Outcomes of delayed chest closure after congenital heart surgery in neonates

We present the outcomes of delayed chest closure in neonates who underwent congenital heart surgery under cardiopulmonary bypass. Eighty-one consecutive neonatal patients (age ≤ 28 days) with congenital heart diseases who underwent heart operations and after surgery, chest remained open in the intensive care unit until DCC. Correction of transposition of the great arteries pathology was the most common surgical procedure (48.1% of patients). Median sternal closure time from surgery was 3 (2-4) days. Median age of neonates was 9 (5-12) days. In addition, in 4 cases (4.9%) there was secretion from the surgical site after DCC and after taking cultures, in 2 (2.4%) of the cases a pathogen was identified. Multivariable linear regression analysis (adjusted to gender and CPB) showed that only the age-predicted the sternum closure time (β=-0.09, 95%CI: - 0.16 to -0.02, p=0.02). In-hospital mortality was 6 (7.4%) patients. Although the DCC in neonates who underwent CHD surgical correction was related to a high mortality rate, only the age of neonates predicted the sternum closure time in the ICU.

Converting the Fontan Circulation: Challenges and Evolution

The Fontan operation, the final palliative step after a series of complex operations in patients with univentricular hearts, has undergone multiple modifications throughout the last decades, with the goal of finding the method which combines the optimal hemodynamic effects of the Fontan circulation with minimal long term side effects. An understanding of the operative evolution and subsequent side effects, as well as the management thereof seems imperative. Since its inception by Francis Fontan the, now obsolete, initial atriopulmonary connection has passed through several milestones into having now reached the era of total cavopulmonary connection. However, recently published results bring to light the new option of biventricular conversion which comes to challenge the management of Fontan patients as we know it. Currently, there is no consensus as to whether to continue with palliation in this challenging group of patients or proceed with heart transplantation. In this collective review, we provide a historic overview of the Fontan evolution as well as future insights, discussing the perspectives of options for patients with failing Fontan, including the latest addition of biventricular correction.

Efficiency and Safety of Patent Ductus Arteriosus Surgical Ligation in Extremely Low Birth Weight Infants Without Chest Tube Placement

Patent ductus arteriosus (PDA) has been associated with increased morbidity and mortality in preterm infants. Surgical ligation (SL) is generally performed in symptomatic infants when medical management is contraindicated or has failed. We retrospectively reviewed our institution's experience in surgical management of PDA for extremely low birth weight (ELBW) infants without chest tube placement assessing its efficiency and safety. We evaluated 17 consecutive ELBW infants undergoing SL for symptomatic PDA (January 2012-January 2018) with subsequent follow-up for 6 months postdischarge. Patients consisted of 9 (53%) females and 8 (47%) males. Mean gestational age (GA) at birth was 27.9 ± 2.1 weeks. Median values for surgical age (SA) from birth to operation was 10 days (interquartile range [IQR]: 8-12); PDA diameter 3.4 mm (IQR: 3.2-3.5); surgical weight (SW) 750 g (IQR: 680-850); and days of mechanical ventilation (DMV) as estimated by Kaplan-Meier curve 22 days (95% confidence interval: 14.2-29.8). We observed a statistically significant negative association between DMV and GA at birth (rho = - 0.587, p  = 0.017), SA (rho = - 0.629, p  = 0.009) and SW (rho = - 0.737, p  = 0.001). One patient experienced left laryngeal nerve palsy confirmed by laryngoscopy. Otherwise, there were no adverse events to include surgical-related mortality, recurrence of PDA, or need for chest tube placement during follow-up. SL of PDA in ELBW infants without chest tube placement is both efficient and safe. Universal consensus recommendations for the management of PDA in ELBW neonates are needed. Further study is required regarding the use of the less invasive option of percutaneous PDA closure in ELBW infants.

Abnormal origin of right pulmonary artery from the ascending aorta in an infant ("Hemitruncus")

Key Clinical Message

Anomalous origin of right pulmonary artery from the ascending aorta is a rare congenital malformation and it needs surgical management. Consequences of this condition affect lead to pulmonary hypertension and severe pulmonary vascular disease.

Abstract

Anomalous origin of right pulmonary artery from the ascending aorta is a rare congenital heart malformation that results in early infant mortality affecting the right pulmonary artery more than the left. These patients are at risk for the early development of significant pulmonary hypertension. The surgical management during the early period of life is imperative.

Investigation of the Role of BMP2 and -4 in ASD, VSD and Complex Congenital Heart Disease

Congenital heart malformations (CHMs) make up between 2 and 3% of annual human births. Bone morphogenetic proteins (BMPs) signalling is required for chamber myocardium development. We examined for possible molecular defects in the bone morphogenetic protein 2 and 4 (BMP2, -4) genes by sequencing analysis of all coding exons, as well as possible transcription or protein expression deregulation by real-time PCR and ELISA, respectively, in 52 heart biopsies with congenital malformations (atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy ofFallot (ToF) and complex cases) compared to 10 non-congenital heart disease (CHD) hearts. No loss of function mutations was found; only synonymous single nucleotide polymorphisms (SNPs) in the BMP2 and BMP4 genes were found. Deregulation of the mRNA expression and co-expression profile of the two genes (BMP2/BMP4) was observed in the affected compared to the normal hearts. BMP2 and -4 protein expression levels were similar in normal and affected hearts. This is the first study assessing the role of BMP-2 and 4 in congenital heart malformations. Our analysis did not reveal molecular defects in the BMP2 and -4 genes that could support a causal relationship with the congenital defects present in our patients. Importantly, sustained mRNA and protein expression of BMP2 and -4 in CHD cases compared to controls indicates possible temporal epigenetic, microRNA or post-transcriptional regulation mechanisms governing the initial stages of cardiac malformation.

Outcomes after repair of complete atrioventricular canal with a modified single-patch technique: a retrospective study

Background

This study aimed to present the short- and midterm outcomes after complete atrioventricular canal defect (CAVC) repair using a single-patch technique.

Methods

This study included 30 children who underwent surgical correction of the CAVC using a single-patch technique.

Results

The median age of the patients was 5.7 months (interquartile range [IQR], 5.0-7.5 months), and 23 patients (76.7%) had type A CAVC. Fourteen patients (46.7%) were female and 17 (56.7%) had been diagnosed with Down syndrome. The in-hospital mortality rate was 0%. No deaths were observed during a median follow-up of 4 years (IQR, 3.5-5.0 years). Patients without Down syndrome were associated with late moderate mitral regurgitation (MR) (p=0.02). Late MR less than moderate degree was observed in 96.6%, 78.5%, and 50% of patients after 2, 4, and 5 years of follow-up, respectively, while late tricuspid valve regurgitation less than moderate degree was observed in 96.7%, 85.9%, and 59.0% of patients after 2, 4, and 6 years of follow-up, respectively. After a median follow-up of 4 years, only one patient had required surgical repair of a left ventricular outflow tract obstruction, which occurred 26 months after the first operation. Multivariable logistic regression analysis adjusted for the type of CAVC, sex, Down syndrome, age, and weight revealed that the absence of Down syndrome was a risk factor for late moderate MR (MR-2) (odds ratio, 0.05; 95% confidence interval, 0.006-0.50; p=0.01).

Conclusion

A single-patch technique for CAVC surgical repair is a safe method with acceptable short- and midterm results.

Acute Kidney Injury Predictors and Outcomes after Cardiac Surgery in Children with Congenital Heart Disease: An Observational Cohort Study

Acute Kidney Injury (AKI) commonly complicates cardiac surgery in children with congenital heart disease (CHD). In this study we assessed incidence, risk factors, and outcomes of postoperative AKI, while testing the hypothesis that, depending on the underlying diagnosis, there would be significant differences in AKI incidence among different diagnostic groups. We conducted an observational cohort study of children with CHD undergoing cardiac surgery in a single tertiary center between January 2019 and August 2021 (n = 362). Kidney Disease Improving Global Outcome (KDIGO) criteria were used to determine the incidence of postoperative AKI. Diagnosis was incorporated into multivariate models using an anatomic-based CHD classification system. Overall survival was estimated using Kaplan−Meier curves. Log-rank test and adjusted Cox proportional hazard modelling were used to test for differences in survival distributions and determine AKI effect on survival function, respectively. AKI occurred in 70 (19.3%), with 21.4% in-hospital mortality for AKI group. Younger age, lower weight, longer cardiopulmonary bypass time, preoperative mechanical ventilation and diagnostic category were associated with postoperative AKI. Resolution rate was 92.7% prior to hospital discharge for survivors. AKI was associated with longer duration of mechanical ventilation, ICU and hospital length of stay. AKI patients had significantly higher probability of all-cause mortality postoperatively when compared to the non-AKI group (log-rank test, p < 0.001). Adjusted hazard ratio for AKI versus non-AKI group was 11.08 (95% CI 2.45−50.01; p = 0.002). Diagnostic category was associated with cardiac surgery-related AKI in children with CHD, a finding supporting the development of lesion specific models for risk stratification. Postoperative AKI had detrimental impact on clinical outcomes and was associated with decreased survival to hospital discharge.

Intraoperative diagnosis of retroaortic left innominate vein in a patient with congenital heart disease

Diagnosis of retroaortic left innominate vein is usually made by echocardiography, computed tomography, and magnetic resonance imaging, but in several cases, diagnosis is made in the theater.

Congenital, acquired, or both? The only two congenitally based, acquired heart diseases

Discrete subaortic stenosis (DSS) is a type of left ventricular outflow tract obstruction whereas double-chambered right ventricle is a form of right ventricular outflow tract obstruction. Both of these cardiac malformations share lots of similar characteristics which classify them as acquired developmental heart diseases despite their congenital anatomical substrate. Both of them are frequently associated to ventricular septal defects. The initial stimulus in their pathogenetic process is anatomical abnormalities or variations. Subsequently, a hemodynamic process is triggered finally leading to an abnormal subaortic fibroproliferative process with regard to DSS or to hypertrophy of ectopic muscles as far as double-chambered right ventricle is concerned. In many cases, these pathologies are developed secondarily to surgical management of other congenital or acquired heart defects. Moreover, high recurrence rates after initial successful surgical therapy, particularly regarding DSS, have been described. Finally, an interesting coexistence of DSS and double-chambered aortic ventricle has also been reported in some cases.

Right atrial thrombus mimicking cardiac tumor in a neonate

Does the cardiac mass should be operated in neonates? When diagnosis of cardiac tumor or mass has been made, the surgical excision should not be delayed for prevention of life-treating complications.

Right superior vena cava draining into the left atrium in a patient with sinus venosus defect

Right superior vena cava draining into the left atrium is an extremely rare anomaly of systemic venous return. It can be isolated or it can be associated with other congenital heart defects, thus clinical presentation may vary. A case of a 9-year-old asymptomatic patient with sinus venous defect and bilateral superior vena cava with the right-sided draining into the left atrium is described.

An alternative technique for downsizing a modified Blalock-Taussig shunt

An alternative surgical approach for downsizing an existed modified Blalock-Taussig shunt is described as a reoperation in a hemodynamically unstable patient. This method was selected in order to minimize the surgical manipulations in the setting of a critically ill infant.

An alternative technique to safely close the chest after placing a child on central venoarterial extracorporeal membrane oxygenation

Central venoarterial (VA) placement of extracorporeal membrane oxygenation (ECMO) is performed surgically, and in the majority of cases, the patient remains with an open sternum. Herein, a case of a 3‐year‐old patient who underwent insertion of a central VA ECMO for heart failure due to acute myocarditis is described. An alternative technique for ECMO placement providing sternal closure and minimizing infection risk for the safe patient transport is described.

One-Stage Repair of an Interrupted Aortic Arch with an Aortopulmonary Window in a Premature Neonate

Interrupted aortic arch with an aortopulmonary window is a rare congenital entity that is associated with high morbidity and mortality, especially in premature low-birth-weight infants, and the proper timing of surgical correction remains a matter of debate. We present the case of a premature infant weighing 1.6 kg who successfully underwent one stage surgical repair to treat interrupted aortic arch with an aortopulmonary window. The therapeutic management of this patient is described below, and a review of the literature is presented.

Large pericardial cyst in an asymptomatic child: a case report

We present a case report of a nine-year-old asymptomatic girl with a large cystic lesion of the left hemithorax, occupying almost 80% of the left hemithorax, first believed to be a parasitic cyst that was operated and proved to be of parietal pericardial origin. Mediastinal cysts and pericardial cysts in particular are mostly discovered accidentally and so was the case with our patient. The diagnosis included not only clinical examination but also the utilization of computed tomography and magnetic resonance imaging. The only treatment for pericardial cysts is surgical excision and patients recover fully with no complication.

Successful surgical repair of a giant arteriovenous fistula of the coronary arteries

Large coronary arteriovenous fistulas (CAVF) cause severe symptoms and their repair involves the serious challenge of occluding the fistula while simultaneously preserving normal coronary flow. We present a case of a giant CAVF involving the right and left coronary arteries in a symptomatic adult patient and its successful surgical repair.

Surgical treatment of the atrial septal defect in adults: effective reduction in cardiac size and excellent overall clinical outcome

OBJECTIVE

Atrial septal defect (ASD), one of the commonest congenital heart lesions, is asymptomatic in most cases and therefore remains undiagnosed until adulthood in a significant number of patients. Despite the employment of transcatheter modalities in its treatment, surgery remains a reliable alternative. This study summarizes our experience in surgical correction of ASD in adult patients.

METHODS

Over a 9-year period (September 1997-August 2006), 171 patients, 73 males and 98 females, aged 18-72 (median 35) years, underwent surgical repair of ASDs'. Of these, 141 patients (82%) had ASD of the secundum type and 30 (18%) sinus venosus ASD with partial anomalous pulmonary venous connection (PAPVC). Fifteen patients with different principal diagnoses and concomitant ASD's were excluded, as were those with ostium primum ASDs'. Eighty six patients (50%) were asymptomatic and 11 (6.4%) had established arrhythmias. Two patients had recurrent lesions, 5 had a previously failed attempted transcatheter closure of which 3 were admitted as emergencies. All underwent complete surgical repair.

RESULTS

Two patients (aged 53 and 69 years) with chronic atrial fibrillation suffered embolic strokes (1.16%), with one of the two subsequently dying from cerebral haemorrhage (0.6%). Other postoperative complications (including atrial arrhythmias) were treated successfully. Median ICU and hospital stay were 1 and 6 days respectively. Significant reduction in heart size was noted postoperatively as defined by the reduction in the cardiothoracic ratio (p=0.003). At mean follow up of 55+/-28 months, there was one late death from heart failure in a patient with advanced preoperative disease. All other patients remain in excellent clinical condition.

CONCLUSION

Surgical correction of ASD is associated with low morbidity and mortality. Arrhythmias and their complications could be prevented by early surgical treatment.

Surgical results after total transatrial/transpulmonary correction of tetralogy of Fallot

INTRODUCTION

Surgical repair of tetralogy of Fallot is associated with low early morbidity and mortality. However, there may be late morbidity and mortality due to right ventricular dysfunction. The transatrial/transpulmonary technique may ameliorate these long-term complications. Here we present the results from our use of this approach.

METHODS

A hundred sixty-three consecutive patients (age 6 months to 45 years, median 1.5 years) underwent transatrial/transpulmonary total correction in our department. In 142 patients the main pulmonary artery was augmented by an autologous pericardial patch, in 31 cases the arterioplasty was extended to the pulmonary artery branches, and pulmonary artery valvuloplasty was needed in 129 patients. A monocusp autologous pericardial valve mechanism was inserted in 14 patients.

RESULTS

Patient follow up was 100% complete with a median duration of 3.05 years. There were no deaths. One patient required early reoperation to relieve residual right ventricular outflow tract (RVOT) obstruction. Median ICU and hospital stay were 3 and 11 days, respectively. At hospital discharge RVOT gradient was 13.7 +/- 13 (median 10) mmHg, while most patients (94%) had up to moderate pulmonary valve insufficiency (1 + in 63.8%, 2+ in 30.6%), and normal (92.6%) or mildly reduced (6.1%) right ventricular function. In 81% some degree of tricuspid regurgitation was noted. One patient required late reoperation for mitral valve repair. All patients are in NYHA class I or II. The degree of pulmonary valve insufficiency remains stable (69.9% with 0-1 + and 24.5% up to 2+). Likewise, tricuspid valve function remains unchanged (96% of the patients had mild or up to moderate regurgitation). There was no significant RVOT obstruction and in most patients (93.2%) right ventricular function was normal.

CONCLUSION

These results compare very favorably to those reported in the literature. The medium-term findings auger well for future adverse event rates, but long-term follow up is still necessary to confirm them.

Minimally invasive long saphenous vein harvesting using a laryngoscope

BACKGROUND

Traditional open incisions for long saphenous vein (LSV) harvesting are common sources of post operative complications after coronary artery bypass grafting (CABG). To reduce pain and wound healing complications, minimally invasive harvesting techniques are being developed. We have investigated the use of a conventional laryngoscope for cost effective saphenous removal using short incisions and long subcutaneous tunnels.

METHODS

The LSV was exposed through small incisions connected by long subcutaneous tunnels. Soft tissue retraction, visualization and illumination were provided by a sterilized laryngoscope with a #3 or #4 Macintosh blade. Dissection was performed with standard instruments while branch ligation was performed with vascular clips. Thirty two patients undergoing CABG between October 1997 and January 1998 underwent minimally invasive vein harvesting assisted by a laryngoscope. Clinical outcomes were evaluated.

RESULTS

There were 27 males and 5 females with a mean age of 62.6 +/- 9.3 years in this study. Adequate saphenous vein was removed in 29 of 32 cases. (In three patients, the vein was so superficial that an open incision proved easier). The length of harvested conduit averaged 38.2 +/- 11.01 centimeters (21-55 centimeters). Harvesting time average 37.1 minutes (+/-10.8 minutes; range from 20 to 62 minutes). Postoperatively, There were no wound dehiscences, infections, cellulitis, or major hematomas. Pain and leg edema were considerably less than with traditional open harvest.

CONCLUSIONS

Minimally invasive vein harvesting is less traumatic to the extremity with fewer complications and superior patient satisfaction. Although commercial disposable systems are now available to permit minimally invasive harvesting of the saphenous vein, a conventional laryngoscope can be used with much reduced costs.