Avaliação da Circulação Coronariana após a Cirurgia de Jatene / Evaluation of Coronary Circulation after Arterial Switch Operation

Resumo Fundamento A avaliação da artéria coronária após a cirurgia de Jatene ainda é um desafio clínico. Objetivo Correlacionar alterações anatômicas identificadas por tomografia computadorizada cardíaca (TCC) com alterações fisiológicas detectadas na avaliação clínica para diagnosticar obstrução coronária no pós-operatório tardio de pacientes submetidos à cirurgia de Jatene. Métodos Este estudo incluiu 61 pacientes consecutivos com idade média de 9,4 anos que foram submetidos à cirurgia de Jatene. Os pacientes realizaram ecocardiografia, eletrocardiografia, teste cardiopulmonar do exercício, e tomografia computadorizada cardíaca para avaliação da capacidade funcional e anatomia da artéria coronária. Resultados A tomografia computadorizada cardíaca revelou que somente 3,3% dos pacientes apresentaram estenose da artéria coronária. Esses pacientes eram assintomáticos, e não foram detectados sinais de isquemia miocárdicas pelos exames realizados. Conclusão A incidência de anormalidades da artéria coronária é de 3,3% no seguimento tardio de nossa coorte de pacientes submetidos à cirurgia de Jatene. Não existe uma diretriz clara sobre o porquê, quando, e como esses pacientes deveriam ser rastreados, ou o que propor quando pacientes assintomáticos forem diagnosticados com obstrução coronária.

Abstract Background Coronary artery evaluation remains after arterial switch operation a clinical challenge. Objective This study aims to correlate anatomical changes diagnosed by cardiac computed tomography (CCT) with physiological alterations on clinical evaluation to diagnose coronary obstruction in late ASO patients. Methods This study included 61 consecutive patients with mean age of 9.4 years who underwent ASO. The patients were submitted to echocardiography, electrocardiography, cardiopulmonary exercise test, and cardiac computed tomography to evaluate functional capacity and coronary artery anatomy. Results Cardiac computed tomography revealed that only 3.3% of the patients had coronary stenosis. These patients were asymptomatic, and no signs of myocardial ischemia were detected by the tests. Conclusion The incidence of coronary abnormalities in late ASO patients was 3.3% in our cohort. There is no clear guideline as to why, when, and how these patients should be screened or what to propose when a coronary obstruction is diagnosed in asymptomatic patients.

Cannot extubate a newborn patient after an arterial switch operation? check major aortopulmonary collaterals!

Abstract The standard treatment of transposition of the great arteries is the arterial switch operation (ASO). Despite successful surgical correction, patients cannot tolerate extubation after the operation. Major aortopulmonary collaterals (MAPCAs) are one of the rare causes of prolonged mechanical ventilation due to significant hemodynamic effects. We report a 28-day-old newborn with transposition of the great arteries and a ventricular septal defect (VSD) who underwent ASO and VSD closure. After postoperative extubation failed twice, four large MAPCAs were revealed during heart catheterization. After transcatheter closure of these four MAPCAs, the patient was extubated and discharged 27 days after the procedure.

Modified closed coronary transfer is a good alternative to the trap-door method during arterial switch operation: a retrospective propensity-matched comparison

Abstract Objective: To compare the early and long-term results of patients in whom was performed modified closed coronary transfer with the results of patients in whom was performed trap-door transfer techniques by utilizing propensity-matching analysis to provide optimal identical patient matching for the groups. Methods: From August 2015 to December 2017, 127 consecutive patients underwent arterial switch operation due to simple and complex transposition of the great arteries, with or without additional arch and complex coronary pattern, by a single surgical team included into the study. Of these, in 70 patients it was performed modified closed coronary transfer technique and in 57 patients it was performed trap-door style coronary transfer technique. The patients were divided into two groups in terms of coronary transfer method. In the final model, after propensity matching, 47 patients from each group having similar propensity score were included into the study. Results: There was no significant difference between the groups regarding patient characteristics. Cross-clamp time and operation time were significantly lower in the modified technique group compared with the other group (P=0.03 and P=0.05, respectively). When compared the early and late postoperative outcomes, there was no significant difference between the groups. Postoperative echocardiographic findings were mostly similar between the groups. Conclusion: The patients in whom was performed our modified technique demonstrate overall good outcomes and the current technique ensures shorter arterial cross-clamp and operation times. It may be an alternative method to the trap-door technique for the coronary transfer during the arterial switch operation.

Late arterial switch surgery under ecmo support in a patient with transposition of the great arteries with intact ventricular septum: a case report

Abstract A 30-month-old male patient with transposition of the great arteries with intact ventricular septum (TGA/IVS) is presented. Arterial switch operation (ASO) was performed in the light of echocardiographic and angiographic findings. The patient remained under extracorporeal membrane oxygenation support for seven days postoperatively, and his cardiac functions returned to normal at the postoperative 10th day. He was discharged at the postoperative 20th day. The present case, which presents one of the most advanced ages at operation for TGA/IVS among previously reported cases, is used to discuss late ASO in this study.

Mid- and Longterm Neo-Aortic Valve Regurgitation after Jatene Surgery: Prevalence and Risk Factors / Regurgitação da Valva Neo-Aórtica a Médio e Longo Prazo após Cirurgia de Jatene: Prevalência e Fatores de Risco

Abstract Background: Jatene surgery became the surgical procedure of choice to repair transposition of the great arteries (TGA) in neonates and infants. Late complications, mainly related to the pulmonary outflow tract and coronary arteries, are well known. The behavior of the neo-aortic valve is a cause of concern because of its potential for requiring late reoperation. Objectives: To assess the prevalence and risk factors of neo-aortic valve regurgitation in 127 patients in the late postoperative period of the Jatene surgery. Methods: Of the 328 survivors of the Jatene surgery at the Biocor Institute from October 1997 to June 2015, all patients undergoing postoperative follow-up were contacted via telephone, 127 being eligible for the study. The patients were divided into two groups, simple TGA and complex TGA groups, with follow-up means of 6.4 ± 4.7 years and 9.26 ± 4.22 years, respectively. Echocardiography was performed with adjusted measurements (Z-score) of the neo-aortic annulus, sinus of Valsalva, sinotubular region and ascending aorta, as well as quantification of the neo-aortic valve regurgitation grade. Results: The incidence of mild neo-aortic valve regurgitation was 29% in a follow-up of 7.4 ± 4.7 years. Moderate regurgitation was identified in 24 patients with age mean (± standard-deviation) of 9.81 ± 4.21 years, 19 of whom (79%) in the complex TGA group. Those patients had a higher aortic annulus Z-score. The reoperation rate due to neo-aortic regurgitation associated with aortic dilation was 1.5%, all patients in the complex TGA group. Conclusion: This study shows that, despite the low incidence of reoperation after Jatene surgery due to neo-aorta dilation and neo-aortic valve regurgitation, that is a time-dependent phenomenon, which requires strict vigilance of the patients. In this study, one of the major risk factors for neo-aortic valve regurgitation was the preoperative pulmonary artery diameter (p < 0.001).

Resumo Fundamento: A operação de Jatene tornou-se o procedimento cirúrgico de escolha para o reparo da transposição das grandes artérias (TGA) em neonatos e lactentes. Complicações tardias, principalmente relacionadas à via de saída pulmonar e às artérias coronarianas, já são bem reconhecidas. O comportamento da valva neo-aórtica tem sido motivo de crescente preocupação pelo seu potencial de necessidade de reoperações tardias. Objetivos: Avaliar a prevalência e os fatores de risco associados à regurgitação da valva neo-aórtica em 127 pacientes em pós-operatório tardio de cirurgia de Jatene. Métodos: Dos 328 sobreviventes da cirurgia de Jatene no Biocor Instituto operados de outubro de 1997 a junho de 2015, todos os pacientes em seguimento de pós-operatório foram contatados via ligação telefônica, sendo 127 elegíveis para o estudo. Os pacientes foram divididos em dois grupos, Grupo TGA simples e Grupo TGA complexa, com médias de follow-up de 6,4 ± 4,7 anos e 9,26 ± 4,22 anos, respectivamente. Foi realizada avaliação ecocardiográfica com medidas indexadas (escore Z) do anel da valva neo-aórtica, do seio de Valsalva, da região sinotubular e da aorta ascendente, bem como quantificação do grau de regurgitação da valva neo-aórtica. Resultados: A incidência de leve regurgitação da valva neo-aórtica em nossa casuística foi de 29% em um follow-up de 7,4 ± 4,7 anos. Regurgitação moderada foi observada em 24 pacientes, com idade média (± desvio-padrão) de 9,81 ± 4,21 anos, sendo 19 (79%) no Grupo TGA complexa. Nesses pacientes, observou-se maior escore Z do anel aórtico. A taxa de reoperação por regurgitação da valva neo-aórtica associada a dilatação da aorta foi de 1,5%, sendo todos os casos no Grupo TGA complexa. Conclusão: O estudo demonstra que, embora reoperações após cirurgia de Jatene por dilatação da neo-aorta e regurgitação da valva neo-aórtica tenham incidência baixa, esse é um fenômeno dependente de tempo, requerendo rígida vigilância desses pacientes. Na nossa casuística, um dos principais fatores de risco para regurgitação da valva neo-aórtica foi o diâmetro da artéria pulmonar no pré-operatório (p < 0,001).

Malformações congênitas: um relato de reabilitação fisioterapêutica em paciente com transposição das grandes artérias / Congenital abnormalities: a physical therapy rehabilitation report in patient with transposition of great vessels

Objetivo: descrever uma abordagem fisioterapêutica na reabilitação neuropsicomotora e respiratória pediátrica em paciente com transposição das grandes artérias. Relato de caso: paciente R. S. C. R, sexo masculino, nascido de parto cesáreo, com diagnóstico clínico de malformações congênitas, portador de Transposição das Grandes Artérias ­ TGA, Comunicação Interatrial ­ CIA e Comunicação Interventricular Ampla ­ CIV. Avaliado aos 09 meses de idade com diagnóstico fisioterapêutico de atraso no desenvolvimento neuropsicomotor. Conclusão: esse relato de caso evidenciou efetiva abordagem fisioterapêutica na reabilitação neuropsicomotora e respiratória de uma criança com TGA + CIA + CIV em acompanhamento clínico, resultando em melhora neuropsicomotora identificada pelo melhor controle cervical e maior tempo na posição sentada, e melhora do desconforto respiratório passando de moderado para leve

Aortic Root Reimplantation in a Patient Who Underwent an Arterial Switch Operation

Neo-aortic insufficiency associated with root enlargement following an arterial switch operation is a serious late complication. To achieve successful surgical correction of this condition, multiple factors should be considered, including the individual patient's anatomy, the challenging nature of the redo procedure, and the patient's young age. However, limited publications have described the use of valve-sparing techniques for the treatment of neo-aortic insufficiency associated with root enlargement following an arterial switch operation. Herein, we report our recent experience of a valve-sparing aortic root procedure with ascending aorta and hemiarch replacement despite the presence of a discrepancy in leaflet size and nearby severe adhesions.

Surgical Reconstruction for High-Output Chylothorax Associated with Thrombo-Occlusion of Superior Vena Cava and Left Innominate vein in a Neonate

We report a case of high-output chylothorax associated with thrombo-occlusion of the superior vena cava (SVC) and left innominate vein (LIV) following an arterial switch operation in a neonate. The chylothorax was resolved by 3 weeks after surgical reconstruction of the SVC and LIV using fresh autologous pericardium. We confirmed the patency of the SVC and LIV with a 1-year follow-up computed tomographic scan at our outpatient clinic.

Experiencia inicial en la cirugía Jatene, en pacientes con transposición clásica de grandes arterias, en el Hospital Nacional de Niños Benjamín Bloom, de junio de 2015 a junio de 2016, serie de casos / Initial experience in Jatene surgery, in patients with classic transposition of the great arteries, at the Benjamín Bloom National Children's Hospital, from June 2015 to June 2016, case series

La transposición clásica de las grandes arterias (TGA) o llamada también discordancia ventrículo arterial, es una anomalía cardiaca congénita en la que la aorta emerge del ventrículo derecho (VD) y la arteria pulmonar del ventrículo izquierdo (VI). Es el segundo defecto cardiaco congénito más común con una prevalencia a nivel mundial de 0.24/1000 nacidos vivos. Antes de la era quirúrgica, la Transposición de grandes arterias, (TGA), representaba la quinta parte de las muertes cardiacas en la niñez. En junio de 2015, fue realizada en El Salvador la primera cirugía Jatene; en el Hospital Nacional de Niños Benjamín Bloom (HNNBB), siendo este el principal centro de referencia nacional e institución pública de tercer nivel de atención que cuenta con un programa cardiovascular, tanto clínico como quirúrgico, desde hace 20 años y que brinda atención cardiaca a la niñez con defectos congénitos y adquiridos de El Salvador; por lo que a través del presente estudio damos a conocer la experiencia inicial obtenida

Catheter Ablation of Peri-Conduit Ventricular Tachycardia in a Patient with Rastelli Procedure for Double Outlet Right Ventricle with Malposition of Great Arteries

No abstract available.

Clinical Outcomes after Anatomic Repair Including Hemi-Mustard Operation in Patients with Congenitally Corrected Transposition of the Great Arteries

BACKGROUND AND OBJECTIVES: The aims of this study were to determine the early and late outcomes of anatomic repair of congenitally corrected transposition of the great arteries (ccTGA) and to evaluate effectiveness of the hemi-Mustard procedure. SUBJECTS AND METHODS: We conducted a retrospective, single-center study of patients who underwent anatomic repair for ccTGA between July 1996 and December 2013. Sixteen patients were included in the study. The median age at the time of the operation was 3.5 years (range: 0.5-29.7), and the median body weight was 13.3 kg (range: 5.8-54). The median follow-up duration was 7.7 years (range: 0.2-17.4). RESULTS: Atrial switch was achieved using the Mustard procedure in 12 patients (hemi-Mustard procedure in 11) or the Senning procedure in four patients. The ventriculoarterial procedure was performed using the Rastelli procedure in 11 patients and arterial switch in five patients. Six patients underwent tricuspid valvuloplasty. The survival rate was 93.8±6.1%. The rate of freedom from reoperation at 5 years was 92.3±7.4% in the Rastelli group. All patients except one were New York Heart Association class I. All patients except one had mild tricuspid regurgitation. CONCLUSION: Anatomic repair can be performed with a low risk of in-hospital mortality. The hemi-Mustard strategy for selected patients is one solution for reducing early mortality and morbidity, and long-term complications such as venous pathway stenosis or sinus node dysfunction.

Transposition of Great Arteries with Intramural Coronary Artery: Experience with a Modified Surgical Technique

Abstract Objective: Transposition of the great arteries is a common congenital heart disease. Arterial switch is the gold standard operation for this complex heart disease. Arterial switch operation in the presence of intramural coronary artery is surgically the most demanding even for the most experienced hands. We are presenting our experience with a modified technique for intramural coronary arteries in arterial switch operation. Methods: This prospective study involves 450 patients undergoing arterial switch operation at our institute from April 2006 to December 2013 (7.6 years). Eighteen patients underwent arterial switch operation with intramural coronary artery. The coronary patterns and technique used are detailed in the text. Results: The overall mortality found in the subgroup of 18 patients having intramural coronary artery was 16% (n=3). Our first patient had an accidental injury to the left coronary artery and died in the operating room. A seven-day old newborn died from intractable ventricular arrhythmia fifteen hours after surgery. Another patient who had multiple ventricular septal defects with type B arch interruption died from residual apical ventricular septal defect and sepsis on the eleventh postoperative day. The remainder of the patients are doing well, showing a median follow-up duration of 1235.34±815.26 days (range 369 - 2730). Conclusion: Transposition of the great arteries with intramural coronary artery is demanding in a subset of patients undergoing arterial switch operation. We believe our technique of coronary button dissection in the presence of intramural coronary arteries using coronary shunt is simple and can be a good addition to the surgeons' armamentarium.

Myocardial perfusion scintigraphy in transposition of the great arteries after an arterial switch operation in infants

An abnormal myocardial perfusion is not uncommon in congenital heart defects (CHD). Many case reports and prospective studies were done describing myocardial peOision scintigraphy (MPS)findings after an arterial switch operation (ASO) among transposition of the great arteries (TCA), but to the best of the authors' knowledge, none have cited MPS findings in the immediate post-operative petiod. This paper aims to show two ckfferent clinicalthuatiomts in which (MPS) was used in the assessment of myocarchalfiinction in TCA immediatelyfollowing an arterial switch operation. Two male infants; aged 2 months and 4 months; both diagnosed with transposition of the great arteries presenting with past-operative morbidities after an arterial switch operation were referred to the Department of Nuclear Medicine/or evaluation. The younger infant was ditty discharged improved with an earlier magical intervention in contrast to the other who expired Bothpatients revealed a scintigraphic picture of myocarcbal ischemia and left ventricular a54ifiniction with concomitant right ventricular hypertrophy MPS .findings and reflective clinical pictures of patients with corrected congenital disease are yet to be/illy elticidated,.from the expected natural course after the stag/Cal intervention and long term complications ofsuch cases. The two cases present an invaluable avenue of non-invasive diagnostic modality using-MPS to assess probable pathologic mechanisms that occur after an arterial switch operation, and perhaps suggest incremental value not only in the post-operative period but in the preoperative scenario in the prognostication of these patients.

Myocardial perfusion scintigraphy in transposition of the great arteries after an arterial switch operation in infants

An abnormal myocardial perfusion is not uncommon in congenital heart defects (CHD). Many case reports and prospective studies were done describing myocardial peOision scintigraphy (MPS)findings after an arterial switch operation (ASO) among transposition of the great arteries (TCA), but to the best of the authors' knowledge, none have cited MPS findings in the immediate post-operative petiod. This paper aims to show two ckfferent clinicalthuatiomts in which (MPS) was used in the assessment of myocarchalfiinction in TCA immediatelyfollowing an arterial switch operation. Two male infants; aged 2 months and 4 months; both diagnosed with transposition of the great arteries presenting with past-operative morbidities after an arterial switch operation were referred to the Department of Nuclear Medicine/or evaluation. The younger infant was ditty discharged improved with an earlier magical intervention in contrast to the other who expired Bothpatients revealed a scintigraphic picture of myocarcbal ischemia and left ventricular a54ifiniction with concomitant right ventricular hypertrophy MPS .findings and reflective clinical pictures of patients with corrected congenital disease are yet to be/illy elticidated,.from the expected natural course after the stag/Cal intervention and long term complications ofsuch cases. The two cases present an invaluable avenue of non-invasive diagnostic modality using-MPS to assess probable pathologic mechanisms that occur after an arterial switch operation, and perhaps suggest incremental value not only in the post-operative period but in the preoperative scenario in the prognostication of these patients.

Comparison of Infective Endocarditis between Children and Adults with Congenital Heart Disease: A 16-Year, Single Tertiary Care Center Review

PURPOSE: This study aimed to evaluate and compare the characteristics of infective endocarditis (IE) between children and adults with congenital heart disease (CHD) at a single tertiary care center. METHODS: In this retrospective medical record review, we extracted the demographic characteristics, diagnostic variables, and outcomes of patients diagnosed with IE and CHD between 2000 and 2016. RESULTS: We identified a total of 14 pediatric patients (nine male; median age at diagnosis, 3 years). Of the 14 patients, six had a history of previous open heart surgery, while four had undergone tetralogy of Fallot repair, with transannular patch or Rastelli procedure. Among the 10 children with positive blood cultures, the most common isolated organism was Staphylococcus spp. (8/10, 80%). Eleven adult patients had IE and CHD. Among the adult patients, only four were diagnosed with CHD before IE, and ventricular septal defect was the most common CHD. The most common isolated organism was Streptococcus spp. (6/11, 55%). Compared with adult patients, pediatric patients had a higher incidence of previously diagnosed CHD (P=0.001), with Staphylococcus spp. as the causative organism (P =0.027). The median duration between the onset of symptoms and diagnosis of IE was 9 days in children and 42 days in adults (P=0.012). CONCLUSIONS: Significant differences with regard to the diagnosis and progress of IE were observed between children and adults. Ageadjusted and systematic reassessment may be necessary for the diagnosis and management of IE.