Preliminary Experience With the Use of an Extracellular Matrix to Augment the Native Pulmonary Valve During Repair of Tetralogy of Fallot.

BACKGROUND: During repair of tetralogy of Fallot (TOF), when a transannular patch is needed in case of a small annulus and dysplastic pulmonary valve, we chose to reconstruct the right ventricular outflow tract by augmenting the divided anterior leaflet with an extracellular matrix (ECM) patch to produce a competent valve. In this study, we present our preliminary experience and early outcomes. METHODS: From March 2013 to December 2015, of the 206 patients who underwent primary repair of TOF, 52 required a transannular incision. The median age was 18 months and the median weight was 8.2 kg. The native hinge mechanism of the valve was preserved by dividing only the anterior leaflet at the time of the transannular incision and augmenting it with an ECM patch that was sutured to the endocardium and to the divided leaflet. RESULTS: Two patients died due to reasons not related to the use of the patch. Intraoperative evaluation showed a competent pulmonary valve without significant outflow gradient. During early follow-up (median 20 months), all patients were doing well without any decongestive therapy. Valve regurgitation was assessed as severe in 2, moderate in 26, and mild in 22 patients. In the majority of patients, the valve appeared thin and pliable in spite of mild to moderate regurgitation. CONCLUSIONS: Early experience with the use of ECM in repair of TOF shows satisfactory outcomes. It does not show obvious growth of the material. Long-term follow-up will be required in order to assess whether the valve function is durable without acquisition of significant regurgitation.

Sternal traction: simple technique to prevent tamponade/compression of the heart.

Routine closure of the sternum after cardiovascular surgery sometimes causes severe cardiac depression because of tamponade, leading to cardiogenic shock. We describe a full-thickness chest wall traction suture taken parasternally and tied to an intravenous fluid stand. Upward (outward) traction is applied to the anterior chest while the sternum is primarily closed, which allows physiologic improvement equivalent to delayed sternal closure. It is a safe and easily reproducible technique.

Total anomalous pulmonary venous connection beyond infancy.

Most patients with total anomalous pulmonary venous connection are operated on in infancy, with low mortality and morbidity, but in developing countries, we still encounter patients beyond infancy. We describe our experience in 26 patients aged 1-16 years (mean, 5.01 years), with total anomalous pulmonary venous connection, who underwent correction between June 2007 and December 2009. Eleven patients were >5-years old. Transthoracic echocardiography was diagnostic in all cases. Mean intensive care unit stay was 2.3 ± 0.87 days, and hospital stay was 9.23 ± 2.34 days. There were no early deaths and no major postoperative complications. Follow-up ranged from 10-40 months. Pulmonary artery pressure, as judged by echocardiography, reduced significantly in all patients. Repair of total anomalous pulmonary venous connection beyond infancy can be carried out safely with acceptable results.

New technique of off-pump atrial septostomy for complex congenital cardiac anomalies.

OBJECTIVES: Atrial septostomy is essential for palliation of some complex congenital cardiac anomalies, such as transposition of the great arteries and left-/right-sided atrioventricular valve stenosis or atresia. Conventionally, balloon atrial septostomy is done in neonates. Beyond the neonatal period, surgical septostomy is done using cardiopulmonary bypass and can lead to increased morbidity and mortality. We report a new technique of atrial septostomy without cardiopulmonary bypass and its follow-up. METHODS: Eleven cases underwent atrial septostomy without using cardiopulmonary bypass from January 2009 to June 2010. Median age of patients was 7 months (2-12 months) and median weight was 6.3 kg (range 4.5-10 kg). Surgical septostomy was performed through the right atrial appendage with a Tubb's dilator, aided by intra-operative transesophageal echocardiography. Atrial septal defect (ASD) less than 5mm was enlarged with a Kerrison bone punch and then dilated with a Tubb's dilator. Associate procedures performed were off-pump Glenn in seven cases, pulmonary artery (PA) banding in three cases, and shunt with PA band in one case. RESULTS: All the restricted ASDs were successfully enlarged with adequate interatrial shunting without any gradient. Echocardiography revealed no evidence of introduction of air or particulate emboli, and no tricuspid valve injury or heart block. There was no postoperative mortality. Follow-up ranged from 1 to 18 months (median 11 months). Echocardiography showed good PA band gradient/well-functioning Glenn shunt and unobstructed ASD with good oxygen saturation. CONCLUSIONS: This technique demonstrates the surgical feasibility of a beating-heart atrial septostomy. It avoids the adverse effects of cardiopulmonary bypass, reduces morbidity, and has no mortality. It is safe, economical, and easily reproducible. To our knowledge, this technique has not been reported in literature so far.

Venoatrial shunt-assisted cavopulmonary anastomosis.

The bidirectional Glenn shunt operation is conventionally performed under cardiopulmonary bypass. Between June 2007 and September 2009, 218 consecutive patients underwent off-pump bidirectional Glenn shunt institution for single ventricle with pulmonary stenosis complex. Their mean age was 4.72 ± 1.80 years (range, 4 months to 6 years) and median weight was 10.12 kg (range, 4.1-19 kg). A temporary shunt was created between the innominate vein and the right atrium, with a 3-way connector for de-airing. Fifty-five patients had bilateral cavae. The mean internal jugular venous pressure on clamping the superior vena cava was 24.69 ± 1.81 mm Hg. Continuous end-tidal CO2 and O2 saturation were monitored. Adequate oxygen saturation and blood pressure were maintained by optimizing inotropics, volume, and inspired oxygen. The mean duration of ventilation was 10.17 ± 8.96 h (range, 1-73 h). There were no gross neurological complications. Postoperative pleural effusion developed in 6 (2.75%) patients, and 4 (1.83%) had nodal rhythm. Four (1.83%) patients died in the immediate postoperative period due to low cardiac output syndrome. Venoatrial shunt-assisted bidirectional Glenn shunt surgery can be performed safely by optimizing intraoperative management strategies. It is economical and avoids the deleterious effects cardiopulmonary bypass.

Veno-venous shunt-assisted cavopulmonary anastomosis.

OBJECTIVE: The bidirectional Glenn shunt is commonly performed under cardiopulmonary bypass for conditions that lead to a single ventricle repair. We report our experience of bidirectional Glenn shunt done without cardiopulmonary bypass. METHODS: Between June 2007 and May 2009, 186 consecutive patients underwent off-pump bidirectional Glenn shunt for a variety of complex cyanotic congenital heart defects. Age ranged from four months to six years and the median weight was 11.17 kg (range 4.3 - 18). After systemic heparinization, the procedure was done by creating a temporary shunt between the innominate vein and the right atrium connected across a three way connector for de-airing. Fifty one patients had bilateral cavae. All cases underwent complete clinical neurological examination. RESULTS: No case required conversion onto cardiopulmonary bypass. Four patients (2.14%) died in the immediate postoperative period. The mean internal jugular venous pressure on clamping the decompressed superior vena cava was 24.69 +/- 1.81 mm Hg. There was no intra-operative hemodynamic instability and oxygen saturation was maintained at more than 70% throughout. Post Glenn shunt, the saturations improved to mid 80s. Seventy four cases had documented forward flow across the pulmonary valve. The mean duration of ventilation was 10.17 +/- 8.96 hours and there were no neurological complications. Six patients (3.22%) developed pleural effusions, 4 patients (2.15%) had nodal rhythm and 9 patients (4.83%) had superficial sternal wound infection. CONCLUSIONS: Our results show that off-pump bidirectional Glenn shunt can be done safely in patients not requiring associated intra-cardiac correction. It avoids cardiopulmonary bypass and its related complications, is economical and associated with excellent results. In our opinion, this is the largest series of off-pump bidirectional Glenn shunt in the literature.

Off-pump Kawashima operation.

We describe the technique of Kawashima repair without using cardiopulmonary bypass in 6 consecutive patients of single ventricle morphology with interrupted inferior vena cava and pulmonary stenosis. No patient had central nervous system disorder or chylothorax. The off-pump technique is feasible in Kawashima repair. This technique avoids use of cardiopulmonary bypass, thereby preventing its deleterious effects, which is also economical.

Sternotomy approach for modified Blalock-Taussig shunt: is it a safe option?

Central aorta-pulmonary artery shunts have fallen into disfavor because of shunt thrombosis and congestive heart failure, and a modified Blalock-Taussig shunt via thoracotomy can lead to pulmonary artery hypoplasia and distortion. We reviewed the outcomes of a modified Blalock-Taussig shunt by a sternotomy approach in 20 infants from July 2007 to October 2009. Their mean age was 5.79 months, and median weight was 5.4 kg. A 4-mm graft was placed in 11 patients, a 5-mm graft in 8, and a 3.5-mm graft in 1. There was no incidence of sepsis, seroma, or phrenic nerve palsy. There was one hospital death. The mean hospital stay was 10.4 +/- 4.3 days (range, 8-15 days). The mean oxygen saturation at discharge was 89% (range, 81%-93%). The sternotomy approach is technically easier to perform, cosmetically preferable, and probably hemodynamically superior. Correction of branch pulmonary stenosis is easily incorporated into this procedure. The theoretical disadvantage of this method is a potential technical difficulty with sternal reentry for subsequent procedures.

Tricuspid valve repair with neopapillary muscle from right ventricular trabecula.

Congenital abnormalities of the tricuspid valve without downward displacement of the septal and posterior tricuspid leaflets are uncommon causes of tricuspid regurgitation. Progressive tricuspid regurgitation can lead to right heart dilatation, arrhythmia, and irreversible deterioration of right ventricular function. Tricuspid valve repair is an important method to stabilize symptomatic children because tricuspid valve replacement has a poor prognosis. We report the successful use of right ventricular trabecula as a "neopapillary muscle" for treating severe low-pressure tricuspid regurgitation in children.

Are trauma patients better off in a trauma ICU?

UNLABELLED: There is very little data on the value of specialized intensive care unit (ICU) care in the literature. To determine if specialize ICU care for the trauma patient improved outcomes in this patient population. Level I Trauma Center Compared outcomes of trauma patients treated in a surgical trauma ICU (STICU) to those treated in non- trauma ICUs (non-STICU). Retrospective review of trauma registry data. STATISTICAL ANALYSIS: Wilcoxon Rank Test, Fischer's Exact test, logistic regression. There were 1146 STICU patients compared to 1475 non-STICU. In all ISS groups there were more penetrating trauma patients in the STICU (32.54% STICU vs. 18.15% non-STICU, P<0.0001 (ISS< 15)), (21.03% STICU vs. 12.98% non-STICU, P=0.0074 (ISS between 15-25)), and (19.42% STICU vs. 11.35% non-STICU, P=0.0026 (ISS> 25)). All groups had similar lengths of stay. The blunt trauma patients were sicker in the STICU (20.8 ISS +/- 12.2 STICU vs. 19.7 ISS +/- 11.9 non-STICU, P=0.03) yet had similar outcomes to the non-STICU group. Logistic regression identified penetrating trauma and not ICU location as a predictor of mortality. Sicker STICU patients do as well as less injured non-STICU patients. Severely injured patients should be preferentially treated in a STICU where they are better equipped to care for the complex multi-trauma patient. All patients, regardless of location, do well when their management is guided by a surgical critical care team.

Suprahepatic approach for peritoneal dialysis in neonatal cardiac surgery.

For peritoneal dialysis of neonates after cardiac surgery under cardiopulmonary bypass, a Tenckhoff catheter was inserted via the sternotomy wound and guided suprahepatically into the abdomen. The technique was used in 84 neonates and found to be safe, simple, and reproducible.

Repair of total anomalous pulmonary venous connection in early infancy.

From May 1995 through October 2001, 19 infants less than 90 days old underwent surgical correction of total anomalous pulmonary venous connection. In 15 babies with isolated total anomalous pulmonary venous connection, there was one operative death. In 4 with complex anomalies, there were 2 operative deaths. The vertical vein was not ligated in 6 cases for various reasons. Two patients died during reoperation for early pulmonary venous obstruction. In the late follow-up, 2 babies required reoperation for late anastomotic stricture; one needed additional balloon dilatation. Of the 14 surviving patients, one had a small residual gradient and infrequent supraventricular tachycardia, the others were asymptomatic and without gradients. Surgical correction of total anomalous pulmonary venous connection can be carried out in early infancy with low mortality and morbidity. However, associated complex cardiac anomalies and small caliber pulmonary arteries and veins carry higher risks. Recurrent pulmonary venous obstruction and diffuse pulmonary vein stenosis are causes of early reoperation and poor surgical outcome.

Anomalous left coronary artery: modified direct aortic implantation.

The technique of direct transfer of an anomalous left coronary artery from the pulmonary artery to the aorta was modified. Using part of the lateral and anterior wall of the pulmonary artery as a flap in continuity with the coronary button as part of the transfer, a tension-free anastomosis is possible. This technique was employed in 3 consecutive infants, with good outcome.

Coarctation of the aorta in neonates and young infants: surgical experience.

A retrospective analysis of repair of aortic coarctation in young infants was conducted. Between April 1997 and December 2000, 21 patients under 4 months of age underwent repair of coarctation. Their mean age and weight were 41 42 days (range, 2 to 120 days) and 3.6 0.7 kg (range, 2.6 to 4.9 kg). The indications for surgery were congestive heart failure and/or shock. Diagnosis was made by 2-dimensional echocardiography with Doppler color flow imaging. Preoperative gradients ranged from 25 to 100 mm Hg. Aortic arch hypoplasia was present in 8 patients; 7 patients also had ventricular septal defect. Wide excision of the coarctation segment with extended end-to-end anastomosis was performed in 20 patients, while 1 required a Gore-Tex interposition graft between the left common carotid artery and the descending aorta. Subclavian angioplasty was performed to augment the anastomosis in 1 patient. There was no early mortality. One patient died 2 months after surgery. Follow-up examination revealed recoarctation in 5 patients (23.8%), all of whom underwent successful balloon dilatation. In conclusion, wider excision of the coarctation with extended end-to-end anastomosis reduces the chances of recoarctation. Percutaneous balloon angioplasty for treating recoarctation is effective in immediately reducing pressure gradients.