Early Outcome of Simplified Standardized Trileaflet Polytetrafluoroethylene Valved Conduit Placement.

BACKGROUND: Use of the expanded polytetrafluoroethylene (ePTFE) valved conduit in the pulmonary position during the correction of congenital heart defects has significantly increased in popularity over the last decade due to its promising conduit longevity. We describe the standardized process to create and implant a trileaflet ePTFE pulmonary conduit along with the early outcomes of such procedures at our institute. METHODS: Records of 100 consecutive patients who underwent ePTFE valved conduit placement using our technique from April 2018 through February 2022 were retrospectively analyzed. The function of the conduit was evaluated by transthoracic echocardiography. RESULTS: The mean age of the patients was 28 ± 13.2 years old at the time of the operation. The conduit diameters ranged from 16 to 24 mm (mean 23.0 ± 1.9 mm). Conduit placement was utilized for pulmonary valve replacement in 68 patients, conduit change in 25 patients, and as a part of total repair in 7 patients. There were 2 in-hospital conduit-unrelated deaths from multi-organ dysfunction and pulmonary hypertensive crisis. From the postoperative echocardiography, the average peak pressure gradient across the conduit was 18.6 ± 9.0 mm Hg, and the conduit regurgitation was graded as none or trace in 81 patients, mild in 17 patients, and moderate in 2 patients. At 589 days of median follow-up, there was no conduit reoperation. Follow-up imaging of 60 available patients at a median time of 511 days did not show a significant change in conduit function. CONCLUSIONS: Our standardized ePTFE valved conduit creation and placement demonstrated satisfactory clinical and echocardiographic outcomes.

Long-term outcomes of repaired and unrepaired truncus arteriosus: 20-year, single-center experience in Thailand.

BACKGROUND: Truncus arteriosus (TA) is a complex congenital heart disease that carries morbidities in the first year of life. Previous authors have reported an operative mortality of 50%. In this report, we aim to report on the survival of patients with TA in our medical center in the recent era. METHODS: A retrospective review of all patients diagnosed with TA in Siriraj Hospital, Thailand from August 1995 to March 2018 was performed. Patients with single ventricle, hemiTA were excluded. The characteristics and outcomes of repaired and unrepaired TA patients with a known recent functional status in 2018 were reviewed. Operative mortality risks were analyzed using a multivariate model. RESULTS: A total of 74 patients (median age at referral: 70 days) were included in the cohort. One-third of the patients had associated anomalies including DiGeorge syndrome (13.5%). Anatomical repair was not performed in 22 patients (29.7%). The median age at time of repair for the 52 patients was 133 days (range: 22 days to 16.7 years). Complex TA was 10%. Early mortality occurred in 16 patients (30.8%). Five patients (9.6%) had late deaths at 0.3-1.2 years. Significant mortality risk was weight at time of operation <4 kg (HR 3.05, 95% CI [1.05-8.74], p-value 0.041). Of the 31 operation survivors, 17 required re-intervention within 0.4-11.4 years. Eight patients had reoperation at 8.7 years (range: 2.7-14.6 years) post-repair. Freedom from reoperation was 93%, 70.4%, and 31%, at 5, 10, and 15 years, respectively. All late survivors were in functional class I-II. Of the 22 unrepaired TA patients, 11 patients (50%) died (median age: 13.6 years; range: 14 days-32.8 years). Survival of unrepaired TA patients was 68.2%, 68.2%, and 56.8, at 5, 10, and 15 years of age, respectively. At the end of study, 11 survivors of TA with palliative treatment had a recent mean oxygen saturation value of 84.1 ± 4.8% and a mean weight for height of 81.4 ± 12.7%, which were significantly lower than those of 31 late-survivors who had undergone anatomical repair. CONCLUSION: Contemporary survival rates of patients with TA following operation in the center has been gradually improved over time. Most of the operative mortality occurs in the early postoperative period. Compared to patients with TA who had palliative treatment, operative survivors have a better functional status even though they carry a risk for re-intervention.

Current era outcomes of pulmonary atresia with ventricular septal defect: A single center cohort in Thailand.

Pulmonary atresia with ventricular septal defect (PA/VSD) is a complex cyanotic congenital heart disease with a wide-range of presentations and treatment strategies, depending on the source of pulmonary circulation, anatomy of pulmonary arteries (PAs), and major aortopulmonary collateral arteries (MAPCAs). Data about the outcomes in developing countries is scarce. We therefore conducted a retrospective study to assess survival rates and mortality risks of 90 children with PA/VSD at Siriraj Hospital, Thailand during 2005-2016. Patients with single ventricle were excluded. Survival and mortality risks were analyzed at the end of 2018. The median age of diagnosis was 0.5 (0-13.8) years. The patients' PAs were categorized into four groups: 1) PA/VSD with confluent PAs (n = 40), 2) PA/VSD with confluent PAs and MAPCAs (n = 21), 3) PA/VSD with non-confluent PAs and MAPCAs (n = 12), and 4) PA/VSD with small native PAs and MAPCAs (n = 17). Of the 88 patients who underwent operations, 32 patients had complete repair at 8.4 ± 4.6 years old. During the follow-up [median time of 5.7 years (7 days-13.6 years)], 17 patients (18.9%) died. The survival rates at 1, 5, and 10 years of age were 95%, 83.7%, and 79.6%, respectively. Significant mortality risks were the presence of associated anomalies and non-confluent PAs.

Midterm results of anatomic repair in a subgroup of corrected transposition.

BACKGROUND: Anatomic repair has become the preferred option in the subgroup of patients with congenitally corrected transposition of the great arteries with ventricular septal defect and pulmonary obstruction. We report our 14-year experience with this approach. METHODS: From April 2001 to February 2014, 22 patients with congenitally corrected transposition with ventricular septal defect and pulmonary obstruction underwent anatomic repair. Nineteen patients had a modified Senning-Rastelli procedure, 2 had a Mustard-Rastelli procedure, and one had a hemi-Mustard-Glenn-Rastelli procedure. The mean age was 10.9 years, and 8 (36.4%) patients were male. RESULTS: There were 2 early deaths from sepsis and ventricular failure at 18 and 81 days postoperatively, and 3 late deaths from ventricular failure at 4, 33, and 113 months postoperatively. Left ventricular failure with mitral valve regurgitation was present in 3 of the 5 patients who died. Among the survivors, 3 underwent 4 transcatheter interventions for right ventricular outflow tract obstruction and 3 underwent 4 reoperations for atrial pathway obstruction, left and right ventricular outflow tract obstruction, or residual shunt. At a median follow-up of 64 months (range 14-167 months), 15 of 17 survivors were in functional class I. One patient had severe mitral valve regurgitation and was awaiting valve replacement. Another patient had right ventricular outflow conduit obstruction and was scheduled for reoperation. CONCLUSIONS: Results of atrial switch-Rastelli procedures in this subgroup of patients with corrected transposition are satisfactory but still imperfect. Mitral regurgitation might predict a poor outcome. Long-term follow-up is necessary.

Surgical Outcomes of Adult Congenital Heart Disease with Left to Right Shunt at Siriraj Hospital.

Background: Outcomes of surgical treatment of adult congenital heart disease (ACHD) in developing country are scant but are of critical importance for caring of these patients. Objective: We studied characteristic and surgical repair outcomes of simple ACHD at Siriraj Hospital. Material and Method: We studied 297 adults with atrial septal defect (ASD), ventricular septal defect (VSD), or patent ductus arteriosus (PDA) whom underwent surgical repair between January 2006 and September 2014. There were 211 ASD, 80 VSD, and 6 PDA. We focused on perioperative data, follow-up data, and factor(s) associated with adverse events. Results: Of 297 patients, 37.4% were males; mean age was 41.8 years (range, 20-78 years). Pulmonary hypertension and valvular regurgitation (mitral, tricuspid, or aortic) were presented in 74.7% and 35.0% of the patients, respectively. Majority of defects were closed with patching (85.4% for ASD and 82.7% for VSD), while the rest were closed directly. Of the 190 concomitant procedures, most of them were tricuspid repair (28.9%), and mitral repair (17.4%). There were eight hospital deaths (2.7%). At median follow-up of 25 months (range, 1-102 months), the mean functional classification was reduced from 1.9 to 1.1 (p<0.01). There were five re-interventions and four late deaths. Overall survival was 96.1% at five years and 76.1% at eight years. Concomitant procedure(s), tricuspid, and mitral regurgitation were associated with worse survival. Concomitant procedure(s), mitral, and aortic regurgitation were associated with re-intervention. Conclusion: Outcomes of surgical repair of simple ACHD were good. Valvular regurgitation and concomitant procedure(s) adversely affected the outcomes.

Validation of EuroSCORE for coronary artery bypass grafting at Siriraj Hospital.

OBJECTIVE: To access the performance of the EuroSCORE when applied to CABG patients at Siriraj hospital. MATERIAL AND METHOD: One thousand five hundred forty nine patients diagnosed with coronary artery disease (CAD) who underwent isolated CABG between January 2007 and December 2009 was prospectively studied. RESULTS: The patients included 1,102 men and 447 women and had a mean age of 67 years old. The mean additive score in expired and survived groups were 9.65 +/- 5.14 and 3.87 +/- 3.06. In logistic, score were 25.43 +/- 26.31 and 4.88 +/- 7.88 respectively (p < 0.001). The best cut-off value of EuroSCORE for prediction of a death rate was 6 for additive score and 10 for logistic score. Area under the curve was 0.831 for the additive score and 0.823 for the logistic score. The observed overall mortality rate was 2.0% while the predict mortality was 5.27%. The difference between observed and predicted deaths was significant with additive score and logistic score (p < 0.001). CONCLUSION: Our results suggest that EuroSCORE is not valid for CABG in Thai patient due to over prediction.

Postoperative fever and major infections after pediatric cardiac surgery.

OBJECTIVE: 1) to identify the current status of major infections and other etiologies of postoperative fever from pediatric cardiac surgery 2) to determine the risk factors of major infections. MATERIAL AND METHOD: Databases of pediatric cardiac surgery patients in 2005 were retrospectively reviewed. The main outcomes of interest were postoperative fever and its etiologies. Potential predictors were analyzed by comparing patients who developed or did not have infections. RESULTS: Two hundred thirty patients, 43% (n = 99) developed postoperative fever. Major infections occurred in 13.5% (n = 31), and postpericardiotomy syndrome (PPS) was seen in 8.7% (n = 20) of the patients. The infection rate was 16.9/100 procedures, including pneumonia (29 episodes) and bloodstream infection (6 episodes). Risk factors were infancy, prolonged ventilator support > 2 days, hospital length of stay (LOS) > 14 days, intensive care unit (ICU) LOS > 3 days, re-open procedure, and extubation failure rate. Conversely, cyanosis and high complexity operations were not associated. Positive erythrocyte sedimentation rate was related to infections or to PPS (the area under the ROC = 0.72). CONCLUSION: Following pediatric cardiac surgery major infections are still problematic. The risks increase with infancy, prolonged ventilator support, prolonged hospital and ICU LOS, re-open procedure, and extubation failure.

Surveillance of pediatric cardiac surgical outcome using risk stratifications at a tertiary care center in Thailand.

Objectives. To determine in-hospital mortality and complications of cardiac surgery in pediatric patients and identify predictors of hospital mortality. Methods. Records of pediatric patients who had undergone cardiac surgery in 2005 were reviewed retrospectively. The risk adjustment for congenital heart surgery (RACHS-1) method, the Aristotle basic complexity score (ABC score), and the Society of Thoracic Surgeons and the European Association for Cardiothoracic Surgery Mortality score (STS-EACTS score) were used as measures. Potential predictors were analyzed by risk analysis. Results. 230 pediatric patients had undergone congenital cardiac surgery. Overall, the mortality discharge was 6.1%. From the ROC curve of the RACHS-1, the ABC level, and the STS-EACTS categories, the validities were determined to be 0.78, 0.74, and 0.67, respectively. Mortality risks were found at the high complexity levels of the three tools, bypass time >85 min, and cross clamp time >60 min. Common morbidities were postoperative pyrexia, bleeding, and pleural effusion. Conclusions. Overall mortality and morbidities were 6.1%. The RACHS-1 method, ABC score, and STS-EACTS score were helpful for risk stratification.

Repair of an isolated congenital left ventricular diverticulum.

Left ventricular diverticulum is a rare congenital anomaly. We report two cases of isolated left ventricular diverticulum with a different clinical presentation. The first case was a nine-year-old boy with a history of congestive heart failure and ventricular arrhythmia. The second case was a 51-year-old asymptomatic male with abnormal electrocardiogram. Both patients had the diagnosis confirmed by cardiac magnetic resonance imaging and underwent successful surgical correction of the abnormality.

Early results of anatomic repair in a subgroup of corrected transposition.

The atrial switch operation with the Rastelli procedure is becoming popular for treatment of the subgroup of corrected transposition of the great arteries with ventricular septal defect and pulmonary obstruction. This technique eliminates the problem of short- and long-term right ventricular failure, and decreases the incidence of iatrogenic atrioventricular heart block. Between April 2001 and November 2002, this technique was used in 3 patients aged 5 to 7 years. Two had a Senning operation and one had a Mustard operation. There was no operative death. The first patient needed re-operation to close the sternum. The last patient was re-explored for bleeding. All patients were in New York Heart Association functional class I at their last follow-up. The atrial switch plus Rastelli procedure is feasible in this subgroup of corrected transposition, but longer follow-up is necessary to determine whether this approach is indeed warranted.

Coronary artery bypass graft in Kawasaki disease patients: Siriraj experience.

Kawasaki disease (KD) is an acute systemic vasculitis. It is one of the most common acquired heart diseases in children. Its important acute complication is coronary artery aneurysm. Although most of these aneurysms resolved overtime but some never did. Coronary artery stenosis and myocardial insufficiency or infarction are late complications. Coronary artery bypass graft (CABG) and catheter intervention are the treatment for these patients. We report our first five cases of Kawasaki patients with myocardial insufficiency who underwent CABG at Siriraj Hospital. Patients' ages ranged from 3.3 to 14.4 years old. Only two patients (40%) had angina. Internal thoracic artery was used as a bypass graft in most patients and postoperative course was uneventful. Coronary bypass operation is a safe and reliable surgical modality for coronary artery sequelae in children with Kawasaki disease. A long-term follow-up is necessary to study the long-term outcome of bypass.

Balloon-expandable stenting, percutaneous coil embolization, and amplatzer septal occluder; treatments after complicated lateral tunnel Fontan: a case report.

The authors report a 7-year-old girl with univentricular heart physiology who developed prolonged pleural effusion due to discrete narrowing of the proximal right pulmonary artery, and progressive cyanosis which resulted from leakage of the atrial baffle, multiple veno-venous collaterals after the lateral tunnel Fontan operation. Percutaneous balloon-expandable stent implantation was used to correct the right pulmonary artery stenosis with an excellent result. Cyanosis was improved by coil embolization of the collaterals and occlusion of the baffle leakage with Amplatzer septal occluder. This is the first successful report in Thailand.

Anesthesia for arterial switch operation in simple transposition of the great arteries: experience at Siriraj Hospital.

Anesthetic management of cardiac patients with complete transposition of the great arteries (TGA) undergoing arterial switch operation (ASO) is challenging. The anesthetic course and perioperative problems were studied. A prospective data collection study of 87 patients was performed between January 1991 and February 2002. The patients were divided into 3 groups: Group 1; 27 neonates with TGA with an intact ventricular septum (IVS), Group 2; 21 with TGA, with IVS who underwent two-stage ASO, and Group 3; 39 with TGA, with a large VSD. The anesthesia consisted of low-dose fentanyl, thiopental, atracurium and isoflurane. Monitoring included ECG, radial or femoral arterial pressure, CVP, LAP, core temperature, SpO2, P(E)CO2, urine output, ABG's, Hct, ACT, serum glucose and potassium. Fortunately the courses of anesthesia were uneventful. Usual vasoactive medication administered following CPB included nitroglycerin, dobutamine and dopamine. Groups I, 2 and 3 contained 18.5 per cent, 14.3 per cent and 33.3 per cent of patients who required adrenaline respectively. And only 7.7 per cent of patients in Group 3 had milrinone as an inotrope. Early tracheal extubation, 2 hours after admission to ICU was performed in 3 patients. Perioperative complications included bleeding, low cardiac output, diaphragmatic paresis, digitalis intoxication, metabolic alkalosis, convulsion, pulmonary hypertensive crisis and death. Two patients who developed a pulmonary hypertensive crisis were successfully managed with inhaled nitric oxide. The overall hospital mortality rate was 19.54 per cent. In conclusion, the anesthetic management for ASO in 87 simple dTGA patients was uneventful at Siriraj Hospital. The major perioperative morbidity and hospital mortality were not directly anesthetic contribution.

Neuropsychological alterations after coronary artery bypass graft surgery.

OBJECTIVE: To evaluate neuropsychological dysfunction in patients following elective coronary artery bypass graft surgery at Siriraj Hospital. PATIENTS AND METHOD: One hundred and ten patients who were scheduled for elective coronary artery bypass graft surgery were included in this study. We used the Thai Mental State Examination (TMSE) in order to detectthe presence of cognitive impairment aftercoronary artery bypass graft surgery. The examinations were conducted on two consecutive occasions; first preoperatively, the day before surgery, secondly on the third - fifth postoperative day. The patients' clinical characteristics were assessed perioperatively. RESULTS: The overall occurrence of neuropsychological deficit was 18.18 per cent. Predictors of neuropsychological dysfunction were older age and preexisting disease such as hypertension, hypercholesterolemia and renal insufficiency. Other risk factors such as gender, history of congestive heart failure, myocardial infarction, diabetes mellitus, dysrhythmia, cardiopulmonary bypass time, hemoglobin during cardiopulmonary bypass <7 g/dl, hemoglobin on admission to surgical cardiac care unit <10 g/dl, and atrial fibrillation arising after surgery were not significant. CONCLUSION: Neuropsychological impairments after coronary artery bypass graft surgery are relatively common. This study did not find an increased incidence with respect to gender as other studies have done. However, long-term follow-up of these patients would be very valuable.