Repair of traumatic avulsion of the right bronchus in children using extracorporeal membrane oxygenation support.

Traumatic avulsion of the right main bronchus in children is usually caused by blunt trauma or traffic accidents. Primary repair by suturing is the preferred treatment. Lesions are life threatening and urgent or emergency surgical repair is indicated. We report our experience with 2 cases of traumatic avulsion of right bronchus in children successfully suture repaired with the use of extracorporeal membrane oxygenation.

Posterior Nutcracker Phenomenon in a Patient with Left Atrial Isomerism.

Background Nutcracker phenomenon (NCP) can occur due to various anatomical anomalies. Anterior and posterior NCP are defined in the literature. Posterior NCP combined with left atrial isomerism is a rare condition. Case description We present a rare case of an asymptomatic posterior NCP involving the azygos vein in a patient with a complex cardiovascular pathology with left atrial isomerism, left ventricular outflow tract obstruction, interrupted inferior vena cava, and azygos continuation. Conclusion Detection of the NCP especially involving such a rare anatomical anomaly as an azygos continuation has a crucial importance for diagnostic and surgical procedures.

A randomized, parallel group, double-blind study of ticagrelor compared with aspirin for prevention of vascular events in patients undergoing coronary artery bypass graft operation: Rationale and design of the Ticagrelor in CABG (TiCAB) trial: An Investigator-Initiated trial.

BACKGROUND: For patients with coronary artery disease undergoing coronary bypass surgery, acetylsalicylic acid (ASA) currently represents the gold standard of antiplatelet treatment. However, adverse cardiovascular event rates in the first year after coronary artery bypass grafting (CABG) still exceed 10%. Graft failure, which is predominantly mediated by platelet aggregation, has been identified as a major contributing factor in this context. Therefore, intensified platelet inhibition is likely to be beneficial. Ticagrelor, an oral, reversibly binding and direct-acting P2Y12 receptor antagonist, provides a rapid, competent, and consistent platelet inhibition and has shown beneficial results compared with clopidogrel in the subset of patients undergoing bypass surgery in a large previous trial. HYPOTHESIS: Ticagrelor is superior to ASA for the prevention of major cardiovascular events within 1 year after CABG. STUDY DESIGN: The TiCAB trial (NCT01755520) is a multicenter, phase III, double-blind, double-dummy, randomized trial comparing ticagrelor with ASA for the prevention of major cardiovascular events within 12 months after CABG. Patients undergoing CABG will be randomized in a 1:1 fashion to either ticagrelor 90 mg twice daily or ASA 100 mg once daily. The study medication will be started within 24 hours after surgery and maintained for 12 months. The primary end point is the composite of cardiovascular death, myocardial infarction, stroke, and repeat revascularization at 12 months after CABG. The sample size is based on an expected event rate of 13% of the primary end point within the first 12 months after randomization in the control group, a 2-sided α level of .0492 (to preserve the overall significance level of .05 after planned interim analysis), a power of 0.80%, 2-sided testing, and an expected relative risk of 0.775 in the active group compared with the control group and a dropout rate of 2%. According to power calculations based on a superiority design for ticagrelor, it is estimated that 3,850 patients should be enrolled. SUMMARY: There is clinical equipoise on the issue of optimal platelet inhibition after CABG. The TiCAB trial will provide a pivotal comparison of the efficacy and safety of ticagrelor compared with ASA after CABG.

Proposing a novel technique to exclude the left ventricle with an assist device: insights from 4-dimensional flow magnetic resonance imaging.

OBJECTIVES: Left ventricular assist device (LVAD) implantation has become an effective treatment for end-stage heart failure patients. However, LVAD support disrupts the natural intracavitary blood flow path through the heart, introducing flow patterns potentially associated with thrombosis especially around the inflow cannula. We present initial insights into in vitro 4D flow magnetic resonance imaging (MRI)-based analysis of flow patterns and an enzyme-activated milk test in a porcine left ventricular (LV) model during LVAD support, in a standard implant technique and in combination with a novel cone-shaped LV sparing prosthesis. METHODS: 4D MRI of an LVAD-supported ex vivo porcine heart failure model was performed in a mock circulatory loop with an LVAD flow of 4.5 l/min. Two separate sets of hearts with an MR-compatible LVAD inflow cannula were used: one with a standard inflow via the pulmonary veins into the LV, one sparing the LV with the cone-shaped prosthesis sutured to the mitral annulus and the LVAD inflow cannula sparing the LV cavity. In correlation, an enzyme-activated milk test was performed to reveal locations of disturbed flows. Data were analysed visually and by performing a case-by-case analysis of flow patterns and enzyme activation locations. RESULTS: Using 4D flow MRI, the standard implant technique showed markedly altered flow patterns with flow velocity reduction in the LV cavity especially around the inflow conduit. The average flow velocity in the LV cavity was 12.8 ± 2.9 m/s. In contrast, the LV-sparing technique with a cone-shaped prosthesis showed faster and more organized flow of 36.3 ± 7.2 m/s on average to the LVAD inflow cannula. Compared with the standard technique, no recirculating blood flow components were detected. The enzyme-activated milk test confirmed the location and extent of helical and vertical flow patterns. CONCLUSIONS: For the first time, intracardiac flows in an LVAD setting have been shown in vitro based on a mock porcine ex vivo heart failure model by applying 4D flow MRI. Differences in flow characteristics of the same model using a prosthesis sparing the LV cavity are encouraging to further investigate their potential to reduce potential LVAD-associated side-effects, such as intracavitary clotting and its sequelae.

Is the Lecompte technique the last word on transposition of the great arteries repair for all patients? A magnetic resonance imaging study including a spiral technique two decades postoperatively.

OBJECTIVES: To compare the Lecompte technique and the spiral anastomosis (complete anatomic correction) two decades after arterial switch operation (ASO). METHODS: Nine patients after primary ASO with Lecompte and 6 selected patients after spiral anastomosis were evaluated 20.8 ± 2.1 years after ASO versus matched controls. Blood flow dynamics and flow profiles (e.g. vorticity, helicity) in the great arteries were quantified from time-resolved 3D magnetic resonance imaging (MRI) phase contrast flow measurements (4D flow MR) in addition to a comprehensive anatomical and functional cardiovascular MRI analysis. RESULTS: Compared with spiral reconstruction, patients with Lecompte showed more vortex formation, supranatural helical blood flow (relative helicity in aorta: 0.036 vs 0.089; P < 0.01), a reduced indexed cross-sectional area of the left pulmonary artery (155 vs 85 mm²/m²; P < 0.001) and more semilunar valve dysfunctions (n = 5 vs 1). There was no difference in elastic aortic wall properties, ventricular function, myocardial perfusion and myocardial fibrosis between the two groups. Cross-sectional area of the aortic sinus was larger in patients than in controls (669 vs 411 mm²/m²; P < 0.01). In the spiral group, the pulmonary root was rotated after ASO more towards the normal left position (P < 0.01). CONCLUSIONS: In this study, selected patients with spiral anastomoses showed, two decades after ASO, better physiologically adapted blood flow dynamics, and attained a closer to normal anatomical position of their great arteries, as well as less valve dysfunction. Considering the limitations related to the small number of patients and the novel MRI imaging techniques, these data may provoke reconsidering the optimal surgical approaches to transposition of the great arteries repair.

4D flow streamline characteristics of the great arteries twenty years after Lecompte and direct spiral arterial switch operation (DSASO) in simple TGA.

Transposition of the great arteries (TGA) is caused by discordance between the great arteries and the ventricles. If left untreated, this anomaly has a disastrous perspective. More recent surgical approach for correction includes the Lecompte technique in which the pulmonary bifurcation is transposed anterior to the aorta, which may be less physiologic. Although the early results are excellent, there is potential for future problems involving the great arteries and semilunar valves1. These potential problems necessitate the development of other improved surgical techniques2. Here we report an MRI 4D flow study related to a case of simple TGA whose primary surgical correction - direct spiral arterial switch operation (DSASO) - was performed twenty years ago in an attempt to restore physiologic arrangement among the great arteries and semilunar valves.

In vitro evaluation of physiological spiral anastomoses for the arterial switch operation in simple transposition of the great arteries: a first step towards a surgical alternative?

OBJECTIVES: The currently most frequently used technique for the arterial switch operation (ASO) in simple transposition of the great arteries (TGA) includes the transposition of the pulmonary artery anterior to the ascending aorta. This arterial arrangement is less anatomical, and although the initial results are excellent, some long-term data are indicating a certain risk of morbidity, encouraging the search for more physiological techniques. As a first step, we studied the feasibility of anatomical spiral anastomoses of the great vessels in vitro. METHODS: A TGA model was constructed to simulate the different spatial positions of the great arteries followed by ASO with physiological spiral connections of the great arteries. RESULTS: It was possible to perform a physiological spiral connection of the great arteries without tension or torsion when the roots of the great vessels were arranged anterior-posterior and with up to 35° rotation of the aortic root to the right around the pulmonary root. With further rotation of the aorta, patch plasties were required for pulmonary artery elongation. The maximal width of the patch was 5 mm. CONCLUSIONS: In this TGA model, it was possible to perform tension- and torsion-free arterial anastomoses for ASO without artificial material, when the aortic root was positioned from 0° up to 35° to the right of the pulmonary root. Evaluation of coronary transfer is the next step.

Risk stratification for adult congenital heart surgery.

OBJECTIVE: At this moment, no risk stratification models are available for adult congenital cardiac surgery. This study aims to identify a suitable stratification tool for the adult congenital heart surgery population. Pediatric congenital cardiac surgery score models were therefore tested in an adult congenital population. In addition, an age component was added to these models and performance was compared with the original score systems. METHODS: The Risk Adjustment in Congenital Heart Surgery (RACHS-1), Basic Aristotle Score, Society of Thoracic Surgeons (STS)-European Association for Cardiothoracic Surgery (EACTS) Score and Comprehensive Aristotle Score were calculated for all adult patients who underwent congenital cardiac surgery between January 1990 and January 2007 in a single center (N=963). In addition, an age component was added to these models. Discrimination was then tested for all models with and without the age component. RESULTS: Application of the original pediatric risk scores resulted in c-statistics for 30-day mortality of 0.60, 0.60, 0.60, and 0.66 respectively. Combining these models with the age component resulted in significantly higher c-statistics of 0.69, 0.70, 0.69, and 0.76 respectively. Age as a sole predictor already resulted in a c-statistic of 0.67. Comparable results were found for 1-year mortality. CONCLUSIONS: The discriminatory power of the pediatric risk scores was suboptimal, but increased when adding age as a score component. The best performance was achieved by the combination of age and the Comprehensive Aristotle Score, for both 30-day and 1-year mortality.

Seventeen years of adult congenital heart surgery: a single centre experience.

OBJECTIVE: With a growing number of children with congenital heart disease (CHD) reaching adulthood, an extensive experience with cardiac surgery in adults with CHD is accumulating. To increase insight in this patient category we report our 17-year single centre experience including predictors for adverse outcome and EuroSCORE performance. METHODS: Patients and operative characteristics of all consecutive adult CHD patients operated upon between January 1990 and January 2007 were collected. Categorisation was done according to the EACTS/STS congenital database. Early and late morbidity and mortality were assessed with follow-up extending up to 17 years. EuroSCORE performance was assessed. RESULTS: Nine hundred and sixty-three procedures were performed in 830 patients (mean age 39.3 years, 50.3% male). A total of 49% were re-do procedures, frequent procedures were for left heart lesions (37%), right heart lesions (31%) and septal defects (8%). The 51% primary procedures largely consisted of less complex procedures but also included 1.4% of tetralogy of Fallot repairs, 4.1% of aortic coarctation repairs and 2.7% of Ebstein's disease repairs. Thirty-day mortality was 1.5% (n=14); predicted mortality by logistic EuroSCORE was 4.6%. c-index was 0.61 (95% CI 0.46-0.75). Major complications such as tamponade requiring intervention occurred in 3.2%, postoperative bleeding requiring re-exploration in 7.1% and renal insufficiency requiring dialysis in 4 (0.4%). Pulmonary hypertension was a strong predictor for short-term mortality; impaired ventricular function and cyanosis for long-term mortality. Overall 17-year survival was 71% (95% CI 61%-82%). Eighty percent of patients were in NYHA class I at last follow-up, 17% in II, 3% in III, 0% in IV. CONCLUSIONS: Surgery in adult CHD patients can be performed with low operative mortality and good clinical outcome. EuroSCORE is not a good model for risk assessment in this group of patients.