Is device closure for direct access valved stent implantation safe?

OBJECTIVE: Despite the progress made in the development of valved stents for trans-apical valve replacement, a reliable closure of the access orifice remains a major issue. The present study was designed to evaluate if device closure of the ventricular wall is safe. MATERIALS AND METHODS: Transventricular access for pulmonary valve replacement was simulated with a 26F sheath and the resulting orifice was closed with an Amplatzer Muscular VSD Occluder (AMuscVSDO) in chronic sheep experiments (body weight 45-48 kg). Mean procedure time, blood loss, and standard hemo-dynamics were recorded. The animals were sacrificed electively and the histopathological changes in and around AMuscVSDO in the right ventricular wall were systematically studied by semi-quantitative analysis of collagenisation, inflammatory response and 'resorptive' process. RESULTS: Mean procedure time was 31+/-10.7 min, blood loss was 22.5+/-8.7 ml, heart rate was 123+/-22.6 bits/min before and 128+/-28.7 bits/min after, mean arterial blood pressure was 88+/-16.7 mm Hg before and 82.6+/-18.3 mm Hg after the procedure. Mean survival was 5.3 weeks. The collagen and scar formation studies revealed three different periods: (1) initial fibrosis (0-3 weeks); (2) so-called 'capsulation' (3-9 weeks after the implantation of the Occluder); and (3) final remodelling and differentiation (9 weeks). The fabric inside the Occluder played the role of a collagenisation promoter, active from the 3rd week till it vanishes. Inflammation plays a role as a temporary reaction (0-3 weeks) during the healing process, with no signs of any active, focal or circumscribed, myocardial damage. CONCLUSIONS: (1) The closure of the free ventricular wall perforation with AMuscVSDO is safe due to the scar tissue resulting from the healing process around and in the device. (2) The myocardial healing around and inside an implanted AMuscVSDO represents two processes: extensive fibrosis ensues around metallic wires with the progression towards the inside of the myocardium, whereas inside AMuscVSDO the loose connective tissue fills the myocardial lesion. During cicatrisation, the fabric elements of AMuscVSDO act as the ground for collagen formation and fibroblast proliferation. (3) The cicatrisation processes after ventricular AMuscVSDO implantation show remodelling, with rearrangement of collagen fibres architecture and distribution.

Congenital heart defect with associated malformations in children.

BACKGROUND: Children with multisystem involvement including congenital heart defect (CHD) are a very salient problem. The purpose of this study was to evaluate the incidence of CHD associated with malformations of other systems and to assess the modalities of treatment and perioperative mortality among patients referred to the department of pediatric cardiac surgery. METHODS: The medical records of 1856 children were reviewed retrospectively from 1997 to 2002 to establish CHD and types of associated malformations. The connections between CHD and other lesions were investigated. Furthermore, the influence of patient and perioperative variables on mortality risk was scrutinized. Univariate and multivariate analyses were used. RESULTS: Eighty-four children (4.53%) had CHD and associated malformations. The malformations of digestive (35.7%), urinary (22.4%), and nervous (14.3%) systems were the most frequently observed associated defects. No relation was found between CHD and concomitant lesions. The results of multivariate logistic regression showed significant influence of patient age, primary cardiac procedure, and CHD type on mortality (ca 19%) in children with multiorgan lesions. CONCLUSIONS: The treatment of children with CHD and associated multiple lesions is connected with higher mortality risk. The following factors: younger age, urgency of surgical procedure, and primary surgical procedure had negative impact on patient's outcome. However, these risks in certain cases are inevitable. The cardiac procedure preceding the surgical operation may improve the overall effect of treatment because of circulatory stabilization, provided that the condition of the patient does not preclude any intervention at all.

[Ross operation using "contegra" conduit in a 5 year old girl with severe aortic valve insufficiency in Kawasaki disease coexisting with infective endocarditis--a case report]. / Ciezka niedomykalnosc aortalna w chorobie Kawasaki wspólistniejaca z bakteryjnym zapaleniem wsierdzia u 5-letniego dziecka. Operacja Ross'a z zastosowaniem Conduitu "Contegra".

A case of a 5-year-old girl with severe dysfunction of aortic valve in Kawasaki disease coexisting with endocarditis, is described. The role of Ross operation in the treatment of this condition is discussed. The 18-months follow-up showed good function of aortic valve and "Contegra" conduit (bovine jugular vein), but long-term follow-up of patients with "Contegra" conduit remains unknown. In conclusion, a Ross operation using "Contegra" conduit in pulmonary position could be effective method in the treatment of dysfunction of aortic valve in Kawasaki disease coexisting with endocarditis in children.

Improved outcome with composite graft versus homograft root replacement for children with aortic root aneurysms.

OBJECTIVE: Review of surgical repair of aortic root aneurysms using composite graft or homograft in children. METHODS: A consecutive series of 34 children (mean age 10.8+/-5.4 years) who underwent elective aortic root replacement using composite graft or homograft from 1987 to 2003 (mean follow-up 5.7+/-3.7 years). RESULTS: Preoperatively, the aortic annulus and aortic root average z-scores were 4.1+/-2.2 and 9.4+/-4.7, respectively. Composite graft root replacement was performed in 22 patients, and cryopreserved aortic homograft root replacement in 12 patients. There was one perioperative death in the homograft group due to sudden cardiovascular collapse. There was one late death in the composite graft group due to acute aortic dissection, and two late deaths in the homograft root replacement group, one at 7 months postoperatively due to coronary artery thrombosis and one due to severe chronic myocardial dysfunction 5 years postoperatively. One patient who initially had a homograft died due to mechanical valve thrombosis following reoperative composite graft replacement. Five patients had reoperations at a median of 7.1 years after initial surgery. One patient in the composite graft group underwent arch replacement. There were no graft related reoperations after composite graft root replacement, but 4 patients in the homograft group had reoperative composite graft replacement. Predictors of reoperation included age at surgery, lower weight, and longer ICU time (P<0.05). CONCLUSIONS: In children with aortic root aneurysms, reoperation is more common after homograft root replacement than composite graft replacement. Composite graft root replacement provides more stable repair of the aortic root.

Arterial switch operation in neonates with complex congenital heart defects.

The aim of the study was to analyze short-term results of the arterial switch operation in 29 neonates with simple transposition of the great arteries (group A) and 18 (group B) with complex heart defects: transposition with a ventricular septal defect (10), coarctation of the aorta (5), or Taussig-Bing anomaly (3). The operations were usually performed on the 7th day of life (2nd-30th day), after a Rashkind procedure when necessary. The mean weight was 3,530 +/- 780 g, body surface area was 0.219 +/- 0.032 m(2). Delayed sternal closure was necessary in 7 patients from group A (24%) and 8 from group B (44%) because of hemodynamic instability after weaning from extracorporeal circulation; these neonates had significantly lower body weights and smaller body surface areas. Perioperative mortality was 13.8% (4 patients) in group A and 27.8% (5 patients) in group B. Correction of complex transposition tends to be associated with a higher operative risk than simple transposition, but the difference was not significant.