Neonatal coarctation repair using extended end-to-end anastomosis

Aortic coarctation without associated intracardiac lesions, with or without posterior arch hypoplasia referred as simple coarctation, is safely and effectively repaired via left posterolateral thoracotomy, whereas median sternotomy and cardiopulmonary bypass are necessary for aortic arch reconstruction in case of complete aortic arch hypoplasia, or coarctation with associated cardiac lesions. There is a wide variety of techniques currently proposed to repair neonatal coarctation, all reported associated with very low operative mortality, nevertheless which one would be the best technique in terms of minimal rate of residual or recurrent obstruction or late complications is still under debate.

Neonatal aortic arch surgery

Surgical repair of the aortic arch is entailed in the neonatal period of patients with: hypoplastic left heart syndrome, interrupted aortic arch, hypoplastic aortic arch and complex aortic coarctation. Aortic arch surgery requires a period of circulatory arrest and deep hypothermia. Cerebral selective perfusion has recently been introduced as an alternative to circulatory arrest with the aim of reducing mortality and neurological complications. Moreover, the arch reconstruction phase can be safely performed under moderate hypothermia and with cerebral and myocardial perfusion (on beating heart), thus, completely avoiding cerebral ischemia and completely avoiding or drastically reducing myocardial ischemia.

Septal defects: surgeons do it better

Until the recent availability of percutaneous devices, the role of the septal defect occluder was played by surgeons. In this paper the pros and cons of the two techniques in the approach to the atrial and ventricular septal defects are analyzed. Although the reported results are rather interesting, it seems clear that one of the crucial aspects to guarantee good results is the selection of patients for the transcatheter approach. Surgery is not confined by the constraints of defect anatomy, and good results may be achieved without regard to patient selection or an otherwise unfavorable anatomy of the defect. Up to now, the follow-up of transcatheter closure has been relatively short and cannot be compared with that of surgery. Therefore, caution should be exercised when proposing the transcatheter approach to septal defects as the true alternative to conventional surgery.

Moderately hypothermic cardiopulmonary bypass and low-flow antegrade selective cerebral perfusion for neonatal aortic arch surgery

BACKGROUND

Although deep hypothermic circulatory arrest has been extensively used in neonates for aortic arch surgery, the brain and other organs might be adversely affected by prolonged ischemia and deep hypothermia.

METHODS

Between December 1997 and January 2005, 70 consecutive neonates underwent Norwood stage I procedure for hypoplastic left heart syndrome (group A, n = 30), or aortic arch repair for interruption or coarctation with arch hypoplasia (group B, n = 40), with antegrade selective cerebral perfusion (ASCP). Mean weights were 3.0 +/- 0.2 kg and 2.8 +/- 0.07 kg, and mean ages were 10 +/- 3.5 days and 14 +/- 10.6 days in groups A and B, respectively. Only 2 patients were older than 30 days. Core body temperature was lowered to 25 degrees C, and mean pump flow during ASCP was initiated at 10 to 20 mL/(kg x min) and adjusted to guarantee a radial/temporal artery pressure of 30 to 40 mm Hg and venous oxygen saturation of more than 70%. Hematocrit was maintained at 30%.

RESULTS

Early mortality was 17% (group A, 23%; group B, 12.5%; p = 0.19). Six late deaths occurred (3 in each group), and at 36 months, Kaplan-Meier overall survival was 64% +/- 9.2% in group A and 85% +/- 5.7% in group B. One patient had postoperative seizures. Age, weight, sex, prematurity, group A, and ASCP duration did not influence early mortality.

CONCLUSIONS

Antegrade selective cerebral perfusion is a safe and effective procedure and might improve outcome of neonatal aortic arch surgery, minimizing neurologic impact without the need for deep hypothermia.

Resternotomy in pediatric cardiac surgery: CoSeal(R) initial experience

Sternal re-entry adds supplementary risk to cardiac re-operations and it may represent the most important factor in the entire hazard estimation. A new anti-adhesive substance, based on a polyethylene glycol material, has been proposed to solve this problem. Results and surgical observations at chest re-entry in five patients treated with this synthetic polymer are herein discussed.

Right Superior Vena Cava Draining in the Left Atrium: Anatomical, Embryological, and Surgical Considerations

A newborn, with SDS (S = situs viscero-atrialis solitus, D = D-loop of the ventricles, S = solitus, normally related great arteries) anomalous drainage of the right superior vena cava in the left atrium, intact atrial septum, and anomalous drainage of the right superior pulmonary veins in the right superior vena cava, underwent surgical repair at our institution. This rare cyanotic, congenital, cardiac malformation is herein described with particular regard to its anatomical, embryological, and surgical implications.

Double orifice tricuspid valve in an infant with tetralogy of Fallot

Atrioventricular valve duplication, also known as double orifice valve, is an excitingly rare anomaly that can involve either the mitral or more uncommonly the tricuspid valve. Herein we describe a case of a double orifice tricuspid valve that prejudiced the complete repair in a symptomatic infant with tetralogy of Fallot.

Adjustable aorto-pulmonary shunt to prevent temporary pulmonary over-circulation

The Blalock-Taussig shunt can produce a temporary pulmonary over-circulation and can be downsized with a metallic clip. This hemodynamic situation can be reversible leading to desaturation. We describe a very simple method to resize temporarily the shunt with a removable metallic clip.

Conversion of atriopulmonary Fontan to extracardiac total cavopulmonary connection improves cardiopulmonary function

BACKGROUND

Experimental studies showed that extracardiac total cavopulmonary connection provides superior hemodynamics than atriopulmonary Fontan.

METHODS

We prospectively assessed the impact of conversion of atriopulmonary Fontan to extracardiac total cavopulmonary connection on exercise capacity and cardiac function in 6 consecutive patients.

RESULTS

Six months after conversion to extracardiac total cavopulmonary connection, we observed an increase in peak oxygen uptake in all patients (p=0.01;+17%). This improvement was associated to an increase of peak O(2) pulse (p=0.01;+16%), but no change in peak heart rate, arterial oxygen saturation at peak exercise, and pulmonary function. Ventricular ejection fraction did not change significantly after surgery. Conversion was associated with an improvement in heart failure symptoms as assessed by the New York Heart Association classification. Patients who had undergone additional anti-arrhythmia surgery for atrial fibrillation had no recurrence of arrhythmia at follow-up.

CONCLUSION

Data indicate that conversion to extracardiac total cavopulmonary connection is associated with an improvement of cardiopulmonary function and heart failure symptoms. Improved exercise capacity is due to an increase in O(2) pulse and may reflect an improved cardiac stroke volume after the operation.

Arterial switch operation for a complex transposition of the great arteries in dextrocardia

A very rare case of a newborn with dextrocardia, complete transposition of the great arteries {S,D,D}, ventricular septal defect, aortic arch hypoplasia, juxtaposition of the morphologically right atrial appendage and superoinferior ventricles is herein presented. He successfully underwent arterial switch operation, ventricular septal defect closure and aortic arch reconstruction with end to end extended direct anastomosis.

Hypoplastic left heart syndrome in situs inversus totalis

A very rare case of a newborn with hypoplastic left heart syndrome and situs inversus totalis is herein reported. Successful surgical treatment of this cardiac malformation was accomplished at our institution and consisted of: modified Norwood stage I procedure, with direct anastomosis of the transected main pulmonary artery to the aortic arch, without any prosthetic material interposition and right ventricle to pulmonary artery polytetrafluoroethylene shunt.

Outcome of cardiac surgery in low birth weight and premature infants1

OBJECTIVE

Low birth weight or premature infants may require early surgical treatment of congenital cardiac lesions because of their poor clinical status. Even thought early repair or palliation is carried out with incremental risk factor for morbidity and mortality, it has been demonstrated to be preferable to medical management and delayed surgery. This retrospective study was undertaken to evaluate early and mid-term results in infants, weighing less than 2500 g, who underwent surgery other than patent ductus arteriosus closure.

METHODS

Since January 1993 to August 2002, 60 consecutive patients underwent early surgical treatment of congenital heart malformations at our institution. 27 patients were premature (born before 37 weeks of gestation). Ninety percent were severely symptomatic. Mean age at operation was 15.5 days (range 4-68 days). Mean weight was 2120 g (range 900-2500 g). Indications for surgery were: coarctation complex 11, transposition of great arteries 9, interrupted or severely hypoplastic aortic arch 9, hypoplastic left heart syndrome 7, truncus arteriosus 5, other 19. Thirty-five patients were operated on CPB, Deep Hypothermia with Circulatory Arrest was used in 9. Complete repair was achieved in 32 patients. Aortic arch reconstruction was required in 32 cases.

RESULTS

There were nine early deaths (15%): heart failure (5), multiorgan failure (3), sepsis (1). Age, weight, prematurity, type of surgery and use of cardio pulmonary by-pass did not influence early mortality. Mean intensive care unit stay and duration of mechanical ventilation were 5.8 days and 75.5 h, respectively. Postoperative neurological complications did not occur in any patient. At follow-up (mean 48 months) there were nine late deaths. Kaplan-Meier survival at 60 months was 70%.

CONCLUSIONS

Surgery for congenital heart disease can be performed in low weight critically ill infants with reduced, but still acceptable early and mid-term survival.

The functionally univentricular circulation in the Norwood procedure: from analysis of fluid dynamics to surgical procedures

the norwood procedure and its modifications have become the most commonly used surgical procedures for patients with hypoplastic left heart syndrome. many efforts have been made to understand the fluid dynamics of the norwood circulation, with the major impetus coming from the lumped-parameter model described by migliavacca et al. in this model, a large number of variables have been analysed to understand their effect on the norwood circulation. in the clinical setting, some of these parameters can be influenced by the surgeon during the operation. the shunt has been demonstrated to be the critical element in regulating the pulmonary and systemic flows, with the goal of the surgeon being to obtain balanced flows. in order to do this, it is possible to influence the flow through the shunt in three ways:

in order to validate or verify the results obtained from the lumped-parameter model, we have reviewed our experience with the norwood procedure since 1992.

Coarctation repair with prosthetic material: surgical experience with aneurysm formation

BACKGROUND

Late aneurysm formation is a common complication after repair of an aortic coarctation with prosthetic material; its incidence varies between 5 and 46%. We reviewed our experience with the management of this complication and propose a radical surgical treatment, which has proved to be free from severe complications; furthermore, we suggest the possibility of a new percutaneous management of this complication.

METHODS

From September 1974 to November 2002, 195 patients underwent primary repair of an aortic coarctation with prosthetic material (Dacron, polytetrafluorethylene or heterologous pericardium), with patch aortoplasty as the most common technique. During the follow-up period, reoperation for aneurysm formation was required in 13 asymptomatic patients. The diagnosis was made at angiography in 3 patients and at magnetic resonance imaging in 10. The indication for reoperation was an isthmic-diaphragmatic aortic diameter ratio > 1.5. Aneurysmectomy and tube graft interposition was performed in 12 patients; femoro-femoral cardiopulmonary bypass with a period of deep hypothermic circulatory arrest was carried out in 7 cases while 5 patients were submitted to normothermic atrio-femoral bypass; 1 patient underwent endovascular prosthesis implantation.

RESULTS

There were no in-hospital deaths. Three patients experienced postoperative complications: bleeding (n = 1), left phrenic nerve paresis (n = 1), and chylothorax (n = 1). The mean follow-up period was 51.8 +/- 46.2 months; all patients were asymptomatic without clinical or instrumental evidence of recurrence.

CONCLUSIONS

Aneurysm formation after primary repair of an aortic coarctation using prosthetic material is a potentially worrisome late complication and lifelong surveillance of these patients by means of magnetic resonance is mandatory. Surgical management, when indicated, has proved to be a definitive treatment and free from major complications. In highly selected patients, interventional management by percutaneous techniques may provide promising results.

Surgical management of double outlet right ventricle with intact ventricular septum

A very rare case of double outlet right ventricle with intact ventricular septum and unrestricted pulmonary flow was successfully palliated with pulmonary banding and delayed bidirectional cavopulmonary anastomosis and mitral avulsion. This is the only case of pulmonary banding with mitral avulsion reported in the literature for this type of heart defect

Repair of a complex aortic arch anomaly associated with cutaneous hemangioma

Aortic coarctation and cutaneous hemangioma is a rare association. We describe the case of a neonate with abnormal looping of the aortic arch associated with hemangioma of the head and neck who underwent complex surgical repair without cardiopulmonary bypass.