RESUMO
OBJECTIVE: Numerous surgical approaches regarding aortic arch advancement for neonatal arch hypoplasia have been described. These repairs can be classified into two categories: those that incorporate a patch and those that do not. The decision between repairs remains largely experiential, rather than empirical, because of the limited number of reported outcomes. We report early outcomes from neonates undergoing modified aortic arch advancement with an anterior patch and our experience using computational fluid dynamic modeling to better understand the hemodynamic consequences associated with this repair. METHODS: A retrospective review of neonates undergoing aortic arch advancement with anterior patch in 2014 at a single institution was performed. Anatomical, perioperative, and follow-up data were collected. Three-dimensional cardiac magnetic resonance images were used to generate computational fluid dynamic models of the modified anterior patch and direct end-to-side repairs. Cardiac waveform inputs were simulated and hemodynamic analyzed. RESULTS: Ten neonates underwent modified aortic arch advancement. No hemodynamically significant gradients were observed at a median follow-up of 0.77 (0.30-1.2) years. Asymmetrical flow was observed in the end-to-side repair, whereas more concentric laminar flow was observed throughout the modified model. Spatial variations in velocities immediately distal to the anastomosis were greater in the end-to-side model (0.35 vs 0.17 m/s, P < 0.001). Time-averaged variations in wall shear stress during systole were greater in the end-to-side model at the same location (3.44 vs 1.98 dynes/cm, P < 0.001). CONCLUSIONS: Early outcomes after the use of an anterior patch for neonatal hypoplastic aortic arch repair show favorable hemodynamic outcomes.
Assuntos
Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/congênito , Doenças da Aorta/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Vasculares , Aorta Torácica/anormalidades , Aorta Torácica/cirurgia , Doenças da Aorta/diagnóstico por imagem , Feminino , Hemodinâmica , Humanos , Imageamento Tridimensional , Recém-Nascido , Imagem Cinética por Ressonância Magnética/métodos , Masculino , Modelos Anatômicos , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodos , Recursos HumanosRESUMO
Standard practice for weaning patients off venoarterial extracorporeal membrane oxygenation (ECMO) occurs by decreasing pump flows until idle flow is achieved. This method is limited in its use because it is difficult to assess a patient's true potential to successfully come off ECMO when supported by idle flow. We have developed a weaning technique that uses a Hoffman clamp on the bridge to decrease blood flow to the patient beyond idle flow. This method was used to wean eight patients from venoarterial ECMO. No patients weaned with this technique required emergent reinstitution of ECMO. The Hoffman clamp technique has allowed us to safely wean patients off ECMO support while maintaining integrity of the circuit.
Assuntos
Oxigenação por Membrana Extracorpórea/instrumentação , Insuficiência Cardíaca/fisiopatologia , Pneumopatias/fisiopatologia , Criança , Pré-Escolar , Constrição , Feminino , Hemodinâmica , Humanos , Lactente , Masculino , Recuperação de Função FisiológicaRESUMO
Hypoplasia of the aortic arch commonly accompanies coarctation of the aorta and should be addressed at the time of coarctation repair to prevent residual gradient. Using a novel technique, McKenzie et al performed an ascending sliding arch aortoplasty to correct hypoplasia using native aortic tissue. This procedure was accomplished with an arrested heart and uses the fact that the ascending aorta associated with the hypoplastic arch is typically elongated. We have furthered the development of the ascending sliding arch aortoplasty by performing the entire procedure without inducing cardiac arrest.
