Trans-aortic DORV repair

Double-outlet right ventricle (DORV) is a group of complex ventriculoarterial connections. In the literature, there are reports of trans-aortic correction of tetralogy of Fallot, as well as ventricular septal defects and complex DORV without right ventricular outflow tract obstruction. However, a pure trans-aortic approach for DORV ventricular septal defect (VSD) right ventricular outflow tract obstruction repair is not reported in the literature. We present a case of pure trans-aortic repair of DORV VSD pulmonary stenosis (PS) in an adult. A 20-year-old male with a known case of DORV, VSD, and PS presented with cyanosis. A pure trans-aortic repair of DORV was done. Complete trans-aortic DORV VSD PS repair is yet to be reported in the literature. The trans-aortic approach avoids a right atriotomy, right ventriculotomy, and injury to coronary arteries in cases of complicated tetralogy of Fallot and avoids injury to the tricuspid valve. This approach can be used in selected patients for intracardiac repair. The advantages are excellent visualization of the defects and avoidance of injury to the aortic cusps and bundle of His. In addition, placement of the VSD patch on the left ventricular outflow side may prevent residual shunts after repair.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01564-x.

Comparison of Left Ventricular Global Longitudinal Strain with Ejection Fraction as a Predictor for Peri-operative IABP Insertion in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting: A Pilot Study

Background

Prophylactic use of intra-aortic balloon pump (IABP) mainly depends on left ventricular (LV) systolic function. Global longitudinal strain (GLS) is a robust prognostic parameter for LV strain. It has proved to be more sensitive than LV ejection fraction (EF) as a measure of LV systolic function and is a strong predictor of outcome.

Aim

To determine whether GLS can be used as a reliable marker and its cut-off value for IABP insertion in patients undergoing elective off-pump coronary artery bypass grafting (OPCABG).

Settings and Design

A prospective observational clinical study which included 100 adult patients scheduled for elective OPCABG.

Materials and Methods

Two-dimensional (2D) speckle tracking echocardiography (STE)-estimated GLS was computed and compared with LV EF measured by three dimensional (3D) echocardiography for the insertion of IABP. The intensive care unit (ICU) parameters were correlated with echocardiographic parameters to predict early post-operative outcome.

Results

IABP insertion correlates better with GLS (post-revascularization > pre-revascularization) than with 3D LV EF. Receiver operating characteristic (ROC) curve analysis revealed the highest area under the curve (AUC, 0.972) with a cut-off value of > -9.8% for GLS compared to 3D LV EF (AUC, 0.938) with a cut-off value of ≤ 44%. ICU parameters show better correlation with E/e'> GLS > WMSI than 3D LV EF.

Conclusion

GLS is a better predictor of IABP insertion compared to 3D LV EF in patients undergoing OPCABG.

Low Flow Venoarterial ECMO Support Management in Postcardiac Surgery Patient

Venoarterial extracorporeal membrane oxygenation (VA ECMO) aims to fully support heart and lung function in postcardiac patients, ensuring end-organ perfusion and allowing time for possible heart recovery. VA ECMO is considered the modified and extended form of cardiopulmonary bypass (CPB), which is used to provide adequate tissue oxygenation. ECMO and the associated management protocols will mechanically support the patient and allow for the optimization of all aspects of care for the period of time necessary for the recovery of native cardiac or respiratory function. Significant technical advancements have been made in the equipment and the clinical management available for short- and long-term ECMO application. There are various parameters that have to be considered to evaluate whether the level of perfusion in patients on VA ECMO is adequate, and the outcomes of patients depend on them.

Role of Platelet Function Test in Predicting Postoperative Bleeding Risk after Coronary Artery Bypass Grafting: A Prospective Observational Study

Patients undergoing cardiac surgery are at risk of excessive bleeding and its associated complications. Excessive bleeding during and after cardiac surgery has an incidence of ~20%. Massive bleeding and subsequent requirement for blood product administration and mediastinal reexploration are associated with significant morbidity and mortality. Postoperative, nonsurgical bleeding in cardiac surgical patients is often multifactorial. Platelet dysfunction, excessive fibrinolysis, hypothermia, preoperative anemia, and deficiency of coagulation factors or their dilution are all suggested etiologies of postoperative bleeding. In the Arachidonic Acid Thromboelastometry (ARATEM) test, platelets are activated with arachidonic acid; in Adenosine diphosphate Thromboelastometry (ADPTEM) test, platelets are activated with adenosine diphosphate; and in TRAPTEM test, platelets are activated with thrombin receptor-activating peptide 6. Measurement time is 6 minutes, and results are expressed in three different parameters: A6 (amplitude at 6 minutes, in Ohm); MS (maximum slope of the aggregation curve in Ohm/min), and AUC (area under the curve in Ohm.min). Algorithm-based point-of-care platelet function testing helped us to preemptively give the right blood component therapy, avoiding fibrinolytic bleeding in the postoperative period.

Vitamin D Deficiency and Its Response to Supplementation as “Stoss Therapy” in Children with Cyanotic Congenital Heart Disease Undergoing Open Heart Surgery

Background Data from many studies suggest that patients with congenital heart disease are vitamin D (vitD) deficient. Following cardiac surgery as a result of intraoperative institution of cardiopulmonary bypass (CPB), serum vitD levels become even low. This may affect postoperative convalescence in terms of mechanical ventilation, inotropic support, infection, and so forth.

Objective We intended to study the prevalence of vitD deficiency pre and post cardiac surgery and the effect of vitD supplementation (stoss therapy) on postoperative convalescence of the children with tetralogy of Fallot (TOF) undergoing intracardiac repair (ICR).

Methodology In this randomized controlled trial (RCT), 60 children younger than 18 years with TOF and serum vitD levels < 20ng/dL were randomized into two groups. The study group received vitD supplementation as “stoss therapy” at 10,000 units/kg body weight. All these children underwent ICR with CPB. Demographic data, preoperative, intraoperative, and postoperative variables were compared between the study and the control groups.

Results Prevalence of severe vitD deficiency was 93.1%. When compared with the control group, study group showed higher serum vitD levels in the immediate preoperative period (p = 0.001), postoperative period following CPB (p = 0.012), and on the first postoperative day (p = 0.003). No statistically significant difference was observed in postoperative mechanical ventilation (p = 0.35), intensive care unit (ICU) stay (p = 0.15), and inotropic duration (p = 0.19).

Conclusion Children with TOF are highly deficient of vitD, its level falls further after CPB, and supplementing vitD preoperatively does not influence postoperative recovery pattern. Supplementation of vitD as “stoss therapy” was useful in raising the serum levels before and after cardiac surgery.

Transesophageal Echocardiography for Ross-Konno Procedure

Ross procedure involves replacing diseased aortic valve with pulmonary autograft and placing a pulmonary/aortic homograft between the right ventricle and pulmonary artery. In case of small aortic annulus in pediatric patients or in patients with multilevel left ventricular outflow obstruction, aortic annulus enlargement might be required concurrently. Konno type of aortic ventriculoplasty is most commonly done. The American Heart Association/American College of Cardiology (AHA/ACC) has classified transesophageal echocardiography (TEE) as class I indication for congenital heart disease

Idiopathic left ventricular outflow tract pseudoaneurysm

Left ventricular outflow tract (LVOT) pseudoaneurysm is a rare occurrence and may produce clinically unpredictable symptoms. A very few cases of LVOT pseudoaneurysm are reported and there has always been a predisposing factor in these reported cases such as history of infective endocarditis, myocardial infarction, prosthetic aortic valve replacement or chest trauma. Our patient did not have the above predisposing conditions. Intra operative transesophageal echocardiography helped patient management and guided the surgical team in securing and isolation of the aneurysmal sac from the LVOT.

Complete transposition of great arteries with cor triatriatum: an unusual coexistence

The combination of complete transposition of the great arteries and cor triatriatum is extremely rare. We report three infants with this rare combination and discuss the anatomic details apparently unique to the combined lesion.

Right atrial myxoma with glandular differentiation: A rare entity in pediatric age group

Cardiac myxomas (CMs) account for nearly half of the primary cardiac tumors in the elderly. They arise from sub-endocardial “reserve” or lepidic” cells, which may show divergent differentiation. We describe a CM with glandular differentiation in the right atrium of a 10-year-old child who presented with respiratory distress on exertion, of 2 months duration. On echocardiography, two large interconnected masses measuring 34×30 mm and 20×17 mm were seen to arise from the free wall of the right atrium. Cut surface of the excised mass was myxoid with areas of calcification. On microscopy, there were typical features of a myxoma with prominent glandular differentiation and characteristic immunophenotype. The case is being reported due to its rarity in pediatric age group as well as its glandular differentiation, which must be recognized as a spectrum of histomorphologic diversity and must not be mistaken for a metastatic adenocarcinoma.

An alternative technique for rechanneling of sinus venosus atrial septal defect with partial anomalous pulmonary venous connection using autogenous right atrial appendage

We report a new technique for closure of sinus venosus atrial septal defect with high partial anomalous pulmonary venous connection. This technique consisted of preservation of the atriocaval junction, advancement of the posterior rim of the atrial septal defect anterosuperiorly and enlargement of the superior caval vein using right atrial appendage. We found this to be a convenient technique and recommend it for correction of this anomaly.

Ventricular septal rupture in a 4-year-old child following blunt chest injury

We report on a 4-year-old child who developed rupture of the ventricular septum after a blunt chest injury. The symptoms appeared more than 12 h later with progressive deterioration in his hemodynamic status. The diagnosis was made by echocardiography and the large defect in the muscular part of the ventricular septum was successfully closed at surgery.

Total anomalous pulmonary venous connection: surgical experience in Indians

BACKGROUND

We report a retrospective analysis of the demographic. morphological and clinical profiles of patients along with results of operative repair for total anomalous pulmonary venous connection.

METHODS AND RESULTS

In the last 15 years, 248 patients (168 boys, 80 girls) underwent repair for total anomalous pulmonary venous connection. Their ages ranged from I day to 24 years (median 8 months) and 145 of them were < or = 1 year of age. The patients' weight ranged from 2 to 52 kg (median 5 kg). About 70% of patients (n = 174) were less than the 50th percentile of predicted weight for age and sex. The anomalous connection was supracardiac in 134 (54%), cardiac in 80 (32.2%), infracardiac in 9 (3.6%) and mixed in 25 (10.1%) patients. Fifty (20.2%) patients had obstructed drainage and 76 patients (30.2%) had moderate or severe pulmonary arterial hypertension. Forty-five patients (18.1%) had to be operated upon on an emergency basis. All the patients were operated upon using moderately hypothermic cardiopulmonary bypass. In 114 patients, circulatory arrest was used. There were 45 (19.1%) in-hospital deaths. The major causes of early death were pulmonary arterial hypertensive crisis in 19 (7.7%) and low cardiac output syndrome in 17 (6.9%) patients. Age < or = 1 year (odds ratio 2.16; 95% confidence interval: 1.22-3.82, p=0.008), severe pulmonary arterial hypertension (odds ratio 5.86; 95% confidence interval: 2-17, p=0.001), and need for emergency surgery (odds ratio 3.65; 95% confidence interval: 1.59-8.38, p=0.002) were independent risk factors for early death. Follow-up ranged from 1 to 180 months (median 48 months). There were 4 lake deaths. Actuarial survival at 12 years was 92.6% +/- 2.8%.

CONCLUSIONS

In Indian circumstances, mortality continues to be high in infants with total anomalous pulmonary venous connection. Severe pulmonary arterial hypertension appears to be the most important predictor of operative mortality. Severe malnutrition, delayed diagnosis and late referrals possibly contribute to the high mortality.