Elevated congenital heart disease birth prevalence rates found in Central Vietnam and dioxin TCDD residuals from the use of 2, 4, 5-T herbicides (Agent Orange) in the Da Nang region.

Congenital heart disease (CHD) birth prevalence rate in Da Nang City and two adjacent provinces in Central Vietnam reported by Giang et al. in 2019 was 20.09/1000 births, much higher than any CHD birth rates previously reported. In this current study, three physicians trained in pediatric cardiology reanalyzed and reclassified the Giang et al 2019 cardiac anomalies data, eliminating singular small PDAs and separating cardiac defects into 27 contemporary CHD subgroups. These CHD subgroups were then statistically compared with Liu et al. 2019 Global CHD birth prevalence study of Asian Low-Middle Income Countries (LMIC) CHD subgroup rate of 9.34/1000 births (95% CI 8.07-10.70). Despite applying newer diagnostic criteria and refining the cardiac anomalies data, the Da Nang region continued to show significantly (p<0.0001) elevated total CHD birth prevalence rates at 14.71/1000 births (95% CI 12.74-16.69) compared to the Asian LMIC CHD birth prevalence rate 9.34/1000 births. This finding raises the question of whether environmental persistence of the contaminant dioxin TCDD from 2,4,5-T herbicides (Agent Orange) used during the Vietnam War (1961-1971) in the Da Nang region might be a factor associated with elevated CHD birth prevalence, as it is not present in other LMIC surrounding Vietnam. We recommend testing of soils and sediments in rural and agricultural areas in Central Vietnam that received high volume applications of contaminated herbicides to assess the relationship of the higher CHD birth prevalence rate and the presence of residual dioxin TCDD. Enhanced fetal cardiac echocardiograpy in the region to screen for CHD would enable early interventions and could improve outcomes for infants and children.

Surgical management of coronary artery arising from the wrong coronary sinus, using standard and novel approaches.

OBJECTIVES: Patients with a coronary artery arising from the wrong sinus are susceptible to ischemia and sudden death. Risk is higher when the artery courses interarterially--between the pulmonary artery and aorta--has an intramural course, or has an abnormal orifice. In single coronary ostium without intramural course, unroofing and coronary reimplantation are inappropriate, and coronary artery bypass grafting is suboptimal. For this variant, we have devised pulmonary artery translocation. METHODS: A retrospective review of 18 patients undergoing repair between January 1999 and March 2005 was performed. Mean age was 8.1 years (range 6 weeks-16 years). All anomalous arteries coursed interarterially. Ten patients had a right coronary artery from the left coronary sinus; 8 had a left coronary artery from the right sinus. Eleven had an intramural course, and 4 had a single coronary ostium without an intramural course. Ten (56%) patients had symptoms: chest pain (9/10), syncope (3/10), or dyspnea (2/10). Repair was implemented by unroofing (n = 11), reimplantation (n = 3), or pulmonary artery translocation (1 lateral, 3 anterior). All patients were followed up clinically and echocardiographically. RESULTS: At a mean of 2.2 years (2 weeks-5 years), there was no mortality. Symptoms improved and function remained normal in all but 1 patient. He had sustained multiple infarcts in the anomalous artery's distribution and required transplantation despite repair. CONCLUSIONS: Repair is indicated in all patients with coronary insufficiency and in asymptomatic patients with high-risk morphologic abnormalities. We recommend unroofing when an intramural component (or slit-like orifice) is present, reimplantation for separate ostia without an intramural course, and pulmonary artery translocation for single ostium without an intramural course. Coronary artery bypass grafting is thus avoided.

The extracardiac conduit Fontan operation using minimal approach extracorporeal circulation: early and midterm outcomes.

OBJECTIVE: Our approach to the extracardiac conduit Fontan operation has evolved over time from full-pump, to partial-pump, to completely off-pump. This study is designed to report our overall experience with the extracardiac conduit Fontan operation and to evaluate the evolution in bypass technique on postoperative outcomes. METHODS: From September 1992 to April 2005, 285 patients, median age 4.5 years (1.4-44 years), median weight 16 kg (9.4-94 kg), underwent a primary extracardiac conduit Fontan procedure. Early and late outcomes were analyzed for the entire cohort and for 2 patient groups depending on whether an oxygenator was used in the bypass circuit (166 patients; 58%) or not (119 patients; 42%). RESULTS: Early failure (including death and takedown) occurred in 7 patients (2.5%). Prevalence of new early postoperative sinus node dysfunction necessitating a permanent pacemaker was 0.4%, and that of new tachyarrhythmias necessitating discharge home on a regimen of antiarrhythmia medications was 2.5%. Ten-year actuarial freedom from Fontan failure, new sinus node dysfunction necessitating a permanent pacemaker, and reoperation for conduit thrombosis or stenosis was 90%, 96%, and 98%, respectively. Fenestration rate was lower (P = .001) in the no-oxygenator group (8%) than in the oxygenator group (25%). Patients in the no-oxygenator group had lower intraoperative Fontan pressure (12.0 +/- 2.3 vs 13.5 +/- 2.4 mm Hg, P < .001), common atrial pressure (4.6 +/- 1.8 vs 5.3 +/- 1.8 mm Hg, P = .003), and transpulmonary gradient (7.5 +/- 2.1 vs 8.3 +/- 2.2 mm Hg, P = .013) than did the oxygenator group. CONCLUSIONS: The extracardiac conduit Fontan operation coupled with minimal use of extracorporeal circulation is associated with favorable intraoperative hemodynamics, low fenestration rate, minimal risk of thrombosis or stenosis, and minimal early and late rhythm disturbance.