[Complex right cervical aortic arch repair: less is more]

Cervical aortic arch is a rare malformation that often has anatomical abnormalities of the supra-aortic trunks and may also be associated with aortic stenosis, aneurysms, or cardiac malformations. To correct them, symptomatic patients undergo surgery, which usually consists of a prosthetic graft repair, aortoplasty patch, or an end-to-end anastomosis. In addition, circulatory arrest and deep hypothermia are often required, as in aortic arch surgery. We report the case of a 13-year-old patient who underwent correction of a right cervical aortic arch stenosis with a post-stenotic aneurysm between the origin of the right carotid artery and the right subclavian artery. The anatomy of the aortic branches was abnormal. The surgical procedure consisted of an extensive resection with direct end-to-end anastomosis, without the use of a prosthetic graft, using moderate hypothermic cardiopulmonary bypass and without circulatory arrest.

Impact of preoperative left pulmonary artery stenting on the Fontan procedure: a retrospective multicentre study

OBJECTIVES

Left pulmonary artery (LPA) or bifurcation stenoses at Fontan palliation can be very challenging to treat and may also require cardioplegia and aortic transection. Moreover, the low pressure of Fontan circulation and the bulkiness of the aorta increase the risk of a patch angioplasty collapse. Pre-Fontan LPA stenting of stenotic LPAs overcomes those drawbacks therefore the present study aimed to evaluate its advantageous impact on Fontan surgery.

METHODS

A multicentre retrospective analysis was performed on 304 consecutive Fontan patients. The study population was divided into 2 groups (LPA stented, n = 62 vs not stented, n = 242); pre-and postoperative data were compared.

RESULTS

LPA-stented patients had a higher prevalence of systemic right ventricle (P = 0.01), hypoplastic left heart syndrome (P = 0.042), complex neonatal palliations (Norwood/Damus-Kaye-Stansel) and surgical LPA patch repair at Glenn (P < 0.001). No differences were found in cross-clamp rates, early (P = 0.29) and late survival (94.6% vs 98.4, P = 0.2) or complications (P = 0.14). Complex palliations on ascending aorta/aortic arch (P = 0.013) and surgical LPA repair at Glenn (P < 0.001) proved to be risk factors for LPA stenting before Fontan at multivariable analysis.

CONCLUSIONS

The LPA-stented group showed similar outcomes in terms of survival and complications rate compared to patients without LPA stenosis; however, they significantly differ in their higher preoperative risk profile and in their more complex anatomy. Complex neonatal palliations involving ascending aorta or aortic arch may increase the risk of pulmonary branches stenosis requiring stenting; therefore, preoperative stenting of LPA stenoses could help to reduce the surgical risk of complex Fontan procedure by avoiding the need for cross-clamp or complex mediastinal dissections to perform a high-risk surgical repair.

Hemoadsorption Contribution in Failing Fontan Pediatric Heart Transplantation

INTRODUCTION

A systemic inflammatory response is triggered in patients undergoing cardiothoracic surgery with cardiopulmonary bypass (CPB). This response is particularly evident in pediatric patients, especially those of low weight and after undergoing long CPB, and can severely impair the surgical result. Adsorptive blood purification techniques have been proposed to limit this systemic inflammatory response. To test its efficacy, we added the hemoadsorption filter Jafron HA 380 to CPB in a much compromised pediatric patient who underwent heart transplantation.

METHODS

A 10-year-old single ventricle patient previously treated with Fontan operation was listed for heart transplantation due to the evidence of failing Fontan condition. He experienced many episodes of cardiac arrest and underwent heart transplantation in much compromised general and hemodynamic conditions. The hemoadsorption filter Jafron HA 380 was used for all the duration of CPB, and the inflammatory biomarker interleukin 6 (IL-6) was assayed.

RESULTS

Postoperative outcome was uneventful and comparable to that of elective pediatric heart transplantation. IL-6 levels showed an impressive postoperative reduction, and after 2 days, the IL-6 level was comparable with a typical uneventful post-transplant course.

CONCLUSIONS

The use of hemoadsorption filter can contribute to improve the pediatric transplant results, especially in very high-risk patients.

Cerebrovascular accidents in paediatric patients supported by the Berlin Heart EXCOR

OBJECTIVES

Ventricular assist device support as a bridge to transplant or recovery is a well-established therapy in children on the cardiac transplant waiting list. The goal of this study was to investigate the incidence of and the associated factors for cerebrovascular accidents in paediatric patients supported by a Berlin Heart EXCOR.

METHODS

All patients <19 years of age supported by a Berlin Heart EXCOR between January 2011 and January 2021 from the European Registry for Patients with Mechanical Circulatory Support were included.

RESULTS

In total, 230 patients were included. A total of 140 (60.9%) patients had a diagnosis of dilated cardiomyopathy. 46 patients (20.0%) sustained 55 cerebrovascular accidents, with 70.9% of the episodes within 90 days after the ventricular assist device was implanted. The event rate of cerebrovascular accidents was highest in the first era (0.75). Pump thrombosis and secondary need for a right ventricular assist device were found to be associated with a cerebrovascular accident (hazard ratio 1.998, P = 0.040; hazard ratio 11.300, P = 0.037). At the 1-year follow-up, 44.4% of the patients had received a transplant, 13.1% were weaned after recovery and 24.5% had died. Event rates for mortality showed a significantly decreasing trend.

CONCLUSIONS

Paediatric ventricular assist device support is associated with important adverse events, especially in the early phase after the device is implanted. Pump thrombosis and the need for a secondary right ventricular assist device are associated with cerebrovascular accidents. Furthermore, an encouragingly high rate of recovery in this patient population was shown, and death rates declined. More complete input of data into the registry, especially concerning anticoagulation protocols, would improve the data.

Study design and rationale of the pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA-R)

Aim

Due to improved therapy in childhood, many patients with congenital heart disease reach adulthood and are termed adults with congenital heart disease (ACHD). ACHD often develop heart failure (HF) as a consequence of initial palliative surgery or complex anatomy and subsequently require advanced HF therapy. ACHD are usually excluded from trials evaluating heart failure therapies, and in this context, more data about heart failure trajectories in ACHD are needed to guide the management of ACHD suffering from HF.

Methods and results

The pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA‐R) will collect data from ACHD evaluated or listed for heart or heart‐combined organ transplantation from 16 countries in Europe and the Asia/Pacific region. We plan retrospective collection of data from 1989–2020 and will include patients prospectively. Additional organizations and hospitals in charge of transplantation of ACHD will be asked in the future to contribute data to the register. The primary outcome is the combined endpoint of delisting due to clinical worsening or death on the waiting list. The secondary outcome is delisting due to clinical improvement while on the waiting list. All‐cause mortality following transplantation will also be assessed. The data will be entered into an electronic database with access to the investigators participating in the register. All variables of the register reflect key components important for listing of the patients or assessing current HF treatment.

Conclusion

The ARTORIA‐R will provide robust information on current management and outcomes of adults with congenital heart disease suffering from advanced heart failure.

The frequency of rare and monogenic diseases in pediatric organ transplant recipients in Italy

Background

Rare diseases are chronic and life-threatening disorders affecting < 1 person every 2,000. For most of them, clinical symptoms and signs can be observed at birth or childhood. Approximately 80% of all rare diseases have a genetic background and most of them are monogenic conditions. In addition, while the majority of these diseases is still incurable, early diagnosis and specific treatment can improve patients’ quality of life. Transplantation is among the therapeutic options and represents the definitive treatment for end-stage organ failure, both in children and adults. The aim of this paper was to analyze, in a large cohort of Italian patients, the main rare genetic diseases that led to organ transplantation, specifically pointing the attention on the pediatric cohort.

Results

To the purpose of our analysis, we considered heart, lung, liver and kidney transplants included in the Transplant Registry (TR) of the Italian National Transplantation Center in the 2002–2019 timeframe. Overall, 49,404 recipients were enrolled in the cohort, 5.1% of whom in the pediatric age. For 40,909 (82.8%) transplant recipients, a disease diagnosis was available, of which 38,615 in the adult cohort, while 8,495 patients (17.2%) were undiagnosed. There were 128 disease categories, and of these, 117 were listed in the main rare disease databases. In the pediatric cohort, 2,294 (5.6%) patients had a disease diagnosis: of the 2,126 (92.7%) patients affected by a rare disease, 1,402 (61.1%) presented with a monogenic condition. As expected, the frequencies of pathologies leading to organ failure were different between the pediatric and the adult cohort. Moreover, the pediatric group was characterized, compared to the adult one, by an overall better survival of the graft at ten years after transplant, with the only exception of lung transplants. When comparing survival considering rare vs non-rare diseases or rare and monogenic vs rare non-monogenic conditions, no differences were highlighted for kidney and lung transplants, while rare diseases had a better survival in liver as opposed to heart transplants.

Conclusions

This work represents the first national survey analyzing the main genetic causes and frequencies of rare and/or monogenic diseases leading to organ failure and requiring transplantation both in adults and children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-02013-x.

Impact of COVID-19 Pandemic on the Italian Humanitarian Congenital Cardiac Surgery Activity: What No One Tells You

More than 4 millions of children with congenital heart disease (CHD) are waiting for cardiac surgery around the world. Few of these patients are treated only thanks to the support of many non-governmental organizations (NGOs). Starting in December 2019, the so-called coronavirus disease 2019 (COVID-19) has rapidly become a worldwide pandemic and has dramatically impacted on all the international humanitarian activities for congenital heart disease. We analyzed data from all the Italian congenital cardiac surgery centers with the aim to quantify the impact of the pandemic on their charities. Fifteen Italian centers participated in the study and contributed to data collection. We analyzed and compared data regarding humanitarian activities carried out abroad and on site from two periods: year 2019 (pre-COVID-19) and year 2020 (COVID-19 pandemic). In 2019, 53 international missions were carried out by Italian congenital cardiac surgeons, resulting in the treatment of 471 CHD patients. In the same period 11 Italian cardiac centers operated on 251 foreign patients in Italy. In 2020, the pandemic led to a reduction of this activity by 96% for the surgery performed overseas and 86% for the interventions carried out in Italy. In conclusion our study shows the important quantitative impact of the pandemic on the Italian humanitarian cardiac surgical activity overseas and in Italy. This shocking result highlights the failure of the systems adopted so far to solve the problem of CHD in developing countries.

The role of primary surgical repair technique on late outcomes of Tetralogy of Fallot: a multicentre study

OBJECTIVES

Repair of Tetralogy of Fallot (TOF) has currently excellent results with either transventricular or transatrial approach. However, it is unclear as to which has better late outcomes and what role of residual pulmonary valve (PV) regurgitation in the long term is. We report on late clinical outcomes after repair in a large series of patients with TOF, focusing on the type of surgical technique.

METHODS

This analysis is a retrospective multicentre study on patients undergoing TOF repair in infancy. The exclusion criteria of the study were TOF with pulmonary atresia or absent PV.

RESULTS

We selected 720 patients who had undergone TOF repair (median age 5.7 months, interquartile range 3.7-11.7). Preoperative cyanotic spells occurred in 18%. A transatrial repair was performed in 433 (60.1%) patients. The PV was preserved in 249 (35%) patients, while the right ventricular outflow tract was reconstructed with a transannular patch (60.4%) or a conduit (4.6%) in the rest of the patients. At a median follow-up of 4 years (range 1-21, 86% complete), 10 (1.6%) patients died, while 39 (6.3%) patients required surgical reoperation and 72 (11.7%) patients required an interventional procedure. The propensity match analysis showed that the incidence of postoperative complications and adverse events at follow-up were significantly increased in patients undergoing transventricular approach repair with transannular patch (P = 0.006) and PV preservation was a significant protective factor against postoperative complications (P = 0.009, odds ratio 0.5) and late adverse events (P = 0.022).

CONCLUSIONS

Surgical repair of TOF in infancy is a safe procedure, with good late clinical outcomes. However, transatrial approach and PV preservation at repair are associated with lower early and late morbidity.

Right mini-thoracotomy approach for grown-up congenital heart disease

BACKGROUND

Right mini-thoracotomy cardiac surgery has been recognized as a safe and effective procedure, with remarkable early and long-terms outcomes. However, most of the literature is focused on mitral valve surgery and few studies report on the minimally invasive approach applied to congenital disease. Aim of this study was to review our experience on patients with grown-up congenital heart (GUCH) undergoing right mini-thoracotomy cardiac surgery.

METHODS

Data of patients with GUCH undergoing right mini-thoracotomy cardiac surgery from 2006 to 2019 were retrospectively analyzed. Inclusion criteria were atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, and mitral or tricuspid valve dysfunction in congenital heart diseases.

RESULTS

During the study period 127 patients with GUCH underwent right mini-thoracotomy cardiac surgery. Mean age was 43.6 years and more than 60% were females; diagnosis was atrial septal defect in 57 cases (44.9%); 24 patients were redo (18.9%). No cases of stroke and major vascular complications were reported. Conversion to sternotomy was required in one case (0.8%). No residual shunts or valves dysfunction were recorded at the postoperative echocardiographic evaluation. Perioperative mortality was 1.6%.

CONCLUSIONS

Right mini-thoracotomy cardiac surgery in selected patients with GUCH allows to avoid the big scar of the sternotomy approach and to accelerate the recovery in a young population. Moreover, in redo cases, it allows the surgeon to reach the heart and the aorta avoiding the well-known risks of a re-sternotomy procedure.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the Italian congenital cardiac surgery system: a national survey

OBJECTIVES

Italy has been one of the countries most severely affected by the coronavirus disease 2019 (COVID-19). The Italian government was forced to introduce quarantine measures quickly, and all elective health services were stopped or postponed. This emergency has dramatically changed the management of paediatric and adult patients with congenital heart disease. We analysed data from 14 Italian congenital cardiac surgery centres during lockdown, focusing on the impact of the pandemic on surgical activity, patients and healthcare providers and resource allocation.

METHODS

Fourteen centres participated in this study. The period analysed was from 9 March to 4 May. We collected data on the involvement of the hospitals in the treatment of patients with COVID-19 and on limitations on regular activity and on the contagion among patients and healthcare providers.

RESULTS

Four hospitals (29%) remained COVID-19 free, whereas 10 had a 39% reduction in the number of beds for surgical patients, especially in the northern area. Two hundred sixty-three surgical procedures were performed: 20% elective, 62% urgent, 10% emergency and 3% life-saving. Hospital mortality was 0.4%. Compared to 2019, the reduction in surgical activity was 52%. No patients operated on had positive test results before surgery for severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19. Three patients were infected during the postoperative period. Twenty-nine nurses and 12 doctors were infected. Overall, 80% of our infected healthcare providers were in northern centres.

CONCLUSIONS

Our study shows that the pandemic had a different impact on the various Italian congenital cardiac surgery centres based on the different patterns of spread of the virus across the country. During the lockdown, the system was able to satisfy all emergency clinical needs with excellent results.

Acute Cardiovascular Manifestations in 286 Children With Multisystem Inflammatory Syndrome Associated With COVID-19 Infection in Europe

BACKGROUND

The aim of the study was to document cardiovascular clinical findings, cardiac imaging, and laboratory markers in children presenting with the novel multisystem inflammatory syndrome associated with coronavirus disease 2019 (COVID-19) infection.

METHODS

This real-time internet-based survey has been endorsed by the Association for European Paediatric and Congenital Cardiologists Working Groups for Cardiac Imaging and Cardiovascular Intensive Care. Children 0 to 18 years of age admitted to a hospital between February 1 and June 6, 2020, with a diagnosis of an inflammatory syndrome and acute cardiovascular complications were included.

RESULTS

<0.05). Polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 was positive in 33.6%, whereas immunoglobulin M and immunoglobulin G antibodies were positive in 15.7% cases and immunoglobulin G in 43.6% cases, respectively, when checked. One child in the study cohort died.

CONCLUSIONS

Cardiac involvement is common in children with multisystem inflammatory syndrome associated with the Covid-19 pandemic. The majority of children have significantly raised levels of N-terminal pro B-type natriuretic peptide, ferritin, D-dimers, and cardiac troponin in addition to high C-reactive protein and procalcitonin levels. In comparison with adults with COVID-19, mortality in children with multisystem inflammatory syndrome associated with COVID-19 is uncommon despite multisystem involvement, very elevated inflammatory markers, and the need for intensive care support.

Malnutrition and chyle leakage: A life-threatening duo in heart transplantation post-Fontan procedure

Protein‐losing enteropathy and chyle leakage may lead to severe malnutrition in heart transplantation for failing Fontan. Nutritional management may be challenging from defining nutrient needs to diagnosis of malnutrition enteropathy, and expertise is necessary. Body composition and hematological nutritional indices may help define malnutrition severity and guide nutritional strategy.

Italian survey on cardiac surgery for adults with congenital heart disease: which surgery, where and by whom?

OBJECTIVES

The population of ageing adults with congenital heart disease (ACHD) is increasing; surgery in these patients presents major difficulties in management. A great debate has developed about whether these patients should be cared for at an adult or paediatric hospital and by an acquired or congenital cardiac surgeon. We analysed data of the surgical treatment of ACHD from the Italian cardiac surgery centres in 2016, focusing on the type of surgery performed, where these patients were operated on and by whom.

METHODS

Ninety-two Italian cardiac surgery centres were contacted and 70 centres participated in this study. We collected data on the types of cardiac operations performed in congenital heart defect patients older than 18 years. In 2016, a total of 913 patients with ACHD were operated on: 440 by congenital cardiac surgeons (group I) in centres with paediatric and adult cardiac surgery units, and 473 by adult cardiac surgeons (group II) in centres with exclusively adult cardiac surgery units.

RESULTS

Pathologies of the right ventricular outflow tract were the most frequent diseases treated in group I and pathologies of the left ventricular outflow tract in group II. Group I included more complex and heterogeneous cases than group II. Surgery for ACHD represented 12% of the activity of congenital cardiac surgeons and only 1% of the activity of adult cardiac surgeons.

CONCLUSIONS

In Italy, ACHD patients are operated on both by congenital and adult cardiac surgeons. Congenital cardiac surgeons working in centres with both paediatric and adult cardiac surgery are more involved with ACHD patients and with more complex cases.

Are probiotics safe? Bifidobacterium bacteremia in a child with severe heart failure

Although few cases of bacteremia or sepsis caused by probiotics have been reported, it is important to consider their pathogenic potential, especially in some categories of patients. We report a case of Bifidobacterium spp bacteremia in a child with heart disease, undergoing probiotic supplementation to prevent antibiotic-associated diarrhea.

Colchicine: An Impressive Effect on Posttransplant Capillary Leak Syndrome and Renal Failure

Capillary leak syndrome is a critical condition occasionally occurring posttransplant and is characterized by acute endothelial hyperpermeability leading to systemic protein-rich fluid extravasation and consequent hypovolemia, hypoperfusion, and acute kidney injury. Treatment is merely supportive and is based on osmotic drugs, diuretics, continuous renal replacement therapy, and surgical drainage. However, removal of the underlying inflammatory cause is mandatory to achieve stable resolution. Herein, we report the first successful treatment with colchicine in 2 life-threatening pediatric cases of capillary leak syndrome with renal failure occurring after transplant (heart and bone marrow) and unresponsive to any other line of therapy. Both cases were only palliated by supportive therapy and revealed an impressively rapid response to colchicine both in terms of diuresis and clinical condition recovery, allowing for the cessation of renal replacement therapy in a few hours. In both patients, colchicine was temporarily discontinued for transient leukopenia (attributed to an additive effect with mycophenolate mofetil), resulting in extravasation, and renal failure recurrence was restored only after colchicine reintroduction. Although the association of colchicine with an immunosuppressive drug was formerly contraindicated, no other adverse events were noted when using a minimized dose. Both patients are now maintaining a good renal function without recurrence of extravasation after 6 months of follow-up. In conclusion, this strikingly positive experience forces physicians to consider this old and cost-effective drug as a new, powerful rescue tool in such critical cases.

The European Registry for Patients with Mechanical Circulatory Support (EUROMACS): first EUROMACS Paediatric (Paedi-EUROMACS) report

OBJECTIVES:

EUROMACS is a registry of the European Association for Cardio-Thoracic Surgery (EACTS) whose purpose is to gather clinical data related to durable mechanical circulatory support for scientific purposes and to publish annual reports. Because the treatment of children with end-stage heart failure has several significantly different characteristics than the treatment of adults, data and outcomes of interventions are analysed in this dedicated paediatric report.

METHODS:

Participating hospitals contributed pre-, peri- and long-term postoperative data on mechanical circulatory support implants to the registry. Data for all implants in paediatric patients (≤19 years of age) performed from 1 January 2000 to 31 December 2017 were analysed. This report includes updates of patient characteristics, implant frequency, outcome (including mortality rates, transplants and recovery rates) as well as adverse events.

RESULTS:

Twenty-five hospitals contributed 237 registered implants in 210 patients (81 ♀, 129 ♂) to the registry. The most frequent diagnosis was any form of cardiomyopathy (71.4%) followed by congenital heart disease (18.6%). Overall mean support time on a device was 11.6 months (±16.5 standard deviation). A total of 173 children (82.4%) survived to transplant, recovery or are ongoing; 37 patients (17.6%) died while on support within the observed follow-up time. At 12 months 38% of patients received transplants, 7% were weaned from their device and 15% died. At 24 months, 51% of patients received transplants, 17% died while on support, 22% were on a device and 9% were explanted due to myocardial recovery. The adverse events rate per 100 patient-months was 11.97 for device malfunction, 2.83 for major bleeding, 2.83 for major infection and 1.52 for neurological events within the first 3 months after implantation.

CONCLUSIONS:

The first paediatric EUROMACS report reveals a low transplant rate in European countries within the first 2 years of implantation compared to US data. The 1-year survival rate seems to be satisfactory. Device malfunction including pump chamber changes due to thrombosis was the most frequent adverse event.

Minimally Invasive Approach to Correct Anomalous Inferior Vena Cava Connection to the Left Atrium

Anomalous drainage of the inferior vena cava into the left atrium is a rare congenital condition. A 20-year-old girl was referred for recurrent transient ischemic attacks. Transthoracic echocardiography revealed a large ostium secundum atrial septal defect, and computed tomography showed anomalous drainage of the inferior vena cava into the left atrium. Through a right mini-thoracotomy, the opening of the inferior vena cava into the atrium was identified under the inferior edge of the interatrial septum, draining into the left atrium, and redirected to the right atrium, using a pericardial patch to reconstruct the atrial septum. Postoperative course was uneventful. Right mini-thoracotomy approach was effective in correcting the anomalous drainage of the inferior vena cava into the left atrium.

Endothelin inhibitors lower pulmonary vascular resistance and improve functional capacity in patients with Fontan circulation

OBJECTIVES

To evaluate the effects of endothelin inhibitors (ERAs) on hemodynamic and functional parameters in patients post-Fontan procedure with high pulmonary vascular resistance (PVR).

METHODS

Among our cohort of patients with Fontan circulation, 8 children, 8 adolescents, and 8 adults had PVR ≥2 WU*m². These patients were treated with ERAs (minors with bosentan, adults with macitentan) and reevaluated after 6 months. Pre- and posttreatment hemodynamic variables were assessed by cardiac catheterization. Functional capacity was evaluated by cardiopulmonary exercise testing (CPET). Our primary endpoint was to obtain a reduction of PVR; the secondary endpoint was to obtain an improvement of functional capacity.

RESULTS

Under treatment, New York Heart Association class improved for adolescents and adults. PVR decreased (P = .01) in all groups: in children from the median value 2.3 (interquartile range 2.0-3.1) to 1.9 (1.4-2.3) WU*m², in adolescents from 2.3 (2.1-2.4) to 1.7 (1.4-1.8) WU*m², and in adults from 2.8 (2.0-4.7) to 2.1 (1.8-2.8)WU*m². In 71% of patients, PVR fell to less than 2 WU*m². Cardiac index increased in adolescents from 2.6 (2.4-3.3) to 3.6 (3.4-4.3) L/min/m², P = .04, and in adults from 2.1 (2.0-2.3) to 2.8 (2.3-4.7) L/min/m², P = .03. CPET showed that only adolescents displayed a significant functional improvement. Anaerobic threshold improved from 17 (13-19) to 18 (13-20) mL/kg/min, P = .03; oxygen consumption and VO₂ max increased from 1.3 (1.0-1.6) to 1.7 (1.1-1.9) L/min, P = .02 and from 25 (21-28) to 28 (26-31) L/min, P = .02, respectively. Oxygen pulse increased from 7.9 (5.7-10.4) to 11.2 (8.2-13.0) L/beat, P = .01.

CONCLUSIONS

This is the first study that assesses by cardiac catheterization and CPET the effects of ERA in patients with Fontan circulation with increased PVR. These results suggest that ERAs might provide most pronounced hemodynamic and functional improvement in adults and adolescents.

Liver stiffness modifications shortly after total cavopulmonary connection

OBJECTIVES

Hepatic damage in Fontan circulation setting is well known. Mainly represented by fibrosis, it is still poorly understood. Transient hepatic elastography (Fibro-Scan) is a useful tool to test liver stiffness and is commonly used in the evaluation of liver fibrosis. Unfortunately, the increase of inferior vena cava pressure consequent to total cavopulmonary connection can probably interfere with Fibro-Scan evaluation altering the result evaluation with the conventional scale. To verify this hypothesis and to quantify the impact of venous pressure on Fibro-Scan results, we checked perioperative liver stiffness changes in patients undergoing total cavopulmonary connection.

METHODS

A prospective observational study was carried out on 9 patients undergoing extracardiac total cavopulmonary connection. Mean age at operation was 4.3 ± 0.6 years, and mean weight 14 ± 2.4 kg. Hepatic stiffness was analysed with Fibro-Scan evaluation immediately before and 4 months after surgery. Results were matched with several perioperative data: pulmonary pressures, conduit size, fenestration, hepatic enzymes and coagulation setting.

RESULTS

Preoperative hepatic stiffness was 6.2 ± 1.5 kPa, with a significant increase to 11.2 ± 4 kPa at a mean follow-up of 4 months (P < 0.01). Mean alanine aminotransferase was 16.9 ± 8.3 mg/dl preoperatively and 16.3 ± 8.7 mg/dl at discharge. Both values showed a significant correlation with liver stiffness raise, their Pearson Correlation Indexes being 0.8 and 0.7, respectively (P < 0.01). Mean aspartate aminotransferase/alanine aminotransferase ratio at discharge was 1.7 ± 0.5 and showed a significant negative correlation with liver stiffness raise, its Pearson Correlation Index being -0.7 (P < 0.01).

CONCLUSIONS

Liver stiffness increases rapidly after total cavopulmonary connection and perioperative variations in some liver enzymes appear to correlate with this change. Since a true anatomical damage is known to develop gradually with Fontan circulation, early liver stiffness raise is likely due to parenchymal congestion only. Fibro-Scan can easily recognize and assess the entity of such a change. For these reasons, this diagnostic tool must be considered useful only to monitor liver stiffness changes and evolution with time, but a conventional evaluation of results, like in other acquired hepatic fibrosis, can be misleading.

Two decades of experience with the Ross operation in neonates, infants and children from the Italian Paediatric Ross Registry

OBJECTIVE

Children undergoing Ross operation were expected to have longer autograft, but shorter homograft durability compared with adults. In order to define the outcome in the second decade after Ross operation in children, a nationwide review of 23 years of experience was undertaken.

METHODS

305 children underwent Ross operation in 11 paediatric units between 1990 and 2012. Age at surgery was 9.4±5.7 years, indication aortic stenosis in 103 patients, regurgitation in 109 and mixed lesion in 93. 116 (38%) patients had prior procedures. Root replacement was performed in 201 patients, inclusion cylinder in 14, subcoronary grafting in 17 and Ross-Konno in 73.

RESULTS

There were 10 (3.3%) hospital and 12 late deaths (median follow-up 8.7 years). Survival was 93±2% and 89±3% and freedom from any reoperation was 76±3% and 67±6% at 10 and 15 years. 34 children had autograft 37 reoperations (25 replacement, 12 repair): three required transplantation after reoperation. Freedom from autograft reoperation was 86±3% and 75±6% at 10 and 15 years. 32 children had right heart redo procedures, and only 25 (78%) conduit replacements (15-year freedom from replacement, 89±4%). Prior operation (p=0.031), subcoronary implant (p=0.025) and concomitant surgical procedure (p=0.004) were risk factors for left heart reoperation, while infant age (p=0.015) was for right heart. The majority (87%) of late survivors were in NYHA class I, 68% free from medication and six women had pregnancies.

CONCLUSIONS

Despite low hospital risk and satisfactory late survival, paediatric Ross operation bears substantial valve-related morbidity in the first two decades. Contrary to expectation, autograft reoperation is more common than homograft.

Pulmonary artery debanding

Pulmonary artery banding is a simple palliative surgical procedure for congenital heart defects with left-to-right shunt or complete mixing and pulmonary over-circulation. Even though indication for pulmonary artery banding has been sensibly reduced, since early reparative surgery has been proved superior to palliation and a staged approach, an increasing support for pulmonary banding has been raised in the last two decades by new indications such as left ventricular retraining, in the late arterial switch operation for complete transposition of the great arteries or before the double-switch operation in congenitally corrected transposition. Along with the increasing interest raised by the new indications and the consequently more diffuse use of banding, debanding has become an important surgical issue. Debanding is usually performed several months after palliation along with the repair of the cardiac malformations; otherwise, it can be done progressively or partially to further delay surgery and let the patient grow. Occasionally, after pulmonary artery banding, a spontaneous resolution of the underlying cardiac malformation can occur; however, a debanding procedure is in any case necessary.

Pulmonary artery banding

Pulmonary artery banding (PAB) is a simple surgical technique to reduce pulmonary overcirculation in some congenital heart disease. In the beginning, when the use of cardiopulmonary bypass was affected by many deleterious effects, this technique played a fundamental role in the treatment of patients with congenital heart defects and an intracardiac left-to-right shunt. The use of PAB has decreased during the last two decades, due to the increasing popularity of early complete intracardiac repair, which results have shown to be superior to staged repair, even in low body weight patients. Moreover, several authors have emphasized the negative effects of PAB such as pulmonary arterial branch distortion, abnormal right ventricular hypertrophy, pulmonary valve insufficiency, sub-aortic obstruction and decreased ventricular compliance in patients with univentricular heart. For all these reasons, this procedure has been placed in the dark corner of surgery, representing, between 2002 and 2005, ∼2% of the total amount of cardiac surgery procedures. In a more recent era, PAB has been performed in instances other than classic univentricular heart, as palliation in small infants with cardiac defects with a left-to-right shunt and pulmonary overcirculation, thus gaining some time prior to a planned staged repair. Recently, the role of PAB is becoming more important in selected subsets of congenital cardiac defects: L-transposition of the great arteries, D-transposition of the great arteries, hypoplastic left heart syndrome, moderately hypoplastic left ventricle (congenitally corrected transposition of the great arteries). This renewed interest in the banding procedure is spurring all surgeons and cardiologists to find new solutions for an easier banding procedure while making debanding less traumatic.

Sinus node dysfunction after partial anomalous pulmonary venous connection repair

OBJECTIVE

Repair of partial anomalous pulmonary venous connection to superior vena cava using an internal patch has been described as a potential cause of obstruction at the systemic or pulmonary vein level and of sinus node dysfunction. Our experience with this operation was reviewed.

METHODS

From 1991 to 2011, 59 patients with a diagnosis of partial anomalous pulmonary venous connection to superior vena cava underwent surgical repair with intracardiac patch rerouting alone (45 patients) or with associated superior vena cava patch enlargement (14 patients). Follow-up evaluation was performed, including electrocardiogram, echocardiogram, electrocardiogram Holter monitor recording, and exercise stress test.

RESULTS

There were no early or late deaths and no reoperations at a mean follow-up of 46 ± 45 months. All patients were asymptomatic in New York Heart Association class I. Echocardiographic evaluation excluded any obstruction at the pulmonary or systemic vein level. At follow-up, 55 patients (93%) presented sinus rhythm and were free from antiarrhythmic medications, 2 patients (3%) presented atrial fibrillation, 1 patient (2%) presented atrial fibrillation and asymptomatic sinus node dysfunction, and 1 patient (2%) presented ectopic atrial rhythm. Electrocardiogram Holter recording demonstrated sinus node dysfunction in 6 of 34 patients (18%). Exercise stress test showed chronotropic incompetence in 8 of 27 patients (30%): All except 1 patient presented sinus rhythm at basal electrocardiogram, and only 4 patients had some evidence of sinus node dysfunction on electrocardiogram Holter recording.

CONCLUSIONS

Intracardiac repair of partial anomalous pulmonary venous connection can be performed with good results at medium-term follow-up. The rate of sinus node dysfunction or other arrhythmias and obstruction at pulmonary or systemic vein level is comparable to other techniques. Exercise stress test evaluation is the best way to detect asymptomatic sinus node dysfunction.

Primary cardiac tumours in the paediatric population

Primary cardiac tumours are relatively rare in the paediatric population, and they may occur with different signs and symptoms in foetal or post-natal life. The clinical manifestations of cardiac tumours in foetal life may include arrhythmias, congestive heart failure and hydrops. In post-natal life, cardiac tumours may cause cyanosis, respiratory distress, myocardial dysfunction, valvular insufficiency, arrhythmias, inflow or outflow tract obstructions and sudden death. Surgical treatment is essential when symptoms are present, while the role of medical therapy can merely be palliative. Results are various and related to the patients' and tumour characteristics. Primary benign heart tumours mainly have a good prognosis, while malignant neoplasms usually have a poor prognosis; in both cases, however, a strict follow-up is always mandatory in order to detect the recurrence of cardiac neoplasms after surgery.

Left main coronary artery stenosis secondary to severe pulmonary artery dilation

A 45-year-old lady with dyspnea and occasional precordial chest pain was diagnosed with a huge sinus venosus atrial septal defect and partial anomalous pulmonary venous return. Preoperative coronary angiography disclosed severe main stem stenosis, considered secondary to compression by the dilated pulmonary trunk. Atrial septal defect closure and pulmonary artery reduction plasty were performed. The left main coronary artery appeared completely patent. The postoperative course was uneventful, and the patient was asymptomatic on follow-up.

[Results and complications of permanent pacing in pediatric patients with congenital or acquired atrioventricular block]

BACKGROUND

Currently there is no evidence to prefer an endocardial or epicardial approach for pacing in pediatric patients. This analysis was aimed at defining the complications of pacemaker implantation in a pediatric population with atrioventricular block according to a strategy of choosing an epicardial system for patients <10 kg and an endocardial system for patients >10 kg.

METHODS

This is a retrospective study performed on 27 patients, with and without congenital heart disease, implanted with a permanent pacemaker because of idiopathic or acquired atrioventricular block at our Pediatric Cardiology and Cardiac Surgery Unit of S. Orsola-Malpighi Hospital in Bologna (Italy) between 1981 and 2010. Patients were divided into two groups: 70% of the population (group A) was implanted with an epicardial system, 30% (group B) with an endocardial system.

RESULTS

After a mean follow-up of 14 years (17 ± 8 years for group A, 7 ± 5 years for group B), the most frequent complications were lead failure (44%) and infection (18%). Both were more common in the epicardial system group: lead failure rate 53% in group A vs 25% in group B (p=0.0001); infection rate 26% in group A vs 0% in group B (p=0.0001); rate of system revision or implantation of a new electrode 42% in group A vs 12% in group B (p=0.0001).

CONCLUSIONS

The present study demonstrates a high complication rate in patients undergoing an epicardial pacing system implantation. However, in patients <10 kg the epicardial system allows subclavian venous access protection for endocardial system implantation after somatic growth, avoiding high-risk procedures of system revision or lead extraction and subclavian vein occlusion in the long term.

Right ventricular outflow tract reconstruction with decellularized porcine xenografts in patients with congenital heart disease

BACKGROUND AND AIM OF THE STUDY

Decellularized xenogeneic pulmonary valves have been introduced for right ventricular outflow tract (RVOT) reconstruction in congenital heart disease. In the present study, the intermediate-term results from three institutions were analyzed.

METHODS

Between January 2006 and September 2008, a total of 61 patients (median age 7 years; range: 9 days to 50 years; median body weight 21 kg; range: 1.9-140 kg) underwent RVOT reconstruction with either the Matrix P (n = 9) or Matrix P Plus (n = 52) tissue-engineered conduit. Eighteen patients underwent surgery in infancy, and 31 patients had previously undergone one or more RVOT interventions or operations.

RESULTS

The valve sizes ranged from 11 to 27mm. Five patients died during the hospital stay or within three months, from non-valve-related causes; hence, the early mortality was 8.2%. No deaths occurred during the follow up period. Reoperation due to valve failure became necessary in four patients; three patients underwent RVOT interventions due to distal anastomotic stenosis, and six reinterventions were performed distal to the valve due to hypoplastic branch pulmonary arteries. Patients with valve implantation during infancy showed a composite freedom from valve-related reoperation, catheter intervention or valve dysfunction (defined as dP(max) > 40 mmHg) of 87% at one and three years postoperatively. Both, computed tomography and magnetic resonance imaging studies demonstrated normal structural features, with no evidence of calcification.

CONCLUSION

The Matrix P/Matrix Plus conduit represents a viable alternative for RVOT reconstruction in patients with congenital heart disease. The intermediate-term performance of the conduits was favorable compared to that of other currently available implants.

Ross-kabbani operation in an infant with mitral valve dysplasia

Background. Mitral valve replacement can be very difficult to obtain in infants because the valve annulus diameter can be smaller than the available prosthesis. Case Report. We describe the case of a 2-month-old female weighing 3.5 kg affected by mitral valve dysplasia leading to severe valve stenosis. Despite full medication, the clinical conditions were critical and surgery was undertaken. The mitral valve was unsuitable for repair and the orifice of mitral anulus was 12 mm, too small for a mechanical prosthesis. Therefore, a Ross-Kabbani operation was undertaken, replacing the mitral valve with the pulmonary autograft and reconstructing the right ventricular outflow tract with an etherograft. Results. The postoperative course was uneventful and the clinical conditions are good at 4-month follow-up. Conclusion. The Ross-Kabbani operation can be an interesting alternative to mitral valve replacement in infants when valve repair is not achievable and there is little space for an intra-annular mechanical prosthesis implant.

[Tetralogy of Fallot with coronary-to-pulmonary artery fistula: a diagnostic snare]

An 11-month-old infant, moderately cyanotic, with diagnosis of tetralogy of Fallot underwent corrective surgery. At echocardiographic evaluation, a subatretic right ventricular outflow tract without aortopulmonary collateral arteries, confluent pulmonary arteries and normal coronary pattern were evidenced. During operation, an undiagnosed large coronary-to-pulmonary artery fistula was disclosed. Because of the large variety of aortopulmonary collateral arteries that can be associated with this pathology, further imaging study is mandatory when oxygen saturation does not match the right ventricular outflow tract obstruction severity.

Neonatal right lung emphysema due to pulmonary artery sling

Pulmonary artery sling is a rare variant of vascular ring where the left pulmonary artery arises from the right and loops behind the trachea or right bronchus causing airway compression. A 40-day-old infant had been mechanically ventilated since birth for severe hypercapnia and right lung emphysema. Left pulmonary artery reimplantation was successfully performed.

Systemic venous segments interposition for pulmonary artery to aorta connection

Two patients with pulmonary atresia and ventricular septal defect underwent implantation of the diminutive pulmonary arteries on the ascending aorta by interposition of short segment of azygos and innominate veins. The very thin structure of the systemic veins' wall matched perfectly the fragile pulmonary arterial wall. The anastomosis were perfectly patent and no aneurism dilatation was evident after three and four months, respectively.

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.