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PubMed1996

Surgical anatomy of the coronary circulation in hearts with discordant atrioventricular connections.

We examined the arrangement of the coronary arterial and cardiac venous systems in 46 specimens with discordant atrioventricular connections so as to identify any structural abnormalities and to consider their surgical implications in terms of anatomical biventricular repair. Grossly abnormal arterial courses were seen in 11 hearts (24%). A substantial branch supplying the morphologically right ventricular outflow tract, which could restrict a ventriculotomy, was found in 61% of cases. The coronary sinus received all the morphologically right ventricular veins, as well as the posterior interventricular vein, in 40 hearts, this pattern being in contrast to the pattern in the normal heart. The morphologically left ventricular and anterior interventricular veins, all of which drain via the coronary sinus in the normal heart, were frequently connected independently to the morphologically right atrium in the specimens with discordant connections, the drainage occurring through the spaces between the pectinate muscles. These direct drainages are at risk of potential damage either by extensive intra-atrial maneuvers or by postoperative intraatrial thrombosis. It is predicted, therefore, that surgical results can be improved still further when account is taken of this vascular anatomy of the heart itself.

Cadaver↗
PubMed2006

Hearts with concordant ventriculoarterial connections but parallel arterial trunks.

OBJECTIVES: To determine the characteristic morphological features of hearts with concordant ventriculoarterial connections and parallel arterial trunks, and to provide unequivocally a method to describe their anatomy. DESIGN, METHODS AND PATIENTS: The entire cardiac database and cardiac pathological archive at the Hospital for Sick Children, Toronto, Ontario, Canada, was interrogated to identify all patients with concordant ventriculoarterial connections and parallel arterial trunks. The clinical records, autopsy reports and actual cardiac specimens of those who underwent autopsy, were reviewed. RESULTS: 8 cases meeting our criteria were identified. The infundibular anatomy was variable, including four hearts with bilateral infundibulums, three with subpulmonary infundibulums and one with bilaterally absent infundibulums. Considerable variability was also found in the type of atrial arrangement, along with the morphology of the atrioventricular junctions. The most common findings were the usual atrial arrangement (n = 5), left juxtaposition of the right atrial appendages (n = 3), an atrial septal defect (n = 6), univentricular atrioventricular connection (n = 5), ventricular septal defect (n = 8) and pulmonary obstruction (n = 4). In addition, five specimens had either a single coronary artery or two coronary arteries arising from the anticipated right coronary aortic sinus. CONCLUSIONS: Concordant ventriculoarterial connections with parallel arterial trunks can be found in a variety of segmental combinations. An accurate diagnosis of these rare hearts can be achieved by detailed analysis of not only the ventriculoarterial connections but also the infundibular anatomy and the spatial relationship of the arterial trunks. Particular attention to the coronary arteries is warranted.

Aorta↗
PubMed1986

Correction of Taussig-Bing malformation by intraventricular conduit.

Repair of double-outlet right ventricle with subpulmonary ventricular septal defect (Taussig-Bing malformation) was accomplished with an intraventricular conduit. The ventricular septal defect was brought into continuity with the aorta via a tubular Dacron prosthesis, which was situated anterior to the subpulmonary conus and ran transversely from the ventricular septal defect to the subaortic conus. The transverse right ventriculotomy was not closed directly, but was sutured to the external surface of the conduit.

Blood Vessel Prosthesis↗
PubMed1984

Pericardial baffle complications following the Mustard operation. Age-related incidence and ease of management.

Pericardial baffle complications with the standard Mustard operation led first to the use of alternative materials of various shapes and finally to the recent popularity of the Senning procedure. At The Oregon Health Sciences University, we have persisted since the mid-1960s in the use of a modified Mustard operation in which a rectangular pericardial baffle is employed. Among 75 patients, there were baffle complications necessitating reoperation in 13. The reoperation-free rates (+/- standard error) at 9 years for patients less than or equal to 6 months, 7 to 12 months, and greater than 12 months of age were 59% +/- 15%, 60% +/- 17%, and 95% +/- 5%, respectively. All 10 patients reoperated upon during the past decade survived with complete relief of symptoms. A double patch to widen both the superior portion of the baffle and the superior vena cava was used most commonly and is our current procedure-of-choice. Baffle complications after the use of pericardium can be managed easily and reoperation on these patients carries a low risk. However, even with experience, the incidence of reoperation remains high in patients under 1 year of age and prompts a critical age-related comparison of these late results with the Senning procedure.

Blood Vessel Prosthesis↗
PubMed1994

Arterial switch operation: a new technique of coronary transfer.

A successful outcome after arterial switch operation (ASO) for transposition of the great arteries (TGA) depends in large part on the adequacy of transfer of the coronary arteries to the neoaorta. The present paper describes a new technique of coronary transfer which was used in 43 patients: 28 neonates with TGA and intact septum (with coarctation in one), 10 neonates with TGA and ventricular septal defect (with coarctation in one), 2 children undergoing ASO after failed Senning operation and 3 patients with complex TGA. A standardized uniform technique of coronary transfer was used; this technique involved reimplantation of the two coronary ostia side by side after excision of a single button of neoaortic wall. Most coronary patterns were encountered: the usual pattern in 30, circumflex from right coronary artery in 7, inverted coronary arteries in 3, inverted circumflex and right coronary arteries in 3. There was no early coronary-related mortality or morbidity. One late death (3 months) was probably coronary-related. The overall coronary risk was 2.3% (70% confidence limits = 0.3%-7.5%). The proposed technique of coronary transfer can be used in most patients with TGA (all patients without coronary arteries running between the great arteries) and entails a low coronary risk.

Aortic Coarctation↗
PubMed1976

Successful total repair of complicated cardiac anomalies with asplenia syndrome.

A one-stage total repair was successfully accomplished in a Japanese girl, 7 years, 8 months old, who had asplenia syndrome with vixceral heterotaxia, isolated levocardia, and complicated cardiovascular anomalies; double-outlet right ventricle with d-malposition of the great arteries (anterior aorta, posterior pulmonary trunk), complete form of endocardial cushion defect, total anomalous pulmonary venous drainage, pulmonary stenosis, sinus venosus type of atrial septal defect, patent ductus arteriosus, bilateral superior venae cavae, and inferior vena cava draining into the left-sided atrium. A routine cardiopulmonary bypass, consisting of ligations of the patent ductus arteriosus and right superior vena cava, was followed by direct and patch closure of atrial and ventricular septal defects. An internal conduit was inserted to drain the systemic venous blood from the left ventricle to the pulmonary artery. Thus a total repair is physiologically possible in such complicated cardiovascular anomalies with an asplenia syndrome. One year after this operation the child is well and attends school daily.

Abnormalities, Multiple↗
PubMed2002

Fate of intramural coronary arteries after arterial switch operation.

BACKGROUND: To evaluate the impact of intramural coronary arteries for the peri-, postoperative and long-term course after arterial switch operation (ASO). METHODS: ASO was performed in 351 patients between 1981 and 2000 with dextrotransposition of the great arteries (d-TGA). Five patients (1.4 %) had an intramural coronary artery. Coronary transfer was performed with a collar under dissection of the commissure without longitudinal splitting of the intramural section. RESULTS: None of these patients died; the intraoperative course was uneventful, and no myocardial ischemic changes were observed. In three patients, follow-up cardiac catheterization after 5, 16 and 53 months revealed an occlusion of the intramural coronary ostium. Exercise electrocardiography and myocardial scintiscan showed myocardial ischemia. Two of these patients underwent a successful internal mammary artery bypass. CONCLUSIONS: The intramural course of coronary arteries in patients with d-TGA is rare and does not cause increased mortality or myocardial infarction rates. However, the risk of coronary occlusion over time seems to be high. Therefore, patients with this condition require selective coronary angiography and frequent exercise investigations. Revascularization with an internal mammary artery bypass may be indicated.

Coronary Angiography↗
PubMed2000

Modified arterial switch operation by spiral reconstruction of the great arteries in transposition.

BACKGROUND: Spiral relationship of the normally related great arteries (SRGA) has never been reconstructed in an arterial switch operation. METHODS: From March 1998 to April 1999, 9 consecutive cases of transposition of the great arteries (TGA) family (from 2 days to 1.6 years old) underwent arterial switch operations with SRGA at our hospital. Two had a congenitally corrected TGA (plus atrial redirection). Lecompte maneuver was not used in all. The posterior wall of pulmonary trunk was not divided but three were reattached, two of whom had had previous pulmonary trunk banding. Thus the wall was shared between the great arteries facing each other. RESULTS: All survived the operation. Supraaortic stenosis was balloon-dilated in 2 cases of early series, but technical modifications later were able to avoid it. Angiogram showed smooth flow into SRGA without upward and anterior tilting of the pulmonary bifurcation. All great and coronary arteries were patent. All were doing well on follow-up (16.5 +/- 4.2 months). CONCLUSIONS: We concluded that the techniques to relocate the coronary arteries using common wall and in situ switch could also be applied to pulmonary arterial reconstruction, so that SRGA can be resumed in TGA.

Anastomosis, Surgical↗
PubMed2000

Intraoperative myocardial ischemia recognized by transesophageal echocardiography monitoring in the pediatric population: a report of 3 cases.

We used continuous intraoperative transesophageal echocardiography (TEE) monitoring to detect intraoperative myocardial ischemia in children after they had been weaned from cardiopulmonary bypass for cardiac surgery. Three pediatric patients are described here to illustrate the usefulness of such TEE monitoring in surgical procedures involving coronary arteries. The indications for intraoperative TEE monitoring and a simplified scheme for immediate qualitative interpretation are discussed.

Adolescent↗