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Konstantinov IE, Fricke TA. Commentary: The balance of flow in azygos continuation of the inferior vena cava. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00508-7. [PMID: 38871049 DOI: 10.1016/j.jtcvs.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 05/29/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Igor E Konstantinov
- Department of Cardiothoracic Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Victoria, Australia.
| | - Tyson A Fricke
- Department of Cardiothoracic Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Hoganson DM, Govindarajan V, Schulz NE, Hammer PE, Rathod RH, Baird CW. Complex patient with azygos continuation of the inferior vena cava: Value of flow simulation. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00357-X. [PMID: 38640997 DOI: 10.1016/j.jtcvs.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024]
Affiliation(s)
- David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass.
| | | | - Noah E Schulz
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Peter E Hammer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
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Miller JR, Hill KD, Thibault D, Chiswell K, Habib RH, Jacobs JP, Jacobs ML, Nath DS, Eghtesady P. Outcomes of the Kawashima: A Society of Thoracic Surgeons Congenital Heart Surgery Database Analysis. Ann Thorac Surg 2024; 117:379-385. [PMID: 37495089 DOI: 10.1016/j.athoracsur.2023.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/10/2023] [Accepted: 07/11/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND We aimed to evaluate the effect of age at operation on postoperative outcomes in children undergoing a Kawashima operation. METHODS The Society of Thoracic Surgeons Congenital Heart Surgery Database was queried for Kawashima procedures from January 1, 2014, to June 30, 2020. Patients were stratified by age at operation in months: 0 to <4, 4 to <8, 8 to <12, and >12. Subsequently, outcomes for those in whom the Kawashima was not the index operation and for those undergoing hepatic vein incorporation (Fontan completion or hepatic vein-to-azygos vein connection) were evaluated. RESULTS We identified 253 patients who underwent a Kawashima operation (median age, 8.6 months; median weight, 7.4 kg): 12 (4.7%), 0 to <4 months; 96 (37.9%), 4 to <8 months; 81 (32.0%), 8 to <12 months; and 64 (25.3%), >12 months. Operative mortality was 0.8% (n = 2), with major morbidity or mortality in 17.4% (n = 44), neither different across age groups. Patients <4 months had a longer postoperative length of stay (12.5 vs 9.3 days; P = .03). The Kawashima was not the index operation of the hospital admission in 15 (5.9%); these patients were younger (6.0 vs 8.4 months; P = .05) and had more preoperative risk factors (13/15 [92.9%] vs 126/238 [52.9%]; P < .01). We identified 173 patients undergoing subsequent hepatic vein incorporation (median age, 3.9 years; median weight, 15.0 kg) with operative mortality in 6 (3.5%) and major morbidity or mortality in 30 (17.3%). CONCLUSIONS The Kawashima is typically performed between 4 and 12 months with low mortality. Morbidity and mortality were not affected by age. Hepatic vein incorporations may be higher risk than in traditional Fontan procedures, and ways to mitigate this should be sought.
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Affiliation(s)
- Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Dylan Thibault
- Duke Clinical Research Institute, Duke University School of Medicine, Durham North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham North Carolina
| | - Robert H Habib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham North Carolina
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dilip S Nath
- Section of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, Washington University in St Louis School of Medicine, St Louis, Missouri.
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Hunt ML, Ittenbach RF, Kaplinski M, Ravishankar C, Rychik J, Steven JM, Fuller SM, Nicolson SC, Spray TL, Gaynor JW, Mascio CE. Outcomes for the superior cavopulmonary connection in children with hypoplastic left heart syndrome: a 30-year experience. Eur J Cardiothorac Surg 2021; 58:809-816. [PMID: 32572451 DOI: 10.1093/ejcts/ezaa117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/17/2020] [Accepted: 03/10/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The objective of this study was to estimate hospital mortality and length of stay (LOS) for children with hypoplastic left heart syndrome undergoing superior cavopulmonary connection (SCPC). METHODS All hypoplastic left heart syndrome interstage survivors who underwent SCPC between 1 January 1988 and 31 December 2017 were included. The study period was divided into 4 eras based on changes in operative or medical management. Mortality rates were estimated using standard binomial proportions. Adjusted and unadjusted logistic regression models were used to identify risk factors for mortality and LOS. RESULTS The most common procedures for the cohort (n = 958) were Hemi-Fontan (57.3%) or Bidrectional Glenn shunt (35.7%). The mortality was 4.1% overall and decreased in all 3 later eras compared to era 1. Factors associated with mortality in a multiple covariate model included longer total support time, earlier gestational age, longer LOS at the Norwood Procedure and need for additional procedures. Overall, the median LOS was 7.0 days with a decrease from eras 1 to 2 and plateaued in eras 3 and 4. Predictors of longer LOS included genetic anomaly, longer Norwood LOS, additional procedures, lower weight at surgery and longer total support time. The type of SCPC was not associated with mortality or LOS. CONCLUSIONS In this large cohort of patients with hypoplastic left heart syndrome undergoing SCPC, hospital mortality has decreased significantly. LOS initially declined but plateaued in recent eras. The risk factors for mortality and longer LOS are related to patient and procedural complexity, especially the need for additional procedures at the time of SCPC.
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Affiliation(s)
- Mallory L Hunt
- Department of Surgery, Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard F Ittenbach
- Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Michelle Kaplinski
- Department of Cardiology, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Chitra Ravishankar
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James M Steven
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Alsoufi B, Rosenblum J, Travers C, Kanter K, Trusty PM, Yoganathan AP, Slesnick TP. Outcomes of Single Ventricle Patients Undergoing the Kawashima Procedure: Can We Do Better? World J Pediatr Congenit Heart Surg 2019; 10:20-27. [DOI: 10.1177/2150135118809082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objectives: Current technology advances in virtual surgery modeling and computational flow dynamics allow preoperative individualized computer-based design of Fontan operation. To determine potential role of those innovations in patients undergoing hepatic vein incorporation (HVI) following Kawashima operation, we retrospectively examined historic cohort of patients who underwent HVI following Kawashima with focus on regression of pulmonary arteriovenous malformations (PAVMs). Methods: Twenty-two children with single ventricle and interrupted inferior vena cava underwent Kawashima operation (2002-12). Twenty-one (96%) patients had left atrial isomerism and 21 (96%) had undergone prior first-stage palliation. Clinical outcomes were examined. Results: Mean O2 saturation (SaO2) increased from 77% ± 8% to 85% ± 6% ( P = .002) after Kawashima. Fifteen (68%) patients developed PAVMs. Eighteen patients underwent HVI (median age and interval from Kawashima: 4.4 and 3.7 years, respectively). Mean SaO2 prior to HVI was 77% ± 8% and increased to 81% ± 10% at the time of hospital discharge ( P = .250), with five patients requiring home oxygen. On follow-up, mean SaO2 increased to 95% ± 4% ( P < .001). Overall ten-year survival following Kawashima was 94%. Conclusions: A large number of patients develop PAVMs and subsequent cyanosis after Kawashima operation. Early following HVI, SaO2 is commonly low and insignificantly different from that prior to HVI. Although SaO2 will improve on follow-up in most patients, a number of patients continue to have low saturations, indicating incomplete resolution of PAVMs. Given the heterogeneity of those patients and lack of preoperative predictors for complete PAVM regression, our findings suggest a role for virtual surgery to determine optimal individual procedure design that would provide even distribution of hepatic blood flow to both pulmonary arteries.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville, Norton Children’s Hospital, Louisville, KY, USA
| | - Joshua Rosenblum
- Department of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Curtis Travers
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Kirk Kanter
- Department of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Philip M. Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Ajit P. Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Timothy P. Slesnick
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Successful Palliation via Kawashima Procedure of an Infant With Heterotaxy Syndrome and Left-Atrial Isomerism. Ochsner J 2018; 18:406-412. [PMID: 30559629 DOI: 10.31486/toj.18.0042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background Heterotaxy is a condition of abnormal lateralization of organs across the body's left-right axis, causing multiple congenital malformations. The anatomic manifestations of heterotaxy syndrome generally follow one of two patterns, referred to as right atrial isomerism (with two similar right atria and duplication of right-sided features of multiple organs) and left atrial isomerism (with two similar left atria and duplication of left-sided features of multiple organs). Cardiac surgical intervention for patients with heterotaxy syndrome depends on ventricular physiology and circulatory balance. For patients with single-ventricle physiology, a Fontan operation, which directs systemic venous return to the pulmonary arteries, is the definitive intervention. Prior to a Fontan operation, many patients require one or more palliative surgeries (eg, a Blalock-Taussig-Thomas shunt or bidirectional Glenn/Kawashima procedure) to prepare them for definitive correction. Case Report We present the case of a term female neonate who was transferred to our pediatric cardiovascular intensive care unit for management of suspected congenital cardiac disease. Echocardiography confirmed the diagnosis of heterotaxy syndrome with left atrial isomerism, an interrupted inferior vena cava with azygos continuation, and a hypoplastic left ventricle with single-ventricle physiology. At 11 months of age, she underwent a Kawashima procedure with subtotal pulmonary artery ligation. She tolerated the procedure well and is anticipated to remain stable for the near future, possibly without the need for further cardiac surgery. Conclusion Patients with heterotaxy syndrome have congenital malformations in several organ systems, requiring lifelong coordination of care among health providers across multiple disciplines.
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Zablah JE, Ross M, Wilson N, Fonseca B, Mitchell MB. Kawashima by Fenestrated Hemi-Fontan for Palliation Following Prior Stage I Norwood Operation. World J Pediatr Congenit Heart Surg 2018; 9:451-453. [DOI: 10.1177/2150135118769326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Single ventricle patients with interrupted inferior vena cava (IVC) and azygos continuation to the superior vena cava (SVC) are typically palliated with a bidirectional cavopulmonary shunt (BCPS), known as the Kawashima operation in this setting. Because the volume of venous blood directed to the pulmonary arteries is substantially greater in the presence of interrupted IVC, Kawashima procedures are commonly delayed to older age compared to other single ventricle patients undergoing BCPS. We report two young infant single ventricle patients with interrupted IVC and azygos continuation to the SVC who underwent stage I Norwood procedures for initial palliation. In both cases, a fenestrated hemi-Fontan procedure achieved successful Kawashima circulations.
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Affiliation(s)
- Jenny E. Zablah
- Interventional Cardiology, Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
| | - Michael Ross
- Interventional Cardiology, Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
| | - Neil Wilson
- Interventional Cardiology, Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
| | - Brian Fonseca
- Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
| | - Max B. Mitchell
- Pediatric Cardiothoracic Surgery, Children’s Hospital of Colorado, Heart Institute, Aurora, CO, USA
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Bryant R, Wallen W, Rizwan R, Morales DL. Modified Aortic Uncrossing Procedure: A Novel Approach for Norwood Palliation of Complex Univentricular Congenital Heart Disease With a Circumflex Aorta. World J Pediatr Congenit Heart Surg 2017; 8:507-510. [DOI: 10.1177/2150135117712248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The circumflex aorta is a rare type of true vascular ring anomaly. It consists of a retroesophageal right aortic arch, a left-sided descending thoracic aorta, and a left-sided ligamentum arteriosum. The “aortic uncrossing procedure” described by Planché and Lacour-Gayet is the procedure of choice for managing this aortic anomaly in patients with a biventricular heart. The presence of a circumflex aorta in a patient with heterotaxy syndrome and univentricular congenital heart disease requiring Norwood palliation is highly unusual. We report such a case and describe our approach to its surgical management.
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Affiliation(s)
- Roosevelt Bryant
- Division of Cardiac Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - William Wallen
- Division of Cardiac Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Raheel Rizwan
- Division of Cardiac Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David L. Morales
- Division of Cardiac Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Talwar S, Jaiswal LS, Choudhary SK, Saxena A, Juneja R, Kothari SS, Airan B. Retrospective Study of Results of Kawashima Procedure. Heart Lung Circ 2014; 23:674-9. [DOI: 10.1016/j.hlc.2014.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/21/2014] [Accepted: 01/30/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Saxena
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rajnish Juneja
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shyam Sunder Kothari
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Cnota JF, Allen KR, Colan S, Covitz W, Graham EM, Hehir DA, Levine JC, Margossian R, McCrindle BW, Minich LL, Natarajan S, Richmond ME, Hsu DT. Superior cavopulmonary anastomosis timing and outcomes in infants with single ventricle. J Thorac Cardiovasc Surg 2012; 145:1288-96. [PMID: 22939855 DOI: 10.1016/j.jtcvs.2012.07.069] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 06/01/2012] [Accepted: 07/26/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES We sought to identify factors associated with the timing and surgical outcomes of the superior cavopulmonary anastomosis. METHODS The Pediatric Heart Network's Infant Single Ventricle trial database identified participants who underwent superior cavopulmonary anastomosis. Factors potentially associated with age at superior cavopulmonary anastomosis, length of stay and death by 14 months of age were evaluated. Factors included subject demographics, cardiac anatomy, measures from neonatal hospitalization and pre-superior cavopulmonary anastomosis visit, adverse events, echocardiographic variables, intraoperative variables, superior cavopulmonary anastomosis type, and number of concurrent cardiac surgical procedures. Age at superior cavopulmonary anastomosis was analyzed using Cox proportional hazards regression. Natural log length of stay was analyzed by multiple linear regression. RESULTS Superior cavopulmonary anastomosis was performed in 193 subjects at 5.2 months of age (interquartile range, 4.2, 6.2) and weight of 5.9 kg (interquartile range, 5.3, 6.6). The median length of stay was 7 days (interquartile range, 6, 10). There were 3 deaths and 1 transplant during the superior cavopulmonary anastomosis hospitalization, and 3 deaths and 3 transplants between discharge and 14 months of age. Age at superior cavopulmonary anastomosis was associated with center and interstage adverse events. A longer length of stay was associated with younger age and greater case complexity. Superior cavopulmonary anastomosis type, valve regurgitation, ventricular ejection fraction, and ventricular end-diastolic pressure were not independently associated with age at superior cavopulmonary anastomosis or the length of stay. CONCLUSIONS Greater case complexity and more frequent interstage adverse events are associated with an earlier age at superior cavopulmonary anastomosis. Significant variation in age at superior cavopulmonary anastomosis among centers, independent of subject factors, highlights a lack of consensus regarding the optimal timing. Factors associated with length of stay could offer insights for improving presuperior cavopulmonary anastomosis care and surgical outcome.
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Affiliation(s)
- James F Cnota
- Heart Institute, Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Vollebregt A, Pushparajah K, Rizvi M, Hoschtitzky A, Anderson D, Austin C, Tibby SM, Simpson J. Outcomes following the Kawashima procedure for single-ventricle palliation in left atrial isomerism. Eur J Cardiothorac Surg 2011; 41:574-9. [DOI: 10.1093/ejcts/ezr003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
A premature neonate who developed respiratory distress in the first few days of life was found to have a pleural effusion, which reaccumulated following drainage. The effusion was demonstrated to be a chylothorax. He required multiple chest drains and was started on a medium chain triglyceride formula feed. This brought about a full resolution of the effusions and he made a complete recovery.
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Eight years after an early primary Kawashima operation. J Thorac Cardiovasc Surg 2011; 141:1085-6. [PMID: 21419906 DOI: 10.1016/j.jtcvs.2011.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 12/12/2010] [Accepted: 01/03/2011] [Indexed: 11/22/2022]
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