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Background: Balloon angioplasty for infant coarctation is associated with a high recurrence rate, making operative repair the gold standard for low-risk infants. Debate exists as to whether high-risk infants might be better served with primary angioplasty. We compared the outcome in high-risk versus low-risk infants over 20 years, in a center that always used surgical repair as the primary intervention., Methods: Of 192 infants from 1986 to 2005, 56 were considered "high-risk," defined as requiring prostaglandin infusion together with either epinephrine infusion for 24 hours preoperatively, or ventilation and milrinone infusion for 24 hours preoperatively. All high-risk patients had a period of ventricular dysfunction prior to surgery, ranging from mild to severe. Outcomes were compared using Bonferroni comparison of means or the Fischer exact test as appropriate., Results: Although the high-risk patients were smaller (3.3 ± 0.1 vs 4.2 ± 0.2 kg, p < 0.01), younger (18 ± 4 vs 57 ± 7 days, p < 0.01), and more often required a concomitant pulmonary artery band (25% vs 15%, p = 0.05), their cross-clamp times were the same as the low-risk patients (18.9 ± 0.9 vs 18.0 ± 0.4 minutes, p = 0.27) and there was no difference in postoperative morbidity (7% vs 3%, p = 0.11). However, there was a trend toward higher perioperative mortality (7% vs 2%, p = 0.07). When compared with the published studies of primary angioplasty in comparable high-risk infants, the mortality rate in our surgically treated high-risk group is much lower. Additionally, only 11% of our high-risk group required reintervention, with two-thirds treated successfully with a single angioplasty at 3.8 ± 2.2 years later, far lower than recurrence rates with primary angioplasty., Conclusions: We propose that primary surgical repair of coarctation in infants who are high risk should be the primary treatment, with angioplasty reserved for recurrent coarctation., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We report a 7-day-old boy referred to our institution with tachypnea and cardiomegaly who was discovered to have an intrapericardial extra-lobar pulmonary sequestration containing a cystic pulmonary adenomatoid malformation type II. He underwent successful surgical resection of the intrapericardial mass, which we believe represents the first reported case of this rare entity.

A premature twin of 1.9 kg had mitral valve endocarditis develop during neonatal intensive care. Vegetation involving the entire anterior mitral valve leaflet was identified. Reconstruction was achieved by near complete resection of the anterior mitral valve leaflet and retention of the peripheral margin of coaptation including primary and secondary chordae. The body of the anterior mitral valve leaflet was reconstructed using fresh autologous pericardium, a technique not previously reported in an infant of this size. Three and a half years later, the child is well and has required no further intervention.

Background: Recurrent coarctation is an ever-present complication of surgical treatment of coarctation of aorta (CoA) among infants. No single operation appears to have a clear superiority., Methods: From January 1, 1986, to June 30, 2002, a consecutive series of 181 patients less than 1 year of age (range 1 to 300 days, median 13.5 days) were referred for CoA repair. Neonates accounted for 135 patients, and hypoplastic arch (less than 1 mm/kg plus 1) was present in 107 infants. Coarctation of aorta was simple (group 1) in 71 patients; complicated by ventricular septal defect (group 2) in 62; and complicated by complex congenital heart disease (group 3) in 48. All patients were assessed by right arm/left leg Dynamap pressures and routine follow-up was performed by the cardiologists. Follow-up was complete in all patients (range 6 months to 16 years, median 7.5 years)., Results: The overall hospital/30-day mortality was 0.5% (group 1 = 0, group 2 = 0, group 3 = 1 [2.0%]). Complications other than recoarctation occurred in 5 patients (2.7%). Late mortality occurred in 15 (11 at intracardiac repair). Recoarctation, ie, a gradient of more than 20 mm Hg, occurred in 4 patients (2.2%). All 4 patients were noted to have a gradient of more than 10 mm Hg (right arm/left leg) postoperatively and as such had residual coarctation. All 4 were successfully treated by balloon aortoplasty., Conclusions: Extended arch aortoplasty in association with ductal and coarctation excision provides excellent coarctation repair with a low incidence of recoarctation. Recoarctation occurred only in proximal aortic arch hypoplasia or low birth weight. Balloon aortoplasty easily and effectively relieved the recoarctation in all cases.

Background: The results of clinical trials of xanthine oxidoreductase inhibition in cardiac surgery are encouraging, although studies have failed to localize the enzyme to the human heart and to localize free radical activity to fresh human heart., Methods: We adapted a histochemical staining technique based on the reduction of nitro blue tetrazolium to formazan by superoxide radical. In six samples of right atrium graded blindly on a scale of 0 through 4, strong staining (median grade, 3) of the microvasculature was seen. This was blocked by allopurinol in paired sections (median grade, 1; p < 0.01). Chemiluminescence can be used as an index of superoxide radical activity. Atrial samples were taken from 13 patients at five time points during coronary bypass grafting and placed in buffered luminol. Then chemiluminescence was measured., Results: A 15-fold rise in chemiluminescence (295.93 +/- 39.47 mV) was demonstrated during reperfusion compared with the control value (19.06 +/- 0.47 mV). Chemiluminescence at 1 minute after release of the cross-clamp was significantly higher (p < 0.05) by analysis of variance versus values obtained before bypass and 1 minute before and 30 minutes after reperfusion., Conclusions: In this study we have identified superoxide radical activity and a possible generating system (xanthine oxidoreductase) in the human heart.

An 11-year-old girl had nearly fatal hemoptysis due to false aneurysm and aortobronchial fistula following ductus division 9 years previously. Silk suture material was implicated as a causative agent in association with dilation of the aortic isthmus. To our knowledge, no previous report of this complication exists in the literature. Twenty-two cases of false aneurysm have been described, 86.3% following ligation. The use of elective hypotension during ligation and monofilament suture during division may prevent this serious late complication in the future.

Pulmonary artery sling with tracheal stenosis is a difficult management problem. We describe the use of cardiopulmonary bypass as a method to facilitate one-stage repair.

The case of a patient with left ventricular endomyocardial fibrosis (EMF) causing severe mitral regurgitation is presented. Excision of the fibrotic tissue through the left atrium and mitral annuloplasty resulted in symptomatic relief and uncomplicated pregnancy. An X-linked congenital dermatological condition, Bloch-Sulzberger syndrome (incontinentia pigmenti), associated with chronic eosinophilia, was also present. This occurrence with EMF has not previously been reported. Atrioventricular valve reconstruction is a feasible alternative to valve replacement in EMF.