Neck cannulation for bypass in redo sternotomy in children and adults with congenital heart disease.

OBJECTIVES: Patients with complex congenital heart disease carry an increased risk of damage to retrosternal structures each time they undergo redo sternotomy. The aim of this study was to evaluate the safety and efficacy of neck cannulation for peripheral cardiopulmonary bypass to alleviate the risks in high-risk redo sternotomy patients. METHODS: Children and adults with congenital heart disease undergoing high-risk redo sternotomy were included in this retrospective study. The primary outcome was the safety and efficacy of neck cannulation for cardiopulmonary bypass. The secondary outcome was to assess preoperative risk factors as an indication for neck cannulation. The right common carotid artery and right internal jugular vein were cannulated and full cardiopulmonary bypass was initiated with vacuum-assisted venous drainage. Redo sternotomy was performed on a decompressed heart, and bifrontal regional cerebral oxygen saturation was monitored via near-infrared spectroscopy. RESULTS: In total, 35 patients were included. No mortality, neurological or vascular complications occurred postoperatively. Mean left- and right-sided near-infrared spectroscopy were 70.0% (±10.5) and 64.2% (±12.0), respectively, and the mean difference was 5.7% (±6.9). Main preoperative risk factors were; adherent ascending aorta (45.7%), adherent conduit (40%), severely dilated retrosternal right ventricle (17.1%) and skeletal deformations (14.3%). CONCLUSIONS: Cannulation of the right neck vessels for peripheral cardiopulmonary bypass prior to high-risk redo sternotomy in children and adults with congenital heart disease is a safe and effective strategy. In combination with near-infrared spectroscopy monitoring, adequate cerebral oxygenation can be ensured while the risk of catastrophic haemorrhage is minimized.

Direct implantation of scimitar vein to the left atrium via sternotomy: a reappraisal.

OBJECTIVES: There is no consensus about optimal surgical technique for the repair of scimitar vein, an anomalous right pulmonary venous connection to the inferior vena cava. Our current experience with a direct anastomosis of the scimitar vein to the left atrium via sternotomy may be shared with other centres, but has not been widely published. METHODS: Six consecutive patients (age 6 months to 17 years, mean 5 years) operated on in 2009-12 were retrospectively reviewed. Through median sternotomy and with cardiopulmonary bypass, the mobilized anomalous right pulmonary vein was brought through a large pericardial opening posterior to the right phrenic nerve and anastomosed onto the right side of the posterior left atrium with access via an existing or a surgically created atrial septal defect. RESULTS: Five patients had primary venous repair and one had a previous failed repair using an intra-atrial baffle. The median cardiopulmonary bypass and cross-clamp times were 88 and 38 min, respectively. The median ventilator time was 1 day and the median stay at the intensive care unit 3.5 days. There were no deaths within a median follow-up of 28 months (range 8-41 months), nor reoperations or instances of pulmonary venous obstruction. CONCLUSIONS: Anatomic repair of the scimitar vein based on reimplantation onto the left atrium via sternotomy is conceptually appealing. The surgery results in a safe and reliable repair in patients with a wide age spectrum. Durability needs on-going assessment in longer-term follow-up.

Rapid 2-stage Norwood I for high-risk hypoplastic left heart syndrome and variants.

OBJECTIVES: Preoperative comorbidities (PCMs) are known risk factors for Norwood stage I (NW1). We tested the hypothesis that short-term bilateral pulmonary arterial banding (bPAB) before NW1 could improve the prognosis of these high-risk patients. METHODS: From January 2006 to October 2011, 17 high-risk patients with hypoplastic left heart syndrome (defined as having ≥4 of the following PCMs: prolonged mechanical ventilation; older age; sepsis; necrotizing enterocolitis; hepatic, renal, or heart failure; coagulopathy; pulmonary edema; high inotropic requirements; anasarca; weight <2.5 kg; and cardiac arrest) were identified. In addition to conventional treatment of PCMs, they underwent bPAB before NW1. bPAB was undertaken with Silastic slings and secured with ligaclips to a luminal diameter of approximately 3.5 to 4.0 mm. The patency of the ductus arteriosus was maintained with prostaglandin. NW1 was performed using a modified, right Blalock-Taussig shunt at a median interval of 8 days after bPAB. The data from these patients were retrospectively reviewed, and the 30-day mortality and 1-year survival were compared with the hypoplastic left heart syndrome population who underwent primary NW1 with <3 PCMs in the same period. RESULTS: Of the bPAB patients, 5 (29.4%) died before NW1. All had ≥5 PCMs. Twelve patients (70.6%) survived to undergo NW1. One early death occurred after NW1 (8.3%). The 1-year survival rate for high-risk patients who underwent NW1 was 66.7%. The early mortality and 1-year survival for the 130 patients with <3 PCMs was 10% and 80%, respectively. CONCLUSIONS: Optimizing the balance between the pulmonary and systemic blood flow with a short period of bPAB and ductal patency can improve the perioperative conditions of high-risk patients before NW1. Those who survived bPAB and underwent NW1 had early mortality and 1-year survival comparable to the standard risk category, despite the severity of their initial condition. A rapid 2-stage NW1 strategy with bPAB and prostaglandin to maintain ductal patency can avoid the risks of suboptimal palliation and vascular injuries associated with hybrid procedures.