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After early repair of congenital cardiovascular defects, such as coarctation of the aorta, late stenosis may become a problem. Use of absorbable sutures has been shown to be superior to use of nonabsorbable sutures in allowing growth of an anastomotic site along with the individual. Some concern has been raised, however, about the potential for aneurysm formation at the site of anastomosis when absorbable sutures are used. This study was undertaken to observe the effects of longitudinal tension on anastomoses made with absorbable polydioxanone suture in growing animals. Six piglets (aged 3 to 4 weeks) underwent a 1-cm resection of the infrarenal aorta and reanastomosis with polydioxanone suture. One animal died prematurely of respiratory illness. The 5 remaining animals were killed after 6 months. The excised aortas demonstrated no stenosis, no dilatation, and no burst-test failure to 250 mm Hg. Histological examination showed disrupted elastic laminae without thinning of aortic wall in all samples of aorta. We conclude that polydioxanone suture is a suitable suture material for vascular anastomoses made under tension where growth of the anastomotic site is expected.
Accuracy of 3-dimensional contrast-enhanced magnetic resonance angiography (MRA) in diagnosing morphology of the branch pulmonary artery (PA) was evaluated in 73 patients (aged 7.2 +/- 6.4 years [mean +/- SD]) with various congenital heart diseases. The presence or absence of localized stenosis of branch PAs, PA diameter, and Nakata's PA index were determined on MRA and axial radiographic angiography, and the results were compared. Sensitivity, specificity, and overall accuracy in detecting branch PA stenoses were 92.7%, 96.2%, and 95.2%, respectively. Correlations between axial radiographic angiography and MRA were excellent in measuring PA diameter (r = 0.956, SEE = 1.49 mm, n = 139) as well as PA index (r = 0.839, SEE = 48.9, n = 37); both p < 0.0001. Bland-Altman plots showed a mean difference +/- SD for PA diameter of 0.17 +/- 1.51 mm and for PA index of 8.5 +/- 50.1. When the main right and left PAs were taken as the first generation, the most distal branches visible on MRA were the 4.7 +/- 0.7 generation with breath-holding (n = 23) and the 3.7 +/- 0.5 without breath-holding (n = 50), respectively (p < 0.0001). Both intra- and interobserver variabilities of MRA measurements were few (9.5 +/- 11.6% and 13.5 +/- 15.0%, respectively, n = 139). In conclusion, 3-dimensional contrast-enhanced MRA enables us to document branch PA morphology clearly in infants and adult patients with congenital cardiovascular defects.
From 1973 to 1982, 253 patients--164 males and 89 females--underwent an operation for coarctation of the aorta in our clinic. Of the patients 72.3% presented with a circumscribed lesion and 58.5% with associated congenital cardiovascular defects. Resection with end-to-end anastomosis was performed in 138 patients (54.5%). Seventy-four patients (29.3%) had vascular graft prosthesis, 1.2% underwent the Clagett's operation, 9.1%, the indirect isthmoplasty and the rest (5.9%), the subclavian flap plastic. Ventricular fibrillation led to the intraoperative death of 3 infants with associated intracardiac and multiple somatic defects. The operative mortality was high in children under 15 months (13.2%), 1% in all the others taken together and 0% in all cases without concomitant lesions. Paraplegia occurred in only one patients (0.4%). One hundred twenty-eight patients were followed-up over a mean period of 3.6 years. The systolic and diastolic pressures decreased by a mean of 30 mmHg and 15 mmHg respectively. Eighty-seven patients (68%) had normal blood pressure at the time of examination. The rest (41 patients) had persistent postoperative hypertension necessitating medical management. The surgical technique elected did not influence the level and incidence of persistent postoperative hypertension, rather the level of the preoperative systolic right arm-to-leg pressure gradient (SPG) related closely to the incidence of persistent hypertension. Thirty patients (23.4%), among whom were 24 children under 10 years--some of them with preductal hypoplasia--presented with an SPG above 20 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)
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Using the methods described, the author has performed AV-valve replacement surgery in seven clinical dogs with AV valve dysfunction. Two dogs received autologous tissue tricuspid valves, three dogs received autologous tissue mitral valves, one dog received a mechanical mitral prosthesis, and one dog received a mechanical mitral and autologous tricuspid prosthesis. The two dogs that received a tricuspid prosthesis recovered from surgery, one dog is normal nearly 3 years after valve replacement surgery, and the second dog was euthanized 3 weeks after replacement surgery because of complications related to other congenital cardiovascular defects (ie, pulmonary artery coartations). The dog that received the mechanical mitral valve prosthesis made a complete immediate postoperative recovery but died from hemorrhage complications related to a femoral artery catheter removal 3 days after surgery. Hemorrhage from the left atrium resulted in the death of one dog after implantation of a bioprosthetic mitral valve. Two dogs with mitral valve bioprostheses and one dog with a mitral and tricuspid valve replacement could not be weaned from the cardiopulmonary bypass pump, even with pharmacological support. Although the initial results in this small clinical trial have not been spectacular, it is apparent from the few clinical cases operated on that the equipment, supplies, and techniques have advanced sufficiently in veterinary surgical practice to perform AV-valve replacement surgery in companion animals. Prosthetic valves are available presently to perform such surgery even in small animal patients (5 kg). However, a significant obstacle that must be overcome before such techniques become routine is the selection of animal patients that have sufficient myocardial reserve to undergo valve replacement surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
The insertion of a Swan-Ganz catheter may cause various complications including intravascular malpositioning due to congenital anomalies of the large veins. A persistent left superior vena cava is the most frequent anomaly of the large vessels. It is usually diagnosed either as an incidental finding at autopsy or during X-ray imaging for confirming proper position of central venous and pulmonary catheters. The incidence of this condition based on autopsy series is approximately 0.3%. CASE REPORT. A 52-year-old patient was admitted to the surgical ICU with the diagnosis of acute pancreatitis. Because of haemodynamic instability, a pulmonary artery flotation catheter was inserted via the left subclavian vein without difficult. The chest radiograph showed the catheter along the left border of the heart going into the right pulmonary artery. An angiographic examination with bolus contrast injection confirmed a persistent left superior vena cava. CONCLUSION. This type of malposition calls for further detailed diagnosis of the vascular status, as the knowledge of accompanying congenital cardiovascular defects is essential for further invasive diagnostic and surgical procedures. The intensivist should be aware of its occurrence in order to not mistake catheters as being present in the arterial circulation or malpositioned outside the venous circulation.
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