The warden procedure through a posterolateral thoracotomy approach.

The Warden procedure for the correction of a right-sided partial anomalous pulmonary venous connection to the high superior vena cava is well established. It has the advantages of avoiding sinoatrial node dysfunction and pulmonary and systemic venous obstruction. In the case related here, a 3-year-old girl presented with a superior vena cava type of sinus venosus atrial septal defect and an anomalously draining right upper pulmonary vein, with bilateral superior venae cavae. Our approach to the Warden procedure was through a right posterolateral thoracotomy, which provided additional advantages.

Hybrid intraoperative pulmonary artery stenting in redo congenital cardiac surgeries.

OBJECTIVE: Reconstruction of branch pulmonary arteries (PAs) can be challenging in redo congenital heart surgeries. Treatment options like percutaneous stent implantation and surgical patch angioplasty may yield suboptimal results. We present our experience with hybrid intraoperative stenting which may be an effective alternative option. METHODS: We retrospectively analyzed data of all patients with PA stenosis who underwent intraoperative PA branch stenting in our institution between January 2011 and December 2012. RESULTS: Ten patients [6 females, median age 10 (1.4 to 37) years], underwent hybrid stenting of the PA. Primary cardiac diagnoses were pulmonary atresia with ventricular septal defect (VSD) in three patients, pulmonary atresia with intact ventricular septum in two, Tetralogy of Fallot (TOF) in one, Double outlet right ventricle (DORV) with pulmonary stenosis (PS) in one, complex single ventricle in two and VSD with bilateral branch PA stenosis in one patient. Concomitant surgeries were revision/reconstruction of RV-PA conduit in 4, Fontan completion in 4, repair of TOF with conduit placement in 1 and VSD closure in 1 patient. The left PA was stented in 7, the right in 2 and both in 1, with a total of 11 stents. There were no complications related to stent implantation. Two early postoperative deaths were unrelated to stent implantation. At mean follow-up period of 14.8 (12-26) months, stent position and patency were satisfactory in all survivors. None of them needed repeat dilatation or surgical reintervention. CONCLUSION: Hybrid stenting of branch PA is a safe and effective option for PA reconstruction in redo cardiac surgeries. With meticulous planning, it can be safely performed without fluoroscopy.

Convulsive syncope after bidirectional Glenn shunts: physiological implications for a neurological event.

OBJECTIVES: Neurological complications after cavopulmonary connections like bidirectional Glenn shunt and Fontan connection are occasionally encountered in the postoperative period. We discuss such a case of bilateral bidirectional Glenn shunt which developed convulsive syncope postoperatively. CASE: A 5-year-old cyanotic girl diagnosed as tricuspid atresia with pulmonary stenosis without any spell history underwent bilateral bidirectional Glenn shunt on the way to a subsequent Fontan. After an uneventful surgery she developed convulsive syncope on straining for defecation in the postoperative period. A thorough neurological and arrhythmia study failed to elicit any organic lesions. DISCUSSION: The diagnosis of a neurological event after a single ventricle palliation is paramount to its management. Differentiating syncope from a seizure has its own management implications. The etiologies of neurological complications are varied after cardiac surgery. The physiology and etiology of syncope and seizure after a cavopulmonary connection is discussed. The role of physiological factors in a situation of altered physiodynamics like a bidirectional shunt and Fontan has not been dealt with before in a clinical setting. We have discussed this case to understand the effects of these factors. The effects of strain on the systemic venous pressure, the pulmonary artery pressure and the intrathoracic pressure, can lead to a neurological event if balance is not maintained between the driving pressure of the systemic venous pressure and the pulmonary capacitance. We have devised a simple test to identify these subsets preoperatively by a modification of the Valsalva maneuver. CONCLUSION: Although neurological complications crop up occasionally after single ventricle palliation, not much in-depth analysis has been done regarding the physiological factors involved after such an altered physiology. The effects of systemic venous pressure, the pulmonary artery pressure and the intrathoracic pressure must be in harmony for proper functioning of the shunt; thus strain can alter physiodynamics to such an extent to manifest clinically as a neurological event. The modified Valsalva maneuver can be applied clinically as a 'biomarker' to identify a subset of patients prone for neurological complications.

Right ventricular mass: a histopathological surprise.

A 33-year-old woman in the postpartum period presented with a mass in the right ventricular outflow tract. She underwent excision of the mass under standard cardiopulmonary bypass. Histopathologic examination of the mass revealed a metastatic lesion from the thyroid, which was follicular carcinoma of the thyroid. Later she underwent total thyroidectomy with lymph node dissection of the neck and radioactive 131I ablation for the residual tumor in the neck. At 1-year follow-up, the patient has no evidence of residual lesion in the heart, neck, or anywhere else in the body. A detailed preoperative workup could have changed the order of interventions and probably avoided a heart operation.