| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 1996;61:1338
© 1996 The Society of Thoracic Surgeons
DR DONALD C. WATSON, JR (Memphis, TN): Doctor Mavroudis was very kind to allow my review of this paper before this session. It is a very elegant description of double-outlet right ventricle, the options for treatment, and a detailed description of his patients.
Doctor Mavroudis, this is a rare abnormality, as you pointed out. In your experience you have 20 patients over about 10 years. There are a few observations that I wanted to make. One is that the death with arterial switch operation apparently occurred early in your experience and was related to myocardial insufficiency, coronary anatomy insufficiency. The reoperative rate in your arterial switch group also included reoperations that were not related to the operative technique per se. Specifically, they were related to mediastinitis, a pacemaker, and coarctation, so I suggest that the reoperative rate is lower than you report for your arterial switch group.
In principle, the Kawashima procedure has an added disadvantage of requiring reoperation because of the complex patch going from the ventricular septal defect to a remote aorta.
My questions are two. Is there something about the Taussig-Bing anomaly with the side-by-side vessels that would prevent the arterial switch operation?
Second, you described two unrecognized ventricular septal defects. Could you describe that phenomenon in double-outlet right ventricle? It is well recognized, and disappointing, and in this series led to mortality and morbidity.
DR MAVROUDIS: Thank you very much for your comments. This issue really is what to do with that smaller subset of patients with Taussig-Bing anomaly who have side-by-side vessels. That is to say, do we recommend a switch or a Kawashima repair, especially because the mortality is more or less the same?
The long-term problem of the arterial switch operation in these patients who have had pulmonary artery band is neoaortic insufficiency, whereas the long term problem of the Kawashima operation is subaortic tunnel stenosis. Probably over the long term, subaortic tunnel stenosis is easier to repair with better outcome as compared with neoaortic insufficiency, which may necessitate a prosthetic valve replacement. As you alluded to, these patients can have multiple ventricular septal defects, which in fact can be missed during an operation. With increased awareness and intraoperative transesophageal echocardiography, this problem has declined dramatically.
DR ERLE H. AUSTIN III (Louisville, KY): I enjoyed your presentation and I thank you for the opportunity to review your manuscript. As Dr Watson mentioned, this is a relatively rare but difficult problem, and I think you are to be commended for such good results.
I am still a little puzzled as to what the best approach is in these children. In an older child who was previously banded at another institution, the Kawashima operation may be the best choice. I am more interested in what you do at the first presentation. I get the feeling that you lean toward an arterial switch and ventricular septal defect closure, but I wonder if you would comment on the relative influences of age at presentation, the presence of a coarctation, and the relationship of the great vessels on your approach when presented with the patient before anything has been done. Is there a role for the placement of a pulmonary artery band?
DR MAVROUDIS: Thank you for your highly relevant question. We do not have enough patients in our series to recommend one operation over the other based on statistical analysis. Whatever the approach to these patients, ie, palliation with pulmonary artery band or early repair, one must recognize the high incidence of post–pulmonary artery banding neoaortic insufficiency after arterial switch and the high incidence of tunnel stenosis after the Kawashima operation. We therefore are leaning toward early repair by arterial switch without palliation, even in those patients with severe coarctation. Unfortunately, the long-term results with this approach have yet to be reported.
Related Article
Ann. Thorac. Surg. 1996 61: 1330-1338.
| ||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
