"Y" incision and rectangular patch enlargement of aortic annulus and valve reconstruction with autologous pericardium in congenital aortic stenosis

Surgical aortic valve replacement in children who have undergone prior balloon or surgical valvuloplasty or both is a formidable challenge. The aortic annulus is small, there is no ideal prosthesis and lifelong anticoagulation is highly undesirable. A "Y" incision and rectangular patch enlargement of the aortic annulus introduced by Dr. Bo Yang in 2020 combined with aortic valve reconstruction introduced by Dr. Shigeyuki Ozaki in 2011, is feasible, as described in this case.

Implications of left atrial enlargement and patent foramen ovale creation on early surgical outcomes in patients with total anomalous pulmonary venous connection

INTRODUCTION

In patients with total anomalous pulmonary venous connection (TAPVC), left atrium (LA) is small and suprasystemic pulmonary artery (PA) pressures may be present in some patients. In our study, we studied the relationship between surgical LA enlargement and patent foramen ovale (PFO) creation separately on the outcomes of patients with TAPVC.

MATERIALS AND METHODS

Out of the 130 patients operated in our institute between January 2014 and December 2020, LA was enlarged in 60 patients. LA enlargement was done using a larger patch for atrial septal defect (ASD) closure. Thus, the LA volume was increased by shifting the patch towards the right atrium (RA). Suprasystemic or high PA pressures were present in 60 patients. In 33 patients, PFO was created. Early surgical outcomes were determined on the basis of vasoactive inotropic score (VIS), hours of ventilation, hours of inotropic support, intensive care unit (ICU) stay, and hospital stay.

RESULT

Between the LA enlarged and nonenlarged group there was statistically significant less VIS score (18 [13-27.5] vs. 24 [18-30], p value .019), hours of ventilation (23 [16-46.5] vs. 26 [18-60], p value .039), hours of inotropic support (45.5 [30-72] vs. 55 [38-84], p value .038), and ICU stay (7 [5-9] vs. 8 [7-10] p value .0352) and statistically nonsignificant less hospital stay (11.5 [9-13] vs. 12 [9-14], p value .424). In patients with preoperative suprasystemic or high PA pressures, there was a statistically significant less VIS score (16 [11-23.5] vs. 18 [13-25], p value .044), hours of ventilation (20 [14-37] vs. 22 [18-39], p value .038), hours of inotropic support (34 [29.5-71] vs. 38 [30-78], p value .042), and hospital stay (9 [5-12] vs. 11 [9-14], p value .038) and statistically nonsignificant less ICU stay (7 [5.5-9] vs. 7 [6-9], p value .886) in the group with a PFO with respect to the other group in which no PFO was created.

CONCLUSION

In patients with TAPVC, LA can be enlarged by using a large ASD patch and thus shifting the septum towards RA. Early surgical outcomes were improved with LA enlargement. In patients with suprasystemic or high PA pressures, leaving a PFO improved the postoperative outcomes.

Mixed type total anomalous pulmonary venous connection: Early results and midterm outcomes of surgical correction

BACKGROUND AND AIM OF THE STUDY

The morphological heterogeneity of anomalous pulmonary venous drainage in mixed type total anomalous pulmonary venous connection (TAPVC) has important implications in preoperative diagnosis and surgical repair resulting in high mortality in these patients.

METHODS

A retrospective review of 14 patients with mixed type TAPVC undergoing biventricular repair between January 2012 and December 2019 was conducted. A descriptive analysis was done, highlighting the anatomic variation, diagnostic and surgical approach, and surgical outcomes in these patients.

RESULTS

The most common anatomic pattern was "3 by 1" (79%) followed by "2 by 2" (21%). The correct diagnosis by transthoracic echocardiography was made in 10 (71%) of the 14 patients. In contrast, preoperative computed tomographic (CT) angiography was performed in 10 patients and correct diagnosis was obtained in 8 (80%) of them. Pulmonary venous obstruction was seen in one patient before surgery. The in-hospital mortality was 14% (2/14). Four patients had pulmonary hypertensive crisis in the postoperative period. The average follow-up was 54 ± 27 months (range: 17-98 months) after surgical repair, and all surviving patients were asymptomatic. There was no late death. No clinically apparent sequelae were seen in six patients in whom isolated left superior pulmonary vein drainage was left uncorrected.

CONCLUSION

An accurate diagnosis of anatomic pattern in mixed type TAPVC can be difficult to establish in all the patients before surgery. Detailed intraoperative assessment, individualized surgical approach, and aggressive perioperative management may reduce surgical mortality. Operative survivors have good midterm outcome.

Short-term outcome of Polytetrafluoroethylene Membrane Valve versus Transannular Pericardial patch Reconstruction of Right Ventricular Outflow Tract in Tetralogy of Fallot: a Randomized Controlled Trial

INTRODUCTION

Reconstruction of right ventricular outflow tract during primary repair of tetralogy of Fallot often requires the placement of a transannular patch which results in pulmonary regurgitation (PR). We compared the short-term outcomes of bicuspid polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of the right ventricular outflow tract.

METHODS

Thirty consecutive patients undergoing primary repair of tetralogy of Fallot were randomly allocated to two groups - polytetrafluoroethylene valve (PTFEV) group (n=15) and transannular pericardial patch (TAP) group (n=15). The two groups had similar preoperative demographic characteristics. We compared the short-term clinical and echocardiographic outcomes between these groups. The transthoracic echocardiographic follow-up was performed at one week, one month and six months after surgery.

RESULTS

The PTFEV group had significantly lower central venous pressure in the immediate postoperative period compared to the TAP group (7.60±2.06 vs. 10.13±1.73, P=0.002). Extubation time was significantly shorter in the PTFEV group compared to the TAP group (12.93±7.55 hrs vs. 22.23±15.11 hrs, P=0.04). PR in the PTFEV group was absent in five patients at 24 hours post-surgery. At the study endpoint, PR was absent in six, trivial in one and mild in eight patients in the PTFEV group compared to TAP group, where all 15 patients had severe PR.

CONCLUSION

The bicuspid polytetrafluoroethylene membrane valves significantly decrease the central venous pressure in the immediate postoperative period, facilitate early extubation and, thus, prevent ventilator-related comorbidities. They achieve a high degree of pulmonary competence and do not increase the right ventricular outflow tract gradient in short-term follow-up.

Surgical repair of ruptured sinus of Valsalva aneurysm: 13-year single center experience

BACKGROUND AND AIM

Untreated ruptured sinus of Valsalva aneurysms ultimately develop into heart failure, thereby affecting patients' survival. We retrospectively analyzed our 13-year experience of the surgical repair for ruptured sinus of Valsalva aneurysm to study the optimal surgical strategy, operative risk and long-term surgical outcome.

METHODS

Twenty-six patients underwent surgical repair of ruptured sinus of Valsalva aneurysm from January 2008 to February 2020. Follow-up data were obtained from the outpatient department records and telephone calls.

RESULTS

Patch closure of ruptured sinus of Valsalva aneurysm was done in all the 26 patients, most often through the transaortic (69%) and dual-chamber approach (23%). Aortic valve repair was done in one patient while seven patients underwent aortic valve replacement for associated significant aortic regurgitation. There was one in-hospital mortality because of noncardiac cause. The median duration of postoperative hospital stay was 8 days (range, 6-11 days). Follow-up data were available for 89% (23/26) patients. The mean follow-up period was 69 ± 43 months (range, 7-147 months). All survivors were in New York Heart Association functional Class I or II. There was no late death. One patient required rehospitalization for recurrent ruptured sinus of Valsalva aneurysm. There was no recurrent or new-onset significant aortic regurgitation and prosthesis-related complications in late follow-up.

CONCLUSION

Surgical repair for ruptured sinus of Valsalva aneurysm carries an acceptable low operative risk and excellent long-term outcome. Though high-risk population, an early diagnosis and optimal surgical approach can prevent worsening of symptoms and consequent heart failure.

A single coronary artery with left circumflex artery crossing right ventricular outflow tract in tetralogy of Fallot with absent left pulmonary artery

Tetralogy of Fallot (TOF) with unilateral absence of pulmonary artery and the anomalous coronary artery is a rare combination. Detailed preoperative evaluation of coronary artery anatomy is must to prevent injury to the major vessels crossing right ventricular outflow tract. We report a rare association of single coronary artery with left circumflex artery crossing right ventricular outflow tract close to the pulmonary annulus in tetralogy of Fallot with absent left pulmonary artery in 11-year-old girl. Though there is a great diversity of coronary anomalies in tetralogy of Fallot, the prepulmonic course of left circumflex artery crossing the right ventricular outflow tract (RVOT) close to the pulmonary annulus has rarely been described in the literature. The patient underwent successful primary single lung intracardiac repair. Right ventricular outflow tract obstruction was treated by handmade valved pericardial autologous conduit and release of the tethering of hypoplastic native unicuspid pulmonary valve leaflet maintaining its integrity.

Giant diffuse neurofibroma of the chest wall involving the sternum: Challenging chest wall reconstruction

Diffuse neurofibroma is a rare form of neurofibroma, usually reported in the head and neck. To our knowledge, diffuse neurofibroma of the anterior chest wall has not been reported previously. Even rarer is involvement of the sternum in neurofibroma. We report a case of a 30-year-old lady who presented with a rapidly growing, painless giant exophytic mass involving almost the entire anterior chest wall. The tumor mass was infiltrating the sternum. Excision of the tumor left a large full-thickness thoracic defect that was covered using polypropylene mesh beneath a pedicled omental flap with a split skin graft over it.

Successful surgical management of an aorto-oesophageal fistula caused by button battery ingestion

Aorto-oesophageal fistula is a rare complication of foreign body ingestion from which few patients survive. Aggressive surgical treatment is the only form of effective therapy for this fatal complication. We present the successful surgical treatment of an aorto-oesophageal fistula in a child without using cardiopulmonary bypass.

Atretic right superior vena cava with left superior vena cava draining directly into left atrium with absent coronary sinus in an adult with partial atrioventricular canal defect and complete heart block

The association of atretic right superior vena cava with persistent left superior vena cava draining directly into left atrium with absent coronary sinus in atrioventricular canal defect is virtually unknown in adults with no case reported so far. Though atretic right superior vena cava with persistent left superior vena cava is an extremely rare venous anomaly seen in congenital heart disease, it has important clinical implications in cardiac surgery and interventional cardiology. Atrial arrhythmias and right bundle branch block are common with advancing age in partial atrioventricualr canal defect but complete heart block has scarcely been reported in the medical literature.

Surgical Valve Repair of Native Pulmonary Valve Endocarditis Using the Ozaki Technique

Surgery for infective endocarditis in the pulmonary position is an effective method of treatment despite a very uncommon pathology and few operations being performed. We present an adult male patient with right-sided infective endocarditis where the pulmonary valve cusps were almost completely damaged. The pulmonary valve was successfully reconstructed using glutaraldehyde-treated autologous pericardium by the Ozaki technique. The Ozaki repair was originally described for aortic valve repair in various aortic valve diseases.

Congenital right coronary artery aneurysm with fistula to right ventricle associated with isolated pulmonary valvular stenosis

Congenital aneurysmal dilatation of coronary artery with coronary cameral fistula is rare in childhood. We report an even rarer association of congenital right coronary artery aneurysm and right coronary artery to right ventricle fistula with bicuspid pulmonary valve stenosis and an intact ventricular septum in a 3-year-old child.

Delayed embolization of ductal occluder device into the aorta with near-complete obstruction of the aorta and critical cardiac decompensation

Delayed embolization of ductal occluder device into the aorta after transcatheter closure of a patent ductus arteriosus (PDA) with almost complete obstruction of the aorta is extremely rare. Our patient had delayed migration of a ductal occluder device into the descending thoracic aorta (DTA) 6 months after its deployment. Because of critical biventricular dysfunction, urgent surgical removal of the device from the descending aorta was done via left posterolateral thoracotomy without using cardiopulmonary bypass. PDA was not closed because of doubt about the reversibility of pulmonary artery hypertension and severe right ventricular dysfunction so that it can act as an outlet to the decompensated right ventricle. The patient made an uneventful recovery. The patient was started on pulmonary vasodilators and is planned for right heart catheterization study after 2 months to check for the operability of PDA.

Surgical outcome of isolated congenital supravalvular pulmonary stenosis: a case series

Background

Supravalvular stenosis of main pulmonary artery is a rare anomaly characterized by the presence of constriction band just above the pulmonary valve. It is mostly acquired after intervention on the pulmonary trunk or less commonly is congenital in origin associated with complex congenital cardiac malformations and very rarely can present as an isolated native congenital supravalvular pulmonary stenosis (SPS).

Case summary

We present a series of four cases of isolated congenital SPS who underwent surgical correction at our tertiary care institute over 8 years. Mean age of the patients was 2.25 ± 0.96 years with all of them being males. Mean peak systolic gradient across the stenosis was 82 ± 21.48 mmHg ranging from 60 mmHg to 110 mmHg. There was no early and medium-term mortality with 100% survival at mean follow-up of 31 months (range 7–85 months).

Discussion

Surgical correction of congenital SPS carries excellent early and mid-term results with almost no mortality and very low risk of re-intervention for restenosis.