Surgical technique for heart transplantation: a strategy for congenital heart disease.

The standard techniques for orthotopic heart transplantation often require certain adjustments when the procedure is carried out for complex congenital heart disease. This is because of both the unusual anatomy and possible distortions caused by previous surgery. Such technical adjustments have been described in various published reports over the years. Those reports, when combined, do cover the full spectrum of the technical difficulties that may be encountered, whether the defects are in their original form or altered by surgery, such that no cardiac malformation or distortion would prohibit transplantation. However, those reports are comprehensive only when combined. None of the individual reports addresses all the possible technical challenges. Consequently, the available information is somewhat fragmented. In addition, the generic aspect of the described technical strategies is not always given the emphasis that it deserves. Indeed, occasionally a technique may be presented as a specific solution for a specific malformation, without necessarily pointing out that the same technique may be applied to other hearts with different overall pathologies but which share that specific malformation. The aim of this review article was to combine all the available published information in one article in a manner that constructs a simple but comprehensive and generic system of decision-making that may be applied to any heart in order to determine the exact technical adjustments needed for transplantation in each case. Such a strategy is possible for two reasons. First, only a few anatomical sites are technically significant, namely the points of anastomosis between the donor's organ and the recipient. The rest of the intracardiac morphology does not affect the operation and may be ignored. Second, each of those anatomical sites can present difficulties in only a few ways, and each of those few difficulties has a well-described and published solution already. Therefore, the exact technical adjustments required in each case may be worked out by the sequential assessment of the anastomotic sites alone.

Risk factors for distal Contegra stenosis: results of a prospective European multicentre study.

Objectives The EUCon study was designed to identify risk factors for distal anastomotic stenosis after bovine jugular vein (Contegra) implantation in children. Methods Between March 2006 and August 2008, 104 devices were implanted in nine European centers. Preoperative, intraoperative, and follow-up data (at discharge, 6, 12, 24 months) including standardized echocardiography were prospectively registered, source data verified and collected in a central database. Main endpoint was distal stenosis (either postvalvular gradient of ≥50 mm Hg or need for intervention for distal stenosis). Eight potential risk factors (age <2 years, diagnosis, running suture, use of glue, flapless anastomosis, oversizing less than + 2 z, anticoagulation, implantation site) were investigated. Cox regression, decision tree analyses, and "Clustering by Response" were applied. Results Patient age ranged from 0 to18 years, mean 6.0 ± 6.1, median 3.2 years. Implantation reasons: 88% congenital malformations, 12% Ross operations. Follow-up was 88.3% complete. Durability (freedom from death, reoperation, degeneration, endocarditis, and explantation) compared well to corresponding homograft literature. Sixteen patients reached study endpoints. Age <2 years was the only invariably significant risk factor (p = 0.044); "Clustering By Response" found young anticoagulated patients with oversized conduits to be at a higher risk than the others (p = 0.018, OR = 3.2). Conclusion Patient age is the main risk factor for development of distal anastomosis stenosis after Contegra implantation. The influence of the other investigated factors is too small to be proven in 104 patients after 2 years, or other risk factors must be taken into consideration to explain outcome differences among recipients under 2 years.

Cierre percutáneo de la comunicación interauricular: resultados a medio plazo de esta nueva opción terapéutica / Percutaneous Closure of Atrial Septal Defects: Midterm Results of a New Therapeutic Strategy

Objetivo. Evaluar los resultados a medio plazo del cierre percutáneo de la comunicación interauricular mediante dos nuevos dispositivos. Pacientes y métodos. Bajo anestesia general se procedió por vía anterógrada al cierre percutáneo de la comunicación interauricular tipo II de nueve niños. La edad fue de 5,1 ñ 1,9 años y el peso 19,7 ñ 7 kg. El procedimiento fue monitorizado mediante ecocardiografía transesofágica. Los dispositivos utilizados fueron el DAS Angel Wings y el Amplatzer. Resultados. Los resultados hemodinámicos fueron: presión arteria pulmonar 12,7 ñ 2 mmHg, resistencias pulmonares 1,5 ñ 0,5 U/m2 y Qp/Qs 2,3 ñ 1. El diámetro del defecto por ecocardiografía transesofágica fue de 11,4 ñ 2 mm y por oclusión con balón de 12,3 ñ 2,6 mm. Se emplearon 13 dispositivos, nueve Amplatzer y cuatro dispositivos de DAS-Angel Wings. Cuatro dispositivos Amplatzer fueron retirados sin problemas a través de su introductor, dos por no estabilizarse en el tabique al ser demasiado pequeños y otros dos por apertura defectuosa en la aurícula izquierda. En los nueve pacientes el dispositivo quedó correctamente implantado y en la angiografía al finalizar el procedimiento existía un mínimo cortocircuito en cinco. La ecocardiografía transtorácica con Doppler color realizada a las 24 h demostró la ausencia de cortocircuito en todos.Los niños fueron dados de alta a las 38 ñ 12 h y en el seguimiento de 9,6 ñ 2,2 meses no se han producido complicaciones, fracturas de la estructura, ni se han demostrado co tocircuitos residuales. Conclusión. Mediante cierre percutáneo se consigue una elevada tasa de cierre sin cortocircuito residual cuando se realiza una adecuada selección de los pacientes (AU)