Novel management strategy for severe cyanosis after Sano modification of the Norwood procedure

Current evidence for pharmacologic therapy following stage 1 palliation for single ventricle congenital heart disease

INTRODUCTION

Infants with single ventricle congenital heart disease are vulnerable to complications between stage 1 and stage 2 of palliation. Pharmaceutical treatment during this period is varied and often dependent on institutional practices as there is little evidence supporting a particular treatment path.

AREAS COVERED

This review focuses on medical management of patients following stage I palliation. We performed a scoping review of the current literature regarding angiotensin converting enzyme inhibitors and digoxin treatment in the interstage period. In addition, we discuss other medication classes frequently used in these patients.

EXPERT OPINION

Due to significant heterogeneity of anatomy, rarity of disease, and other confounding factors, there is limited evidence to support most commonly used medications within the interstage period. Digoxin is associated with improved mortality within the interstage period and should be considered; however, no large randomized controlled trial exists supporting its use. Prevention of thrombotic complication with aspirin is also associated with improved outcomes and should be considered unless a contraindication exists. The addition of other prescriptions in this patient population should be considered only after an evaluation of the risks and benefits of each medication, recognizing the burden and risk of polypharmacy in this fragile patient population.

Use of a Modified Classic BT Shunt in a Patient With Multiple Conduit Obstructions With Positive Lupus Anticoagulant

The use of a right ventricle-to-pulmonary artery conduit has re-emerged as a popular alternative to a systemic artery-to-pulmonary artery shunt in the Norwood procedure. Both proximal obstruction secondary to dynamic compression and distal obstruction at the anastomosis site with the pulmonary arteries are well described. In an effort to prevent complications, a technique where in the conduit is placed through the entire full thickness, or dunked, through the RV free wall has been described. We report a case of a patient with HLHS and positive lupus anticoagulant who developed recurrent conduit obstructions. The "Sano" was abandoned in favor of an autologous source of pulmonary blood flow-the modified Blalock-Taussig shunt using the "turn down" of the carotid artery.

Mathematical Analysis and Physical Profile of Blalock-Taussig Shunt and Sano Modification Procedure in Hypoplastic Left Heart Syndrome: Review of the Literature and Implications for the Anesthesiologist

The first stage of surgical treatment for hypoplastic left heart syndrome (HLHS) includes the creation of artificial systemic-to-pulmonary connections to provide pulmonary blood flow. The modified Blalock-Taussig (mBT) shunt has been the technique of choice for this procedure; however, a right ventricle-pulmonary artery (RV-PA) shunt has been introduced into clinical practice with encouraging but still conflicting outcomes when compared with the mBT shunt. The aim of this study is to explore mathematical modeling as a tool for describing physical profiles that could assist the surgical team in predicting complications related to stenosis and malfunction of grafts in an attempt to find correlations with clinical outcomes from clinical studies that compared both surgical techniques and to assist the anesthesiologist in making decisions to manage patients with this complex cardiac anatomy. Mathematical modeling to display the physical characteristics of the chosen surgical shunt is a valuable tool to predict flow patterns, shear stress, and rate distribution as well as energetic performance at the graft level and relative to ventricular efficiency. Such predictions will enable the surgical team to refine the technique so that hemodynamic complications be anticipated and prevented, and are also important for perioperative management by the anesthesia team.

Palliative procedures for congenital heart defects

Although total repair of some congenital heart defects is possible in young children, palliative procedures still play an important role in relieving patients' symptoms, particularly in emergent settings, when total correction or surgical repair is not available. However, the concepts and taxonomies of the palliative procedures for congenital heart diseases sometimes seem to be ambiguous and confusing for young cardiac surgeons and cardiologists. This article gives a full-scope overview of the concepts, categories, indications, historical developments and clinical outcomes of the palliative procedures for congenital heart defects that have been documented in the literature. In total, there are 21 palliative procedures for the surgical management of congenital heart defects, which can be classified into four categories: firstly, increasing pulmonary artery flow for pulmonary oligaemia (including shunt procedures); secondly, decreasing pulmonary artery flow for pulmonary overcirculation (pulmonary banding and Norwood procedure); thirdly, enhancing intracardiac blood-oxygen mixture for systemic hypoxaemia (atrial septostomy subjected to different techniques); and, finally, other procedures, including congenital mitral or aortic stenosis palliation, coarctation of aorta palliation and hybrid palliative procedures for hypoplastic left heart syndrome. Modified Blalock-Taussig's and Glenn's shunts and pulmonary artery banding represent the pre-eminent palliative procedures for congenital heart defects and have been proven to be satisfactory after long-term clinical application. It seems that there is a growing trend towards the use of interventional techniques with stent deployment as an alternative to the surgical approach.

Thrombus formation within the right ventricle-to-pulmonary artery conduit (Sano shunt) as a cause of acute cyanosis in a patient with hypoplastic left heart syndrome

We describe a case of thrombus formation within a right ventricle-to-pulmonary artery conduit (Sano shunt) in a patient with hypoplastic left heart syndrome with resulting acute cyanosis and hypotension requiring emergency balloon angioplasty.