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(BQ) Part 2 book Reoperations in cardiac surgery has contents: Reoperations after mustard and senning operations, reoperations after arterial switch operation, aortic valve reoperations, aortic root replacement, reoperations for atrioventricular discordance,... and other contents.
Chapter 14 Reoperations After Mustard and Senning Operations J Stark Introduction Senning introduced the physiological repair of transposition of the great arteries in 1958 (Senning 1959) and Mustard published his experience with the atrial switch in 1964 (Mustard 1964) The Mustard operation soon became the operation of choice, and survival rates of over 90% for patients with simple transposition were reported (Waldhausen et al 1971; Lindesmith et al 1973; Ebert et al 1974; Stark et al 1974a) The original concept of the Mustard operation was a two-stage correction A Blalock-Hanlon atrial septectomy enabled a sick infant to survive Because of the fear that the small size of the atria would preclude successful repair, the Mustard operation was often delayed into the second or third year of life The balloon atrial septostomy was introduced by Rashkind and Miller in 1966 (Rashkind and Miller 1966) This considerably improved the survival of infants with transposition of the great arteries However, the improvement achieved by a balloon sept ostomy did not usually last as long as the improvement following a surgical septectomy Attempts, therefore, were made to lower the age for an elective Mustard operation, and soon results which were comparable with or better than the results achieved in older children were reported (Aberdeen 1971; Stark et al 1974a; Bailey et al 1976; Oelert et al 1977; Turley and Ebert 1978) The advantage of early balloon septostomy followed by a Mustard operation during the first year of life rapidly became apparent Reports of complications of the Mustard operation such as SVC obstruction (Mazzei and Mulder 1971; Stark et al 1974b) and pulmonary venous obstruction (Stark et al 1972; Driscoll et al 1977; Oelert et al 1977) led to several technical modifications of the original Mustard operation Although some of these modifications reduced postoperative complications, others actually increased them Brom reintroduced the Senning operation in 1975 (Quagebeur et al 1977); the incidence of complications was reduced significantly but not completely eliminated Today, both the Senning and Mustard operations offer excellent early and good medium-term results Recent reports of the arterial switch operation for neonates with simple transposition (Jatene et al 1975; Castaneda et al 1974; Quaegebeur et al 1986) suggest that the J atene operation may become the operation of choice for this group of patients 188 As is often the case in surgery of infants and young children, some complications may be growth-related, manifesting themselves only years after the original operation For this reason, it is important to follow these patients for many years It is equally iinportant to be familiar with the diagnosis of the complications and with the surgical techniques of their repair, even though the original operation may not be in use any more Problems Mustard Operation The following problems/complications have been reported after the Mustard operation: Systemic venous obstruction (SVe, IVC) Pulmonary venous obstruction Tricuspid valve incompetence Baffle leaks Residual/recurrent ventricular septal defect Residual/recurrent left ventricular outflow tract obstruction Right and left ventricular dysfunction Arrhythmias Some of these complications may not manifest themselves clinically, and are discovered only on routine restudy (isolated obstruction of the sve, small baffle leaks) Other complications may require medical treatment (arrhythmias, ventricular dysfunction) In this chapter we shall concentrate only on those complications which require surgical treatment: systemic and pulmonary venous pathway obstruction, leaks in the baffle, and tricuspid valve incompetence Residual ventricular septal defects and left ventricular outflow tract obstruction are described in detail elsewhere (see pp 165-167 and 285) Systemic Venous Obstruction Incidence and Causes sve obstruction is much more common than obstruction of the IVe Reoperations in Cardiac Surgery Frequently it is the intracardiac part of the sve channel, rather than the sve itself, which becomes narrow In the Ive channel, the obstruction usually occurs between the coronary sinus and the right inferior pulmonary vein Pathway obstruction may have several causes: construction of too narrow a pathway, inadequate resection of the upper margin of the interatrial septum, and thrombosis of the pathway possibly originating on the raw area remaining after resection of the septum Narrowing of the sve at the cannulation site can also occur Late obstruction may be caused by thickening and/or contraction of the baffle The incidence of systemic venous pathway obstruction varies in different series Venables et al (1974) reported 14 cases of sve obstruction among 20 restudied patients; had symptoms Park et al (1983) reviewed 78 patients; 33 had gradients over mmHg Eighteen obstructions were seen; of these, six required reoperation Silverman et al (1981) observed partial and complete obstructions in a series of 18 restudied patients A high incidence of systemic venous pathway obstruction was also reported by Marx et al (1983) Of their 59 survivors of the Mustard operation, 32 had gradients, with 11 requiring reoperation In our experience a higher incidence of sve obstruction was observed in patients in whom a Dacron patch was used for the Mustard repair From the experience of other authors it seems likely that the shape of the baffle is more important than the material Egloff et al (1978) observed systemic venous obstruction in out of 10 patients in whom a "butterflyshaped" patch was used A dumbbell-shaped patch resulted in 25 obstructions among 84 operated patients, while only obstructions were observed among 58 patients with a trousershaped pericardial patch (Stark et al 1974a) Trusler et al (1980) has reported a higher incidence of systemic venous obstruction in the latter part of their series (10/100 compared with 5/105) This was probably due to the less aggressive resection of the superior part of the interatrial septum Avoidance of excessive resection decreased the incidence of arrhythmias in their series, but it increased the incidence of sve obstruction Inferior vena cava obstruction is much less common (Trusler et al 1980 - 3/192 sur- Reoperations After Mustard and Senning Operations vivors) Partial obstruction of both the SVC and IVC is a more serious complication than isolated SVC obstruction The patient may present with a low cardiac output Thrombosis of the IVC has been described after preoperative cardiac catheterisation (Venables et al 1974) IVC obstruction is particularly rare if the coronary sinus is opened widely into the left atrium during the Mustard operation Barratt-Boyes (Kirklin and Barratt-Boyes 1986) has seen only one IVC obstruction among 166 patients (0.6%) Diagnosis Some patients with SVC obstruction are asymptomatic Others develop puffiness of the eyelids or facial oedema, pleural effusion or even chylothorax Tortuous venous collaterals on the chest wall usually develop in the presence of severe obstruction only An increasing head circumference with widening of the cranial sutures and delayed closure of the fontanelles has been described (Silverman et al 1981) Significant IVC obstruction causes hepatomegaly, ascites and leg oedema Protein-losing enteropathy has been described (Moodie et al 1976) SVC obstruction can be diagnosed noninvasively by Doppler ultrasound (Wyse et al 1979) or two-dimensional contrast echocardiography (Silverman et al 1981) Cardiac catheterisation and cineangiography should be performed prior to the operative revision This investigation demonstrates not only the· exact location, length and severity of the obstruction, it also visualises the width of the non-obstructed channel It is important to detect any other residual/recurrent lesions so that these can be repaired at the time of revision of the systemic venous pathways Asymptomatic isolated SVC obstruction does not require treatment All IVC obstructions and symptomatic SVC obstructions are indications for operative revisions Recently, successful balloon dilatation of partially obstructed pathways has been described by the Boston group (Lock et al 1984) We have used balloon dilatation successfully It would seem reasonable, therefore, to attempt to dilate such pathways during the diagnostic cardiac catheterisation Even if a perfect result is not achieved, dilatation can be repeated or surgery considered at a later 189 date In the meantime the symptoms will usually be relieved Pulmonary Venous Obstruction Causes and Incidence Pulmonary venous obstruction is a less frequent but much more serious complication of the Mustard operation It is probably caused by a redundant baffle which becomes adherent to the lateral right atrial wall It occurs more frequently when Dacron is used for the baffle (Driscoll et al 1977; Oelert et al 1977) Occasionally, isolated left pulmonary vein stenosis occurs, but more frequently the stenosis is anterior to the entry of the right pulmonary veins The ostium may be very small and divides the pulmonary venous atrium into a posterior and anterior compartment Driscoll et al (1977) observed pulmonary venous obstruction in of their 25 survivors, Oelert et al (1977) in of 43 survivors Eight among the 48 restudied patients at the Mayo Clinic (Hagler et al 1978) and 10 of 376 survivors in Toronto (Trusler 1984) developed pulmonary venous obstruction We have reported pulmonary venous obstructions among 113 survivors of the Mustard operation (Stark et al 1972) Pulmonary venous obstruction was not seen by BarrattBoyes in patients in whom he used a V-Y atrioplasty (Kirklin and Barratt-Boyes 1986) Likewise, obstruction is rare in the series where the pulmonary venous atrium is enlarged, even when the operation is performed in infancy (Turley and Ebert 1978; Stark et al 1980) Diagnosis Tachypnoea, dyspnoea, cough, fatigue and decreasing exercise tolerance are the common symptoms Mild cyanosis may be present The condition may be wrongly diagnosed as asthma or pneumonia (Driscoll et al 1977) Pulmonary venous congestion or interstitial pulmonary oedema is seen on the chest radiograph The diagnosis of pulmonary venous obstruction may be made by twodimensional echocardiography It is confirmed by cardiac catheterisation; the catheter has to be passed retrogradely through the right ventricle and the tricuspid valve across the stenotic area into the pulmonary veins On angiocardiography ,(direct or pulmonary artery 190 injection) narrowing is best seen in the lateral projection Urgent reoperation is indicated for all patients with pulmonary venous pathway obstruction Recently we have successfully used balloon dilatation of this obstruction The balloon was passed retrogradely through the aortic valve, right ventricle and tricuspid valve into the pulmonary venous atrium and through the stenotic area Leaks in the Baffle A significant baffle leak is rare Trusler et al (1980) reported 12 in his series of 60 recatheterised patients (20% ), but only required reoperation Park et al (1983) described small baffle leaks in 22 (25%) patients The leak was detected by oximetry in four, while in 18 it was visualised only by cineangiography None of their patients required surgery Indications for surgery would be similar to those for atrial septal defect with a left-to-right shunt If the SVC or IVC pathways are also obstructed, a baffle leak above the site of obstruction may cause considerable right-toleft shunting This is repaired at the time of the relief of the pathway obstruction Tricuspid Valve Incompetence Causes and Incidence Mild to moderate tricuspid valve incompetence can be seen in some patients before the Mustard operation (Tynan et al 1972) The abnormalities of the tricuspid valve are more common in patients with TGA and VSD Huhta et al (1982) has reviewed 121 autopsy specimens with TGA and VSD and found structural abnormalities of the tricuspid valve in 38 (31%) Valve dysplasia, straddling, double orifice, accessory tricuspid valve tissue and abnormal chordal attachment were observed The reported incidence of tricuspid valve incompetence after the Mustard operation varies It is speculated that the tricuspid valve can be injured when the baffle is sutured close to the tricuspid valve annulus or when the VSD is repaired through the tricuspid valve We have seen the tricuspid valve and/or the chordae become adherent to the VSD patch Incom- Reoperations in Cardiac Surgery petence can also develop secondary to right ventricular dysfunction/failure or to arrhythmias Takahashi et al (1977) and Marx et al (1983) did not see serious tricuspid valve incompetence in respective series of 110 and 59 survivors of the Mustard operation Trusler et al (1980) has reported 10 cases of mild tricuspid incompetence among 192 survivors in Toronto In our series of 563 Mustard operations, tricuspid valve replacement was performed in patients The incidence of serious tricuspid incompetence is higher in patients operated on for TGA and VSD Hagler et al (1979) reported a high incidence of this complication from the Mayo Clinic They found mild and moderate tricuspid valve incompetences among 33 restudied asymptomatic patients and mild to moderate and severe among 16 symptomatic patients Four out of 17 patients operated for TGA and VSD by Barratt-Boyes had moderate to severe incompetence (Kirklin and BarrattBoyes 1986) In Park's series, 6/24 patients with TGA and VSD developed incompetence; required surgery (Park et al 1983) Diagnosis The patients present with increasing breathlessness, a cough and fatigue A systolic murmur is heard along the right sternal border The chest radiograph will show cardiomegaly, pulmonary venous congestion and later pulmonary oedema The tricuspid valve is best assessed by crosssectional echocardiography Anomalies, such as straddling, overriding and prolapse, are usually well demonstrated Doppler echocardiography detects a regurgitant jet; the degree of regurgitation can be estimated Cardiac catheterisation and angiography should exclude additional residual/recurrent lesions and assess the right ventricular function Mild to moderate tricuspid valve incompetence is often tolerated; if severe, an operation is indicated Tricuspid valve incompetence secondary to right ventricular dysfunction may be considered for an alternative treatment Mee (1986) has suggested that the pulmonary artery be banded unless the left ventricular pressure is considerably elevated After this preliminary banding, the Mustard operation is changed into an arterial repair (arterial switch) (see Chap 16, p 217) 191 Reoperations After Mustard and Senning Operations Residual!Recurrent VSD ResiduaVrecurrent VSD can occur, as it does after VSD repair in other anomalies The diagnosis and treatment is described in Chapter 12 (see p 161) Residual!Recurrent Left Ventricular Outflow Tract Obstruction It is often difficult to relieve left ventricular outflow tract obstruction (LVOTO) at the time of the Mustard operation This is particularly so If the Mustard operation is performed during the first 3-6 months of life L VOTO is often ~ell tolerated in patients whose LV pressure IS less than systemic and in whom the pulmonary artery pressure is close to normal Under such circumstances we not attempt to relieve LVOTO; the obstruction rarely progresses (Park et al 1983) We have serially recatheterised several patients over a period of 15 years· the gradient remained more or less the same: In only a few patients, the obstruction develops late after the operation, or, if present originally, progresses The diagnosis of L VOTO is made by crosssectional echocardiography, cardiac catheterisation and angiography Detailed assessment of ~h~ anatomy of the obstruction and its severity is Important before reoperation is indicated An attempt should be made to distinguish obstruction which could be relieved at a late operation (valvar stenosis, subvalvar membrane or aneurysm of the membranous part of the interventricular septum) from obstruction which must be bypassed (long fibromuscular tunnel or abnormal attachment of the mitral valve) ~eoperation is indicated in symptomatic patients whose LV pressure is at systemic level and in asymptomatic patients with suprasystemic LV pressure Ventricular Dysfunction Right ventricular (RV) function may be reduced after the Mustard operation; impairment of the LV function is less common The cause of dysfunction is not clear; it has been suggested that the morphological right ventricle is not capable of functioning normally as a systemic ventricle Ventricular dysfunction is more common in patients in whom the VSD was ~losed in.addition to the Mustard operation, particularly 10 those in whom the VSD was closed through a right ventriculotomy (Park et al 1983) Ventricular function after the Mustard operation was studied by measurement of RV and LV ejection fraction and RV and LV enddiastolic volume using standard or radionuclide angiocardiography (Graham et al 1975· Hurwitz et al 1985) Some have performed these studies on patients both at rest and during exercise (Murphy et al 1983; Ramsay et al 1984) Hagler et al (1979) has studied 37 as~mptomatic patients after the Mustard operation The RV ejection fraction calculated for this group of patients was found to be significantly below normal, and RV end-diastolic volume was significantly increased LV ~u~ction was relatively well preserved A high IOcid~nce of RV dysfunction at rest and during exercise was also demonstrated in a group of 26 asymptomatic patients studied by Murphy et al (1983) In our group, Weller has shown a statistically significant (p=O.OI) reduction in maximal working capacity in a group of 45 asymptomatic patients studied 5-12 years after the ~ustard operation (Stark et al 1980) Despite the decreased exercise tolerance all ' our patients were asymptomatic and were leading a normal life The same observation has been made by other authors (Mathews et al 1983; Ramsay et al 1984) The reports of RV dysfunction have prompted the exploration of alternative techniques of ~orrec~i.on for TGA, especially techniques which utIhse the left ventricle as a systemic ventricle Mee (1986) has demonstrated recently that some patients with impaired RV function following a Mustard operation can be treated by pulmonary artery banding followed by an arterial switch operation (see Chap 16, p 220) Rhythm Disturbances Serious arrhythmias (atrial fibrillation or flutter, atrioventricular dissociation) were seen more frequently after operations performed in 192 earlier years (Breckenridge et al 1972; EI Said et al 1972; Ebert et al 1974; Beerman et al 1983; Hayes et al 1986) It is not clear why the incidence of reported rhythm disturbances has decreased considerably in recent years (Turley et al 1978; Ullal et al 1979; Trusler et al 1980; Deanfield et al 1989) Possibly a better knowledge of the exact position of the sinus node, sinus node artery and atrioventricular node has enabled surgeons to protect these structures better during the Mustard operation Ebert et al (1974) have reported a higher incidence of arrhythmias in patients who had the coronary sinus cut open; however, this was not confirmed by Clarkson et al (1976) Fewer arrhythmias were seen in patients in whom a less extensive resection of the superior part of the interatrial septum was carried out (Trusler et al 1980) The incidence of post Mustard arrhythmias varies in reported series Southall et al (1980) have pointed out that some arrhythmias may be detected on Holter monitoring even before the Mustard operation Our prospective study (Deanfield et al 1989) did not confirm this finding Changes of P wave amplitude and contour are seen in almost all patients after the Mustard operation (EI Said et al 1972) Atrial fibrillation, atrial flutter and atrioventricular dissociation occurred frequently in earlier series (Breckenridge et al 1972; Ebert et al 1974); fortunately, the current incidence of these is very low Sick sinus syndrome (sinus bradycardia with sinus arrest and junctional escape) was the predominant arrhythmia in the experience of Hayes et al (1986) Junctional rhythm does not usually cause any problems Episodes of supraventricular tachycardia are more serious; they occur in a small percentage of patients (Hayes et al 1986) Some arrhythmias may only become "unmasked" during maximal exercise testing (Mathews et al 1983) Late deaths have been described in several series after the Mustard operation Some of these may possibly have been caused by arrhythmias (Aberdeen 1971; Lewis et al 1977; Hayes et al 1986) Patients discharged from hospital in sinus rhythm may lose this rhythm later At Green Lane Hospital, Auckland, 72% of patients were in sinus rhythm year after the Mustard operation This number decreased to 56% at Reoperations in Cardiac Surgery years and 50% at 10 years (Kirklin and Barratt-Boyes 1986) In our postoperative study (Deanfield et al 1989), we have followed patients with 24-h Holter monitoring before and after the operation All were in sinus rhythm before the operation and 91 % at discharge from the hospital The incidence of stable sinus rhythm decreased to 83% at 1-3 years and 66% at 6-8 years Benign arrhythmias not require treatment Supraventricular tachycardia is treated medically However, it may be resistant to several drugs Some patients with bradyarrhythmias require insertion of a pacemaker Senning Operation The Senning operation was first performed in 1958, but it was the Mustard operation which became the operation of choice soon after its introduction in 1964 There is a possible explanation why the Mustard operation was favoured The mortality of the Senning operation was high in early reports (Kirklin et al 1961) Today we know that the high mortality was due to the selection of the patients rather than to the operative technique There were several infants and young children with TGA and VSD in Kirklin's series; and some of these had pulmonary vascular obstructive disease In contrast, in Toronto, many patients with simple transposition were well palliated by a Blalock-Hanlon septectomy These children were stable and in a good condition in their second, third or fourth year of life - excellent candidates for intra-atrial repair Brom reintroduced the Senning operation in 1975 (Quaegebeur et al 1977), and since then it has become the intra-atrial repair of choice for most cardiac centres The idea of reviving the Senning operation was an attempt to reduce obstructive complications and arrhythmias We shall briefly review here the complications seen after the Senning operation In principle the complications are similar to those seen after the Mustard operation but are much less frequent Reoperations After Mustard and Senning Operations 193 Systemic Venous Obstruction Baffle Leaks In several series, sve obstruction was not detected after the Senning operation (Parenzan et al 1978; Quaegebeur et al 1977; Bender et al 1980) Two sve obstructions required reoperation in the early experience at Birmingham (Kirklin and Barratt-Boyes 1986) The Boston group (Marx et al 1983) have reported obstructions in a group of 54 survivors of the Senning operation To our knowledge, IVe obstruction was not reported after the Senning operation In our series of 196 Senning operations patient required reoperation for sve obstruction The obstruction was due to technical error, and reoperation was performed within 24 h after surgery The sve and IVe orifices were closer together than normal Both sve and IVe pressures were elevated after surgery At reoperation we found that the area under the septum was narrow, thus presenting obstruction to flow from both the sve and IVe The diagnosis and indications for reoperation are identical to those after the Mustard operation Baffle leaks are uncommon after the Senning operation This has been our experience as well as that of other authors Pulmonary Venous Obstruction Pulmonary venous obstruction is rare after the Senning operation We believe that this complication could be avoided if the technique of Brom (Quaegebeur et al 1977) is used for the Senning operation To our knowledge, pulmonary venous obstruction only occurred in patients in whom the pulmonary venous atrium was enlarged with a patch: three patients in the initial Birmingham experience and six patients in the Boston series (Pacifico 1979; Marx et al 1983) We have seen this complication in patient among 196 consecutive Senning operations; reoperation to correct the technical error was performed within 24 h of the original operation Pulmonary venous obstruction did not occur in the series reported by Parenzan et al (1978), Quaegebeur et al (1977) and Bender et al (1980) No case of pulmonary venous obstruction was seen in the Green Lane Hospital series and in the recent (1977-1984) Birmingham series (Kirklin and Barratt-Boyes 1986) The diagnosis and the indications for reoperation are identical to those after the Mustard operation Tricuspid Valve Incompetence Tricuspid valve incompetence can occur after the Senning operation Penkoske et al (1983) has reported three mild and three severe tricuspid valve incompetences in 39 survivors of the Senning operation and VSD closure Severe incompetence required tricuspid valve replacement in three patients The reason why tricuspid valve incompetence has been reported less frequently after the Senning operation than after the Mustard operation is probably due to the fact that the Senning operations have been performed more recently, when perhaps the techniques of bypass and myocardial protection have been improved The lower incidence of arrhythmias after recent atrial repairs may also be attributed to this fact Residual/Recurrent VSD and LVOTO There are no special differences between the diagnosis and treatment of residual/recurrent VSD or LVOTO after the Senning operation and after the Mustard operation Ventricular Function Ventricular function has not,as yet, been extensively studied after the Senning operation However, Bender et al (1980) did not show any difference in their group of Mustards and Sennings Arrhythmias Parenzan et al (1978) have reported a high incidence of sinus rhythm soon after the Senning operation We have carried out a prospective study (Deanfield et al 1989), assessing patients who underwent a Mustard or Senning operation The standard electrocar- 194 Reoperations in Cardiac Surgery diogram and 24-h Holter monitoring was performed before the operation, after the operation prior to discharge from the hospital, at year and at years The study showed a low incidence of active arrhythmias However, there was a continuing decrease in the number of patients remaining in a stable sinus rhythm during the follow-up period No statistically significant difference was found between the Mustard and Senning groups Operative Technique Mustard Fig 14.2 The technique of the original operation may influence the development and the incidence of some late complications Therefore, we shall first describe some of the steps of the Mustard operation which we consider important to avoid complications Primary Operation SVC Cannulation The sve is usually cannulated directly through a purse-string suture This suture is placed at least 10 mm above the CORRECT INCORRECT Fig 14.1 sinus node to avoid its injury The purse-string is oblong (Fig 14.1) rather than circular to avoid narrowing of the sve when the pursestring is tied after the sve cannula is removed Alternatively, the purse-string is not tied after decannulation but the partial occlusion clamp is applied on the cava and an incision in the sve is formally closed with a fine polypropylene stitch (Fig 14.2a, b) We favour the technique of an oblong purse-string which is tied after decannulation Shape and Material used for Baffle The shape and the material of the baffle and the technique of its insertion may contribute to the development of obstruction It is important to construct the sve pathway in such a manner that the baffle forms less than 50% of its circumference If at least 50% of the pathway is constructed of the atrial wall, obstruction is unlikely to develop if the patch does not grow, or even if it shrinks (Fig 14.3) In our early experience both the material used for the baffle and the shape of the baffle played an important role (Stark et al 1980) We found that a redundant , thin Dacron patch had a tendency to fold upon itself (Fig 14.4a) Apposition of platelets and fibrin and subsequent fibrosis of this tissue led to severe thickening of the patch (Fig 14.4b, c) Brom has suggested cutting the patch into a "trouser shape" (Quagebeur and Brom 1978) He constructed the patch on the basis of measurements of sve and IVe circumference 195 Reoperations After Mustard and Senning Ope rations is to suture the patch away from the SVC and IVC orifices and to pull the atrium onto the patch (Kirklin and Barratt-Boyes 1986) ' -Baffle Thrombosis Thrombosis may cause SVC pathway obstruction, especially if the lumen was already compromised by a faulty operative technique Insertion of several central venous cannulae into the internal jugular vein may be another cause This may be of particular importance in young infants Infusion of platelets and/or hypertonic solutions through these lines may be another contributing factor It is useful to evaluate the adequacy of the SVC pathway soon after the operation by Doppler echocardiography or by an injection of contrast media through an internal jugular Fig 14.3 line and performing a chest radiograph at the same time Both these techniques are useful (distances E-D and D-F in Fig 14.5a) and the and can be easily performed in the intensive distance between the edge of the intra-atrial care unit The diagnosis of even mild SVC septum and the pulmonary veins (C-D in Fig pathway narrowing would alert us to avoid 14.5a) Subsequently, good results have been infusions of hypertonic solutions Under such achieved with this patch irrespective of whether circumstances, it may be safer to remove the it was tailored from Dacron or pericardium jugular vein cannula and place it elsewhere The Toronto group has always used pericardium The original large quadrangular patch Inadequate Resection of Intra-atrial Sepof the Mustard operation has been only slightly tum Inadequate resection of the intra-atrial modified (Trusler et al 1980) (Fig 14.5b) septum may leave a ridge of tissue which Barratt-Boyes uses a small patch His concept then causes turbulence and contributes to the A a b a c B Fig 14.4 Fig 14.5 Reoperations in Cardiac Surgery 196 Fig 14.6 development of obstruction On the other hand, too extensive resection may damage the sinus node artery and lead to arrhythmias (Trusler et al 1980) If one avoids an extensive resection, it is possible to use the superior part of the atrial septum as a flap, which is then sutured to the baffle (Turley and Ebert 1978) This step is illustrated in Fig 14.6 manoeuvre may cause arrhythmias, it has not been confirmed by others (Clarkson et al 1976) We have not cut the coronary sinus routinely; however, we find the technique very useful in children in whom the distance between the SYC and IYC orifices is short The suture line from the left to the right pulmonary veins should diverge to avoid pulmonary venous obstruction This may, on the other hand, compromise the IYC pathway; therefore , under such circumstances we prefer to open the coronary sinus deep into the left atrium (Fig 14.7) It is important to open the coronary sinus with one cut Repeated, short cuts may catch the fold in the atrial wall and cut outside the heart This does not cause problems if recognised in time It is very difficult to control the bleeding from the posterior part of the left atrium without the aid of cardiopulmonary bypass Therefore, we routinely lift the heart up before discontinuing perfusion to check for any damage to this area Width of the Baffle Too redundant a baffle may form adhesions with the lateral atrial wall and cause pulmonary venous obstruction We assess the width of the patch during insertion When the suture line around the left pulmonary Coronary Sinus Cut-back Opening the cor- veins and towards the right upper and lower onary sinus deep into the left atrium ensures pulmonary veins has been completed we hold a wide IYC pathway Although it has been the opposite edge of the patch with forceps suggested (Ebert et al 1974) that this and keep it close to the cut edge of the atrial septum A curved instrument then pushes the patch from behind towards the lateral atrial wall (Fig 14.8) If the patch reaches the atrial wall it is too redundant and should be trimmed Coronary sinus Placement of the Baffle The correct placement of the baffle is important to avoid either systemic or pulmonary venous obstruction Concern about one of these complications may cause the other one The suture line from the left pulmonary veins should diverge upwards between the SYC and right pulmonary vein Inferiorly, the suture line runs from the left pulmonary veins to between the right lower pulmonary vein and the orifice of the lYe Figure 14.9 illustrates the correct and incorrect placement of a baffle Fig 14.7 Incision in the Right Atrium and Enlargement of the Pulmonary Venous Atrium Various 375 Reoperations for Thoracic and Thoracoabdominal An eurysms Fig 26 24 Fig 26.23 clamp injury to the thin, friable aortic walls and to allow maximal distal resection and replacement When the transverse arch segment harbours the site of origin, it is routinely replaced Nevertheless, in acute dissection, the false lumen is obliterated as the aortic walls are reinforced between two circumferentially placed Teflon felt strips, allowing the distal anastomosis to direct flow into the true lumen (Fig 26.25a-c) In chronic dissection cases in which only ascending aortic reconstruction is required, the aortic tissues are often infiltrated with fibrous tissue and can be safely clamped In chronic dissection, the rigidity of the inner wall between the true and false lumen and contraction of the true lumen determine whether or not the dissected aortic walls can be reapproximated When reapproximation of the aortic walls is not possible , removal of a generous portion of the inner septum distally is undertaken (Fig 26.25b) to avoid obstruction of either lumen and distal perfusion of both A similar approach is taken with the proximal descending thoracic aorta when the entire transverse arch is replaced for chronic dissection The technique of proximal aortic reconstruction varies with the extent of involvement of the aortic root and the type of aortic disease present In the non-Marfan 's patient, with a competent aortic valve and aortic sinuses of a normal size, the graft replacement extends to just above the coronary artery origins (Fig 26.26) The aorta at this level is transected and Teflon strips are used to reinforce the aortic wall, if thin and friable , prior to end-to-end anastomosis (Fig 26.27a, b) Completion of the repair is shown in Fig 26.28a, b When the aortic valve is incompetent and the sinuses completely normal, separate valve and tube graft replacement is undertaken (Fig 26.29) In all patients with Marfan's syndrome, other patients with sinus enlargement , and in many cases of acute proximal aortic dissection, composite valve graft replacement with reattachment of coronary artery origins is required In c Fi g 26.25 376 Reope rations for Thoracic and Thoracoabdominal Aneurysms a Fig 26.26 b Fig 26.27 Fig 26.29 b Fig 26.28 most instances, complete resection of the aneurysm down to the aortic valve annulus can be accomplished with preservation of a small portion of aortic wall around the coronary artery origins The proximal coronary arteries are mobilised for short distances (Fig 26.30) to allow tension-free direct attachment to the graft using a continuous suture of 3-0 polypropylene after the aortic valve portion of the composite valve graft prosthesis is sutured into place The aortic valve portion of the composite graft is inserted with closely placed pledgetted sutures of 2-0 Ti-Cron, using a horizontal mattress technique with an average of four to six sutures per aortic cusp Tension-free reattachment of the coronary artery origins in composite valve graft replacement is critical in preventing false aneurysm development at this site In aortic root enlargement , the coronary artery origins are displaced distally from the valve annulus and laterally by sinus enlargement; consequently, the Bentall technique (Bentall and DeBona 1968), whereby the graft is approximated to the aortic wall around the coronary artery origins, places their reattachment under tension Mobilisation of the coronary artery origins and direct reattachment 377 Reoperations for Thoracic and Thoracoabdominal Aneurysms eliminates tension and provides access for haemostasis This is achieved by the following technique: the sutures are placed through the preserved aortic wall, surrounding the coronary artery origin rather than through the delicate coronary artery itself, and the suture line is often reinforced with Teflon felt When composite valve graft replacement is performed as described by Bentall, overlapping suture lines can make achieving haemostasis both difficult and dangerous Wrapping the aneurysm wall around the graft can assist in achieving haemostasis; however, bleeding within the perigraft space after control with an aortic wall wrap can initiate the need for a second operation as the suture line leak can result in progressive dilatation of the aneurysmal wrap (Fig 26.31a, b) Total aortic resection down to the valve annulus with an open technique of repair provides access to all suture lines for direct haemostasis and eliminates false aneurysm formation In redo procedures, it is often not possible to resect the aneurysm completely because of scar formation and adherence of surrounding structures, thus not Fig 26.30 a b Fig 26.31 378 Reoperations for Thonicic and Thoracoabdominal Aneurysms Cabrol et a1 (1986) is applicable in many conditions requiring reoperation, both with and without dissection, and has the advantages of less dissection and tension-free repair The presence of proximal or distal coronary artery disease and acute dissection rendering the coronary artery origin unsuitable for anastomosis requires distal coronary artery bypass using reversed segments of autogenous sap~enous vein or internal mammary artery, or both Descending and Thoracoabdominal Aorta Fig 26.32 permitting mobilisation of the coronary artery origins Options under these circumstances include interposition with short segments of Dacron (Fig 26.32a) or saphenous vein (Fig 26.32b) directly to the coronary artery origins or distal coronary artery bypass with saphenous vein (Fig 26.33) Reattachment of coronary artery origins using a short Dacron graft as described by Fig 26.33 The general principles of exposure and graft replacement using the inclusion technique and direct reattachment of appropriate branch vessels are applicable (Crawford 1974; Crawford et al 1978; Crawford and Crawford 1984) Redo posterolateral thoracotomy is used for proximal disease, whereas a thoracoabdominal approach is required for more extensive disease with involvement in the region of the origin of the visceral vessels Simple proximal aortic clamping' with control of its haemodynamic sequelae using pharmacological agents has been the most commonly applied method of aortic control Heparin has not been used in our experience Although reattachment of intercostal and lumbar arteries has been extensively used in an attempt to prevent postoperative neurological deficits in the lower extremities, the comparative analysis of cases involving reattachment of intercostal arteries and those without reattachment has failed to reveal a significant statistical difference (Crawford et al 1986) Redo operation upon the thoracoabdominal aorta requires careful attention to haemostasis We routinely use a cell-saving device designed to collect shed blood from the operative field, wash it, and return the washed red cells to the patient very rapidly, at a rate of unit every Advances in blood banking allowing appropriate component therapy of packed red cells, fresh plasma, cryoprecipitate, platelets and other elements have clearly been of value The risks of descending thoracic and thoracoabdominal aneurysm repair including death, paraplegia and renal failure are not influenced by adjunctive distal perfusion, but rather are 379 Reoperations for Thoracic and Thoracoabdominal Aneurysms Table 26.1 Redo operations prior to November 1984 Ascending aorta Acute dissection Chronic dissection Non-dissection Totals Aortic arch No of cases Combined No of cases 30-day survival (75%) 11 (82%) 2 (100%) (71%) 22 17 (77%) determined by the nature and extent of the aortic aneurysm (Livesay et al 1985) To evaluate the influence of distal arterial perfusion with left atrial to femoral artery bypass during aortic clamping combined with somatosensory evoked potential monitoring of spinal cord function, we prospectively applied these techniques in 205 patients These methods were found to be unreliable in predicting and preventing postoperative paraplegia and renal dysfunction and cannot be recommended Results of Reoperation Ascending Aorta and Aortic Arch Despite the unique technical challenges of reoperation upon the ascending aorta and 30-day survival No of cases Total 30-day survival No of cases 30-day survival I (100%) (80%) 16 13 (81%) 29 24 (83%) (67%) (50%) 12 (67%) (80%) 19 15 (79%) 46 36 (78%) aortic arch, these procedures can be performed with very acceptable morbidity and mortality In the senior author's experience, reoperation upon the ascending and/or aortic arch prior to November 1984 carried an overall survival rate of 78% (36/46) (Table 26.1) The authors' total experience in reoperation upon the ascending aorta and transverse aortic arch consists of 86 patients with a 30-day survival rate of 83% (72 patients) Applying the surgical principles described in this chapter, significant improvement in results has been achieved with 40 patients treated from November 1984 to December 1986: reoperation carried a 30-day survival rate of 90%(36 patients) (Table 26.2) It is noteworthy that all 10 patients (100%) requiring combined ascending aorta and aortic arch replacement who were operated upon for conditions other than acute dissection have survived since 1984, compared with 14 of 18 patients (78%) prior to that time Table 26.2 Redo operations from November 1984 to December 1986 Acute dissection Chronic dissection Non-dissection Totals Ascending aorta Aortic arch No of cases No of cases 30-day survival Combined 30-day survival (67%) 13 11 (85%) 2 (100%) 7 (100%) 4 (100%) 23 20 (87%) 6 (100%) No of cases II Total 30-day survival No of cases 30-day survival (0%) (50%) (100%) 24 22 (92%) (100%) 12 12 (100%) 10 40 36 (90%) (91%) 380 Reoperations for Thoracic and Thoracoabdominal Aneurysms Table 26.3 Reoperation on descending and thoracoabdominal aorta Extent Descending Thoracoabdominal Totals No of patients Early survivors Percentage 16 91 15 77 94 85 107 92 85 Descending and Thoracoabdominal Aorta Between June 1960 and December 1986, our experience with redo operations upon the descending thoracic and thoracoabdominal aorta has involved 107 patients with 92 early survivors (Table 26.3) Redo operation in 16 patients was limited to the descending thoracic aorta, and in 91 patients it involved the thoracoabdominal aorta Early mortality in each group was only 6% and 15% respectively, comparing favourably with primary procedures in similar aortic segments (Livesay et al 1985; Crawford et al 1986) Descending thoracic aneurysms have been encountered on seven occasions by the senior author in patients originally treated for coarctation Two cases involved anastomotic false aneurysms secondary to the use of arterial silk in the early 1960s These patients were successfully treated by reresection and tube graft replacement Two cases involved later diffuse involvement of the entire descending thoracic aorta in aneurysm formation following coarctation repair by resection and tube graft replacement These patients were also treated by resection and graft replacement Three patients developed aneurysms after patch graft repair of coarctation at 3, 11 and 13 years, and each was successfully treated with aneurysm resection and graft replacement All cases demonstrated diffuse medial degenerative disease on histological examination of aortic wall References Becker HM, Stelter WJ, Kortmann H, Heberer G (1983) Anastomotic arterial aneurysms Thorac Cardiovasc Surg 31: 2-7 Bentall M, DeBona A (1968) A technique for complete replacement of ascending aorta Thorax 23: 338-339 Bergdahl LAL, Blackstone EH, Kirklin JW, Pacifico AD, Bargeron LM (1982) Determinants of early success in repair of aortic coarctation in infants J Thorac Cardiovasc Surg 83: 736-742 Bickerstaff LK, Pairolero PC, Hollier LH et al (1983) Thoracic aortic aneurysms: an epidemiologic study Surgery 92: 1103-1108 Cabrol C, Pavie A, Mesnildrey P et al (1986) Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries J Thorac Cardiovasc Surg 91: 17-25 Cooley DA, Livesay JJ (1981) Technique of "open" distal anastomosis for ascending and transverse arch resection Cardiovasc Dis (Bull Tex Heart Inst) 8: 421-426 Crafoord C, Nylin G (1945) Congenital coarctation of the aorta and its surgical treatment J Thorac Surg 14: 347-361 Crawford ES (1974) Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, and celiac arteries Ann Surg 179: 763-772 Crawford ES (1983) Marfan's syndrome Broad spectral surgical treatment of cardiovascular manifestations Ann Surg 198: 487-505 Crawford ES, Crawford JS (1984) Diseases of the aorta including an atlas of angiographic pathology and surgical technique Williams & Wilkins, Baltimore Crawford ES, Snyder DM, Cho, GC, Roehm JOF Jr (1978) Progress in treatment of thoraco-abdominal and abdominal aortic aneurysms involving celiac, superior mesenteric, and renal arteries Ann Surg 188: 404-422 Crawford ES, Walker HSJ III, Saleh SA, Norman NA (1981) Graft replacement aneurysm in descending thoracic aorta: results without bypass or shunting Surgery 89: 73-85 Crawford ES, Crawford JL, Stowe CL, Safi HJ (1984a) Total aortic replacement for chronic aortic dissection occurring in patients with and without Marfan's syndrome Ann Surg 199: 358-362 Crawford ES, Stowe CL, Crawford JL et al (1984b) Aortic arch aneurysm: a sentinel of extensive aortic disease requiring subtotal and total aortic replacement Ann Surg 199: 742-752 Crawford ES, Crawford JL, Safi HJ, Coselli JS (1985) Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch Ann Thorac Surg 40: 439-455 Crawford ES, Crawford JL, Safi HJ et al (1986) Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients J Vasc Surg 3: 389-404 Donaldson RM, Ross DN (1982) Composite graft replacement for treatment of aneurysms of the ascending aorta with aortic valve disease Circulation 66 (suppl 1): 1-116-121 Grey DP, Ott DA, Cooley DA (1983) Surgical treatment of aneurysm of the ascending aorta with aortic insufficiency J Thorac Cardiovasc Surg 86: 864-877 Hehrlein FW, Mulch J, Rautenburg HW, Schlepper M, ScheId HH (1986) Incidence and pathogenesis of late aneurysms after patch graft aortoplasty for coarctation J Thorac Cardiovasc Surg 92: 222-230 Jacobs NM, Godwin JD, Wolfe WG, Moore AV Jr, Breimann RS, Korogkin M (1982) Evaluation of the grafted ascending aorta with computed tomography Radiology 145: 749-753 Kouchoukos NT, Karp RB, Blackstone EH et al (1980) Replacement of the ascending aorta and aortic valve with a composite graft: results in eighty-six patients Ann Surg 192: 403-413 Kouchoukos NJ, Marshall WG Jr, Wedige-StecherTA (1986) Eleven yearexperience with composite graft replacement of the ascending aorta and aortic valve J Thorac Cardiovasc Reoperations for Thoracic and Thoracoabdominal Aneurysms Surg 92: 691-705 Livesay 11, Cooley DA, Ventemiglia RA et al (1985) Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia Ann Thorac Surg 39: 37-46 McCready RA, Pluth JR (1979) Surgical treatment of ascending aortic aneurysms associated with aortic valve insufficiency Ann Thorac Surg 28: 307-316 McNamara 11, Pressler VM (1978) Natural history of arteriosclerotic thoracic aortic aneurysm Ann Thorac Surg 26: 468-473 Miller DC, Stinson EB, Oyer PE et al (1979) Operative treatment of aortic dissection: experience with 125 patients over a 16-year period J Thorac Cardiovasc Surg 78: 365 Miller DC, Stinson EB, Oyer PE et al (1980) Concomitant resection of ascending aortic aneurysm and replacement of the aortic valve J Thorac Cardiovasc Surg 79: 388-401 Moreno-Cabral CE, Miller DC, Mitchell RS et al (1984) Degenerative and atherosclerotic aneurysms of the thoracic aorta J Thorac Cardiovasc Surg 88: 1020-1032 381 Penkoske PA, Williams WG, Oiley PM et al (1984) Subclavian arterioplasty repair of coarctation of the aorta in the first year of life J Thorac Cardiovasc Surg 87: 894-900 Pressler VM, McNamara JJ (1980) Thoracic aortic aneurysm: natural history and treatment J Thorac Cardiovasc Surg 489-498 Pressler VM, McNamara 11 (1985) Aneurysms of the thoracic aorta: review of 260 cases J Thorac Cardiovasc Surg 98: 50-54 Sade RM, Taylor AB, Chariker EP (1979) Aortoplasty compared with resection of coarctation of the aorta in young children Ann Thorac Surg 28: 346-353 Sanchez GR, Balsara RK, Dunn JM, Mehta A V, O'Riordan AC (1986) Recurrent obstruction after subclavian flap repair of coarctation of the aorta in infants J Thorac Cardiovasc Surg 91: 738-746 Wheat MW Jr, Wilson JR, Bartley TD (1964) Successful replacement of the entire ascending aorta and aortic valve JAMA 188: 717-719 Subject Index Accelerated graft atherosclerosis 93, 95,99 Adhesions 41, 43, 49, 50, 52, 96, 100, 131, 196, 197, 220, 223, 334, 336, 347 Air embolism 336, 356 Alpha-blocking agents 145 Alveolar collapse 144 Aminophylline 145 Amiodarone 298 Amphotericin 33 Anaesthesia 39-42 congenital heart disease 42 coronary artery bypass grafts 41 monitoring 40-1 preoperative assessment 39-40 selection of technique 40 valvar heart disease 41 Anastomotic stricture 147-8, 156 Aneurysmal disease 361 Aneurysmal rupture 362 Aneurysms 44 aortic 238, 261, 362, 372, 379 ascending aortic 364, 365 atherosclerotic 362 conduit 280 dissecting 372 false 29, 109-10, 366, 370 formation 115, 366 fusiform 363, 369 in coarctation of the aorta 109-10 left ventricular 357-8 mycotic 46, 58 of ascending and arch aorta 363 of ascending aorta 259 right ventricular 44, 171, 176, 177 ruptured mycotic 121 saccular 368 sinus 364 ventricular 280 see also Extracardiac valved conduits; Thoracic aneurysms; Thoracoabdominal aneurysms; Coarctation of the aorta Angina 34, 39 Angiocardiography 4, 5, 12, 21, 26, 34, 46, 95, 109, 146, 163, 175, 189, 191,262, 276, 277, 292, 293,294 Angioplastic enlargement of pulmonary vein ostia 156 Angioplasty 35, 369 Annuloplasty 340, 343, 344, 346 Antibiotics 32, 55, 56, 65, 71, 76, 78, 164, 231, 238, 243, 269, 288 Anticoagulants 20, 22, 34, 35 oral 29 Antiplatelet agents 34, 35 Aortic anastomosis 14 re-stenosis of 131-6 stenosis of 126-7 Aortic aneurysms 238, 261, 361-2, 362, 372, 379 Aortic annulus enlargement 244-7 alternative procedures 245 indications for reoperation i44-5 operative technique 245-6 problems encountered 244-5 results 246-7 Aortic coarctation 44 See also Coarctation of the aorta Aortic homografts 61-2, 181, 182, 184, 201, 238, 240, 241, 274, 294,300 Aortic insufficiency 332 Aortic paraprosthetic leaks 23 Aortic root abscess 31 Aortic root dilatation 27 Aortic root replacement 259-70 history 259-60 homograft 244, 262, 265-8 indications for 262 indications for reoperation 260 operative technique 262-8 postoperative management 268-9 reoperation after 268 results 269 structural defects 261-2 Aortic stenosis 14, 21, 27, 126 residual/recurrent 249-50 subvalvar 250-1 supravalvar 135, 250 Aortic valve disease 24, 235 gradient 21 homograft 241 infection 58 injury 251 insufficiency 250, 363, 365 prosthesis 24, 29, 244 infection 58-62 regurgitation 27, 167-8, 261 reoperations 233-47 replacement 18-21, 27, 234, 246, 263, 363 see also Secondary aortic valve replacement stenosis 126, 135 Aortic valvotomy 135, 237 problems following 249-51 see also Secondary aortic valvotomy Aortocoronary bypass 58 graft 62, 64 graft infection 57 Aortography 12, 372 Aortoplasty 364, 366, 368 subclavian patch 115-16 Aortopulmonary collateral arteries 278, 287, 293, 295 residuallrecurrent 278, 287 Aortopulmonary shunt 286 Aortoventriculoseptoplasty 245 Aprotinin 347 Arrhythmias See Cardiac arrhythmias Arterial anastomoses 14 Arterial pressure monitoring 41 Arterial switch operation 209-15 complications 209-11 conversion of Mustard/Senning operation to 223-31 diagnosis and indications for reoperation 213 management 220-31 original operation 211-13 problems related to atrial repair 218-20 reoperation technique 213-14 results of reoperation 214 surgical technique 211-14, 220-31 Arterial valve damage 163 Arteriography 29 Arteriotomy 310 Artificial valves 20 Ascending aortic aneurysm 364, 365 Aspirin after coronary bypass surgery 35 Atelectasis 144 Atherosclerosis 46, 363 384 Atherosclerotic aneurysms 362 Atracurium 145 Atrial fibrillation 29, 191, 192 Atrial flutter" 192 Atrial reseptation 226-31 Atrial septal defect (ASD) 7, 147, 149, 183, 222, 291-2, 295, 303 residual/recurrent 177, 183, 291-2, 295 Atrial septal defect (ASD), repair of 183 Atriopulmonary conduit 300-1 Atriopulmonary connection 299, 301, 303 Atriotomy 337-8 Atrioventricular block 68, 97 Atrioventricular connection 301 Atrioventricular discordance 305-12 anatomical features 307 conduction system 308-9 pacemaker insertion 311 postoperative care 311 residuallrecurrent LVOTO 305 6, 309, 310 residuallrecurrent VSD 306, 310 results of reoperations 311 spatial relationship of cardiac chambers and great arteries 307 surgical considerations 307-9 surgical techniques 309 11 systemic atrioventricular valve regurgitation 306-7 systemic ventricular failure 306-7 Atrioventricular node Atrioventricular septal defect 6, 164 Atrioventricular valve 326 dysfunction 163, 168 incompetence 276, 295, 302 regurgitation 13, 169, 306-7 Atropine 39 Austin Flint murmur 23 Automatic cardioverter/defibrillator (AICD) 358-60 Azathioprine 96, 98, 102 Bacterial endocarditis 330 Baffle leakage 190, 193, 201, 218 placement of 196 shape and material 194 width 196 Ball variance 23-4 Balloon angioplasty 119, 131 Balloon aortic valvotomy 20-1 Balloon atrial septostomy 187 Balloon catheter 337 Balloon dilatation 119, 121, 156-7, 189, 190, 214, 286 Balloon valvuloplasty 237 Beta lactam antibiotics 33 Betadine 61 Bicuspid aortic valve 140, 249 Bicuspid valve 20, 127, 135 Bilateral thoracotomy 43 Bileaflet valve 22 prosthesis 29, 30 Bioprosthesis 332, 333, 341, 344, 345 acute thrombosis of 30 Subject Index construction of 325 contraindicated 21 failure 22 in pregnancy 29 leaking 22 occlusion of 22 primary tissue failure 348 valve degeneration 238 valve replacement 20, 21 Bjork-Shiley valve 29, 30, 201, 244, 333 Blalock-Hanlon atrial septectomy 187 Blalock-Taussig shunt 4, 14, 43, 126, 183, 286 Blood cultures 32, 33, 55, 262 Blood group incompatibility 99 mismatch 94 Blood loss 41 Blood pressure 41, 42 Blood products 97, 102 Blood transfusion 41 Bone marrow depression 98 Bovine pericardial bioprosthesis 184 Bronchial asthma 19 Bronchiectasis 100 Bronchiolitis obliterans 100, 102-3 Bronchopulmonary segments Bulboventricular communication Bundle branch block Bundle of His 8, 68, 298, 307 Calcific constriction 25-6 Calcific embolisation 238 Calcific nodules 327 Candida albieans 31, 82 Cardiac arrhythmias 8, 15, 145, 218, 351-60 Fontan operation 293, 298 in mitral valve replacement 332 Mustard operation 191-2, 201 Senning operation 7, 187 Cardiac catheterisation 10-12 15, 25, 27, 29, 30, 57 Cardiac denervation 95 Cardiac massage 81 Cardiac retransplantation 93-100 constrictivelrestrictive dysfunction 99 criteria for selection of donor hearts 94 indications for 93-5 postoperative care 98 results 98-9 survival experience 98 technique 95-8 Cardiac suture line infection 57-8, 64 Cardiac transplantation, cause of death following 95 Cardiac tumours 27-8 Cardioplegia 223 Cardiopulmonary bypass (CPB) 13, 58, 96, 100, 102, 115, 131, 133, 213, 235, 236, 252, 265 279, 285, 295, 300, 317-19, 325, 334-5, 343, 347, 352, 356, 364, 69 CarotI.'d37~ smus hypersensltIvlty Carpentier ring 25, 182, 340, 345 Carpentier-Edwards valve 244, 280 Catecholamine 5, 70, 237 Cavopulmonary connection 303 Cell Saver 234, 243, 335 Central venous pressure (CVP) 293, 297 Cephalic vein 73 Cerebral damage 145 Cerebral emboli 32 Chest radiography 8-9 Chloral hydrate 39 Chordal elongation 329, 330 Chordal rupture 328, 329 Chordal transposition 328 Chylothorax 110-11, 298 Cineangiography 172, 189 Closure of ventricular septal defect (VSD) 161-70 additional VSDs 166-7 conduction disturbances 164 endocarditis 169 haemolysis 169 multiple VSDs 167 pacemaker insertion 169 perimembranous VSD 166 postoperative bacterial endocarditis 164 postoperative care 169 70 postoperative haemolysis 164 residual/recurrent intracardiac shunts 161, 165 surgical techniques 165-9 Coarctation of the aorta 107-23 aneurysm/pseudoaneurysm 109 10, 120, 121 balloon angioplasty 119 bypass of re-coarctation with graft 117-18 chylothorax development 110-11 diagnosis of aneurysms 110 diagnosis of re-coarctation 109 false aneurysms 109 10 femoro-femoral bypass 120 follow-up after repair 109 graft interposition 117 incidence of aneurysms 110 indication for reoperation 109 operative technique 112-20 paraplegia 112 patch aortoplasty 115 phrenic nerve palsy 111 problems following repair 107-12 reoperation results 120-1 repair techniques 107 resection and end-to-end anastomosis 113 residual/recurrent 108-9, 112, 120-1 reversed subclavian flap aortoplasty 116 selection of operative technique 112 spinal cord protection 112 subclavian flap aortoplasty 115-16 systemic hypertension 111-12 vocal cord palsy 111 Colour flow-guided Doppler echocardiography 5, 22, 23 Composite valve graft replacement 375 385 Subject Index Computed tomography See cr scan Conduction disturbances 250, 307 Conduits aneurysms 280 atriopulmonary 300-1 Dacron 280, 294, 303, 310 extracardiac valved See Extracardiac valved conduits function 15 Hancock 287 heterograft 272, 273, 275 homograft 184, 272-3, 275 valved 184 Congenital See under Specific defects Congenital aortic stenosis 233, 237, 249 Congenital heart block 68 Congenital heart defects 271 Congenital heart disease 11 Congenitally corrected TGA 43 Congestive heart failure (CHF) 95, 162, 163, 218, 222, 223, 298-300, 303 Constrictive pericarditis 35 Coronary angina surgery study (CASS) 34 Coronary arteries in atrioventricular discordance 308 insufficiency 250 Coronary artery disease 315-23 incidence of reoperation 315 indications for reoperation 31&-17 results of reoperation 322 surgical technique 317-21 Coronary bypass graft infection 64 reoperation 33-5 revascularisation by 33-5 Coronary sinus cut-back 196 unroofed 7, 292, 295-6 Corticosteroids 94, 97 C-reactive protein (CRP) 33 Criss-cross heart 308 CT scan 18, 26, 32, 46, 58, 110, 273, 276, 362, 372 Cusp function deterioration 15 Cyclosporin 93, 95, 96, 98, 99, 102 Dacron conduits 280, 294, 303, 310 Dacron graft 117, 256, 259, 260, 273, 365, 370, 378 Dacron patch 253, 254, 303 Dakin's solution 83 DeBakey Type I dissection 365 Dehiscence 22, 32, 296, 330, 340, 344,346 de Vega's procedure 344 Diathermy restriction in pacing 75, 76,79-80 Diazepam 40 Di George's syndrome 136 Digital subtraction angiography (DSA) 18 Digital vascular imaging 109 Digoxin 40, 221, 269, 294, 298 Dipyridamole after coronary bypass surgery 35 Dissecting aneurysms 372 Distal anastomosis 15 Diuretics 221, 294, 297 Dobutamine 237 Dopamine 94, 102, 221, 230, 237 Doppler measurements 5, 6, 15, 17 see a/so Echocardiography Double outlet right ventricle 136, 217 Ductus arteriosus 286 Duramedics valve 22 Dye dilution methods 11, 174 Early prosthetic valve endocarditis 31-3 Echocardiography 5, 6, 9, 10, 17, 18, 21-30, 32, 35, 57, 94, 109, 125-7, 136, 146, 162, 163, 173-5, 189-91, 195, 231, 234, 237, 273, 276, 277, 292-4, 305, 306, 317, 327-30, 334, 340, 346,372 EEG 373 Electrocardiography Electrophysiological study (EPS) 351, 352, 354-6, 358 Encapsulation 30-1 Endocarditis 262 fungal 32-3 in closure of ventricular septal defect 161-70 in tricuspid valve replacement 345 infective 29, 31-3, 334 native valve 31 postoperative bacterial 164 prosthetic valve 31-3, 5&-7, 334 tricuspid valve 348 Enfturane 40 Enterobacter 82 Epstein-Barr virus 98 Escherichia coli 55, 82 Ethrane 40 Etomidate 40 Exercise echocardiography 17 stress testing 35 testing 109 Extracardiac valved conduits 271-90 cannulation 279-80 complications related to conduit insertion 272 complications requiring reoperation 271-2 complications unrelated to conduit insertion 27&-8 conduit aneurysmlpseudoaneurysm 276,285 conduit obstruction causes and incidence 272-3 diagnosis and indications for operation 273-5 conduit replacement operation 280-3 conduit valve incompetence 275 infection 278, 287 operative technique 278-87 postoperative care 287-8 residual/recurrent LVOTO 277-8, 285 residual/recurrent major aortopulmonary collaterals 278,287 residual/recurrent pulmonary branch stenosis 278, 286 residual/recurrent VSD 277, 284 results 288 re-thoracotomy 279 80 sternal re-entry 279-80 systemic atrioventricular valve incompetence 276 truncal valve incompetence 277, 284 ventricular aneurysm/ pseudoaneurysm 276, 285 Fallot's tetralogy See Tetralogy of Fallot False aneurysms 29, 109-10, 366, 370 Femoro-femoral bypass 41, 42, 46, 59, 63, 65, 112, 113, 118, 120, 234, 279, 298 Fentanyl 40, 145, 220, 223 Fibromas 28 Fibrosarcoma 28 FlucloxacilJin 32 Fluoroscopy 29, 30, 111 Fontan operation 7, 9, 71, 139, 291-304 arrhythmias 293, 298 chronic congestive heart failure 293-4, 298-300 conduit obstruction 294, 300-1 diagnosis of problems 291-5 high CVP 293, 297 incomplete occlusion of PDA, surgical shunt or major aortopulmonary collateral 295 mdications for reoperation 291-5 postoperative care 302-3 residual/recurrent ASD 291-2, 295 residual/recurrent atrial to ventricular communication 29&-7 residual/recurrent communication between ventricle and pulmonary artery 296 residual/recurrent right atrium to ventricle communication 293 residual/recurrent shunt from ventricle to pulmonary artery 292 residual/recurrent VSD 292, 296 restrictive VSD 294, 300 results of reoperation 303 right atrial thrombi 294, 302 RVOTO 294, 302 surgical techniques/treatment 295-302 SVClIVC valve stenosis 294, 301 unroofed coronary sinus 292, 295-6 Frater stitch 284 Frusemide 297 Fungal emboli 32 Subject Index 386 Fungal endocarditis 32-3 Fusiform aneurysm 363, 369 Gentamicin 32 Glenn shunt 303 Glomerolonephritis 33 Glutaraldehyde-formalin-resorcinol (GFR) 64 Glycerol trinitrate 268 Gore-Tex graft 126, 129, 131-3, 139, 173, 183, 297 Gore-Tex patch 60, 63, 199, 200, 213, 227, 228, 301 Graft atherosclerosis 95, 99 failure 98 hypothermia 101 occlusion 33-5 rejection 94, 99, 102 Gram-negative organisms 82 Great arteries, transposition of See Transposition of the great arteries Growth changes 14-15 Haemodynamic assessment Haemorrhage 42-4, 50, 51, 81, 88, 100, 113, 150, 243, 260, 263, 264, 317, 334 Halothane 40 Halothane hepatitis 40 Hancock conduit 287 Hancock modified orifice (MO) valve 244 Heart block 8, 165, 311 Heart failure 57, 372 acute donor 93, 94 Heart-lung retransplantation 100-3 indications for 100 postoperative care 102 results 102-3 technique of 100-2 Heart preservation technique 94 Heart retransplantation See Cardiac retransplantation; Heart-lung retransplantation Hegar dilators 173, 179, 180, 280-1, 301 Heparin 29, 223, 231, 234, 264, 335, 378 Hepatic necrosis 150 Hepatitis 42 Heterograft conduit insertion 272 conduit obstruction 273 conduits 275 prostheses 182 semilunar valve 15 His bundle See Bundle of His Histocompatibility mismatch 95 Homograft aortic 61-2, 181, 182, 184, 201, 238, 240, 241, 265-8, 274, 281, 294, 300 aortic root 262 aortic root replacement 244, 265-8 aortic valve 240, 241 conduits 272-3, 275 pulmonary 181, 201, 282 replacement 260 replacement of aortic root See Aortic root replacement semilunar valve 15 tubes 107 valve dysfunction 244 valved conduit 184 Hyoscine 39 Hypertension 112, 322 Hypertrophic cardiomyopathy 69 Hypocalcaemia 136 Hypotension 7, 29 Hypotensive agents 42 Hypothermia 112, 131, 150, 295, 372-4 Idiopathic constriction 25-6 Iliac-iliac bypass 46 Infection complications 55-66 cardiac suture line 57-8, 64 general considerations 55 in extracardiac valved conduit reoperation 278, 287 mitral valve 62-3 pacing systems 78 prosthetic valve 56 result of surgery 65-6 surgical technique 58-65 tricuspid valve 64 see also Endocarditis Inferior vena cava (lYe) 101, 149, 150, 189, 193, 196-9, 202, 203, 283, 294, 295, 301-3, 336, 352, 373 Infundibular septal displacement 168 Infundibulectomy 179, 182 Intermittent positive pressure ventilation (IPPY) 144, 158 Internal mammary artery (IMA) bypass 81, 83, 90 Interrupted aortic arch (IAA) 125-41 clinical examination 126 complete repair 127-9 diagnosis 125 incomplete repair 129-31 left lateral thoracotomy 139 main causes for reoperation 126 operation through left thoracotomy 138 operative techniques 127-36 planned reoperation 126 postoperative care 136 previous palliation 127 reoperation technique 131 repair of associated defects 136 results 136-40 techniques for first operation 127-31 type A 130, 133, 134 type B 129-31, 137, 139 type C 130 unplanned reoperation 126 Interventricular septum Interventricular shunts 161 Intra-atrial septum, resection of 195-6 Intraventricular tunnel, increase in diameter 168-9 Investigations acquired heart disease 17-37 congenital heart disease 1-16 emergencies 29-33 invasive 10-13, 18-19 non-invasive 8-10, 17-18 requirements 1-2 traumatic heart disease 29 Ionescu-Shiley pericardial valve 244 Isoflurane 40 Isoprenaline 97, 101, 145, 306 Isoproterenol See Isoprenaline Jackson-Pratt bulb suction 88 Jatene operation 187 see also Arterial switch operation Jugular vein 74 Kelly clamp 45, 51 Ketamine 40 Klebsiella 31, 82 Kocher clamps 48, 49 Konno aortoventriculoplasty 252-4 postoperative management 256 Late prosthetic valve endocarditis 33 Leak, aortic paraprosthetic 23 Lecompte manoeuvre 212, 225-6 Left atrial anastomosis 96 Left atrial myxoma 28 Left atrial pressure 24 Left to right shunt 6, 11 Left ventricular aneurysm 357-8 Left ventricular-aortic conduit 255-6 postoperative management 256 Left ventricular dilatation 27 Left ventricular dysfunction 218, 219 Left ventricular outflow tract obstruction (LYOTO) 191, 193, 201, 209, 214, 218, 219, 231,249-57, 259-61, 266, 272, 277-8, 285, 305-6, 309, 310 diagnosis and evaluation 251 increasing 310 operative technique 251-6 recurrent or increasing 305-6 residual/recurrent 193, 201, 277-8, 285, 305-6, 309, 310 Left ventricular pseudoaneurysm 64 Left ventricular to right atrial fistula 162-3 Legionella 98 Limb vessel embolectomy 31 Lymphocyte crossmatch 94 Lytic agents 34 McGoon ratio 172, 173 Magnetic resonance imaging (NMR) 18, 46, 109, llO, 273, 362, 372 Main pulmonary artery (MPA) 221-3,225 Manouguian procedure 245, 246 MAPCAs (major aorto-pulmonary collateral arteries) 278, 287 Marfan's syndrome 27, 362-4, 366, 375 Mechanical haemolysis 23 Medial degenerative disease 368 387 Subject Index Median sternotomy, infection after 81 Mediastinal haematoma 81 Mediastinitis 64, 81-91 aetiology 81 bacteriology 81-2 complications of reconstructive options 88-90 in infants and children 90 incidence 81 management options 82 omental transposition 83-5 pectoralis major transposition 85-6 reconstructive options 83-7 rectus abdominis transposition 86-7 sternal blood supply 82-3 Mediastinum 87 infected 287 Methylprednisolone 102, 112 Mitral valve 163, 325-42 causes and incidence of re-stenosis ·326-8 commissurotomy 325, 327, 338-9 conservative surgery 326-30 disease 18, 19, 28 dysfunCtion after annuloplasty 340 diagnosis of 330 infection 62-3 injury 251 insufficiency 327 paraprosthetic leaks 23 paravalvar abscess 31 prolapse 20 prosthesis 24, 27, 29, 331 prosthesis infection 62-3 reconstruction 338-40 regurgitation 6, 26, 27, 328-30, 344 residual/recurrent 328-30 reoperation 43 problems of 326 timing of reoperation 330 repair 19, 20 stenosis 19, 27 Mitral valve replacement 18-19, 26, 331-42 access to mitral valve 334-8 air venting 336-7 aortic insufficiency 332 arrhythmias 332 atrial thrombosis 338 atriotomy 337-8 cannulations 336 causes for reoperation after 331 dissection 336 infective endocarditis 334 mechanical intravascular haemolysis 333 operative technique 334-42 paravalvar leak 331 patient/prosthesis mismatch 333 patient-related problems 333-4 prosthesis entrapment 332 prosthesis-related problems 332 prosthesis size disproportion 331 surgical technique 331-2 thrombosis 333 tissue ingrowth 334 ventricular rupture 332 Mitral valve rereplacement 340 excision of prosthesis 340 implantation of new prosthesis 342 Mitral valvotomy/repair 19-20 Morphine 145, 220, 223 Mosquito clamp 51 Muscle relaxation 220, 223 Mustard operation 7, 69, 136, 139, 187-207 arrhythmias 191-2, 201 cannulation 198 complications of 187 conversion to arterial switch 223-31 problems/complications of 188 pulmonary venous obstruction 200 reoperations 197-201 residual/recurrent LVOTO 191, 201 residual/recurrent VSD 191, 201 results of reoperations 205 right ventricular failure after 217-32 systemic venous obstruction 198-200 take-down of repair 226 technique 194-201 Mycotic aneurysm 58 of ascerrding aorta 46 Myocardial biopsy 25 dysfunction 93, 94 failure 27 function 27 infarction 69, 95, 316, 322 ischaemia 95 oxygen supply/demand 40, 41 protection 58, 243, 246, 266, 352, 357 revascularisation 315, 316, 322 Myocardium 26-7 Myxoma 27-8 Native valve endocarditis 31, 238, 334 Neosynephrine 356 Nicks procedure 246 Nitroprusside 97 see also Sodium nitroprusside Nitrous oxide 40, 131 NMR See Magnetic resonance imaging Noradrenaline 230 Obstructive lesions 13 Omentum 83-6, 88 Opiates 40 Pacing systems 67-80 antiarrhythmic 69 atrial 73 battery lifespan 69 bipolar 70, 71 body parameters 70 cardioversion in 80 choice of 69-71 code of pacing modes and functions 67-8 diathermy restriction 75, 76, 79-80 dual chamber 73 endocardial 70 alternative venous access 73-4 subclavian approach 71-3 epicardial 70, 71, 74-5, 78 follow-up 78 generator 67-70 implantation 75-7 replacement 77-8 infection 78 insulation 70 lead problems 78 pacemaker insertion 169, 311 pectoral/axillary approach 76 permanent 71 indications for 68-9 physiological pacing 69-70 programmability 69 rate-responsive pacemakers 70 reoperation 77-80 restrictions 79-80 subxiphoid approach 76 suprarenal approach 76-7 temporary 71 transvenous 71, 78 unipolar 70 ventricular 72 wire 70 Pancuronium 40 Papaveretum 39 Papaverine 112 Paraplegia 112, 121 Paraprosthetic abscesses 32 infection 32 leak 22-3, 41 valve incompetence 238 Paravalvar leaks 348 Patent foramen ovale (PFO) 147, 157 Pectoralis major, transposition of 85-6 "Peel", obstruction compounded by 15 "Peel" formation 15, 146, 294, 301 Penicillin 32 Percutaneous balloon aortic valvotomy 237 Percutaneous transluminal coronary angioplasty (PTCA) 34 5, 316 Pericardial closure 44 constriction 24 effusion (PE) 9, 18, 26, 297 fluid 10, 12 sac substitutes 45 syndromes 35 valve 61 Pericardiectomy 25-6, 94 I Pericardium 94 Periprosthetic leakage 244 Peritoneal dialysis 230 388 Persistent ductus arteriosus (PDA) 125, 126, 145, 295 Phenoxybenzamine 145, 223, 230 Phenylephrine 41 Phrenic nerve damage 145 palsy III pedicles 101 Pleural effusion 9-10, 297 Polydiaxonone (PDS) 114 Porcine bioprosthesis 184 Porcine valve 25, 57, 61 Porcine xenograft 333, 347 Positive end expiratory pressure (PEEP) 144, 243 Postoperative constrictive pericarditis 26 Postoperative pericardia I fluid 35 Potassium crystalloid cardioplegia 94 Potassium supplementation Povidone-iodine solution 85 Prednisone 96, 98, 102 Pregnancy 28-9 Premedication 39 Primary mesothelioma of the pericardium 28 Prostacyclin 145 Prostaglandins 97, 125 Prosthesis aortic valve 24, 29, 58-62, 244 between subclavian and pulmonary arteries bileaflet 29, 30 disproportionately small endocarditis 31-3, 56-7, 334 excision 340 heterograft 182 implantation 342 infection 56 low-profile disc 344 mechanical 22, 23, 29, 30, 184, 332, 337, 341 mechanical failure 21 mitral valve See Mitral valve; Mitral valve replacement and rereplacement orientation 347 replacement 20 sizing 342, 347 thrombosed aortic 31 thrombosis 343 tricuspid valve 24-5 tube grafts 127 wrong style or size 19 see also Para prosthetic Prosthetic valve aortic 256 deterioration of 14-15 dysfunction 368 endocarditis 22, 31-3, 56-7, 59, 238, 243, 244, 262, 269, 334 infection 64, 345 antibiotic therapy 56 replacement 259 sewing rings 334 sounds 29 thrombosis 30 1, 238 Prosthetic valve/patient mismatch 238,244 Subject Index Protamine 230, 268 Proteus 82 Proximal anastomosis 15 Pruning appearance 95 Pseudoaneurysms 43, 58, 368 formation 261, 366 in coarctation of the aorta 109-10, 120, 121 left ventricular 64 ventricular 276, 285 Pseudomonas 57, 82 Pulmonary arterial tree Pulmonary artery anastomosis 4, 97 banding 130, 136, 139, 220 2, 231 bifurcation 225 Pulmonary atresia with VSD Pulmonary branch stenosis 278, 281, 286 recurrent/residual 286 Pulmonary cusp sinus 167 Pulmonary drainage in total anomalous pulmonary venous connection (TAPVC) 143 Pulmonary homografts 181, 201, 282 Pulmonary hypertension 98-9, 144-5 Pulmonary oedema 29, 144 Pulmonary stenosis 119 Pulmonary valve homograft 181 incompetence 175-6, 231 regurgitation 163 replacement 182, 184 Pulmonary vascular disease 100 Pulmonary vascular resistance 15 Pulmonary vein stenosis 156, 158 Pulmonary venous desaturation Pulmonary venous drainage 6, 14 Pulmonary venous obstruction 146, 148, 156, 189-90, 193, 197, 200,202-5 causes and incidence 189 diagnosis 189-90 Pulmonary/systemic flow ratio 174, 177 Radionuclide studies 221, 222, 231 Rashkind septostomy 47 Rectus abdominis transposition 86-7 Recurrent embolisation 31 Redo sternotomy 95 Renal infarction 33 Residual cardiac lesion, signs suggestive of 5, 7, 13 Residual/recurrent lesions 5, 7, 13 Residual/recurrent shunts 13, 148-51, 161-3, 165-6, 177, 183 Respiratory complications 42 Respiratory failure 100 Re-thoracotomy See Thoracotomy Retinoscopy 32 Reversed subclavian flap aortoplasty 116 Rhabdomyosarcoma 28 Rheumatic disease 326, 328, 330 Rheumatic heart disease 20, 24, 29 Rhythm disturbances See Cardiac arrythmias Rifampicin 32 Right atrial anastomosis 97 Right to left shunt 7, 13 Right ventricular aneurysm 183 diastolic pressure 24 dysfunction 98, 191, 201, 217-19, 231 failure 98, 220 myocardial failure 24 myocardium outflow tract aneurysm 44, 171, 176, 177 Right ventricular" outflow tract obstruction (RVOTO) 171, 173, 175, 179-82, 294, 302 repair of 179-82 residual/recurrent 175, 179-82, 302 see also under Tetralogy of Fallot Ring annuloplasty 327, 328, 329 Saccular aneurysms 368St Jude mechanical prosthesis 22, 64, 182, 201, 240, 244 Salicylates 317 Saphenous vein 378 bypass grafts 65 Secondary aortic valve replacement 238-44 indications for reoperation 238 mortality 243 operative technique 238-43 postoperative care 243 Secondary aortic valvotomy 233-7 indication for reoperation 234 postoperative care 237 results of reoperation 237 surgical technique 234-7 Seldinger technique 71 See also Percutaneous Semilunar valve 4, 15 regurgitation 13 Senning operation 7, 69, 187 arrhythmias 193-4 cannulation 201 conversion to arterial switch 223-31 problems/complications occurring in 192-4 pulmonary venous obstruction 202-3,204 reoperations 203-5 residual/recurrent VSD and LVOTO 193 results of reoperations 205 right ventricular failure following 217-32 systemic venous obstruction 203-4 take-down of repair 227-31 technique 201-5 Septal bulging 219 Septostomy, Rashkind 47 Serratia 82 Shock 29 Sick sinus syndrome 192, 218 Silas tic ball valves 23 Silastic drains 88 Sinus aneurysms 364 Situs inversus 308 389 SUbject Index Situs solitus dextrocardia 307, 310, 311 levocardia 307 mesocardia 307-8, 310, 311 Smeloff-Cutter mitral valve 348 Sodium nitroprusside 114, 145, 268 Spinal cord protection 112, 113, 121 Spironolactone 297 Staphylococcus 57, 66, 82, 334 Staphylococcus aureus 32, 334 Staphylococcus epidermidis 31-3, 334 Starr-Edwards valve 19, 22-4, 28, 32, 59, 61, 345 Sternal re-entry 44-51 cannulation 46 degrees of preparedness 46 operative technique 45-51 perfusion 46 preventive measures 44-5 results 51 technique of 47-51 Sternotomy 44, 97, 115, 117 Steroids 41 Stockert-Shiley cannula 128 Stokes-Adam syndrome 201 Streptococcus 57, 58, 66 Streptokinase 31, 34 Strut fracture 29 Sub annular aneurysms 61 Subaortic obstruction 163, 164, 168, 169 Subaortic stenosis 134-5, 140 Subclavian artery 117 Subclavian flap aortoplasty 115-16 Subpulmonary obstructions 168 Subvalvar stenosis 126, 127, 236, 250 1, 261 Sudden death 95 '65, 233 Superior vena ca\ 'SVC) 157, 196 8, 202-4, 283, 292, 295, 301, 303, 336, 338, 352, 373 cannulation 194 obstructions 9, 193 Supravalvar aortic obstruction 261 aortic stenosis 135, 250 pulmonary artery stenosis 213 pulmonary stenosis 214 stenosis 127 Supraventricular arrhythmias 293 tachyarrhythmias 298 tachycardia 192 Systemic hypertension 111-12 Systemic-pulmonary anastomosis Systemic venous obstruction 188 9, 198 200, 203-4 diagnosis 189 incidence and causes 188 Systolic pump failure 25 Tachybradycardia syndrome 218 Tamponade Taussig-Bing anomaly 136, 139 Teflon graft 259 Temazepam 39 Temporary pacing 97 Tetracyclin 111, 298 Tetralogy of Fallot 5, 7, 68, 71, 161, 162, 164, 171-85, 272, 295 postoperative care 183 pulmonary insufficiency 175-6, 182 residual ASD 177, 183 residual/recurrent VSD 174, 177 residual RVOTO 175, 179 82 residual surgical shunt 177, 183 results of reoperations 183 surgical technique 177-83 Thiopentone 40 Thoracic aneurysms 361-81 ascending aorta and aortic arch replacement 362-70, 373 current reconstruction techniques 373 descending and thoracoabdominal aorta reconstruction techniques 368 70, 378 diagnosis 270 operative technique 372-9 perfusion techniques 372 problems associated with reoperations 362-70 profound hypothermia and circulatory' arrest 372-3 results of reoperation 379 80 Thoracic artery graft 320 Thoracoabdominal aneurysms 361-81 ascending aorta and aortic arch replacement 362-70, 373 current reconstruction techniques 373 descending and thoracoabdominal aorta reconstruction techniques 368 70, 378 diagnosis 270 operative technique 372-9 perfusion techniques 372 problems associated with reoperations 362-70 profound hypothermia and circulatory arrest 372-3 results of reoperation 379 80 Thoracotomy 51-2, 117, 118, 131, 132, 136, 140, 151, 198,298, 318, 335, 345, 352, 359, 378 Thromboembolic complications 22 Thromboembolism 29 Thrombosis 110 atrial 338 in Fontan operation 294, 302 in Mustard operation 195 in TAPVC 150 in tricuspid valve replacement 345 prosthesis 343 right atrial 294 valve 30 Thrombotic encapsulation 30 Thrombus formation 302 Tisseel 51 Tolazoline 145 Total anomalous pulmonary venous connection (TAPVC) 143 60 anaesthesia 154 case report 157-8 classification 143 complications related to specific types 150 complications requiring medical management 144-5 complications requiring surgical management 145-51 early mortality after primary operation 158 late deaths following primary operation 158 management of anomalous common pulmonary vein 149 monitoring 154 original operation 151-4 perfusion 155 postoperative management 158 problems arising in postoperative period 143 51 pulmonary venous obstruction 156 reoperation 154-8 residual shunts and associated defects 148 51 specific surgical problems 155-6 surgical technique 151-7 Tracheal anastomosis 101 Transbronchial biopsies 102 Transposition of the great arteries (TGA) 6, 14, 43, 136, 187, 212, 214, 217, 219, 223, 231, 273, 274, 276, 283 Tricuspid valve 165, 171, 219, 343 access to 345 atresia 291 cannulation 345-6 chordae 306 hypoplasia 293 incompetence 184, 190, 193, 200, 217, 219, 222, 231 infection 64 insufficiency 176, 182 main cause for reoperation 344 patch dehiscence 293, 296, 296 postoperative care 347 problems after commissurotomy and annuloplasty 344-5 prolapse 27 prosthesis 24-5 regurgitation 219, 306, 344 reoperation 43, 345-7 replacement 205 results of reoperation 347-8 special features 343 stenosis 163, 343 surgical techniques 343 Tricuspid valve replacement 43, 283-4, 311 bacterial endocarditis 345 paravalvar leaks 345 thrombosis 345 Tricuspid valvulectomy 64 Truncal valve incompetence 164, 277,284 Truncus arteriosus 164, 273, 288 Tubbs dilator 325 Tuberculous constrietion 25 Ultrasound 189, 221, 222 USCI cannula 128 Subject Index 390 Valvar stenosis 127, 234 Valve failure 21 replacement 21-4, 28 thrombosis 30-1 see also under specific valves Valvotomy aortic 135, 249-51 mitral 19-20 Valvulectomy tricuspid 64 Vancomycin 32 Van Praagh's operation 153 Vasculitis 61 Vein graft atherosclerosis 316, 318-19 Vena caval pathway narrowing 13 Ventilation 101, 136, 220, 243 Ventricular arrhythmias 95, 332 failure 306-7 fibrillation 40, 42, 47, 69, 79, 264 function 5, 27 rupture 251, 332 Ventricular septal defect (VSD) 4, 5, 13, 29, 43, 57-9, 68, 119, 125-7, 129, 136, 139, 140, 149, 173,174, 177, 191, 193,201, 209, 212, 217, 219, 220, 222, 273, 274, 277, 284, 292, 294, 296, 300, 306, 309, 310 additional 166-7 closure of See Closure of ventricular septal defect (VSD) multiple 167 perimembranous 166-7 residual/recurrent 174, 177-9, 191, 193, 277, 284, 292, 296, 306, 310 Ventricular septal shift 164 Ventricular tachycardia (VT) 355-8 ablation techniques 357 diagnosis and indications for reoperation 356 intra-operative mapping 356 myocardial protection 357 postoperative care 358 results of reoperations 358 surgical technique 356 ventriculotomy closure 357-8 Ventriculo-arterial discordance 294 Vocal cord palsy 111 Warfarin 22 Waterston vascular clamps 265 Watson-Cheyne dissector 214, 266 Wolff-Parkinson-White syndrome (WPW) 351-5 diagnosis and indications for reoperation 3-51 endocardial dissection 353 myocardial protection 352 posterior septal pathways 352-3 postoperative care 355 results of reoperation 355 surgical approach 352 venous cannulation 352 Wound infection 88 Z value 173, 180 ... of the sinus mode The sve channel 20 4 Reoperations in Cardiac Surgery Fig 14 .25 is easily visualised from within the pulmonary venous atrium (Fig 14 .25 b) Part of the suture line attaching the... intracardiac part of the SVC channel may be constructed too narrow if the right atrial incision is too close to the crista terminalis (Fig 14.19) 20 2 Reoperations in Cardiac Surge ry CORRECT INCORRECT... point it must be noted that LV retraining requires time As rapid deterioration in RV performance may preclude adequate time for LV retraining, the timing of PA banding is important In our initial