Multiple ventricular septal defects: a new strategy.

INTRODUCTION: A multicenter prospective study was conducted to evaluate a new strategy for multiple Ventricular Septal Defects (VSDs). MATERIALS AND METHODS: From 2004 to 2012 17 consecutive children (3 premature, 14 infants), mean age 3.2 months (9 days-9 months), mean body weight 4.2 kg (3.1-6.1 kg), with multiple VSDs underwent Pulmonary Artery Banding (PAB) with an adjustable FloWatch-PAB(®). Associated cardiac anomalies included patent ductus arteriosus (1), aortic coarctation (2), hypoplastic aortic arch (2), and left isomerism (3). Five patients (5/17 = 29.4%) required pre-operative mechanical ventilation, with a mean duration of 64 days (7-240 days) RESULTS: There were no early or late deaths during a mean follow-up of 48 months (7-98 months), with either FloWatch removal or last observation as end-points. FloWatch-PAB(®) adjustments were required in all patients: a mean of 4.8 times/patient (2-9) to tighten the PAB, and a mean of 1.1 times/patient (0-3) to release the PAB with the patient's growth. After a mean interval of 29 months (8-69 months) 10/17 (59%) patients underwent re-operation: 7/10 PAB removal, with closure of a remaining unrestrictive VSD in 6 (peri-membranous in 3 patients, mid-muscular in 2, and inlet in 1) and Damus-Kaye-Stansel, bi-directional Glenn, and atrial septectomy in 1; 3/9 patients required only PAB removal. All muscular multiple VSDs had closed in all 10 patients. PA reconstruction was required in 1/10 patient. In 5/7 of the remaining patients with the PAB still in situ, all muscular VSDs had already closed. The only 2 patients with persistent muscular multiple VSDs are the 2 patients with the shortest follow-up. CONCLUSION: This reproducible new strategy with an adjustable PAB simplifies the management of infants with multiple VSDs and provides the following advantages: (a) good results (0% mortality), delayed surgery with a high incidence (15/17 = 88%) of spontaneous closure of multiple muscular VSDs, and facilitated closure of residual unrestrictive VSD (peri-membranous, mid-muscular, or inlet) at an older age and higher body weight; PAB with FloWatch-PAB(®) and its subsequent removal can potentially be the only procedure required for Swiss cheese multiple VSDs without an associated peri-membranous unrestrictive VSD.

Complete atrioventricular septal defect: outcome of pulmonary artery banding improved by adjustable device.

OBJECTIVE: We sought to evaluate pulmonary artery banding in infants with complete atrioventricular septal defects. METHODS: From 2000 to 2009, 20 infants with complete atrioventricular septal defects underwent pulmonary artery banding because of unsuitable anatomy (unbalanced ventricles, associated lesions, or both) or clinical condition (infection, chronic lung disease, or noncardiac malformation). Patients were divided into 2 groups: the conventional PAB group (n = 13 [65%]; mean age, 74 ± 56 days [range, 6-187 days]; mean weight, 3.3 ± 1.1 kg [range, 2.1-5.8 kg]) and the FloWatch-PAB group (n = 7 [35%]; mean age, 111 ± 40 days [range, 81-187 days]; mean weight, 4.3 ± 1.2 kg [range, 3.2-6.1 kg]). There was no statistical difference in age or weight. Preoperative mechanical ventilation was required in 3 (23%) of 13 infants in the conventional PAB group and 5 (71%) of 7 infants in the FloWatch-PAB group (P < .05). RESULTS: Ten (77%) of 13 infants in the conventional PAB group died versus 0 (0%) of 7 infants in the FloWatch-PAB group (P < .001). Sternal closure was delayed in 6 (46%) of 13 infants in the conventional PAB group and 0 (0%) of 7 infants in the FloWatch-PAB group (P < .05). The mean duration of mechanical ventilation, intensive care unit stay, and hospital stay was significantly longer (P < .05) in the conventional PAB group than in the FloWatch-PAB group (21 ± 17 days [range, 4-61 days] vs 3 ± 2 days [range, 1-8 days], 22 ± 18 days [range, 5-61 days] vs 7 ± 6 days [range, 2-21 days], and 54 ± 12 days [range, 40-71 days] vs 29 ± 25 days [range, 9-81 days], respectively). Left atrioventricular valve regurgitation increased (mild to moderate) in 2 infants in the conventional PAB group and decreased (severe to moderate) in 2 infants in the FloWatch-PAB group. Six of 10 survivors (1 in the conventional PAB group and 5 in the FloWatch-PAB group) underwent pulmonary artery debanding and repair after a median interval of 125 days (range, 34-871 days); 4 of 10 are awaiting repair. CONCLUSIONS: In selected patients with complete atrioventricular septal defects, pulmonary artery banding followed by late repair is a viable alternative strategy. In our study the FloWatch-PAB device resulted in improved survival and made later repair possible in a better clinical state.

Predictors of permanent pacemaker implantation during the early postoperative period after valve surgery.

The ability to preoperatively identify patients who may require permanent pacemaker implantation is rather poorly understood. The aim of this study is to determine the current incidence of permanent pacing after valve surgery and to determine which factors place the heart valve patient at risk of requiring permanent pacemaker implantation. We audited the records of 2,392 consecutive adult patients who underwent cardiac valve surgical procedures by the same surgical team from 25 April 1998 through 31 March 2003. Of these, 118 patients (group A) required the postoperative implantation of permanent pacemakers during the same hospitalization; they were compared with 1,959 heart valve patients (group B) who did not require pacemaker placement. Multivariate logistic regression analysis showed that reoperations (odds ratio [OR], 8.23; P <0.001), longer cumulative cross-clamp times (OR, 5.9; P <0.001), multiple-valve surgical procedures (OR, 3.46; P <0.05), and absence of preoperative sinus rhythm (OR 2.52; P <0.001) were independent predictors of the need for permanent pacemaker implantation after valve surgery. These results suggest that patients who display these risk factors for arrhythmias that require permanent pacemaker implantation receive closer observation and advance counseling about the likelihood of such implantation.

Does the type of prosthesis influence the incidence of permanent pacemaker implantation following isolated aortic valve replacement.

BACKGROUND: The incidence of conduction disorders requiring permanent pacing (PPM) in patients operated on for aortic valve replacement (AVR) has been reported to be 5.7%. However, perioperative risk predictors for PPM following AVR are not well characterized and debate exists regarding selection of the prosthesis-type most likely to minimize this incidence. The aim of the study was to assess whether the type of the prosthesis used influences the prevalence of PPM following aortic valve replacement. METHODS: A total of 782 consecutive patients with predominant aortic stenosis accepted for isolated non-emergent AVR were studied over a 3 year period; of which 305 patients (Group A) received mechanical prostheses, 335 received stented tissue prostheses (Group B), and the remaining 142 received stentless tissue valves (Group C). A stepwise logistic regression analysis was used to identify the independent predictors for PPM and statistical significance was accepted at a level of P < .05. RESULTS: Univariate and multivariate analyses showed a significant relationship between the preoperative factors (poor ejection fraction < 35%; P < .001), left atrial enlargement (LAE; P < .001) and left bundle branch block (LBBB; P < .001), the perioperative variables (bypass time > 100 minutes with x-clamp time > 70 minutes; P < .001) and the incidence of PPM. CONCLUSIONS: The proposed predictive model correlated highly with actual pacemaker use, suggesting that the requirement for PPM results from either operative trauma or increased ischemic burden and the incidence of PPM is independent of prosthesis-type implanted.

The complications of repeat median sternotomy in paediatrics: six-months follow-up of consecutive cases.

Repeat median sternotomy in paediatrics though associated with increased perioperative risks, yet the incidence of injury to the underlying structures during sternal re-entry is poorly quantified. We reviewed 108 patients undergoing repeat sternotomies (group-I) and a control group of 516 patients undergoing first time sternotomy (group-II) over six years with six-months follow-up. Overall mean age was 17 months (range 1 day-16 years). Uncontrollable bleeding was encountered in 4 patients (3.7%), non-fatal cardiac laceration in 10 (9.2%), minor injuries to aorta in 7 (6.4%) and right atrium in 8 (7.4%) in Group-I. Forty-one times (38%) pericardial sac was closed and 55 times (51%) artificial materials (Dacron/Gortex) were used in initial procedures. The incidence of injuries during sternal re-entry was significantly lower in those patients where pericardial sac was closed initially (P<0.001). Hospital mortality was 3.7% in Group-I and 2.7% in Group-II, however, overall survival was 95% (group-I) and 97% (group-II) at 6 months' follow-up. Complete heart block, neurological problems and persistence of shunts being the most common reported morbidities in both groups. In conclusion, low incidence of morbidity and mortality in repeat median sternotomy is possible with careful surgical approach. The closure of pericardial sac in initial procedure provides many potential and practical advantages with regard to lesser trauma to underlying structures.

Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure.

OBJECTIVE: The application and timing of hemofiltration (continuous veno-venous hemofiltration, CVVH) in patients with acute renal failure (ARF) post cardiac surgery has been called into question because of uncertain short-term outcome. The aim of the present study was to identify how the timing of introduction of hemofiltration affects the morbidity and mortality in patients with ARF after cardiac surgery. METHODS: 1264 consecutive patients who underwent adult cardiac surgical procedures performed between January 2002 and January 2003 were audited. Out of these, case notes of 64 patients who required renal supportive intervention were reviewed. Statistical significance was accepted at a level of P<0.05. RESULTS: Of the 64 (5%) patients, who developed ARF and required CVVH, there were 48 males and 16 females. Mean age was 70+/-6.8 years. The hospital mortality was 43% (12 patients) in Group-I and 22% (8) in Group-II (P<0.05), giving an overall 1.5% mortality associated with ARF. The mean time between the operation and the initiation of CVVH was 2.55+/-2.2 days in Group-I and 0.78+/-0.2 days in Group-II (P<0.001). The mean duration of CVVH was 4.57+/-11.4 days in Group-I and 4.61+/-2.0 days in Group-II (P=NS). Older age (P=0.013), elevated preoperative creatinine (P=0.002), postoperative pulmonary oedema (P=0.01), sepsis (P=0.001), multiple organ failure (P=0.031), hypotension (P=0.031) and preoperative renal failure (P<0.05) were the independent factors influencing the poor postoperative outcome and cardiac instability. CONCLUSION: Early and aggressive use of CVVH is associated with better than expected survival in severe ARF after cardiac operations.