Cyanotic Congenital Heart Disease: Surgical Techniques and Pitfalls DWIGHT C. McGooN, M. D.

A B S T R A C T : A review is presented of the currently employed approaches and techniques for the treatment of several forms of cyanotic congenital heart disease. Emphasis is placed on unusual associated defects which require special approaches for management. The question of definitive repair in infancy, as opposed to early palliation and later repair, is particularly pertinent to these conditions. It is evident that considerable progress has been made during the thirty-year evolution of surgery for congenital heart disease, but there are m a n y advances yet to be made. K E Y W O R D S : tetralogy, pulmonary atresia, common ventricle, truncus arteriosus, conotruncal anomalies, pulmonary hypertension, anomalous coronary arteries.

T h e finest object in all creation is a child, for he has the most perfect and complex body and brain of any creature, and he abounds with promise of a good, rewarding life. To have all this, except for a defective heart, is a tragedy of unsurpassed sadness. The opportunity to care effectively for such a child should therefore be highly rewarding, and much progress has been made toward this end during the thirty-year history of surgery for congenital heart disease. M a n y advances have been made by Japanese surgeons, and it is a pleasure and an honor for me to be with you here in O k a y a m a today. The status of the Japanese surgeon is second to none, especially in his ingenuity, imaginativeness, and thorough scrutiny of the problems and results of his endeavors. I thank you for the privilege of being here, and also I bring you greetings from m y associates in cardiac surgery at the M a y o Clinic : Drs. Robert Wallace, Gordon Danielson, J a m e s Pluth, and Donald Barnhorst. Thirty years ago the Blalock-Taussig operation 4 gave help for the first time in history to a child in whom there was a congenital defect of the heart itself. T o d a y all congenital cardiac defects can be given consideration for correction, save two of which I am aware: 1) complete absence of true pulmonary arteries, and 2) severe hypoplasia of a ventricle, as in tricuspid atresia or mitral atresia. But the hour is too short to discuss all of the correctable conditions, so we shall look just at some of those which cause cyanosis.

Tetralogy of Fallot Within that group of hearts classified as the tetralogy of Fallot, there is great variation in the configuration of the right ventricular outflow tract. It is convenient to classify the varieties of outflow tract obstruction into four groups (Fig. 1) 7. On the one hand are those with primarily infundibular stenosis who have a relatively normal pulmonary valve and a

From Department of Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A. JAPANESEJOURNAL OF SURGERY, VOL. 5, No. 1, pp I - I I, 1975

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Fig. 1. Sites of outflow tract obstruction in tetralogy of Fallot (202 patients).

Fig. 2. An illustration of a specimen showing the ventricular septal defect and pulmonary stenosis of a patient with tetralogy of Fallot, as modified from the publication of Rosenquist et al (reference 3). Dotted lines have been placed on the illustration, indicating the limits of resection of the parietal band of the crista and emphasizing the deep resection of this band adjacent to the aortic annulus, leaving sufficient intact muscle and endocardium for secure attachment of the patch closing the ventricular septal defect.

thin-walled, well-developed infundibular chamber. It is in this group primarily that we will often employ a transverse ventriculotomy for the repair of tetralogy. At the opposite end of the spectrum are those hearts in which the outflow tract, pulmonary annulus, and even proximal pulmonary artery may be severely hypoplastic, and in which there is no possibility of relieving pulmonary stenosis merely by valvotomy and resection of muscle. Between these two extremes is an intermediate group showing moderate hypoplasia of the outflow

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tract or pulmonary annulus, including a subgroup having an anteriorly located ventricular septal defect which, when closed at operation, further contributes to outflow tract obstruction. In the rarest of the types, stenosis is only at valvular level. For those types of outflow tract which include a significant element of hypoplasia, and consequently which encompass a majority of patients coming to operation for tetralogy, we prefer a longitudinal ventriculotomy. This is placed over the outflow tract and extends superiorly to the pulmonary annulus itself, but is limited in its caudal extent in order to avoid as much as possible the sinus portion of the right ventricle. The first step in the intracardiac repair is the relief of infundibular stenosis. This is accomplished by relatively conservative resection of the septal band of the crista in order to avoid injury to the ventricular septum itself and to significant septal branches of the left anterior descending coronary artery. However, the parietal band of the crista is radically resected. I have placed dotted lines on an illustration (Fig. 2) taken from a paper by Rowe and associates 24 from the Johns Hopkins Hospital, who studied a large n u m b e r of autopsied tetralogy hearts. This demonstrates the caudal amputation of the parietal band of the crista and its mobilization from the entire anterior and lateral aspect of the outflow tract, leaving a significant band of intact muscle and endocardium along the aortic annulus to which the ventricular septal repair can be secured. The valvular stenosis must next be radically and thoroughly relieved. It is usually not sufficient to incise the commissures of the pulmonary valve, for the free margins of the cusps are not sufficiently long to allow an adequate orifice during systole. In most instances, therefore, it is necessary to disengage the cusps slightly on each side of the commissure in order to lengthen the cusp margins, even realizing that in so doing, some degree of pulmonary insufficiency will result. I f the patient's outflow tract anatomy is that of significant hypoplasia, to the extent that even after thorough infundibular resection and valvotomy it will not adequately relieve the stenosis, it is necessary to perform an outflow tract reconstruction. It is our custom to assess the need for outflow tract reconstruction by determining if the small finger of the surgeon's hand will pass freely through the outflow tract in the dynamically beating heart of a child, or the index finger in a larger patient. I f such is not possible, outflow tract reconstruction is undertaken. Seldom is it sufficient to reconstruct only the infundibular area. Usually the annulus must be enlarged also, in which case the ventriculotomy is extended across the pulmonary annulus and often extended to the bifurcation of the pulmonary artery or onto the origin of the left pulmonary artery. In so doing, the pulmonary valve is completely defunctionalized, and we have come in recent years to the common practice of resecting the remnants of pulmonary cusp tissue. Repair of the ventricular septal defect in the tetralogy must be extremely precise and complete and permanent, since any residual defect is particularly poorly tolerated by the tetralogy patient, who has suddenly undergone relief of his pulmonary stenosis and is unprepared for any degree of increased work load on the left ventricle or increased pulmonary blood flow. I dwell on the technical aspects of surgery for tetralogy simply to emphasize that the precision of technique, the attention to detail, and the experience of the surgeon which allow him to cope with the unexpected are clearly the primary determinants to assure success of the entire effort to manage any patient with congenital heart disease. For example, constant vigilance to preserve myocardium, as by avoiding air embolism to the coronary arteries (Fig. 3) 17, must play an important role. There are several additional anomalies which m a y be associated with tetralogy of Fallot and which m a y be encountered unexpectedly at the time of operation. One of these

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Fig. 3.

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Successful repair of congenital heart disease requires attention to multiple details. For example, air must be evacuated from the aortic root in order to avoid coronary air embolism as the aortic clamp is released on each occasion. A simple method to accomplish this when a ventricular septal defect is present is illustrated.

is the anomalous distribution of coronary arteries. Such is said to be present in 2-6 per cent of all patients with tetralogy, 5, 6 and the most common is the origin of the anterior descending coronary artery from the right coronary artery. Careful attention must be given to this possibility during the early stages of the operation. However, if the pericardium has been entered at a previous operation, the epicardial thickening m a y prevent detection of the anomaly, and an anomalous anterior descending artery could be inadvertently cut across if the incision were extended onto the pulmonary artery in preparation for a patch graft reconstruction of the outflow tract. In such patients it is important to perform preoperative coronary arteriograms to identify anomalous arteries. I f the anomalous anterior descending be cut, death results from massive antero-septal infarction of the left ventricle. Fortunately, in one such patient of ours, a saphenous vein graft could be placed from the aorta to the distal anterior descending to accomplish salvage. I f such an anomalous coronary artery is detected before injury, pulmonary stenosis m a y often be relieved by working through a ventriculotomy caudal or cephalad to it, or both, but if not relievable, an outflow tract reconstruction using an external conduit may be required. An additional, though uncommon, associated anomaly is the occurrence of aortic origin of one or the other pulmonary artery15. Correction involves re-implantation of the right pulmonary artery into the main pulmonary artery after dividing it at its origin from the ascending aorta. Such a condition m a y be surprisingly difficult to identify at preoperative study and must be considered whenever excessive intracardiac return of blood is encountered during cardiotomy. A recent review of my five-year experience with all patients undergoing operation for tetralogy of Fallot showed that 63 per cent of all patients had previously undergone a shunt procedure, repair of 47 per cent of the patients included an outflow tract patch graft reconstruction, nearly all of the patients were over 4 years of age, the ages extended into the sixth decade of life, and the hospital mortality was 2 per cent. The question which now so prominently demands our attention relates to the proper timing of corrective surgery for the infant or young child who is so deeply cyanotic and incapacitated as to require surgical help. The choice is between complete repair in infancy

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as a one-stage repair or early palliation followed by later corrective surgery. It is extremely important, in my opinion, that a sharp distinction be drawn between infants with decreased pulmonary blood flow and those with increased pulmonary blood flow in the consideration of repair in infancy. For more than a decade my colleagues and I have favored complete correction in infancy, using extracorporeal circulation, whenever surgical treatment is indicated, for conditions such as ventricular septal defect in which there is increased pulmonary blood flow and wherein the correction greatly reduces the work load of the heart. The pioneering work of Doctors Horiuchi et al 1 and Hikasa et al s in promoting the use of profound hypothermia for corrective surgery in infants is known and admired the world over. It is for the tetralogy in particular, however, that uncertainty persists as to the proper choice between palliation or repair in infancy. These points favor early repair: 1) the well-recognized inherent desirability of a single operation over a staged procedure; 2) early repair would avoid risks of postponing operation, such as brain abscess or bacterial endocarditis; 3) early repair avoids the "mutilation" of a shunt procedure. Against early repair: 1) an increased risk which might be involved in comparison with that for early palliation and later repair; 2) the threat of late recurrence of pulmonary stenosis following early repair; and 3) intracardiac exposure is less adequate in the infant than in the older child, thus requiring the need for relatively larger ventriculotomies and possibly resulting in less precise repair of septal defects and in increased incidence of heart block. It is my judgment that correction of tetralogy in infancy has enouth merit to warrant its evaluation in clinical trial, but that its use should be cautiously tested in a limited experience by a few expert surgeons well-versed in the surgical treatment of tetralogy and in the demanding requirements for care of the infant following cardiac operation. Following repair of the tetralogy, it is essential that detailed intracardiac and great vessel pressures be obtained after resuming normal circulation. In this way, one can obtain an indication of the adequacy of the relief of pulmonary stenosis. Should the right ventricular to left ventricular systolic pressure ratio be found to exceed 0.7 as a result of residual pulmonary stenosis in a patient who has not had an outflow tract reconstruction, it is our custom to resume extracorporeal circulation and accomplish such a pericardial graft reconstruction of the outflow tract. In a few patients the presence of pulmonary hypertension following repair will be detected by such measurements. We have found that there are three chief causes for such pulmonary hypertension :IX 1) In some patients there is peripheral pulmonary arterial stenosis. We have been impressed that the result in these patients is generally satisfactory. 2) The second most common cause is the presence of pulmonary vascular obstructive disease associated with a previous shunt procedure, most commonly a Potts anastomosis that has enlarged. In these patients, those who have a pulmonary resistance less than 10 units M 2 have a favorable result, and those whose resistance is higher are currently not considered candidates for operation. 3) The third is a small group, but also the most important because of the associated grave prognosis. These patients have pulmonary hypertension as the result of a residual or additional ventricular septal defect, and virtually all such patients will succumb in the postoperative period unless re-operated. It is consequently an absolute requirement that a patient with pulmonary arterial hypertension following repair of the tetralogy must have documentation that the ventricular septum is completely closed before the operation is completed. We have become increasingly enthusiastic about the value of intra-operative dye curve determinations to accomplish this documentation.

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Pulmonary atresia We have said that the tetralogy presents a spectrum of variations. At one end of this spectrum the ventricular septal defect becomes so large as to constitute a common ventricle. At the other end, the pulmonary stenosis becomes so severe as to be complete, and thus to constitute an atresia between right ventricle and pulmonary artery. We shall discuss this latter group now. Indeed, there is a large variety of conditions which share the common characteristic of absence of origin of pulmonary arterial blood supply directly from the heart 5. These conditions can be classified into three broad categories, namely those in which pulmonary arteries are present, those in which no pulmonary arteries are present, and those with a pulmonary artery extending to one lung but none in the opposite lung. We have reviewed all patients fitting into this classification who have been studied at our institution 3, and of the total of 262 such patients, 9 per cent were of the mixed type, 24 per cent had no true pulmonary arteries, but rather, bronchial collateral circulation only, and the remaining 176 patients had pulmonary arteries present. T h e vast majority of these had confluence of the right and left pulmonary arteries. Nearly half of this latter group had truncus arteriosus. The remaining 82 patients (Table 1) showed atresia of the pulmonary trunk, and in them the principal source of pulmonary blood flow was through a patent ductus arteriosus. Particularly interesting is the small group of patients having a fistula between the left coronary artery and the pulmonary trunk a4. This condition can be detected pre-operatively by the unique angiographic appearance of an aorto-pulmonary tunnel (Fig. 4), resulting from immense dilatation of the proximal left coronary artery between its origin and its fistulous communication with the pulmonary trunk. Table 1. Atresia of pulmonary trunk (Principal source of pulmonary blood flow) Patent ductus arteriosus Bronchial .(s) Surgical systemic-pulmonary shunts Blaloek-Taussig Waterston Potts Left coronary artery Aortopulmonary communication Undetermined Total

44 13 10 2 3 4 1 5 82

Also of unique interest are those patients whose pulmonary blood supply is derived from associated large bronchial collateral arteries. A wide variety of completely random patterns of this bronchial blood supply has been encountered 18. In some instances an anastomosis is present between the large bronchial collateral artery and the true pulmonary arteries, whereas in other instances, sometimes in the same patient, the large bronchial collateral artery m a y independently supply portions of the pulmonary parenchyma which are also supplied by true pulmonary arteries. In other instances, a segment or lobe of the lung m a y be supplied only by bronchial collateral arteries, with the true pulmonary arterial distribution being deficient for those particular areas. O n occasion the true pulmonary arteries m a y be too severely hypoplastic to allow complete correction (Fig. 5), and in such instances a shunt can be accomplished in the hope of progressively dilating and enlarging the pulmonary arterial tree and allowing a later correction. We have become increasingly enthusiastic about the use of a knitted dacron prosthetic artery as the method of choice for

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The lateral view of an aortogram in a 4-year-old girl having atresia of the proximal pulmonary trunk and with pulmonary blood flow supplied by a fistula between the left coronary artery and the main pulmonary artery. The dilated portion of the left coronary artery is seen passing transversely from the posterior aspect of the aorta to the pulmonary artery, and this dilated segment of proximal left coronary artery has been identified as an "aortico-pulmonary tunnel."

establishing a shunt between the systemic and pulmonary arterial circulation. On occasion, a combined median sternotomy and thoracotomy may be required for the appropriate control of these large bronchial collateral arteries.

Truncus with banding Cyanosis may occur in patients having truncus arteriosus in whom salvage has been achieved by previous banding of the pulmonary arteries in infancy. We have now operated upon 24 patients with truncus arteriosus who have undergone previous banding of one or more pulmonary arteries. T h o u g h the technical procedure is considerably complicated by the previous banding and the resulting adhesions, there has been an early mortality of only 3 out of the 24 patients, and a late mortality in one additional patient, indicating that the results for this group can be as successful as for those patients not previously banded. This knowledge, combined with the reported high infant mortality for attempted correction of truncus, leads us to the tentative conclusion that the proper management of the infant with truncus arteriosus who is in intractable failure should be banding of the pulmonary artery or arteries and deferral of complete correction.

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Fig. 5.

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This patient exhibits hypoplastic confluent right and left pulmonary arteries with the pulmonary blood supply provided by large bronchial collateral arteries. Since the pulmonary arteries were considered too hypoplastic for corrective operation, palliation was provided by inserting a dacron graft from the aorta to the small pulmonary arteries, anticipating enlargement of the pulmonary arteries as a result of the increased pulmonary arterial flow, thus allowing later corrective operation.

Common ventricle A moment ago I mentioned the condition known as common ventricle. Pioneering work in the correction of common ventricle has been accomplished by Arai et aP, Sakakibara et al z5, and other Japanese surgeons, who have reported successful clinical experience. A significant contribution to our knowledge in this area was made by Dr. Shuji Seki of Okayama, while working in our research laboratories at the Mayo Clinic a few years ago. Seki demonstrated 26, 27, 28 lhat the ventricular septum was not essential as a contractile structure but that its only essential function was to divide the ventricles into chambers of about equal size. Based on this knowledge, and with the additional availability of a His bundle locater, 11, in we too have successfully operated on a number of patients with the several varieties of common ventricle. If cyanosis is significant due to associated pulmonary stenosis, repair is usually best accomplished by means of an external conduit connecting the pulmonary ventricle to the distal pulmonary artery. The preferred conduit in our experience during the last three years has been a dacron graft containing a preserved porcine aortic valve. The particular problems related to repair of common ventricle are: the avoidance of heart block, the avoidance of residual defects between the prosthetic septum and the ventrieular wall, and particularly the precise eompartmentation of the ventricle into two chambers of essentially equal size. In hearts of the type having a rudimentary right ventricular outflow chamber (A I I I ) 2z, the support mechanisms of the two atrioventrieular valves are consistently separable, which allows placement of the prosthetic septum between them. However, in common ventricle of the type having two well-developed ventricles but absence of an intervening septum (type C), there is often intermingling of the chordae, which may necessitate the replacement of at least one of the valves in order to create a plane within the ventricle in which to place the prosthetic septum. Several examples of gratify-

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Normal DOLV ~ ~ . . . ~ R V ~

L TGAWithout

~/QJ~/v/~f

( ...... 1;

)TGA~rOverriding IA (ease 3)

iLnvTerGtiAo+n~OaRniVeIWiotnh~ talyrer t r ieuIar Fig. 6.

Range of positional anomalies of conotruncus. DORV, Double-outlet right ventricle. DOLV, Double-outlet left ventricle. TGA, Transposition of great arteries. PA, Pulmonary artery. L-TGA, Levotransposition of great arteries. Ao, Aorta. RV, Right ventricle. LV, Left ventricle.

ingly successful results of correction for the varieties of c o m m o n ventricle have caused us to a d o p t an increasingly optimislic outlook for correction of this condition. Conotruncal anomalies

Finally, in the few remaining m o m e n t s we must mention the wide spectrum of abn o r m a l inter-relationships which m a y exist between the great arteries and their respective ventricles, a group of conditions we m i g h t call "conotruncal anomalies" (Fig. 6) 12. T h e surgeon has at his c o m m a n d three basic methods for repair of this condition: 1) A tunnel can be created from the ventricular septal defect along the floor of the right ventricle to the aorta, as in the classical form of double outlet right ventricle a3. 2) In other hearts the aorta has rotated completely anterior to the p u l m o n a r y artery, or even in some instances somew h a t to the left and anterior to the p u l m o n a r y artery, in which case the repair must be effected by creation of a tunnel along the roof of the right ventricle 21, thus connecting the left ventricle via the septal defect to the aorta. C o m m o n l y in such instances it is necessary to enlarge drastically the ventricular septal defect anteriorly. Indeed, in the presence of a very large basilar ventricular septal defect, a true transposition of the great arteries can be corrected by such an intraventricular tunnel operation n. 3) Finally, in those instances where there is no suitable ventricular septal defect for intraventricular repair, and in which the p u l m o n a r y artery originates primarily from the left ventricle, the third approach, namely the M u s t a r d modification 2z for intra-atrial transposition of venous return, is appropriate. As an ancillary technique, usually in the presence of associated p u l m o n a r y stenosis and ventricular septal defect, the classical Rastelli operation 22, 23 can be accomplished. T h e challenges in these complex forms of anomalies of the right ventricular outflow tract are immense, but the rate of success is improving significantly. Corrective surgery can now be offered most children unfortunate enough to be born

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w i t h c o n g e n i t a l h e a r t disease. I t all b e g a n w i t h t h e B l a l o c k - T a u s s i g o p e r a t i o n j u s t t h i r t y years ago. T h e r e is m u c h yet to b e d o n e - - a m p l e o p p o r t u n i t i e s to p r o v i d e a r e w a r d i n g c h a l l e n g e to i n d u s t r i o u s a n d c l e v e r s u r g e o n s for g e n e r a t i o n s to c o m e . (Received for publication on May 26, 1975) References 1. Arai, T., Hiyama, T., Miura, I., Takayasu, S., Morikawa, T., Akabane, I., Takao, A., and Ando, M.: Radical Surgery of Type A Single Ventricle. I. Two Successfully Treated Cases and an Evaluation of Radical Surgery. Jap. J. Thorac. Surg. 25: 394--400, 1972. 2. Berry, B. E., and McGoon, D. C.: Total Correction for Tetralogy of Fallot with Anomalous Coronary Artery. Surgery 74: 894~898, 1973. 3. Berry, B. E., McGoon, D. C., Ritter, D. G., and Davis, G. D. : Absence of Anatomic Origin from Heart of Pulmonary Arterial Supply: Clinical Application of Classification. J. Thorac. Cardi0vasc. Surg. 68: 119-125, 1974. 4. Blalock, A., and Taussig, H. B. : The Surgical Treatment of Malformations of the Heart in Which There Is Pulmonary Stenosis or Pulmonary Atresia. J.A.M.A. 128: 189-202, 1945. 5. Edwards, J. E., and McGoon, D. C. : Absence of Anatomic Origin from Heart of Pulmonary Arterial Supply. Circulation 47: 393-398, 1973. 6. Fellows, K. E., Freed, M. D., Keane, J. F., Van Praagh, R., Bernhard, W. F., and Castaneda, A. C.: Results of Routine Preoperative Coronary Angiography in Tetralogy of FaUot. Circulation 51 : 561-566, t975. 7. Hawe, A., Rastelli, G. C., Ritter, D. G., DuShane, J. W., and McGoon, D . C . : Management of the Right Ventricular Outflow Tract in Severe Tetralogy of Fallot. J. Thorac. Cardiovasc. Surg. 60: 131-143, 1970. 8. Hikasa, Y., Shirotani, H., Satomura, K., Muraoka, R., Abe, K., Tsushimi, K., Yokota, Y., Miki, S., Kawai, J., Mori, A., Okamoto, Y., Koie, H., Ban, T., Kanzaki, Y., and Yokota, M. : Open Heart Surgery in Infants with an Aid of Hypothermic Anesthesia. Arch. Jap. Chir. 36: 495-508, 1967. 9. Horiuchi, T., Koyamada, K., Ishitoya, T., Honda, T., Abe, T., and Sagawa, Y.: Radical Operation Under Hypothermia for Ventricular Septal Defect in Infancy: A Report of 64 Consecutive Cases. J. Cardiovasc. Surg. 8: 85-92, 1967. 10. Kaiser, G. A., Waldo, A. L., Black, P. M., Bowman, F. O., Jr., Hoffman, B. F., and Maim, J. R.: Specialized Cardiac Con-

duction System: Improved Electrophysiologic Identification Technique at Surgery. Arch. Surg. 101 : 673-676, 1970. 11. Kinsley, R. H., McGoon, D. C., Danielson, G. K., Wallace, R. B., and Mair, D . D . : Pulmonary Arterial Hypertension After Repair of Tetralogy of Fallot. J. Thorac. Cardiovasc. Surg. 67: 110-120, 1974. 12. Kinsley, R. H., Ritter, D. G., and McGoon, D. C. : The Surgical Repair of Positional Anomalies of the Conotruncus. J. Thorac. Cardiovasc. Surg. 67: 395-403, 1974. 13. Kirklin, J. W., Harp, R. A., and McGoon, D. C.: Surgical Treatment of Origin of Both Vessels from the Right Ventricle Including Cases of Pulmonary Stenosis. J. Thorac. Cardiovasc. Surg. 48: 1026-1036, 1964. 14. Krongrad, E., Ritter, D. G., Hawe, A., Kincaid, O. W., and McGoon, D. C.: Pulmonary Atresia or Severe Stenosis and Coronary Artery-to-Pulmonary Artery Fistula. Circulation 46: 1005-1012, 1972. 15. Kuers, P. F. W., and McGoon, D. C.: Tetralogy of Fallot with Aortic Origin of the Right Pulmonary Artery. J. Thorac. Cardiovasc. Surg. 65 : 327-331, 1973. 16. Maloney, J. D., Ritter, D. G., McGoon, D. C., and Danielson, G. K. : Identification of the Conduction System in Patients with Corrected Transposition of the Great Arteries or Common Ventricle at Operation. Mayo Clin. Proc. (in press). 17. M cGoon, D. C. : Technics of Open Heart Surgery for Congenital Heart Disease. Current Problems in Surgery 3~1~2, 1968. 18. McGoon, D. C., Baird, D. K., and Davis, G. D. : Surgical Management of Large Bronchial Collateral Arteries with Pulmonary Stenosis or Atresia. Circulation (in press). 19. McGoon, D. C.: Intraventricular Repair of Transposition of the Great Arteries. J. Thorac. Cardiovasc. Surg. 64: 430~34, 1972. 20. Mustard, W. T., Keith, J. D., Trusler, G. A., Fowler, R., and Kidd, B. S. L.: The Surgical Management of Transposition of the Great Vessels. J. Thorac. Cardiovasc. Surg. 48: 953-958, 1964. 21. Patrick, D. L., and McGoon, D. C.: An Operation for Double Outlet Right Ventricle with Transposition of the Great Arteries. J. Cardiovasc. Surg. 9: 537-542, 1968.

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22. Rastelli, G. C. : A New Approach to "Anatomic" Repair of Transposition of the Great Arteries. Mayo Clin. Proc. 44: 1-12, 1969. 23. Rastelli, G. C., McGoon, D. C., and Wallace, R. B. : Anatomic Correction of Transposition of the Great Arteries with Ventricular Septal Defect and Subpulmonary Stenosis. J. Thorac. Cardiovase. Surg. 58: 545-552, 1969. 24. Rosenquist, G. C., Sweeney, L.J., Stemple, D. R., Christianson, S. D., and Rowe, R. D.: Ventricular Septal Defect in Tetralogy of Fallot. Am. J. Cardiol. 31 : 749-754, 1973. 25. Sakakibara, S., Tominaga, S., Imai, Y., Uehara, K., and Matsumuro, M.: Successful Total Correction of Common Ventricle. Chest 61 : 192-194, 1972. 26. Seki, S., and McGoon, D. C.: Surgical

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Techniques for Replacement of the Interventricular Septum. J. Thorac. Cardiovasc. Surg. 62: 919-925, 1971. 27. Seki, S., Tsakiris, A., and McGoon, D. C.: The Effect of a Prosthetic Ventricular Septum on Canine Cardiac Function. Surgery 71 : 241-245, 1972. 28. Seki, S., Tsakiris, A. G., Mair, D. D., and McGoon, D. C.: Radical Correction of Single Ventricle in Experimental Model: Experimental and Clinical Results. Ann. Surg. 176: 748-752, 1972. 29. Van Praagh, R., Ongley, P. A., and Swan, H. J . C . : Anatomic Types of Single or Common Ventricle in Man: Morphologic and Geometric Aspects of 60 Necropsied Cases. Am. J. Cardiol. 13: 367-386, 1964.

Cyanotic congenital heart disease: Surgical techniques and pitfalls.

A review is presented of the currently employed approaches and techniques for the treatment of several forms of cyanotic congenital heart disease. Emp...
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