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During the 37 year period between 1943 and 1980, 68 pediatric patients underwent 86 major pulmonary resections during 73 separate operations. The surgical procedures included lobectomy (55), segmentectomy (25), pneumonectomy (three), and cyst excision (three). The 73 operations were performed for nontuberculous infection, congenital malformation, tuberculosis, tumor, obstructive lung disease, cardiac-related problems, immunologic disease, and trauma in decreasing order of frequency. The operative mortality was 4.4%; the disease-related late mortality was 6.2%, due to either chronic respiratory failure or metastatic disease. Complications occurred in 21.9% of the operations. Only one death occurred during the last two decades, but the morbidity rate remained constant through all decades. Analysis by decade showed a striking change in the spectrum of pediatric pulmonary operations over the 37 year study period. Three major trends were identified: (1) Bronchiectasis and tuberculosis, once the major indications for pulmonary resection, have, from a surgical standpoint, virtually disappeared. (2) Congenital pulmonary anomalies now account for the majority of major pediatric pulmonary resections. As a consequence, the patient age at operation has steadily decreased, and pulmonary resections in infants (under 1 year of age) make up almost half of the surgical resections currently being done. (3) Despite the marked decline in the number of operations performed for infectious pulmonary disease, the total number of pulmonary operations in the pediatric age group has not decreased.

The risk of fatal hemorrhage may limit the completeness of resection in hepatic malignancies and in vascular extensions of Wilms' tumors. We have used Ein's technique of deep hypothermia (average 17 degrees C) with cardiac arrest (average 39 minutes) and exsanguination in performing five hepatic and two intravenous Wilms' tumor resections. The initial hepatic resection takes less than 15 minutes to perform in a bloodless field and the specimen is immediately examined by frozen section for determination of adequacy of margin. Additional resection is easily performed. Of four trisegmentectomies and one left lobectomy, two required additional resections. Mattress sutures were used to control hemorrhage during recirculation. One patient died from bleeding and cardiac decompensation and another from recurrence of tumor. The Wilms' tumors extended from the iliac vein into the right atrium in one child and from the right renal vein to the right atrium with extensions into the hepatic and lumbar veins in another. After nephrectomy, the atria and inferior vena cava were opened and the tumor extracted under direct vision. Both patients are well.

A four-year-old boy with DORV and hypoplastic left ventricle underwent a modified Fontan procedure. He had a very difficult postoperative course complicated by continued pleural effusions. Eventually he died during a last ditch effort to ligate the thoracic duct at the right diaphragm. At autopsy, an obstructing giant thrombus was found in the right atrium. This rare complication probably was due to multiple factors, but we now anticoagulate all Fontan patients routinely in an effort to prevent this fatal problem.

Nonpenetrating traumatic ventricular septal defect is rare. A triad of blunt chest trauma, holosystolic precordial murmur, and ECG abnormalities should suggest the diagnosis. Surgical repair, when indicated by progressive failure, rising pulmonary artery pressures, or significant (2:1 or larger) left-to-right shunt, has been shown to be very effective. Optimally, a period of several weeks from the injury should elapse before operative intervention is undertaken. Intra-aortic balloon pump may be helpful to stabilize patients acutely, and, in selected instances, allow delay of surgical repair so that the tissue around the defect may hold sutures more securely.

The experience at the University of Colorado with the St. Jude Medical cardiac valve was reviewed to determine the feasibility of placing this prosthesis in children and the role of anticoagulation. A St. Jude Medical cardiac valve was placed in 33 patients ranging in age from 2.5 months to 17 years. Seven patients were less than 1 year of age. Nineteen valves were placed in the aortic position in patients aged 5 months to 17 years (mean 9.5 years). Five patients had valve replacement only, 13 had concomitant aortoventriculoplasty and 1 a Manouguian procedure. Indications for anulus enlarging procedures were recurrent subaortic stenosis or inability to place an adult-sized valve in the native aortic anulus, or both. There were no early or late deaths. Fourteen valves were placed in the mitral position. They were anular positioned in 6 patients aged 6 months to 16 years and supraanular positioned in 8 patients aged 2.5 months to 2 years. There were no deaths with the anular positioned replacements and seven deaths (two early and five late) with the supraanular positioned replacements. Four of the five late deaths were associated with marked pre- and postoperative left ventricular dysfunction. The follow-up time was 784 patient-months in 31 long-term survivors. Anticoagulation was achieved with warfarin, usually in combination with sulfinpyrazone, dipyridamole or aspirin. There were four episodes of thromboembolism, three occurring in patients with sub-optimal anticoagulation, and one in a patient lost to follow-up. In conclusion: 1) results of St. Jude Medical cardiac valve replacement in infants and children are excellent; 2) anticoagulation with warfarin is warranted; and 3) morbidity and mortality are more often related to the underlying disease (mitral anular hypoplasia or left ventricular dysfunction, or both) rather than to valve malfunction.

A case of inflammatory polyposis of the ileum after ileosigmoid anastomosis is reported. Two features are noteworthy. First, the polyps were localized in a blind ileal loop. Second, while rare ileal inflammatory polyps related to enteroenteric anastomosis have been reported, to our knowledge this is the first instance of approximately 50 polyps to be described at such a site. The etiology of these lesions is unknown but may be related to fecal irritation, stasis, bacterial overgrowth, or bacterial toxin. These polyps may ulcerate and bleed, causing iron deficiency anemia, and they must be distinguished from neoplastic polyps. Since side-to-side and end-to-side anastomoses have become more common with use of the surgical stapler, inflammatory polyps may be encountered more frequently.

Twelve patients with anomalous left coronary artery (LCA) from the pulmonary artery were treated surgically. Mean age was 13 months and mean weight, 7.7 kg. One of the following techniques was used in 8 patients: suture obliteration of the coronary orifice, ligation of the anomalous LCA and grafting of the internal mammary artery to the distal LCA, aortic reimplantation of the anomalous LCA, creation of an aortopulmonary window, and direct anastomosis to the right subclavian artery. In 4 patients, a new technique to establish a two-coronary artery system involved tube extension of the anomalous LCA with pulmonary artery wall and then anastomosis to the right subclavian artery using cardiopulmonary by-pass without aortic cross-clamping. There were two hospital deaths (17%) and one late death. The condition of the 9 long-term survivors was improved at late follow-up. Postoperative assessment showed smaller Q wave on the electrocardiogram, reduced cardiac size, and good left ventricular function. All patients in whom the repair was done using the new technique were free from postoperative cardiac complications, had shortened hospital stays, and were alive with a patent two-coronary artery system at late follow-up. We believe this approach is a safer method for establishing a two-coronary artery system in infants and small children with an anomalous LCA arising from the pulmonary artery.

Over the past 20 years, 37 patients (31 children and six adults) have undergone operations for discrete subvalvular aortic stenosis. Prior to 1975, resection of the subvalvular membrane alone was the procedure of choice. However, the recurrence rate was high (36%). Since 1975, resection of the membrane plus left ventricular myectomy has been routine. The recurrence rate in this group has been lower (20%) but is still high. Overall, 11 patients (30%) have had significant recurrence (average gradient 63 mm Hg). Eight of these 11 have undergone a second operation with re-resection of a membrane and left ventricular myectomy. One patient died and in three others (42% ) significant symptoms and gradients remained. One of these three has undergone a successful aortoventriculoplasty, and two patients are awaiting a similar operation. Lessons learned from this experience include the following: (1) Regardless of the type of initial operation, a significant rate of recurrence can be anticipated. (2) Progressive aortic insufficiency and fibromuscular tunnel stenosis occur commonly unless adequate relief of the obstruction is achieved by the first operation. (3) Because repeat resection with left ventricular myectomy is unlikely to be effective when aortic insufficiency and/or tunnel stenosis are present, aortoventriculoplasty should be employed as the definitive reoperative procedure.

Complex left ventricular outflow tract obstruction after operation for subaortic stenosis or with hypoplastic aortic anulus remains a challenge for pediatric cardiac surgeons. We have recently applied a new technique of extended aortic root replacement using a cryopreserved aortic allograft to treat two patients who had previously been operated on for subaortic stenosis and a third who had aortic stenosis with a hypoplastic aortic anulus. This new procedure combines the concept of aortoventriculoplasty with aortic root replacement and coronary artery reimplantation. The valved aortic homograft is used in place of an aortic valve prosthesis and the attached anterior mitral leaflet augments the interventricular septum to relieve the subvalvular left ventricular outflow tract obstruction. The coronary ostia are then reimplanted into the allograft and an anastomosis between the distal graft and the ascending aorta is completed. Allograft aortic tissue is then used to patch the right ventricular outflow tract One patient had aortic stenosis with annular hypoplasia and did well after extended root replacement Two patients had previous operations for subaortic stenosis before undergoing extended aortic root replacement One required mediastinal exploration and drainage at 2 weeks for Serratia marcescens mediastinitis and bacteremia, but uncomplicated recovery followed. The other patient had complete heart block for 2 days, but normal sinus rhythm resumed and convalescence was benign. This modified technique with the aortic allograft was very helpful in treating these difficult problems, and the lack of mortality, limited morbidity, and good functional results are encouraging.

Aortoventriculoplasty was performed in 16 children between July, 1980, and July, 1984. Indications for the procedure were 1) aortic stenosis or insufficiency, or both, necessitating replacement of an aortic valve whose anulus would not accept a 19 mm diameter valve, (2) replacement of a small valve prosthesis, or (3) recurrent tunnel subaortic stenosis. Patients were 5 months to 17 years old at operation, 14 had previous repairs, and four had prior aortic valve replacement. There were 13 long-term survivors followed up for 14 to 38 months; 12 are asymptomatic with normal exercise tolerance. Three had residual ventricular septal defects, two requiring repair. All patients were given warfarin with or without antiplatelet agents. There have been no thromboembolic episodes and no hemorrhagic complications. Aortoventriculoplasty is well tolerated in children and appears to be a viable surgical option in the management of young patients with a hypoplastic left ventricular outflow tract.

Cryopreserved allograft valves and valved conduits have been used in 122 patients during the past 3 years for surgical repair of congenital heart disease. In 55 of these patients, the right ventricular outflow tract was reconstructed with a pulmonary allograft conduit. Although most children requiring a conduit had complex lesions, 12 patients with tetralogy of Fallot without pulmonary atresia or absent valve syndrome have been treated in this manner since April 1985. Patients were selected for conduit therapy because of congenital or iatrogenic pulmonary artery problems (nine patients had 12 prior shunts) or increased pulmonary vascular resistance. Ages ranged from 7 months to 6 years (mean 3.1 years) and weights from 7.4 to 18.5 kg (mean 12.2 kg). Pulmonary artery conduit size ranged from 16 to 24 mm internal diameter (mean 22 mm). Distal pulmonary artery reconstruction beyond the bifurcation was required in nine patients and the proximal connection was completed with a hood-shaped patch. One operative death (8.3%) occurred at 20 days as a result of severe right ventricular dysfunction. Left pulmonary artery thrombosis was discovered postmortem. Eleven survivors observed for 3 to 37 months (mean 17 months) are without cardiac symptoms. A chronologically overlapping group of tetralogy of Fallot repairs accomplished with a transannular patch was also reviewed. Twenty-five patients aged 2 months to 4 years (mean 1.7 years) and weighing 3.6 to 14.8 kg (mean 9.2 kg) underwent this procedure from April 1983 to January 1987 (seven patients had one prior shunt each). The mortality rate in this group was 28% (six operative deaths and one late death). Of 18 survivors observed from 20 to 60 months (mean 41.4 months), five (28%) have required pulmonary artery conduit reconstruction for chronic right ventricular failure. Postrepair right ventricular/left ventricular pressure ratios were available in 19 patients, including five of seven who died and three of five who required reoperation. The ratios averaged 0.54, which indicates adequate relief of obstruction. The operative mortality rate from a number of series for transannular patch repair of tetralogy of Fallot averages 16%, ranging from 3% to 63%. However, when distal pulmonary artery problems are added as a risk factor this rate rises to 21%, and valved conduit insertion increases the mortality rate (Kirklin and Barratt-Boyes, 1986). Although not clearly superior, pulmonary artery conduit repair of tetralogy of Fallot achieves results comparable with those of transannular patch repair and is recommended as an alternative, particularly when distal pulmonary artery anatomy is abnormal or vascular resistance is elevated.

Objectives: This report reviews our experience with repeated aortic root replacement after failure of cryopreserved aortic allografts placed during childhood and compares replacement with aortic allografts, pulmonary autografts, and mechanical valved conduits in these patients. Methods: This was a retrospective analysis of all such patients from 1986 through May 2001. Results: There were 25 operations (11 aortic allografts, 9 pulmonary autografts, and 5 mechanical valved conduits) among 23 patients. The mean time to reoperation was 6.3 years. There were 2 in-hospital deaths (8%, 1 patient with a pulmonary autograft and 1 with a mechanical valved conduit). There were 2 early nonfatal valve-related events (1 patient with an aortic allograft and 1 with a pulmonary autograft). There were no late valve-related deaths and 2 late non-valve-related deaths of patients with aortic allografts placed. No variable predicted early death or early valve-related event. No differences in preoperative characteristics, hospital variables, early outcomes, or late outcomes were detected among the groups. Overall, 19 patients are alive (18 in New York Heart Association functional class I and 1 in New York Heart Association functional class III) at a mean follow-up of 49 months. Two late aortic allograft failures necessitated reoperation. All patients with successful pulmonary autografts had excellent autograft function at a mean follow-up of 68 months. All early survivors with mechanical valved conduits are alive and free of valve-related events (mean follow-up 71 months). Five-year freedoms from valve-related death or event (Kaplan-Meier) were 84% for all patients, 91% for aortic allografts, 78% for pulmonary autografts, and 80% for mechanical valved conduits (no statistically significant group differences by log-rank test). Conclusions: Replacement of cryopreserved aortic root allografts placed during childhood is safe. Five-year pulmonary autograft durability is excellent, although the risk of early failure may be increased. Differences in 5-year conduit longevity were not detectable. J Thorac Cardiovasc Surg 2002;124:459-70

ObjectivesWe sought to analyze the indications and outcome of extracorporeal membrane oxygenation (ECMO) for early primary graft failure and determine its impact on long-term graft function and rejection risk.BackgroundEarly post-operative graft failure requiring ECMO can complicate heart transplantation.MethodsA retrospective review of all children requiring ECMO in the early period after transplantation from 1990 to 2007 was undertaken.ResultsTwenty-eight (9%) of 310 children who underwent transplantation for cardiomyopathy (n = 5) or congenital heart disease (n = 23) required ECMO support. The total ischemic time was significantly longer for ECMO-rescued recipients compared with our overall transplantation population (276 ± 86 min vs. 242 ± 70 min, p < 0.01). The indication for transplantation, for ECMO support, and the timing of cannulation had no impact on survival. Hyperacute rejection was uncommon. Fifteen children were successfully weaned off ECMO and discharged alive (54%). Mean duration of ECMO was 2.8 days for survivors (median 3 days) compared with 4.8 days for nonsurvivors (median 5 days). There was 100% 3-year survival in the ECMO survivor group, with 13 patients (46%) currently alive at a mean follow-up of 8.1 ± 3.8 years. The graft function was preserved (shortening fraction 36 ± 7%), despite an increased number of early rejection episodes (1.7 ± 1.6 vs. 0.7 ± 1.3, overall transplant population, p < 0.05) and hemodynamically comprising rejection episodes (1.3 ± 1.9 vs. 0.7 ± 1.3, overall transplant population, p < 0.05).ConclusionsOverall survival was 54%, with all patients surviving to at least 3 years after undergoing transplantation. None of the children requiring >4 days of ECMO support survived. Despite an increased number of early and hemodynamically compromising rejections, the long-term graft function is similar to our overall transplantation population.

A 31/2-year-old boy experienced right ventricular failure approximately two years after an operation for critical pulmonic stenosis. Severe pulmonary and tricuspid valvular insufficiency was documented echocardiographically and at cardiac catheterization. Treatment consisted of a tricuspid valve annuloplasty and creation of an autologous monocusp valve using the anterior wall of the pulmonary artery. The procedure was well tolerated, and early competence of the pulmonary valve was shown intraoperatively by pressure recordings and postoperatively by Doppler echocardiography. However, at recatheterization one year later, there was no evidence that the monocusp valve was functioning. This experience does not support the prior successful application of this technique in animals.

A patient is described in whom the diagnosis and location of a traumatic ventricular septal defect and laceration of a mitral leaflet were documented by two-dimensional echocardiographic studies. The echocardiographic study provides information not available from catheterization and contrast angiogram, and may be very valuable in subsequent patient management, as in this case.

Congenital sinus of Valsalva aneurysm is an uncommon lesion that frequently presents after rupture in adult life. This report describes a patient with a left sinus of Valsalva aneurysm that ruptured into the main pulmonary artery, a previously unreported anatomic variant. Anatomic and clinical features of previously reported cases of ruptured sinus of Valsalva aneurysm are reviewed.

A case of a 21-year-old male with blunt abdominal trauma and subsequent acute thrombosis of the inferior vena cava, presenting as abdominal pain, is reported. The apparent mechanism of proximal inferior vena cava thrombosis with distal extension into the iliac veins differs from that suggested in earlier reports. Resolution of symptoms was achieved by heparinization and bedrest alone, in spite of thrombus in the suprarenal vena cava.

A total of 20 children with total anomalous pulmonary venous drainage (TAPVD) underwent complete repair within the past six years. The drainage was supracardiac in 11, infracardiac in seven, and into the coronary sinus in two. At repair mean age was nine weeks, and weight was 3.7 km. Operative technique in extracardiac types included complete mobilization of the common vein with division of anomalous channel when possible. The incision in the confluent vein was extended into the lobar veins when necessary to permit extensive incorporation of this structure into the posterior wall of the left atrium and resulted in a nonobstructing stellate-type anastomosis. Operative mortality was 10% (2 of 20). Deaths occurred only in the group of infants in whom severe obstruction to pulmonary venous return required emergency operation, and one of these patients has persistent neurologic deficit. Late cardiac catheterization has been performed in 11 of 18 survivors. Nine had no or only minor abnormalities and two required reoperation. There have been no late deaths with follow-up of 2-8 years (mean = 4 years). Currently, all of the survivors are without cardiac symptoms and only one requires cardiac medication. Our experience identifies pulmonary venous obstruction with critical symptoms as the major operative risk factor in patients with TAPVD. With early operation prior to onset of critical symptoms, mortality is low and functional results are excellent.

Thrombosis of a porcine bioprosthesis in the aortic valve position is uncommon and usually occurs more than 1 year after implantation. 1 Only 3 patients with thrombosis of a porcine aortic valve bioprosthesis less than 1 year after insertion have been described. 2–4 We report life-threatening thrombosis of a Carpentier-Edwards porcine bioprosthesis in the aortic valve position 6 months postoperatively.

Two consecutive infants with pulmonary artery sling underwent successful surgical repair utilizing a median sternotomy for surgical exposure and adjunctive aortopexy. Bronchoscopy demonstrated severe tracheomalacia in both patients which was corrected under direct bronchoscopic control. Median sternotomy (rather than recommended left thoracotomy) provided perfect exposure of the pulmonary artery at its bifurcation thus permitting easy reconstruction of pulmonary artery. Aortopexy eliminated postoperative respiratory symptoms. Both patients are well.

Successful surgical repair of an 8½-month-old infant weighing 8 kg with d -transposition of the great arteries associated with ventricular septal defect and left ventricular outflow tract obstruction was accomplished utilizing a recently described technique. To our knowledge, this is the first attempt to use this technique in an infant.

As one progresses from the beginning of this book to the end, it is abundantly clear that the editors and contributors have had extensive experience with the surgical diseases of the esophagus. Although this treatise is primarily for the thoracic or general surgeon interested in the esophagus, it offers not only a clear and concise approach to the surgical aspects of each disorder but also a fair and reasonable evaluation of the medical approach. In fact, as surgeons, they are unafraid to champion the medical side when warranted. This is somewhat refreshing in a surgical text. The book itself is divided into 11 chapters, and they cover all aspects of the esophagus. First, one is prepared to deal with complex issues of the diseases of the esophagus by a very basic, understandable description of the anatomy, physiology, diagnostic technique, and tests of esophageal function. Then esophageal perforations, mobility disorders, reflux

• A patient with a right-sided descending colon, left-sided ascending colon, and transverse colon in front of the superior mesenteric artery is described. We believe that this is only the second case of "prearterial" reversed midgut rotation existing with normally situated stomach and liver. The best explanation for these relationships seems to be ( a ) anomalous positioning of the primitive midgut-hindgut junction right of midline; ( b ) ensuing midgut rotation in a reversed, or clockwise, direction. ( Arch Surg 1981;116:1084-1087)

• Congenital right posterolateral (Bochdalek's) diaphragmatic hernia usually has clinical manifestations different from those of left Bochdalek's hernia; it often masquerades as a pleural effusion, an asymptomatic intrathoracic mass, or an intestinal obstruction. The primary reason for the difference in symptoms is the presence of the liver on the right, which occludes the diaphragmatic defect and permits normal development of the ipsilateral lung. We recommend a transabdominal approach for surgical repair. (Arch Surg1982;117:341-344)

This book has an impressive list of contributors who have jointly, under the guidance of Eduardo Arciniegas, summed up the state of the art in pediatric heart surgery. At first glance one would think that it would therefore be of interest to only a handful of physicians. However, each chapter covers not only the key surgical principles of even the rarest congenital anomaly but also the natural history, diagnosis, pathophysiology, and long-term results of each particular problem. It is clear, concise, and accurate and should be beneficial to all who are involved with the practice of pediatric medicine. I include in this group medical students, nurses, and pediatricians as well as all cardiac surgeons, cardiologists, and surgical residents in training. There are similarities between this book and Gibbons' Surgery of the Chest, but Pediatric Cardiac Surgery seems more concise in that it deals only with the field of pediatric heart

This is a collection of papers from a conference held at the University of Maryland, Baltimore, that highlights major controversies in the surgical management of seven common congenital heart defects. An additional section concerns techniques of profusion and hypothermia. Both sides of controversial issues are discussed by authorities. The section on transposition of the great arteries includes a detailed description of the technique and results of the Mustard procedure by Trusler and the advantage of the Senning procedure by Brom, and Yacoub tells why he abandoned the baffle procedure and went to anatomic correction. Ebert presents his excellent results on primary repair of truncus arteriosus and stresses the importance of early operation, while the child is in reasonable condition. The section on the repair of an atrioventricular septal defect by Carpentier, Danielson, and Bjork presents both sides of the use of a single vs two-patch technique. Perhaps the most interesting