Combined transaortic/transapical left ventricular septal myectomy for subaortic and midventricular obstruction in a paediatric patient

The patient is a 15-year-old girl who was diagnosed with hypertrophic cardiomyopathy and has been symptomatic due to severe left ventricular outflow tract obstruction. Combined transaortic and transapical left ventricular septal myectomy was performed to relieve the left ventricular outflow tract obstruction and address both subaortic and midventricular gradients.

Efficacy of automated fasteners versus hand-tied knots in cardiac surgery: a systematic review and meta-analysis

Valve surgery is common in cardiac procedures, with fasteners like COR-KNOT® and hand-tied knots used for knot securing. This study compares their efficacy in valve surgery patients. We searched PubMed, SCOPUS, and Cochrane Central until August 2023. Outcomes assessed included aortic cross-clamp time (AXT), cardiopulmonary bypass (CPB) time, valvular regurgitation, mortality, prolonged ventilatory support, atrial fibrillation, postoperative left ventricular ejection fraction (LVEF), and renal failure. Subgroup analysis was performed for minimally invasive and open cardiac surgery. We used a random effects model for analysis. We included eight observational studies and two randomized controlled trials (RCTs) with a total of 1.411 participants. COR-KNOT significantly reduced AXT [MD -15.14, 95 % CI (-18.57, -11.70), P<0.00001] and CPB time [MD -12.38, 95 % CI (-14.99, -9.77), P<0.00001]. Valvular regurgitation [RR 0.40, 95 % CI (0.26, 0.61), P<0.0001] and need for prolonged ventilatory support [RR 0.29, 95 % CI (0.13, 0.65), P=0.003] were significantly lower with COR-KNOT. There were no significant differences in mortality [RR 0.39, 95 % CI (0.09, 1.69), P=0.44], atrial fibrillation [RR 1.03, 95 % CI (0.83, 1.27), P=0.81], LVEF changes [MD 0.05, 95 % CI (-1.37, 1.47), P = 0.95], or renal failure [RR 0.87, 95 % CI (0.16, 4.80), P = 0.87]. COR-KNOT devices reduce operative time and valvular regurgitation without increasing mortality or adverse outcomes. This supports their use in enhancing surgical efficiency and patient outcomes. However, ongoing discussions about suturing techniques, especially in minimally invasive procedures, highlight the need for further research and consensus among practitioners. See also the graphical abstract(Fig. 1).

Towards Zero Phrenic Nerve Injury in Reoperative Pediatric Cardiac Surgery: The Value of Intraoperative Phrenic Nerve Stimulation

BACKGROUND

Phrenic nerve injury is a devastating complication that results in significant morbidity and mortality. We developed a novel technique to localize the phrenic nerve and evaluate its success.

METHODS

Two groups of children underwent repeat sternotomy for a variety of indications. Group I (69 patients, nerve stimulator) and Group II (78 patients, no nerve stimulator).

RESULTS

There was no significant difference in the mean age and weight between the two groups: (6.4 ± 6.5 years vs. 5.6 ± 6.4 years; p = 0.65) and (25.2 ± 24.1 vs. 22.6 ± 22.1; p = 0.69), respectively. The two groups were comparable in the following procedures: pulmonary conduit replacement, bidirectional cavopulmonary anastomosis, aortic arch repair, and Fontan, while Group I had more pulmonary arterial branch reconstruction (p = 0.009) and Group II had more heart transplant patients (p = 0.001). There was no phrenic nerve injury in Group I, while there were 13 patients who suffered phrenic nerve injury in Group II (p < 0.001). No early mortality in Group I, while five patients died prior to discharge in Group II. Eleven patients underwent diaphragm plication in Group II (p = 0.001). The mean number of hours on the ventilator was significantly higher in Group II (137.3 ± 324.9) compared to Group I (17 ± 66.9), p < 0.001. Group II had a significantly longer length of ICU and hospital stays compared to Group I (p = 0.007 and p = 0.006 respectively).

CONCLUSION

Phrenic nerve injury in children continues to be associated with significant morbidities and increased length of stay. The use of intraoperative phrenic nerve stimulator can be an effective way to localize the phrenic nerve and avoid its injury.

Partial anomalous venous connection with intrapulmonary dual drainage: Transcatheter treatment of a rare entity

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital condition, and dual-drainage connection PAPVR to the left atrium has been reported in a few cases in the literature; in which cases, percutaneous catheterization was successfully used in lieu of surgery. We, hereby, describe a 7-month-old boy with a functional single-ventricle physiology with dual drainage of the left upper pulmonary vein to the left atrium and the innominate vein. Appropriate recognition of this entity allowed safe occlusion of the anomalous draining vein.

Early Concerning Outcomes for the Edwards Inspiris Resilia Bioprosthesis in the Pulmonary Position

BACKGROUND

The Inspiris Resilia (Edwards Lifesciences LLC) bioprosthesis has gained widespread use in the aortic position; however no robust data are available about its use in the pulmonary position.

METHODS

We reviewed our outcomes for the Inspiris Resilia in the pulmonary position between August 2019 and October 2021.

RESULTS

Twenty-seven patients (15 female patients [56%]; mean age, 22.26 ± 14.99 years) were included. The most common original pathology was tetralogy of Fallot (13 patients, 48%). Five patients (18.5%) had prior transcatheter interventions. The mean right ventricular end-diastolic volume index was 164.25 ± 45.1 mL/m2. Sternotomy or repeat sternotomy was the most common approach (21 patients, 77.8%). The standard technique for pulmonary valve replacement was used in 22 patients (81.5%), whereas the prosthesis was implanted as a conduit in the remaining 5 (18.5%). Trivial to mild prosthetic regurgitation was present in 6 patients (22.2%) at the time of discharge. There was no early mortality. Follow-up was complete in all patients (mean, 16 ± 8 months), with no late mortality or late reoperations. New prosthetic regurgitation developed in 13 patients (48%), all of whom underwent replacement with the standard surgical technique. No regurgitation occurred in the conduit cases. This progressed to moderate regurgitation in 6 patients (22%) and severe in 3 (11%). Three patients (11%) underwent transcatheter valve-in-valve after their surgical pulmonary valve replacement.

CONCLUSIONS

The early data regarding the Inspiris Resilia bioprosthesis use in the pulmonary position is concerning. The prosthesis design may not be suitable for low-pressure circulation, or modification of its implantation technique may be needed.

Late complications after Norwood stage 1 palliation: surgical strategies and a word of caution

The current case represents one of the complications that may occur when inserting a stent in the left pulmonary artery after a previous Norwood procedure and in the presence of an aneurysmal neo-aorta and large Damus-Kaye-Stansel connection. We demonstrate the technique of a fourth sternotomy with reconstruction of the left pulmonary artery and the neo-aorta in a 12-year-old boy with a functional single ventricle who underwent all three previous stages of palliation of hypoplastic left heart syndrome.

Repair of Partial Anomalous Pulmonary Venous Connection to the Azygous Vein via Right Thoracotomy

A 21-month-old boy was diagnosed with partial anomalous pulmonary venous connection, with the right upper pulmonary veins draining to the superior vena cava (SVC). Intraoperatively, it became evident that the right upper pulmonary veins connected to the azygous vein before draining to the SVC.

Surgical Experience With Crossed and Anomalous Origin of the Pulmonary Arteries From the Pulmonary Trunk: A Single Center Report of 24 Cases

BACKGROUND

Anomalies of the pulmonary origin of the pulmonary arteries are uncommon; however, the true incidence is unknown and may be underestimated. We sought to review our experience with this unusual pathology and examine its surgical implications.

METHODS

We reviewed medical records between 2011 and 2022.

RESULTS

A total of 24 patients were identified. Genetic syndromes were present in 12 patients (50%). The patients were divided into two main groups. Those with septal defects (14 patients,58.3%), and those without (10 patients, 41.7%). Aortic arch hypoplasia with/without coarctation was present in nine patients (37.5%). Pulmonary arterial branch hypoplasia and/or obstruction was present in six patients (25%) with resultant preoperative systemic or suprasystemic right ventricular pressure. Four patients (16.7%) underwent pulmonary artery branch and/or right ventricular outflow tract interventions prior to surgery. All patients underwent surgical interventions for their associated cardiac defects. The crossed pulmonary arteries were uncrossed for those four patients (16.7%) who required concomitant pulmonary arterioplasties and pulmonary arterial branch rehabilitation and who had elevated right ventricular pressures preoperatively. No early or late mortalities. One Alagille's syndrome underwent liver transplant prior to discharge. Late transcatheter interventions were needed in four (16.7%) during the follow-up period, while four patients required repeat aortic arch augmentation for recurrent arch obstruction.

CONCLUSIONS

Anomalous origin of the pulmonary arteries from the pulmonary trunk including crossed pulmonary arteries is an uncommon anomaly that may be underrecognized. It can occur in isolation or in association with other heart defects. Recognition of this malpositional anomaly is important as it has specific surgical and/or transcatheter implications.

Single-incision, off-pump repair of a right aortic arch with an aberrant left subclavian artery and diverticulum of Kommerell in an adult

Repairing a complete vascular ring in adults can be challenging. A right aortic arch with an aberrant retro-oesophageal left subclavian artery and persistent diverticulum of Kommerell represents one of the most common variants seen in adults, and the ring is completed by the left-sided ligamentum arteriosum. Most presentations in adults occur secondary to oesophageal compression, resulting in varying degrees of dysphagia. Owing to the difficulty and challenges associated with exposure in adults, it is not unusual for surgeons to offer a two-incision approach or to stage the procedure. We present a detailed surgical technique for a single-incision repair of a right aortic arch with an aberrant retro-oesophageal left subclavian artery via a left posterolateral thoracotomy.

Safety and Efficacy of Right Axillary Thoracotomy for Repair of Congenital Heart Defects in Children

BACKGROUND

Minimally invasive repair of congenital heart defects in children has not gained wide popularity yet compared to minimally invasive approaches in adults. We sought to review our experience with this approach in children.

METHODS

This study included a total of 37 children (24 girls, 64.9%) with a mean age of 6.5 ± 5.1 years, who underwent vertical axillary right minithoracotomy for repair of a variety of congenital heart defects between May 2020 and June 2022.

RESULTS

The mean weight of these children was 25.66 ± 18.3 kg. Trisomy 21 syndrome was present in 3 patients (8.1%). The most common congenital heart defects that were repaired via this approach were atrial septal defects (secundum in 11 patients, 29.7%; primum in 5, 13.5%; and unroofed coronary sinus in 1, 2.7%). Twelve patients (32.4%) underwent repair of partial anomalous pulmonary venous connections with or without sinus venosus defects, while 4 patients (10.8%) underwent closure of membranous ventricular septal defects. Mitral valve repair, resection of cor triatriatum dexter, epicardial pacemaker placement, and myxoma resection occurred in 1 patient (2.7%) each. No early mortality or reoperations. All patients were extubated in the operating room, and the mean length of hospital stay was 3.3 ± 2.04 days. Follow-up was complete (mean 7 ± 5 months). No late mortality or reoperations. One patient required epicardial pacemaker placement due to sinus node dysfunction 5 months after surgery.

CONCLUSIONS

Vertical axillary right thoracotomy is a cosmetically superior approach that is safe and effective for repair of a variety of congenital heart defects in children.

Bilateral branch pulmonary arterial reconstruction in the Alagille syndrome: The technique and its pitfalls

This tutorial describes in detail the surgical technique of bilateral branch pulmonary arterial reconstruction in a 10-month-old boy with Alagille syndrome and advanced liver disease. The procedure was performed via a standard median sternotomy and moderate hypothermia and involves bilateral pulmonary branch arterioplasties combined with relief of valvular and supravalvular pulmonary stenosis and subtotal closure of secundum atrial septal defect. The patient presented with systemic/suprasystemic right ventricular pressure.

Cor triatriatum sinister: Long-term surgical outcomes in children and a proposal for a new classification

BACKGROUND

Cor Triatriatum Sinister (CTS) is a rare congenital anomaly with an estimated incidence of 0.4%, resulting from abnormal left atrial septation. It may present in isolation or in association with other heart defects. High percentage of patients require surgery with low mortality and recurrence rates. CTS has been classified in the past however we aim to describe a case series with more comprehensive and inclusive classification.

METHODS

This was a single-center retrospective cohort study of 16 children with the diagnosis of CTS between 2000 and 2020. Medical records were reviewed for clinical presentations, hospital, and postoperative courses.

RESULTS

Sixteen patients (63% female), with a median age at diagnosis of 4.3 months, five (31%) were neonates. Six (38%) had isolated CTS, two (13%) with functional single ventricle (SV), and the remaining eight patients (50%) had other associated heart defects (septal defects in three, coarctation of the aorta in another three, and anomalous pulmonary venous connections in three). Eight patients (50%) presented with obstructed CTS. Twelve patients (75%) underwent surgical intervention. Mortality occurred in three patients (19%) with two surgical (one with total anomalous pulmonary venous connection and another with SV) and one nonsurgical (septal defect with Fanconi anemia). The surgical median follow up was 4.7 years. Recurrence of the membrane occurred in two patients (17%).

CONCLUSIONS

This study showed good long-term outcomes for patients with isolated and complex CTS. Complete and proper classification of CTS ensures appropriate diagnosis, surgical planning, and better family counseling which may correlate with outcomes.

Descending thoracic aortic homograft for superior vena caval translocation in the Warden procedure: Report of six cases

BACKGROUND

Warden procedure has been described for repair of partial anomalous pulmonary venous connections inserted high into the superior vena cava. In the current report, we describe a new modification.

METHODS

A total of six patients (five females, 83%) with a mean age of 18.8 ± 10.8 years, underwent a modified Warden procedure with a descending thoracic aortic (DTA) homograft connected to the free wall of the right atrium, rather than to the right atrial appendage in the period between June 2021 and July 2022.

RESULTS

All patients had evidence of enlarged right-sided cardiac chambers. Two patients had intact interatrial septum (33.3%), while three patients had sinus venosus (50%) and one had secundum atrial septal defects (16.7%). The procedure was performed via minimally invasive right thoracotomy in half of the patients. Patients were extubated in the operating room or soon after. No early mortality or reoperation. One patient required concomitant aortic root replacement and one needed repair of anomalous left upper pulmonary vein connection to the left innominate vein. Follow-up was complete in all patients with a mean of 6.2 ± 4.6 months. No late mortality or reoperation. All patients were discharged on antiplatelet therapy. Follow-up imaging studies showed satisfactory repair with widely patent superior vena caval and pulmonary venous pathways.

CONCLUSIONS

The use of DTA homograft to facilitate superior vena caval translocation in the modified Warden procedure appears to be beneficial as it decreases tension on the anastomosis and avoids the need for anticoagulation.

Successful rapid staged hybrid approach for obstructed total anomalous pulmonary venous connection

Obstructed total anomalous pulmonary venous connection (TAPVC) represents a true pediatric cardiac emergency. The patient may present in extremis secondary to severe pulmonary hypertension and cardiogenic shock which increases perioperative mortality. We present a neonate who underwent a successful staged hybrid approach for an Infradiaphragmatic obstructed TAPVC.

Extracardiac Fontan completion after the Kawashima procedure with a custom-made bifurcated graft

The patient is a 5-year-old girl who underwent a previous Kawashima procedure with a left-sided bidirectional cavopulmonary anastomosis as a stage I palliation for her functional single ventricle. Her cardiac defect consisted of an unbalanced, right-dominant complete atrioventricular septal defect and a double outlet right ventricle. She also had heterotaxy syndrome with left isomerism, polysplenia, and an interrupted inferior vena cava with azygous continuation to a right-sided superior vena cava. Her native main pulmonary artery was left in continuity with her branch pulmonary arteries. She developed sinus node dysfunction, dilated ascending aorta, and progressive cyanosis. We proceeded with the completion Fontan using a bifurcated graft from both hepatic veins to the pulmonary arterial confluence, replacement of her dilated ascending aorta, disconnection of her native main pulmonary artery with excision of the pulmonary valve cusps, and placement of a dual-chamber epicardial pacemaker.

National outcomes of the Fontan operation with endocardial cushion defect

BACKGROUND

The traditional outcomes of the Fontan operation (FO) in endocardial cushion defect (ECD) patients have been suboptimal. Previous studies have been limited by the smaller number of ECD patients, longer study period with an era effect, and do not directly compare short-term outcomes of FO in ECD patients with non-ECD patients. Our study aims to address these shortcomings.

METHODS

A retrospective analysis of the Kids Inpatient Database (2009, 2012, and 2016) for the FO was done. The groups were divided into those who underwent FO with ECD as compared to non-ECD diagnosis. The data were abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used.

RESULTS

Three thousand three hundred eighty patients underwent the FO of which 360 patients (11%) were FO-ECD. ECD patients were more likely to have Down syndrome, Heterotaxy syndrome, transposition/DORV, and TAPVR as compared to non-ECD patients. FO-ECD had a higher discharge-mortality (2.84% vs. 0.45%, p = .04). The length of stay (16 vs. 13 days, p = .05) and total charges incurred ($283, 280 vs. $234, 106, p = .03) for the admission were higher in the FO-ECD as compared to non-ECD patients. In multivariable analysis, ECD diagnosis, cardiac arrest, acute kidney injury, and postoperative hemorrhage were predictors of mortality.

CONCLUSION

Contemporary outcomes for FO are excellent with very low overall operative mortality. However, the outcomes in ECD patients are inferior with higher operative mortality than in non-ECD patients. The occurrence of postoperation complications and a diagnosis of ECD were predictive of a negative outcome.

National Fontan Operation short-term outcomes at or below 2-years-of-age compared to older than 2-years-of-age

INTRODUCTION

Opinion is divided about optimal early timing of the Fontan Operation (FO). While some studies have suggested 3 years-of-age, others have shown good outcomes below 2 years-of-age. We analyzed the impact of age ≤2 years as compared age >2 years on short-term outcome of the FO using a large national database.

METHODS

A retrospective analysis of the Kids Inpatient Database (2009-16) for the FO was done. The groups were divided into those who underwent FO at age ≤2 years (Early FO [EF]) as compared to age >2 years (Late FO [LF]). The data was abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used.

RESULTS

A total of 3381 patients underwent FO during this period of which 1482 (44%) were EF. The mean ages of the EF and LF were 1.6 and 4.3, respectively (p < .001). LF were more likely to be non-White, female, and have Heterotaxy syndrome. HLHS was more common in EF. There was no difference in the discharge mortality, length of stay, disposition (majority went home), and mean total charges incurred. The overall discharge mortality was low at 0.7% (24/3381). In multivariate analysis: cardiac arrest, acute kidney injury, mechanical ventilation >96 h, endocardial cushion defect and non-White ethnicity were predictors of a mortality and not age.

CONCLUSION

Contemporary outcomes for FO are excellent with equivalent short-term outcomes in both the age groups. Occurrence of postoperative complications, non-White ethnicity and endocardial cushion defect diagnosis were predictive of a negative outcome.

Predictors of 90-Day Functional Outcome Following Direct Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion: A Prospective Study

Background: Mechanical thrombectomy (MT) is becoming a growing trend in the management of large vessel occlusion (LVO) during the past few decades, although data on the predictors of outcome following MT are scarce. We aimed to study the predictors of 90-day outcome in a cohort of patients with ischemic stroke with large-vessel occlusion. Methods: This was a three-month prospective study of 40 patients with anterior circulation LVO who underwent MT and were followed up for three months with modified Rankin Score (mRS). Results: Of the 40 patients recruited, 55% were men. M1 was the most common vessel occluded (32.5%) followed by internal carotid artery (ICA) and carotid trunk (20%). Tandem occlusion occurred in 25% of the cases. Among the demographic, clinical, radiological, and procedural variables studied, the factors that had a significant impact on the mRS at 3 months were age, diabetes mellitus (DM), hyperlipidemia, stroke mechanism, blood glucose level during procedure, post-procedural National Institutes of Health Stroke Scale (NIHSS), baseline Alberta stroke program early CT score (ASPECT) score, collaterals grade, and procedural thrombolysis in cerebral infarction (TICI) score (P<0.05). On multivariate regression, patients’ age (B: 0.025, 95% CI: 0.001- 0.049, P=0.038), post-procedural NIHSS (B: 0.192, 95% CI: 0.101–0.283, P<0.001), and baseline ASPECT score (B: -0.442, 95% CI: -0.838- -0.046, P=0.03) were the most independent factors to affect the mRS at 3 months. Conclusion: Patients’ age, baseline ASPECT score and post-procedural NIHSS are significant predictors of 90-day outcome of large-vessel occlusion following MT.

Modified Barbero-Marcial repair for type I truncus arteriosus in a 2.7-kg neonate

Truncus arteriosus is a rare cardiac anomaly, accounting for less than 4% of all congenital lesions. It is the result of failed aorticopulmonary septation during the fifth week of gestation leading to a single arterial trunk overriding the interventricular septum, a single semilunar valve, and typically a large conotruncal ventricular septal defect. Several classifications exist, and it typically requires surgical repair in the neonatal period. We present a 5-day old female neonate who was diagnosed postnatally with type I truncus arteriosus in which the pulmonary arteries arose from a discrete pulmonary trunk that originated from the posterolateral aspect of the common arterial trunk. A successful repair was undertaken using a variant of the Barbero-Marcial technique.

Left heart bypass for repair of aortic coarctation in children: Technical tips and pitfalls

Spinal cord injury secondary to coarctation repair in children is a serious, though relatively uncommon, complication. Several measures have been proposed to minimize this risk, which seems to affect more older children than neonates and those with inadequate collateral circulation. Left heart bypass has been proposed as a protective strategy.

Hirudotherapy for limb ischemia in the pediatric intensive care unit: A retrospective observational cohort

BACKGROUND

Acute limb ischemia due to microvascular malperfusion may be refractory to initial therapies. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and reconstructive surgery to improve venous congestion in ischemic flaps; however, there are minimal reports related to ischemia secondary to arterial malperfusion. We evaluated a pediatric cohort from an academic intensive care unit with refractory limb ischemia in whom hirudotherapy was attempted to elucidate its use and outcomes.

METHOD

Institutional patient database was queried to identify pediatric patients (<18 years) who received hirudotherapy in the pediatric critical care unit and met inclusion/exclusion criteria. Patient charts were evaluated for indices including demographics, primary disease, coagulative status, vascular access, vasoactive medication dosing, bleeding, leech use, limb and mortality outcomes. Data was evaluated to identify trends or suspected impact on outcomes.

RESULTS

Hirudotherapy was used in 7 patients for limb ischemia, 5 with congenital heart disease, and 2 others with viremic shock. Time to leech application following recognition of ischemia averaged 3 days, with duration of use averaging 3.9 days. Five patients discontinued therapy due to bleeding. Mortality rate was 57%, all secondary to multiorgan failure. In 3 surviving patients, 4 of 5 treated limbs resulted in at minimum partial amputation. Vasoactive-inotropic score tended higher prior to leech application, suggesting a vasoconstrictive pathway for arterial malperfusion. No identifiable trends appeared associated with salvaged limb or adverse effects. Blood loss predictably increased with leech application, as did total transfusion requirement.

CONCLUSION

This case series establishes baseline data for use of hirudotherapy in critically ill children with acute limb ischemia caused by arterial malperfusion. Based on this retrospective cohort, we cannot recommend routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric intensive care unit. Application of leeches should be aligned with a protocol defining start and stop parameters, standardized leech utilization, and monitoring for adverse outcomes. Future study would benefit from consensus definitions of study outcomes, including perfusion recovery, tissue/limb salvage and bleeding manifestations. Additional prospective studies are needed prior to any standard or systematic recommendations for use.

Resection of a large left atrial myxoma combined with mitral valve repair via a vertical right axillary thoracotomy in a pediatric patient

Cardiac myxomas are extremely rare in the pediatric population; however, if they do develop, they occur most often in the left atrium. We present a 16-year-old male who had a murmur discovered during a routine sport examination. A transthoracic echocardiogram showed a large left atrial tumor that caused severe inflow obstruction to the left ventricle and at least moderate mitral valve regurgitation. Through a minimally invasive, muscle-sparing vertical right axillary thoracotomy, he underwent complete resection of the mass, combined with posterior mitral valve annuloplasty. A histopathological examination confirmed a cardiac myxoma.

Modified Starnes procedure as a bridge to 2-ventricle repair in neonatal Ebstein's anomaly: A paradigm shift

Severe tricuspid valve regurgitation secondary to Ebstein's anomaly represents several challenges in neonates. It can result in significant respiratory and/or hemodynamic compromise that mandates urgent interventions. When conservative management fails, 2 surgical options are available: tricuspid valve repair or single ventricle palliation. The overall results of neonatal tricuspid valve repair are  unsatisfactory especially in sick neonates and those with preoperative hemodynamic instability. Single ventricle palliation utilizing the Starnes procedure with right ventricular exclusion provides a quicker way to improve hemodynamics and allows rapid decompression of the right ventricle but carries the long-term disadvantages of the single ventricle pathway. We were recently faced with a challenging case of neonatal Ebstein's anomaly resulting in severe tricuspid valve regurgitation (TR) and significant hemodynamic and respiratory instability. We performed an initial stage I palliation with a modified Starnes' procedure, which allowed stabilization and rapid recovery of the patient to be followed 5 months later with conversion to 2-ventricle repair using the cone technique. We believe combining these 2 strategies for suitable neonatal candidates may be a useful technique that should be considered in the algorithm for neonatal Ebstein's anomaly.

Vertical right axillary thoracotomy for a modified Warden procedure with a descending thoracic aortic homograft: Tips and pitfalls

The Warden procedure has been described for the repair of a partial anomalous pulmonary venous connection that is inserted high in the superior vena cava. One long-term concern remains, which is related to the narrowing of the superior vena caval anastomosis. In fully grown teenagers and adults, we have modified the procedure by using an interposition graft that consists of a descending thoracic aortic homograft. It usually matches the size of the superior vena cava and avoids the need for anticoagulation. We also insert the homograft into the free wall of the right atrium rather than into the atrial appendage. We present the technique in a 16-year-old girl through a vertical right axillary thoracotomy.

First-in-Human Segmental Esophageal Reconstruction Using a Bioengineered Mesenchymal Stromal Cell-Seeded Implant

Introduction

Resection and reconstruction of the esophagus remains fraught with morbidity and mortality. Recently, data from a porcine reconstruction model revealed that segmental esophageal reconstruction using an autologous mesenchymal stromal cell-seeded polyurethane graft (Cellspan esophageal implant [CEI]) can facilitate esophageal regrowth and regeneration. To this end, a patient requiring a full circumferential esophageal segmental reconstruction after a complex multiorgan tumor resection was approved for an investigational treatment under the Food and Drug Administration Expanded Access Use (Investigational New Drug 17402).

Methods

Autologous adipose-derived mesenchymal stromal cells (Ad-MSCs) were isolated from the Emergency Investigational New Drug patient approximately 4 weeks before surgery from an adipose tissue biopsy specimen. The Ad-MSCs were grown and expanded under current Good Manufacturing Practice manufacturing conditions. The cells were then seeded onto a polyurethane fiber mesh scaffold (Cellspan scaffold) and cultured in a custom bioreactor to manufacture the final CEI graft. The cell-seeded scaffold was then shipped to the surgical site for surgical implantation. After removal of a tumor mass and a full circumferential 4 cm segment of the esophagus that was invaded by the tumor, the CEI was implanted by suturing the tubular CEI graft to both ends of the remaining native esophagus using end-to-end anastomosis.

Results

In this case report, we found that a clinical-grade, tissue-engineered esophageal graft can be used for segmental esophageal reconstruction in a human patient. This report reveals that the graft supports regeneration of the esophageal conduit. Histologic analysis of the tissue postmortem, 7.5 months after the implantation procedure, revealed complete luminal epithelialization and partial esophageal tissue regeneration.

Conclusions

Autologous Ad-MSC seeded onto a tubular CEI tissue-engineered graft stimulates tissue regeneration following implantation after a full circumferential esophageal resection.

Berlin Excor Cannulation of Left Atrial Appendage in Left Ventricular Restrictive Physiology: A Novel Bailout Strategy

Ventricular assist device (VAD) management continues to be a challenge in the presence of restrictive physiology. Left atrial (LA) decompression is not satisfactory even with good function and position of the left ventricular cannula. We describe an alternate approach with LA cannulation via the left atrial appendage (LAA) as a rescue strategy in a patient who had restrictive physiology, in our case was secondary to viral myocarditis acute systolic heart failure with subsequent insidious diffuse endomyocardial fibrosis and superimposed massive calcification, causing inadequate emptying of the left ventricle despite optimal VAD apical cannula position.

The Ross-Konno procedure for congenital aortic stenosis

Left ventricular outflow tract (LVOT) obstruction can result from supravalvular, valvular and/or subvalvular etiologies. Congenital aortic valvular stenosis is frequently associated with aortic annular hypoplasia. Aortoventriculoplasty with pulmonary autograft, "The Ross-Konno" operation, provides more or less a radical solution to multilevel LVOT obstruction by enlarging the aortic annulus and the subvalvular area, thus relieving both valvular and subvalvular obstructions. In addition to this, the procedure carries the major advantage of having a competent autograft in the LVOT. An autograft that has the potential for growth and provides excellent quality of life without the need for anticoagulation. The procedure is most commonly performed as a complete root implantation, harvesting the coronary arteries as buttons, and harvesting the autograft with a muscle skirt to allow a single unit reconstruction of the LVOT. The procedure has been modified over time to minimize the risk of conduction tissue injury and the development of complete heart block by modifying the interventricular septal incision. The Ross-Konno procedure has changed the approach to patients with complex multilevel LVOT obstruction. However, while it can be performed early in life, one should be aware that this procedure is technically demanding and can be associated with a higher surgical risk. Nevertheless, it is considered "the ultimate solution" for those with complex multilevel LVOT obstruction.

Orthotopic Heart Transplantation in a Child with Single Ventricle after Pneumonectomy

We report a 6-year-old with single ventricle physiology secondary to tricuspid atresia who had cardiorespiratory failure who was not a candidate for further single ventricle palliation. The patient underwent planned staged left pneumonectomy for recurrent pneumonias secondary to bronchomalacia followed by orthotopic heart transplantation. This aggressive approach improved the patient candidacy for heart transplantation by removing the source of recurrent infection and respiratory failure (left lung).

Left Thoracotomy Beating Heart Repair of Mitral Periprosthetic Regurgitation

Left thoracotomy is a recognized, albeit not a commonly utilized approach for mitral valve exposure. This approach represents a good alternative to repeat median sternotomy and repeat right thoracotomy especially in cases of hostile mediastinum. We present a 72-year-old woman who underwent a beating heart left thoracotomy repair of recurrent severe mitral periprosthetic regurgitation in the presence of a porcelain aorta.

Left bundle branch block revealing a primary small bowel carcinoid metastasizing to the interventricular septum

Carcinoid tumours of the heart occur most commonly as a result of metastatic disease and usually affect the right side of the heart. We report a case of a solitary carcinoid metastasis to the interventricular septum without hepatic involvement in a 74-year-old man.

Hirudotherapy for neonatal limb ischemia during ECMO support: A word of caution

INTRODUCTION

Disordered coagulation, clot formation and distal limb ischemia are complications of extracorporeal membrane oxygenation (ECMO) with significant morbidity and mortality. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and orthopedic surgeries to improve venous congestion and salvage ischemic flaps. To our knowledge this has not been reported in pediatric cardiac surgery or during ECMO support. We present a complex neonate whose ECMO course was complicated by distal limb ischemia for whom leech therapy was attempted.

PATIENT AND INTERVENTION

A 2-week-old 2.7 kg infant required ECMO support secondary to perioperative multiorgan system dysfunction following repair of critical coarctation and ventricular septal defect. Despite systemic anticoagulation, his clinical course was complicated by arterial thrombus, vasopressor-induced vascular spasm and bilateral distal limb ischemia. Medicinal leech therapy was tried after initially failing conventional measures.

RESULT

Following the third leech application, this patient developed significant hemorrhage from the web space adjacent to the left great toe. An estimated 450 ml of blood loss occurred and more than 300 ml of blood product transfusions were required. He ultimately progressed to irreversible systemic end organ dysfunction and comfort care was provided.

CONCLUSION

The use of medicinal leech therapy in pediatric cardiac surgery may be considered to minimize the consequences of advanced limb ischemia and venous congestion. However, this should be used with caution while patients are systemically anticoagulated during ECMO support. A directed review is presented here to assist in determining optimal application and potential course of therapy.

Intraoperative fluorescence with indocyanine green in congenital cardiac surgery: Potential applications of a novel technology

Background

Achieving successful repair of congenital heart defects requires attention to detail. Careful evaluation of anastomotic site patency, reimplanted coronary arteries, location of epicardial coronaries, and myocardial perfusion may be necessary to ensure safe conduct of the operation and achieve excellent outcomes.

Methods

Intraoperative fluorescence angiography (IOFA) was performed using indocyanine green in patients undergoing the following procedures: coronary artery reimplantation, coronary artery unroofing, evaluation of intraoperative coronary anatomy, reoperation requiring ventriculotomy, coarctation/interrupted aortic arch repair, systemic-to-pulmonary artery shunt, Norwood procedure, thoracic duct localization, and vascular rings.

Results

The technique was feasible in all patients. No mortality or adverse events related to the dye were encountered. Adequate intraoperative imaging was obtained in 15 patients (20 images), which correlated well with postoperative studies. The imaging quality was superior for assessing shunt patency, myocardial perfusion, and anastomotic patency and determining the location of epicardial coronary arteries but was less so for assessing branch pulmonary arteries.

Conclusions

IOFA is a useful and safe technique that can provide a quick on-table assessment of a variety of congenital surgical procedures. This may help answer questions that can minimize postoperative interventions and help ensure a smooth perioperative course and excellent outcomes.

Anomalous Aortic Origin of the Right Pulmonary Artery From the Ascending Aorta With Spontaneous Dissection and Thrombosis

Anomalous aortic origin of the pulmonary artery is rare. It can affect either of the main branches and can be an important cause of neonatal respiratory distress. Early diagnosis and surgical repair is associated with improved survival and long-term outcomes.

Pulmonary valve replacement via left anterior minithoracotomy: Lessons learned and early experience

OBJECTIVE

Median sternotomy has been the standard for pulmonary valve replacement (PVR) in patients with free pulmonary regurgitation (PR) and right ventricular enlargement. With the introduction of transcatheter therapy, the search for an alternate to sternotomy is mandated. We present our early experience with a limited anterior left thoracotomy approach.

METHODS

We used a left anterior mini-thoracotomy in six male patients (15 ± 1.94 years of age) who developed progressive right ventricular enlargement due to chronic PR.

RESULTS

Primary diagnoses were tetralogy of Fallot in five patients and pulmonary atresia with an intact septum in another. Four patients had previous median sternotomy with transannular patch repair. The mean right ventricular end-diastolic volume index was 189 ± 27.13 ml/m² . The procedure was feasible in all patients. All patients had satisfactory adult size pulmonary bioprosthesis (25 or 27 mm valve), with a mean peak gradient of 18 ± 2.40 mmHg across the prosthesis at discharge. All patients were extubated intraoperatively at the end of the procedure and required no intraoperative transfusions. There were no early or late mortalities. Early morbidities included left hemidiaphragm paralysis in one patient, and re-sternotomy for prosthetic valve endocarditis in one. One patient required late reoperation for a common femoral artery pseudoaneurysm.

CONCLUSIONS

Minimally invasive access for PVR is feasible in both primary and repeat settings, through a limited anterior left minithoracotomy in the absence of intracardiac shunts and the need for other concomitant cardiac procedures. Longer-term studies with a larger number of patients are needed to compare the efficacy of this approach to standard sternotomy.

Off-Pump "Clamp and Sew" Extracardiac Fontan With Inverted Bifurcated Graft for Dextrocardia With Heterotaxy Syndrome

Avoiding cardiopulmonary bypass during palliation of single ventricle has the advantages of minimizing transfusions, pulmonary vascular resistance, and avoiding the inflammatory response from cardiopulmonary bypass. It is however not always straightforward, and the technique may be faced with challenges.

Case Report: Traumatic Stress and Developmental Regression: An Unintended Consequence of Complex Cardiac Care

This brief case report outlines a novel approach to supporting the development of a pediatric complex cardiac care patient. Patient X is a 19-month old patient who spent 5.5 months in hospital and underwent multiple surgeries including heart transplantation. This case report explores the impacts of his condition and care on his development and family functioning within the framework of an integrated care model. This case report is uniquely complimented by outpatient neurodevelopmental follow up, dyadic trauma-informed intervention and use of telemedicine allowing for a deeper understanding of the family adaptation that provide novel insight into long-term trajectory beyond discharge. Throughout care Patient X met criteria for both a traumatic stress disorder and global developmental delay. This case study highlights the threat complex care poses to neurodevelopment, pediatric mental health and family dynamics as well as opportunities for intervention.