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Ann Thorac Surg 1995;59:304
© 1995 The Society of Thoracic Surgeons
DR CARL L. BACKER (Chicago, IL): I enjoyed your talk very much. These are excellent results in a very complex group of patients, as those of us doing congenital heart surgery know. Three quick questions. First, with regard to the pulmonary blood flow, what size shunts were you using and did you base that on the patient's weight or other factors? I do not want to put you on the spot too much, but do you have in a similar time period the results with the Norwood operation for classic hypoplastic left heart syndrome, and how do they compare with your results in this series?
Finally, do you think that the reason you have such good results with this group is that more of them have a left ventricular morphology as compared with a right ventricular morphology for their single ventricle?
DR JOHN H. CALHOON (San Antonio, TX): These are excellent results and beautifully presented. My question, along the lines of Dr Backer's, pertains to the shunt; first, what size do you use, but more importantly, how do you choose between a central versus a more peripheral shunt? Is it chosen because of the arterial size, such as the branch size of the innominate or the subclavian?
DR KANTER: Sixteen of the 18 children had a 4-mm shunt; 2 of the children had a 3.5-mm shunt, and both of those were under 2.5 kilograms. So we used the size of the infant to determine the size of the shunt. As time goes on, however, we have struggled with excessive pulmonary blood flow early on and are starting to move more toward the 3.5-mm shunt.
During a similar time frame our results with the first-stage Norwood procedure for hypoplastic left heart syndrome were not as good, with about a 60% survival for the first stage and no late deaths, with no deaths in either the second or third stage with the hypoplastic left heart syndrome.
I agree with Dr Backer that probably the reason our results are better in this group than with children with hypoplastic left heart syndrome is that 8 of the 18 children had a dominant left ventricle, and clearly the left ventricle is a better pumping chamber than the right ventricle as it is designed to do that. Also, some of these children with dominant right ventricles had ventricular septal defects and small, inadequate left ventricles, but clearly those small left ventricles did contribute to the cardiac output. So I think the fact that some of the children had a left ventricle and that there was some contribution from both ventricles in all the children, even if one was small, did help the results.
In answer to the question about central shunt versus a modified Blalock-Taussig shunt, early on we performed the central shunt and then converted over to the modified Blalock-Taussig when we had decided that the second stage would be a bidirectional Glenn shunt and thought that would facilitate the second operation. In fact it really makes no difference, but we have become used to the modified Blalock-Taussig shunt and use that exclusively now.
Related Article
Ann. Thorac. Surg. 1995 59: 301-304.
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