Ebook Reoperations in cardiac surgery: Part 2
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Ebook Reoperations in cardiac surgery: Part 2
Chapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2eat arteries in 1958 (Scnning 1959) and Mustard published his experience with the atria) 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 (Waldhauscn et al. 1971; Lindesmith C Ebook Reoperations in cardiac surgery: Part 2t 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 atrialEbook Reoperations in cardiac surgery: Part 2
septectomy enabled a sick infant to survive. Because of the fear that the small size of the atria would preclude successful repair, the Mustard operatChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2 Miller 1966). This considerably improved the survival of infants with transposition of the great arteries. However, the improvement achieved by a balloon septostomy did not usually last as long as the improvement following a surgical septectomy. Attempts, therefore, were made to lower the age for a Ebook Reoperations in cardiac surgery: Part 2n elective Mustard operation, and soon resultswhich were comparable with or better than the results achieved in older children were reported (AberdeenEbook Reoperations in cardiac surgery: Part 2
1971; Stark et al. 1974a; Bailey et al. 1976; Oclcrt et al. 1977; Turley and Ebert 1978). The advantage of early balloon septostomy followed by a MusChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2 and Mulder 1971; Stark et al. 1974b) and pulmonary venous obstruction (Stark et al. 1972; Driscoll Ct al. 1977; Oelcrt et al. 1977) led to several technical modifications of the original Mustard operation. Although some of these modifications reduced postoperative complications, others actually inc Ebook Reoperations in cardiac surgery: Part 2reased them.Brom reintroduced the Senning operation in 1975 (Quagcbeur Ct al. 1977); the incidence of complications was reduced significantly but notEbook Reoperations in cardiac surgery: Part 2
completely eliminated. Today, both the Scnning and Mustard operations offer excellent early and good medium-term results. Recent reports of the arteriChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2 operation may become the operation of choice for this group of patients.1SXRcopcrations in Cardiac SurgeryAs 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 i Ebook Reoperations in cardiac surgery: Part 2mportant to follow these patients for many years. It is equally important to be familiar with the diagnosis of the complications and with the surgicalEbook Reoperations in cardiac surgery: Part 2
techniques of their repair, even though the original operation may not be in use any more.ProblemsMustard OperationThe following problems/complicatioChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2affle leaks5Residual/recurrcnt ventricular septal defect6Residual/recurrent left ventricular outflow tract obstruction7Right and left ventricular dysfunction8Arrhythmias.Some of these complications may not manifest themselves clinically, and are discovered only on routine rcstudy (isolated obstructi Ebook Reoperations in cardiac surgery: Part 2on of the SVC, small baffle leaks). Other complications may require medical treatment (arrhythmias, ventricular dysfunction). In this chapter we shallEbook Reoperations in cardiac surgery: Part 2
concentrate only on those complications which require surgical treatment: systemic and pulmonary venous pathway obstruction, leaks in the baffle, andChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2ee pp. 165-167 and 285).Systemic Venous ObstructionIncidence and Causes. SVC obstruction is much more common than obstruction of the IVC.Frequently it is the intracardiac part of the SVC channel, rather than the SVC itself, which becomes narrow. In the IVC channel, the obstruction usually occurs bet Ebook Reoperations in cardiac surgery: Part 2ween the coronary sinus and the right inferior pulmonary vein. Pathway obstruction may have several causes: construction of tlX) narrow a pathway, inaEbook Reoperations in cardiac surgery: Part 2
dequate resection of the upper margin of the interatrial septum, and thrombosis of the pathway possibly originating on the raw area remaining after reChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2 the baffle.The incidence of systemic venous pathwayobstruction varies in different scries. Venables et al. (1974) reported 14 cases of SVC obstruction among 20 rcstudied patients; 8 had symptoms. Park Ct al. (1983) reviewed 78 patients; 33 had gradients over 5 mmHg. Eighteen obstructions were seen; Ebook Reoperations in cardiac surgery: Part 2 of these, six required reoperation. Silverman Ct al. (1981) observed 5 partial and 4 complete obstructions in a series of 18 rcstudied patients. A hiEbook Reoperations in cardiac surgery: Part 2
gh incidence of systemic venous pathway obstruction was also reported by Marx Ct al. (1983). Of their 59 survivors of the Mustard operation, 32 had grChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2d 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 7 out of 10 patients in whom a “butterflyshaped” patch was used. A dumbbell-shaped patch resul Ebook Reoperations in cardiac surgery: Part 2ted in 25 obstructions among 84 operated patients, while only 2 obstructions were observed among 58 patients with a trousershaped pericardial patch (SEbook Reoperations in cardiac surgery: Part 2
tark Ct al. 1974a). Trusler Ct al. (1980) has reported a higher incidence of systemic venous obstruction in the latter part of their series (10/100 coChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2ction decreased the incidence of arrhythmias in their scries, but it increased the incidence of SVC obstruction.Inferior vena cava obstruction is much less common (Trusler et al. 1980 - 3/192 surReoperations After Mustard and Scnning Operationsvivors). Partial obstruction of both the SVC and IVC is Ebook Reoperations in cardiac surgery: Part 2a more serious complication than isolated SVC obstruction. The patient may present with a low cardiac output. Thrombosis of the IVC has been describedEbook Reoperations in cardiac surgery: Part 2
after prcopcrat-ivc cardiac catheterisation (Venables Ct al. 1974). 1VC obstruction is particularly rare if the coronary sinus is opened widely into Chapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2%).Diagnosis. Some patients with SVC obstruction arc 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 circumferenc Ebook Reoperations in cardiac surgery: Part 2e with widening of the cranial sutures and delayed closure of the fontanelles has been described (Silverman et al. 1981).Significant IVC obstruction cEbook Reoperations in cardiac surgery: Part 2
auses hepatomegaly, ascites and leg oedema. Protein-losing enteropathy has been described (Moodie Ct al. 1976). SVC obstruction can be diagnosed non-iChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2ineangiography 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 rcsidual/recurrent lesions so that Ebook Reoperations in cardiac surgery: Part 2these can be repaired at the time of revision of the systemic venous pathways. Asymptomatic isolated SVC obstruction does not require treatment. All IEbook Reoperations in cardiac surgery: Part 2
VC obstructions and symptomatic SVC obstructions arc indications for operative revisions. Recently, successful balloon dilatation of partially obstrucChapter 14Reoperations After Mustard and Senning OperationsJ. StarkIntroductionScnning introduced the physiological repair of transposition of the gre Ebook Reoperations in cardiac surgery: Part 2ore, 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 laterIK9date. In the meantime the symptoms will usually be relieved.Pulmonary Venous Obstruction Ebook Reoperations in cardiac surgery: Part 2Gọi ngay
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