival. We recommend pulmonary homograft patch aortoplasty because it achieves complete relief of anatomic afterload with a tension-free anastomosis and low incidence of recoarctation.

Aorta, Thoracic↗
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↗
PubMed1991

Cardiac output and oxygen delivery during exercise in sickle cell anemia.

Desaturation in patients with sickle cell anemia (SCA) can lead to intravascular sickling and vascular occlusion. The increased metabolic demands of exercise tend to increase oxygen extraction, giving rise to a fall in saturation in the capillary bed that may predispose to sickling. This could be minimized with an increase in cardiac output. The aims of this study were to assess the role of increased stroke volume (SV) in augmenting cardiac output (Q) and to estimate the role of enlarged arteriovenous O2 content difference in maintaining O2 transport in children with SCA. A group of 30 children with SCA (Hb 65 to 133 g/L) and 16 healthy controls of the same racial group and of similar height and weight performed incremental and steady-state exercise at 50% Wmax. Cardiac output (Q) was measured by the indirect (CO2) Fick method during steady state. The slope of delta HR/delta VO2 during incremental exercise was higher in SCA subjects compared with controls (4.01 +/- 1.73 versus 2.80 +/- 0.61 bpm per ml/min/kg VO2, p = 0.001). Q for VO2 was abnormally high in patients, particularly older ones with lower Hb levels. HR (% predicted) was higher in patients than in controls (106 +/- 11 versus 92 +/- 8% predicted, p less than 0.0001), as was SV (113 +/- 16 versus 98 +/- 14% predicted, p = 0.002). Multiple linear regression of Q % predicted and SV % predicted on Hb and age showed a positive correlation with age and a negative correlation with Hb (r = 0.84 for Q and r = 0.76 for SV).(ABSTRACT TRUNCATED AT 250 WORDS)

Anemia, Sickle Cell↗
PubMed1991

[Transfemoral vein catheter occlusion of patent ductus arteriosus].

Between February 1988 and September 1989, 15 patients underwent closure of patent ductus arteriosus by the Rashkind technique modified by Mullins. The insertion of the occluder was achieved in all cases; however, in one patient, the prosthesis migrated to the abdominal aorta several hours after implantation. No other complications were observed. All patients were discharged from hospital under 24 hours after the procedure. The follow-up period ranges from 3 to 12 months. The rate of complete closure of the ductus was 50% 24 hours after implantation, 57% at 3 months, 66% at 6 months and 82% 12 months after the procedure. Our results suggest that the Rashkind technique for the closure of patent ductus arteriosus by the transvenous femoral approach is an effective and low risk procedure.

Adolescent↗
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↗
PubMed1989

Congenital abdominal aortic aneurysm.

The authors report the extremely rare occurrence of a congenital abdominal aortic aneurysm, 6 cm in diameter, found in a 1-month-old infant. Prenatal ultrasonography at 34 weeks' gestation had shown the aneurysm, which at that time was interpreted as a renal cyst. At operation, an 8-mm polytetrafluoroethylene tube graft was interposed between the infrarenal aorta and the bifurcation. Cardiopulmonary bypass facilitated operative management by permitting return of blood lost and by maintaining body temperature. In a review of the literature, the authors could not find any report of a neonatal aneurysm of this magnitude. Regrettably, the cause of this true aneurysm remains obscure.

Aorta, Abdominal↗
PubMed1989

Transseptal catheterization of the left heart in infants and children: experience in a small volume catheterization laboratory.

During a five-and-one-half year period, the transseptal technique was used for left heart catheterization in 37 patients with a variety of congenital heart disease. The age of the patients ranged from four months to 21 years and weights ranged from 6.6 to 65 kg. Access to the left heart cavities and ascending aorta was achieved in all but two patients. There were no complications. Even when used infrequently, the transseptal technique allows rapid and safe entry to the left heart cavities in infants and children.

Cardiac Catheterization↗
PubMed1988

Ventricular tachycardia related to transcutaneous pacing.

A 3-year-old child with Haemophilus influenzae endocarditis and aortic route abscesses presented with sudden cardiovascular collapse. During resuscitation, the child was noted to be in complete heart block. Transcutaneous pacing was instituted three times, and ventricular dysrhythmias were associated with each pacing attempt. When pacing was discontinued, the patient spontaneously reverted to complete heart block without ventricular ectopy. An emergency thoracotomy revealed rupture of the aortic route, and the patient died during surgery. Transcutaneous pacing may precipitate serious dysrhythmias; appropriate precautions are recommended.

Cardiac Pacing, Artificial↗
PubMed1987

Noninvasive transcutaneous cardiac pacing in children.

Noninvasive transcutaneous cardiac pacing is an emergency pacing modality with proven benefits for adult patients. During induction of anesthesia for heart surgery, we externally paced 22 children (aged 0.9-17.9 years and weighing 6.96 to 51 kg) using a commercially available device to pace approximately 10 beats per minute faster than the spontaneous heart rate. Three pacing electrode sizes were used (the standard adult size and two specially manufactured smaller sizes). A total of 56 pacing trials were conducted, 53 of which were successful in obtaining capture. A mean output of 63 +/- 14 mA (range, 42-98) at threshold using the large electrodes was comparable to published adult requirements. Lower current outputs were needed with the medium (53 +/- 12 mA; range, 36-92) and small electrodes (51 +/- 11 mA; range, 29-82). In any given patient, the large electrodes required more current (p less than 0.01) to obtain capture, but delivered less current density (p less than 0.01) and exhibited less impedance (p less than 0.01) than the smaller electrodes. The mean threshold energy requirement was 0.12 +/- 0.01 joules/beat regardless of pad size. Output, current density, impedance and energy requirements did not vary with age, weight or chest size. No complications of external pacing were noted. We conclude that noninvasive transcutaneous pacing can be used safely and effectively in children, and that chest size might necessitate the use of smaller electrodes in children weighing less than 15 kilograms.

Adolescent↗