Prenatal diagnosis of hypoplastic left heart syndrome: current knowledge / Diagnóstico pré-natal da síndrome hipoplásica do coração esquerdo: conhecimentos atuais

Abstract Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the left-sided heart structures. The prenatal diagnosis of this congenital heart disease is crucial because a newborn with undiagnosed HLHS often presents with clinical signs of low cardiac output once the ductus arteriosus begins to close. With that in mind, the aim of this article was to perform a non-systematic review focusing on the key ultrasound features that can be used in the prenatal diagnosis of HLHS. Severe forms of HLHS are characterized by a markedly abnormal four-chamber view of the fetal heart (small left atrium, hypoplastic left ventricle, or abnormal mitral valve). The left ventricular outflow tract view allows the degree of hypoplasia in the tract to be evaluated and the diameter of the ascending aorta to be measured. The Z-scores are intended to aid in the diagnosis and follow-up of HLHS. In mild forms of HLHS, a right ventricle/left ventricle length ratio > 1.28 was the strongest predictor of a univentricular outcome.

Resumo A síndrome do coração esquerdo hipoplásico (SCEH) é caracterizada pelo subdesenvolvimento das estruturas cardíacas do lado esquerdo. O diagnóstico pré-natal dessa cardiopatia congênita é crucial, uma vez que recém-nascido com SCEH não diagnosticado apresenta, frequentemente, sinais clínicos de baixo débito cardíaco, quando o canal arterial começa a se fechar. Por isso, o objetivo deste artigo foi realizar uma revisão não sistemática sobre as principais características ultrassonográficas que podem ser usadas no diagnóstico pré-natal da SCEH. As formas graves de SCEH são caracterizadas por plano de quatro câmaras marcadamente anormal (átrio esquerdo pequeno, ventrículo esquerdo hipoplásico, válvula mitral anormal) do coração fetal. A visualização da via de saída do ventrículo esquerdo permite a avaliação do grau de hipoplasia dessa via e a mensuração da aorta ascendente. Os escores Z têm como objetivo auxiliar no diagnóstico e acompanhamento da SCEH. Nas formas leves da SCEH, a relação comprimento do ventrículo direito/comprimento do ventrículo esquerdo > 1,28 foi a variável mais forte para identificar o desfecho univentricular.

Use of Extracorporeal Membrane Oxygenation and Cerebral Oximetry in a Stage 1 Norwood Repair for Hypoplastic Left Heart Syndrome

The role of extracorporeal membrane oxygenation (ECMO) and its indications in stage I Norwood palliation are controversial. The decision to initiate ECMO and its timing remains difficult with no definitive cut?off points or evidence?based guidelines. It varies on a case?to?case basis. We report a case where the use of ECMO was beneficial after stage I Norwood palliation with severe ventricular dysfunction. The systemic?to?pulmonary artery shunt was kept open to balance the systemic and pulmonary circulations. Cerebral oximetry can be useful as an additional monitoring modality to guide management, monitor cerebral perfusion, and help detect cerebral steal.

Associated Factors with Congenital Heart Disease in the Most Populated State of Brazil Between 2010 and 2018

Abstract Background Cardiac anomalies are the most prevalent congenital malformations among live births in the world. In Brazil, it is estimated that nearly 25,757 new cases occur each year, and the Southeast region presents the highest prevalence, with 10 new cases/1,000 live births. Objective The aim of this study is to evaluate the epidemiology of congenital heart disease (CHD) in the state of São Paulo. Methods This is a cross-sectional and time-series observational study with data from the Brazilian Information System on Live Births. Heart-related cardiac malformation cases — International Classification of Diseases (ICD) 10th revision Q20.0 to Q24.9 — were selected from January 2010 to December 2018, in the state of São Paulo, Brazil. This study analyzed rates of malformations per year and investigated associated factors, using single and multiple logistic regression models. The significance level adopted in this study was 5%. Results The highest cardiac malformation rate was in the São Paulo metropolitan region (2.84:1000), while the lowest was found in the region of Franca (0.3:1000). The most frequent defect was interatrial communication (38.2%). The main associated factors observed in this study were prematurity of 22 to 27 weeks (OR=4,401 95% CI: 3,796-5,104) — CI: Confidence Interval; OR: Odds ratio —, mother's age between 35 and 49 years of age (OR=1,602 95% CI: 1,525-1,682), yellow race (OR=1,481 95% CI: 1,235-1,775), triple or more pregnancy (OR=1,438 95% CI: 1,004-2,060), and history of a dead child (OR=1,213 95% CI: 1,152-1,277). Conclusion The main factors associated with this outcome, which are part of the obstetric history of mothers, should be addressed and considered when pregnancy is a planned event.

A Systematic Review of Benefits and Risks of Fetal Surgery for Congenital Cardiac Defects Such as Pulmonary Valve Stenosis and Critical Aortic Stenosis

ABSTRACT Introduction: Congenital heart diseases (CHDs) constitute the most prevalent congenital pathology, and they are a consequence of structural and functional abnormalities during fetal development. The etiology of CHD involves the interaction of genetic and environmental factors. Fetal cardiac surgery aims at preventing natural pathways of CHD in utero, mitigating progression to more complex abnormalities. The goal of this review was to demonstrate the benefits and risks of fetal interventions in the two most prevalent CHDs, pulmonary stenosis and pulmonary atresia with an intact ventricular septum, but also critical aortic stenosis and hypoplastic left heart syndrome. Methods: Original and relevant articles were selected by meta-aggregation to perform a qualitative analysis of fetal cardiac interventions for pulmonary stenosis and critical aortic stenosis. The Joanna Briggs Institute's Qualitative Assessment and Review Instrument (or JBI-QARI) was used for data quality appraisal. Results: Of 61 potential articles, 13 were selected, and nine were finally included. Discussion: The present review demonstrated that fetal cardiac surgery increases right ventricular growth and hemodynamic flow in pulmonary stenosis, whereas in critical aortic stenosis it enables growth of the left ventricle and increases left ventricular pressure. However, it has a high complication rate, along with considerable morbidity and mortality. Conclusion: The benefits of fetal cardiac surgery for pulmonary stenosis and critical aortic stenosis are well-described in the literature; however, there is a significant risk of complications which can be reduced by the surgeon's technical expertise and well-structured hospital facilities.

The value of right atrial myocardial fibrosis in evaluating the prognosis of isolated tricuspid valve surgery after left heart valve surgery / 中国胸心血管外科临床杂志

@#Objective    To investigate the predictive value of right atrial myocardial fibrosis in the prognosis of isolated tricuspid regurgitation surgery after left heart valve surgery. Methods    The patients who underwent tricuspid valvuloplasty by the same operator in Guangdong Provincial People's Hospital from April 2016 to August 2021 due to long-term isolated severe tricuspid regurgitation after left heart valve surgery were included in the study. According to the degree of right atrial myocardial fibrosis, the patients were divided into three groups: a mild group, a moderate group, and a severe group. The clinical data of these patients were compared and analyzed. Results    A total of 75 patients were enrolled, including 16 males and 59 females with an average age of 57.0±8.4 years. There were 30 patients in the mild group, 29 patients in the moderate group and 16 patients in the severe group. In terms of the preoperative data, there were statistical differences in cardiac function grade, right atrial diameter, tricuspid incompetence area among the three groups (P<0.05). In terms of the postoperative data, there were statistical differences among the three groups in the cardiopulmonary bypass time, mechanical ventilation time, ICU monitoring time, complication rate and mortality (P<0.05). Further pairwise comparison showed that, compared with the mild group, the severe group had longer mechanical ventilation time (P=0.024), longer ICU monitoring time (P=0.003) and higher incidence of postoperative complications (P=0.024), while the moderate group had no statistical difference in all aspects (P>0.05); compared with the moderate group, the severe group had longer ICU monitoring time (P=0.021) and higher incidence of complications (P=0.006). Conclusion    The early outcome of tricuspid valvuloplasty in patients with isolated tricuspid regurgitation after left heart valve surgery with severe right atrial myocardial fibrosis is worse than that in the patients with mild and moderate fibrosis, suggesting that the degree of myocardial fibrosis in the right atrium can be a predictor of the effect of tricuspid regurgitation surgery and a judgement indicator of the surgery timing.

Resultados Precoces do Procedimento de Norwood em um Centro de Referência no Brasil / Early Outcomes of the Norwood Procedure in a Reference Center in Brazil

Resumo Fundamento Apenas dois artigos abordam os resultados precoces de pacientes com síndrome do coração esquerdo hipoplásico (SHCE) submetidos à operação de Norwood, no Brasil. Objetivos Avaliamos pacientes com SHCE submetidos ao primeiro estágio da operação de Norwood para identificar os fatores preditivos de mortalidade precoce (nos primeiros 30 dias após a cirurgia) e intermediária (desde a sobrevida precoce até o procedimento de Glenn). Métodos Foram incluídos pacientes com SHCE submetidos em nosso serviço ao primeiro estágio da operação de Norwood de janeiro de 2016 a abril de 2019. Dados demográficos, anatômicos e cirúrgicos foram analisados. Os desfechos foram mortalidade precoce (nos primeiros 30 dias após a cirurgia), mortalidade intermediária (desde a sobrevida precoce até o procedimento de Glenn) e a necessidade de suporte pós-operatório com ECMO. Foram realizadas análises univariadas e multivariadas e calculados odds ratios, com intervalos de confiança de 95%. Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados Um total de 80 pacientes com SHCE foram submetidos ao primeiro estágio da operação de Norwood. A taxa de sobrevida em 30 dias foi de 91,3% e a taxa de sobrevida intermediária foi de 81,3%. Quatorze pacientes (17,5%) necessitaram de suporte com ECMO. Menor peso (p=0,033), estenose aórtica (vs atresia aórtica; p=0,036) e necessidade de suporte pós-operatório com ECMO (p=0,009) foram fatores preditivos independentes para mortalidade em 30 dias. A estenose da valva mitral ( vs atresia da valva mitral; p=0,041) foi um fator preditivo independente para mortalidade intermediária. Conclusão O presente estudo inclui a maior coorte brasileira de pacientes com SHCE submetidos ao primeiro estágio da operação de Norwood na era recente. Nossas taxas de sobrevida foram comparáveis às mais altas taxas de sobrevida relatadas globalmente. Baixo peso corporal, estenose valvar aórtica e necessidade de suporte pós-operatório com ECMO foram preditores independentes para mortalidade em 30 dias. A estenose da valva mitral foi o único fator preditivo independente para mortalidade intermediária.

Abstract Background Only two papers have addressed the early outcomes of patients with hypoplastic left heart syndrome (HLHS) undergoing the Norwood operation, in Brazil. Objectives We evaluated patients with HLHS undergoing the first-stage Norwood operation in order to identify the predictive factors for early (within the first 30 days after surgery) and intermediate (from early survival up to the Glenn procedure) mortality. Methods Patients with HLHS undergoing the stage I Norwood procedure from January 2016 through April 2019, in our service, were enrolled. Demographic, anatomical, and surgical data were analyzed. Endpoints were early mortality (within the first 30 days after surgery), intermediate mortality (from early survival up to the Glenn procedure) and the need for postoperative ECMO support. Univariate and multivariate analyses were performed, and odds ratios, with 95% confidence intervals, were calculated. A p-value <0.05 was considered statistically significant. Results A total of 80 patients with HLHS underwent the stage I Norwood procedure. The 30-day survival rate was 91.3% and the intermediate survival rate 81.3%. Fourteen patients (17.5%) required ECMO support. Lower weight (p=0.033), aortic stenosis (vs aortic atresia; p=0.036), and the need for postoperative ECMO support (p=0.009) were independent predictive factors for 30-day mortality. Mitral valve stenosis (vs mitral valve atresia; p=0.041) was an independent predictive factor for intermediate mortality. Conclusion The present study includes the largest Brazilian cohort of patients with HLHS undergoing the stage I Norwood procedure in the recent era. Our survival rates were comparable to the highest survival rates reported globally. Low body weight, aortic valve stenosis, and the need for postoperative ECMO support were independent predictors for 30-day mortality. Mitral valve stenosis was the only independent predictive factor for intermediate mortality.

Spinal Anesthesia for Open Gastrostomy in an Infant after Stage I Norwood for Hypoplastic Left Heart

Infants with hypoplastic left heart are at increased risk of adverse events including mortality when they undergo procedures with general anesthesia in the inter?stage period after stage I Norwood. This is primarily caused by an imbalance between pulmonary and systemic blood flows augmented by decreased function of the single ventricle. These factors can be aggravated by general anesthesia, hence the increased risk. Many of these infants experience feeding dysfunction and require a gastrostomy to optimize nutrition. We report a case of open gastrostomy in an infant with Norwood physiology under spinal anesthesia with an excellent outcome.

Manejo anestésico en síndrome corazón izquierdo hipoplásico: Reporte de un caso / Anesthetic management in hypoplastic left heart syndrome: A case report

Introducción: El síndrome corazón izquierdo hipoplásico puede presentarse con signos clínicos inmediato al nacimiento, siendo responsable de las muertes neonatales en la primera semana de vida. El reconocimiento clínico y los hallazgos ecocardiográficos son claves para un diagnóstico y tratamiento oportuno. Reporte de caso: describe el manejo anestésico de un neonato con inestabilidad hemodinámica que requirió cirugía de emergencia con banding pulmonar bilateral para mantener el equilibrio entre la relación del flujo sanguíneo pulmonar y sistémico cercano a la unidad, junto a maniobras de ventilación mecánica, medicamentos anestésicos, inotrópicos y adyuvantes con el objetivo de manipular las resistencias vasculares y el flujo sanguíneo logrando estabilidad hemodinámica del paciente que permitió al quinto día ser sometido a una cirugía electiva de Norwood Sano, tolerando procedimiento con extubación a los 15 días de la cirugía. Conclusión: el momento oportuno de la indicación quirúrgica aumenta la sobrevida de los pacientes síndrome corazón izquierdo hipoplásico.

Background: Hypoplastic left heart syndrome may appear with clinical signs immediately at birth, being responsible for neonatal deaths within the first week of life. Clinical recognition and echocardiographic findings are key to timely diagnosis and treatment. Case report: describes the anesthetic procedure of a neonate with hemodynamic instability who required emergency surgery for bilateral pulmonary banding to maintain the balance between pulmonary and near-unit systemic flow ratio, along with mechanical ventilation maneuvers, anesthetic, inotropic and adjuvant drugs to control vascular resistance and blood flow, thus achieving hemodynamic stability of the patient, which allowed him to undergo an elective Norwood Sano procedure on the fifth day, and which was tolerated with extubation 15 days after surgery. Conclusion: The right timing of the surgical indication increases the survival of patients with hypoplastic left heart syndrome.

Pulmonary Hypertension Registry of Kerala, India (PRO-KERALA): One-year outcomes

Background: Short term outcomes of patients with pulmonary hypertension are not available from low and middle-income countries including India. Methods: We conducted a prospective study of 2003 patients with pulmonary hypertension, from 50 centres (PROKERALA) in Kerala, who were followed up for one year. Pulmonary hypertension (PH) was mainly diagnosed on the basis of Doppler echocardiography. The primary outcome was a composite endpoint of all-cause death and hospital admission for heart failure. All cause hospitalisation events constituted the secondary outcome. Results: Mean age of study population was 56 ± 16 years. Group 1 and Group 2 PH categories constituted 21.2% and 59% of the study population, respectively. Nearly two-thirds (65%) of the study participants had functional class II symptoms. 31% of Group 1 PH patients were on specific vasodilator drugs.In total, 83 patients (4.1%) died during the one-year follow-up period. Further, 1235 re-hospitalisation events (61.7%) were reported. In the multivariate model, baseline NYHA class III/IV (OR 1.87, 95% C.I. 1.35e2.56), use of calcium channel blockers (OR 0.18, 95% C.I. 0.04e0.77), vasodilator therapy (OR 0.5, 95% C.I. 0.28e0.87) and antiplatelet agents (OR 1.80, 95% C.I. 1.29e2.51) were associated with primary composite outcome at one-year (p < 0.05). Conclusion: In the PROKERALA registry, annual mortality rate was 4%. More than half of the patients reported re-hospitalisation events on follow up. Uptake of guideline directed therapies were suboptima

Efficacy of left heart attracting pressure monitoring technology applied in cardiopulmonary bypass in cardiac surgery / 中华麻醉学杂志

Objective:To evaluate the efficacy of left heart attracting pressure monitoring technology applied in cardiopulmonary bypass (CPB) in cardiac surgery.Methods:Eighty patients of both sexes, aged 40-64 yr, weighing 50-80 kg, of American Society of Anesthesiologists physical status Ⅱ-Ⅳ, with New York Heart Association grade Ⅱ or Ⅲ, with left ventricular ejection fraction≥40%, undergoing elective cardiac valve replacement, were divided into 2 groups using a random number table method: traditional left heart aspiration group (T group) and modified left heart aspiration group (M group), with 40 patients in each group.The rotation speed of left ventricular suction pump was adjusted according to left ventricular suction volume and surgical field clarity in group T and by monitoring the pressure in the left suction tube in real time in group M. After aspiration returned to normal aspiration, blood of the left heart returned after aspiration was collected to determine the concentration of free hemoglobin.The number of adjustments after left ventricular aspiration, intraoperative hemoglobinuria, and occurrence of tissue sediment in the aspiration tube after operation were recorded.Results:Compared with T group, the concentration of free hemoglobin, incidence of intraoperative hemoglobinuria and incidence of tissue sediment in the aspiration tube after operation were significantly decreased, and the number of adjustments after left ventricular aspiration was decreased in M group ( P<0.05). Conclusion:Left heart attracting pressure monitoring technology can be safely and effectively applied in CPB in cardiac surgery.

Treatment of thoracoabdominal aortic aneurysm by prosthetic vessel replacement under left heart bypass / 中南大学学报(医学版)

OBJECTIVES@#Thoracoabdominal aortic aneurysm (TAAA) prosthetic vessel replacement is one of the most complex operations in the field of cardiovascular surgery. The key to success of this operation is to prevent and avoid ischemia of important organs while repairing TAAA. This study aims to summarize and analyze the effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA.@*METHODS@#Data of 15 patients with TAAA who underwent prosthetic vessel replacement under left heart bypass in Xiangya Hospital of Central South University were retrospectively analyzed. According to Crawford classification, there were 2 cases of type I, 8 cases of type II, 3 cases of type III, and 2 cases of type V. There were 14 cases of selective operation and 1 case of emergency operation. All operations were performed under left heart bypass, and cerebrospinal fluid drainage was performed before operation. Left heart bypass was established by intubation of left inferior pulmonary vein and distal abdominal aorta or left femoral artery. The thoracoabdominal aorta was replaced segment by segment. After aortic dissection, the kidneys were perfused with cold crystalloid renal protective solution, and the celiac trunk and superior mesenteric artery were perfused with warm blood.@*RESULTS@#One patient with TAAA after aortic dissection of type A died. During the operation, straight blood vessels were used to repair TAAA, and the celiac artery branches were trimmed into island shape and anastomosed with prosthetic vessels. After the operation, massive bleeding occurred at the anastomotic stoma, then anaphylactic reaction occurred during massive blood transfusion, resulting in death. One patient suffered from paraplegia due to ischemic injury of spinal cord. The other patients recovered well and were discharged. The postoperative ventilation time was (16.5±13.8) h and the postoperative hospital stay was (10±4) d. The amount of red blood cell transfusion was (13±9) U. The patients were followed up for 2 months to 2 years, and the recovery was satisfactory.@*CONCLUSIONS@#The effect of prosthetic vessel replacement under left heart bypass in the treatment of TAAA is good, which is worthy of clinical promotion.

Clinical Observation of Sacubitril Valsartan Sodium Tablets Combined with Bailing Capsules in the Treatment of Chronic Left Heart Failure with Renal Insufficiency / 中国药房

OBJECTIVE：To study the efficacy and safety of sacubitril valsartan sodium tablets combined with Bailing capsules in the treatment of chronic left heart failure with renal insufficiency ，and to provide reference for clinical drug use. METHODS ： Totally 96 patients with chronic left heart failure with renal insufficiency who sought medical care in our hospital from Nov. 2018 to Nov. 2019 were divided into group A ，B and C according to table of random numbers ，with 32 cases in each group. Group A received conventional heart failure treatment and and Bailing capsules （2 g each time ，3 times a day ）；group B received conventional heart failure treatment and Sacubitril valsartan sodium tablets （50 mg each time ，twice a day ）；group C was given with heart failure treatment and Sacubitril valsartan sodium tablets （50 mg each time ，twice a day ）and Bailing capsules （2 g each time，3 times a day ）. 3 groups received consecutive 6 months of treatment. Clinical response rates of 3 groups were compared. Left heart function indexes [left ventricular end systolic diameter （LVESD），left ventricular end-diastolic diameter （LVEDD），left ventricular ejection fraction （LVEF）] and serological indexes [interleukin 1（IL-1），IL-6，N terminal brain natriuretic peptide precursor，glomerular filtration rate （GFR）] were detected before and after treatment. The occurrence of ADR were observed and recorded. RESULTS ：During this study ，a total of 6 patients fell off ，and eventually 90 patients completed the study ，including 29 cases in group A ，30 cases in group B and 31 cases in group C. Before treatment ，there was no statistical significance in left heart function indexes or serological indexes among 3 groups（P＞ 0.05）. After 6 months of treatment ，clinical response rate of group C was significantly higher than those of group A and B 163.com （P＜0.05）. Compared with before treatment ， LVEDD， LVESD and serological indexes of 3 groups were decreased significantly after treatment （P＜0.05），while LVEF and GFR were increased significantly （P＜0.05）；the changes of above indexes （except for IL- 1 level in serum ） in group C were significantly better than group A and B ，the changes of above indexes in group B （except for GFR ）were significantly better than group A （P＜0.05）. No significant ADR were observed in 3 groups. CONCLUSIONS ：Sacubitril valsartan sodium tablets combined with Bailing capsules can significantly decrease the level of serum inflammation factors ，and improve cardiac and renal function in patients with chronic left heart failure with renal insufficiency ，with good safety.

Diagnóstico Prenatal de Fibroelastosis Endocardica

Resumen La fibroelastosis endocárdica es una cardiopatía congénita caracterizada por presentar un engrosamiento difuso del endocardio, esto condiciona una miocardiopatía dilatada en la mayoría de los casos o menos frecuente una miocardiopatía restrictiva. Puede ser una patología primaria o secundaria a otras malformaciones cardíacas, sobre todo a una estenosis o atresia de la aorta. Se estima que la incidencia global al nacimiento es de 1 de cada 5 000 y de 4 por cada 100 cardiopatías congénitas. Se presenta el caso clínico de una gestante de 37 años de edad, quien fuera ingresada a las 19.1 semanas de gravidez en el Hospital Obrero N°2 de Cochabamba-Bolivia, por el diagnóstico ecográfico prenatal de cardiopatía fetal estructural, fibroelastosis endocárdica.

Abstract Endocardial fibroelastosis is a congenital heart disease characterized by diffuse thickening of the endocardium, this conditions a dilated cardiomyopathy in most cases or less frequent restrictive cardiomyopathy. It can be a primary pathology or secondary to other cardiac malformations, especially a stenosis or atresia of the aorta. The global incidence at birth is estimated to be 1 in 5 000 and 4 in 100 congenital heart disease. The clinical case of a 37-year-old pregnant woman is presented, who was admitted at 19.1 weeks of pregnancy in Hospital Obrero N ° 2 in Cochabamba-Bolivia, due to the prenatal ultrasound diagnosis of structural fetal heart disease, endocardial fibroelastosis.

The study on brain biometry and cerebral hemodynamics in fetuses with hypoplastic left heart syndrome in the second trimester of gestation / 中华超声影像学杂志

Objective:To explore the changes of biparietal diameter, head circumference and cerebrovascular hemodynamics in fetuses with hypoplastic left heart syndrome (HLHS) during middle pregnancy.Methods:The biparietal diameter, head circumference, middle cerebral artery pulsatility index (MCA-PI), umbilical artery pulsatility index (UA-PI) and MCA-PI/UA-PI (CPR) of 41 fetuses with HLHS(HLHS group) were retrospectively analyzed from January 2015 to December 2019 in Beijing Anzhen Hospital, and were compared with those of 82 normal fetuses matched for gestational age at the same period (control group).Results:The Z-scores of head circumference, MCA-PI and CPR in with HLHS group were lower than in control group(all P<0.05); Head circumference in HLHS group were weakly and positively correlated with the MCA-PI and CPR ( r=0.385, 0.416; all P<0.05). Conclusions:There are some changes in the head circumference and cerebral hemodynamics in fetuses with HLHS during mid-gestational age, and the head circumference is weakly and positively correlated with MCA-PI and CPR, which has clinical significance.

Extubación fallida postoperación de Norwood en pacientes con síndrome de hipoplasia de ventrículo izquierdo / Extubation failure after Norwood procedure in hypoplastic left heart syndrome patients

Resumen: Introducción: En pacientes con Síndrome de Hipoplasia de Ventrículo Izquierdo (SHVI) la primera etapa hacia una fisiología univentricular de Fontan es la operación de Norwood, cuya mortalidad es 10-30%. En estos pacientes la extubación fallida se presenta en un 18% y se ha asociado a aumento de la mortali dad. Objetivo: Describir la frecuencia de extubación fallida y sus factores de riesgo en pacientes con SHVI operados (Norwood). Pacientes y Método: Estudio de casos y controles que incluyó a todos los pacientes con SHVI manejados con cirugía de Norwood en el Hospital Clínico de la Pontificia Universidad Católica (enero-2000 a febrero-2018). Se define como casos a pacientes con falla en la extubación y como controles a los pacientes sin esta complicación. Se registraron variables demográficas, quirúrgicas, y post-quirúrgicas, y se realizó análisis univariado y multivariado (regresión logística) para determinar los factores de riesgo asociados a la falla en la extubación. Resultados: De un total de 107 pacientes, 26 pacientes tuvieron extubación fallida (24,3%). En el análisis univariado los factores asociados a extubación fallida fueron: mayor tiempo de ventilación mecánica postquirúrgico, desarrollar atelectasias, derrame pleural, quilotórax, tener otras comorbilidades respiratorias (apnea y traqueítis), y mayor tiempo de uso de morfina y midazolam. En el análisis multivariado, la presencia de quilotórax, otras comorbilidades respiratorias, y mayor tiempo de uso de midazolam fueron variables asociadas a extubación fallida (p<0,03). La extubación fallida no se asoció a mayor mortalidad. Conclusiones: La presencia de quilotórax, complicaciones respiratorias y uso de mida zolam prolongado deben considerarse para definir el momento de la extubación, con el objetivo de evitar su fracaso.

Abstract: Introduction: Hypoplastic left heart syndrome (HLHS) is the main cause of mortality due to congenital heart disea se. The Norwood surgery is the first procedure of the surgical staging process towards a single ventri cle physiology or Fontan-type operation and has a mortality rate of 10% to 30%. Extubation failure during the postoperative period occurs in up to 18% of these patients and is associated with increased mortality. Objective: To describe extubation failure rates and risk factors in pediatric patients with HLHS who underwent Norwood procedure. Patients and Method: Case-control study that included all the patients with HLHS managed with Norwood surgery at the Hospital Clínico de la Pontificia Universidad Catolica between January 2000 and February 2018. Cases and controls were defined as patients with extubation failure and as patients without this complication, respectively. The following variables were recorded demographic, surgical, and post-surgical ones, and univariate and multivariate analyses (logistic regression) were performed to determine risk factors associated with extubation failure. Results: Out of 107 patients, 26 of them presented extubation failure (24.3%). In the univariate analysis, longer mechanical ventilation time during the postsurgical period, atelectasis, pleural effusion, chylothorax, other respiratory morbidities (i.e. apneas and tracheitis), and longer infusion times of morphine and midazolam, all were associated with a higher extubation failure rate in this population. In the multivariable analysis, chylothorax, other respiratory comorbidities, and longer infusion time of midazolam remained associated with this complication, however, it was not associated with higher mortality. Conclusions: Chylothorax, respiratory comorbidities, and longer use of Midazolam should be addressed before planning airway extubation in order to avoid failure.

Two-dimensional echocardiography in evaluating left ventricular morphology and systolic function at early stage after transcatheter aortic valve implantation / 第二军医大学学报

Objective To monitor and analyze the cardiac morphology and functional status at early stage after transcatheter aortic valve implantation (TAVI) by two-dimensional echocardiography. Methods A total of 33 patients with TAVI were selected from Dec. 2017 to Dec. 2019 in the Department of Cardiovascular Surgery of our hospital. The age, gender, New York Heart Association (NYHA) cardiac function classification, previous cardiac surgery history, Society of Thoracic Surgeons (STS) score, surgical approach, complication, other basic data, as well as echocardiography data were collected before and after TAVI (0-2 months). Results Thirty-three patients met the inclusion criteria, including 20 patients with severe aortic stenosis (SAS group), eight patients with severe aortic regurgitation (SAR group), and five patients with SAS combined with SAR (combined group). In the early postoperative period, one patient in SAS group was hospitalized twice for heart failure aggravated by arrhythmia, four patients in SAS group had tiny perivalvular leakage and one patient had large perivalvular leakage; moderate perivalvular leakage occurred in one patient in SAR group, and mild perivalvular leakage occurred in one patient in the combined group. Compared with the preoperative values, early after operation 33 cases had decreased left ventricular end-diastolic volume (LVEDV), left atrial volume (LAV), and maximum aortic valve pressure gradient (AVPGmax), increased effective aortic valve area (AVA) (all P0.01), and unchanged left ventricular ejection fraction (LVEF), interventricular septum thickness (IVST), and posterior wall thickness (PWT) significantly (all P0.05). In SAS group, LVEF and AVA increased, while LAV and AVPGmax decreased significantly (P0.05 or P0.01). In SAR group, LVEDV and LAV decreased, while IVST increased significantly (P0.05 or P0.01). In combined group, LVEDV, LAV and AVPGmax decreased, while AVA increased significantly (P0.05 or P0.01). Conclusion Early after TAVI, the cardiac remodeling and systolic function are improved to different degrees in patients with SAS, SAR, and SAS combined with SAR. High risk patients with SAR alone or combined with SAS can benefit from TAVI.

Emergency Pulmonary Artery–to-Systemic Artery Shunt to Break the Positive Feedback Loop of a Pulmonary Hypertensive Crisis after Neonatal Coarctation Repair / 대한흉부외과학회지

A 2.5-kg neonate with coarctation of the aorta and a small left ventricle experienced a severe pulmonary hypertensive crisis. An emergency pulmonary artery-to-systemic artery shunt was placed to break the positive feedback loop caused by pulmonary hypertension and functional mitral stenosis. This shunt provided immediate relief of suprasystemic pulmonary hypertension and the resultant low cardiac output.

Progress of treatment criteria for tricuspid regurgitation in patients receiving left heart valve surgery / 解放军医学杂志

[Abstract] Left heart valve disease may often lead to tricuspid regurgitation. If not treated at appropriate timing, tricuspid regurgitation will be gradually aggravated to impair the function of right heart and cause right heart failure, which would exert a great impact on the prognosis and life quality of patients. As tricuspid regurgitation is affected by a variety of factors, the surgical indications of tricuspid regurgitation in patients undergoing left heart valve surgeries have not yet reached a unified specifications and standards. The authors reviewed in present paper the pathological mechanism, ultrasonic diagnosis, surgical indications and patterns of the left heart valve disease accompanied with tricuspid regurgitation for the purpose of reducing the incidence of tricuspid regurgitation and optimizing the treatment in patients undergoing left heart valve surgery.