Complex Cyanotic Congenital Heart Disease Research Articles

Prostaglandin E1 Therapy: Is It Associated with a Higher Incidence of Wound Infection in the Cyanotic Neonate?

Prostaglandin (PGE1) may be used to maintain ductal patency in the infant with cyanotic congenital heart disease, but the risk of infection may be increased. Between October, 1976 and December, 1982, 38 neonates with complex cyanotic congenital heart disease required operations creating systemic-to-pulmonary artery shunts. Of 13 patients who did not receive PGE1 therapy, none developed a wound infection. Of 25 patients who did receive PGE1 therapy, four (16 percent) developed a significant wound infection. The two patient groups were similar when compared by age and weight at operation, by severity of heart disease and by the presence of other congenital anomalies. Pathogenic Staphylococcus epidermidis was recovered from all infected wounds, all of which responded favorably over a period of two to four weeks with a short course of antibiotics and wound debridement.

Use of saphenous vein allografts for aortopulmonary artery anastomoses in neonates with complex cyanotic congenital heart disease.

A saphenous vein allograft was used to create an aortopulmonary communication in 16 infants with cyanotic congenital heart disease and ductus-dependent pulmonary blood flow. These grafts measured from 3 to 8 mm in diameter and were placed between the aorta and main pulmonary artery in eight patients, between aorta and right pulmonary artery in eight, and between aorta and left pulmonary artery in one (one child had two grafts). Before heparin was used, early in the series, four of these grafts occluded and three of the four infants died during attempted revision. Another infant died early from renal failure. Late mortality has claimed four: one from cerebral hemorrhage, two from hypoxia, and one at open-heart surgery for repair. There are eight late survivors (50%). Most of the allografts were used before small diameter Gore-Tex was available; in more recent patients, 4- to 6-mm Gore-Tex grafts have been used. In our most recent patient, however, the attempt to place a Gore-Tex graft was unsuccessful, but the more pliable saphenous vein graft was readily placed and an adequate shunt obtained. Both the saphenous vein graft and the Gore-Tex have the advantage of providing pulmonary flow without the higher risk of congestive failure or pulmonary hypertension seen in patients with a Waterston or Potts anastomosis. They are easier to perform, require less anesthesia time than the Blalock-Taussig shunt, last as long as the Blalock-Taussig when done under similar conditions, and are easy to take down at the time of total repair.

Computerized axial tomography of the chest for visualization of "absent" pulmonary arteries.

To expand the search for central pulmonary arteries in six patients with absence of cardiac-pulmonary continuity, computerized axial tomography (CAT) of the chest was performed. The CAT scans were compared with previous arteriograms and pulmonary vein wedge angiograms. Three patients with type IV truncus arteriosus were studied, and none had a central, right or left pulmonary artery on CAT scan. However, two patients with tetralogy of Fallot with pulmonary atresia and a patent ductus arteriosus to the right lung demonstrated the presence of a left pulmonary artery. In addition, one child with truncus arteriosus with "absent" left pulmonary artery demonstrated a left pulmonary artery on the CAT scan. The CAT scan may therefore enhance our ability to search for disconnected pulmonary arteries in children with complex cyanotic congenital heart disease.

Arterial prosthesis of microporous expanded polytetrafluoroethylene for construction of aorta-pulmonary shunts

A new arterial prosthesis made of polytetrafluoroethylene (OTFE) was evaluated in 10 infants with complex cyanotic congenital heart disease. All grafts used were 4 mm. in diameter and varied in length from 0.8 to 6 cm. The grafts were anastomosed to the main pulmonary artery or its bifurcation in 8 infants and to the right and left pulmonary arteries in one each. There were two early deaths, one of which was related to shunt failure. The advantages of a shunt to the main pulmonary artery are obvious, and the intraoperative procedure is facilitated with the prosthesis. Follow-up averages 9 months in the 8 survivors, and the patients have nearly doubled their preoperative weight. A shunt murmur is present in each case and the children have mild-to-moderate cyanosis at rest. Repeat aortograms in 2 patients, 8 and 10 months postoperatively, show a smooth graft without luminal narrowing. The aortic oxygen saturations were 73 per cent. The PTFE graft and/or anastomoses will not grow with the growth of the child and therefore may not accommodate growth by increased flow. This may prove to be a limiting factor in its long-term use in fants. We reserve the use of these grafts for infants with complex cyanotic defects undergoing emergency surgery or in older children in whom a conventional shunt is not possible or a previous shunt has failed.

Right atrial partition and right ventricular exclusion: Another surgical approach for complex cyanotic congenital heart disease

A 5-year-old child with asplenia, situs inversus, single ventricle, common atrium, severe subvalvular pulmonary stenosis, 1-transposition of the great arteries, and absent inferior vena cava presented with severe limitation (resting arterial saturation 74 per cent). At operation, the systemic venous atrium was partitioned with a Dacron baffle, so that hepatic venous and coronary sinus blood was enabled to drain with the pulmonary venous blood into the single ventricle and aorta. The superior portion of this atrium was anastomosed to the divided main pulmonary artery, so that most of the systemic venous blood was allowed to flow directly to the lungs. Intraoperative hemodynamic studies revealed a pulmonary artery pressure of 12/9 mm. Hg and a superior vena caval flow that was 88 per cent of the ascending aortic blood flow. Follow-up catheterization studies revealed an intact partition, no anastomotic gradient, superior vena cava pressure of 20 mm. Hg, arterial saturation of 84 per cent, and excellent flow of contrast from superior vena cava to atrium to pulmonary artery. Exercise tolerance was markedly improved, and chronic fluid retention was not observed. This operation offers a new alternative for long-term palliation of complex lesions amenable to exclusion of the right ventricle, such as single or common ventricle with unreconstructable anomalies of the atrioventricular valves.