Oxigenación por membrana extracorpórea como rescate de la insuficiencia cardiovascular y respiratoria en niños. Experiencia del Hospital Universitario Austral / Oxygenation by membrane extracorporeal as a rescue cardiovascular insufficiency and Respiratory in children. Experience of the Austral University Hospital

Introducción: La circulación de membrana extracorpórea consiste en el uso de una bomba de circulación extracorpórea con intercambio gaseoso, de forma prolongada, para proveer soporte vital temporario. Brinda soporte circulatorio, oxigena y remueve dióxido de carbono sin las complicaciones que puede generar la ventilación mecánica convencional. Diseño: Descriptivo, retrospectivo, observacional. Población: Se revisaron los registros clínicos de pacientes pediátricos y neonatos con diagnóstico de patología respiratoria y cardiovascular (0-192 meses) ingresados en ECMO entre el 1 de octubre de 2008 y el 30 de septiembre de 2013. Criterios de inclusión: edad gestacional >34 semanas y >2 kg), sin coagulopatía grave ni hemorragia cerebral grados III o IV, con enfermedad cardíaca reversible, enfermedad respiratoria con hipoxemia o hipercapnia , resistentes al mayor soporte mecánico ventilatorio disponible. Resultados: Ingresaron en ECMO 16 pacientes (mediana de la edad 24 meses, 0-192), 10 niñas y 6 niños. Cuatro ingresados por causas respiratorias y 12, por causas cardiovasculares. La mortalidad por ECMO respiratorio fue del 25% (1/4), cardiovascular 75% (10/12). El PIM de ingreso en la UCIP tuvo una mediana de 3 (1-10). La mediana de estadía en ECMO fue de 7 días (rango 3-16), la de estadía en UCIP-UCIN fue de 22 días (3-120) y en el hospital, de 40 (3-300).Cuatro pacientes recibieron canulación venovenosa y los restantes 12, arteriovenosa. El índice de oxigenación medio de ingreso fue de 26 (DE ± 4); mediana de presión media de la vía aérea, 22 (rango 19-35); media de PartO2 43 (DE ± 8) y la media de PCO2 53 (DE ± 5). El índice Pa/Fi al ingreso tuvo una mediana de 42 (rango 32-74). Conclusión: El ECMO es una herramienta útil para el rescate de pacientes con falla cardíaca e insuficiencia respiratoria, pues permite sostener al paciente, evitando los efectos nocivos de la ventilación mecánica convencional (cuando no se puede mantener la estrategia de protección pulmonar) y de altas dosis de drogas vasoactivas. No obstante, el desarrollo de programas costo- efectivos de ECMO en nuestro país plantea un escenario difícil.(AU)

Introduction: Extracorporeal membrane circulation (ECMO) is the use of cardiopulmonary bypass with prolonged gas exchange to provide temporary life support. The ECMO offers circulatory support, oxygenates and removes carbon dioxide without the complications that can generate conventional mechanical ventilation. Design: Descriptive, retrospective, observational. Population: Clinical records of pediatric and neonatal patients diagnosed with respiratory and cardiovascular disease (0-192 months) admitted to ECMO from October 10, 2008 to September 30, 2013 were reviewed. Inclusion criteria: gestational age >34 weeks and >2 kg, absence of severe coagulopathy and cerebral hemorrhage grade III or IV, with reversible heart disease, respiratory disease with hypoxemia and/or hypercapnia refractory to the most ventilatory mechanical support available. Results: Sixteen children with a median age of 24 months (0-192) (10 girls and 6 boys) were admitted to ECMO. Four children were admitted due to respiratory illness and 12 for cardiovascular disease. Mortality from respiratory ECMO was 25% (1/4), cardiovascular 75% (10/12). PIM at the PICU admissions had a median of 3 (1-10). Median ECMO stay was 7 days (range 3-16), median PICU-NICU stay 22 days (3-120) and hospital stay 40 (3-300). The kind of cannulation was veno-venous (4), and arteriovenous (12). Mean oxygenation index at admission, 26 (SD ± SD 4); median average pressure of air, 22 (range 19-35); average PartO2, 43 (SD ± 8) and mean PCO2 53 (SD ± 5). Median Pa/Fi index at admission, 42 (range 32-74 ). Conclusions: The ECMO is a useful tool for the rescue of patients with heart failure and respiratory failure, avoiding the deleterious effects of conventional mechanical ventilation (when it is not possible to maintain lung protective strategy) and high doses vasoactive drug. However the development of cost-effective ECMO programs in our country poses a difficult scenario.(AU)

[Blepharoplasty and eyebrow lifting]. / Blepharoplastik und Brauenlift.

Upper eyelid blepharoplasty is one of the most common procedures in facial plastic surgery (in 2011 second place in the annual statistics of the American Association of Facial Plastic and Reconstructive Surgeons, AAFPRS). Nowadays, a simple resection of the excess skin is ineffectual if the aim is to achieve an optimal functional and aesthetic result. According to the treatment of the upper eyelid the surgeon has to examine and possibly treat the position of the eyebrow in order to correctly estimate the amount of excess skin of the eyelid. This article presents the state of the art techniques of surgical correction of dermatochalasis of the upper eyelids and eyebrow ptosis and clinical examples are demonstrated.

Microsurgical chest wall reconstruction after oncologic resections.

Defect reconstruction after radical oncologic resection of malignant chest wall tumors requires adequate soft tissue reconstruction with function, stability, integrity, and an aesthetically acceptable result of the chest wall. The purpose of this article is to describe possible reconstructive microsurgical pathways after full-thickness oncologic resections of the chest wall. Several reliable free flaps are described, and morbidity and mortality rates of patients are discussed.

Post-cardiotomy circulatory support with the Terumo Baby-Rx oxygenator in a newborn.

Some patients with severe post-cardiotomy ventricular dysfunction are unable to be separated from cardiopulmonary bypass (CPB). In this setting, extracorporeal circulatory support (ECS) should be instituted to obtain eventual myocardial recovery. We present a newborn in whom an ECS was established with the oxygenator used for the surgical correction.

Twenty-five-year experience with rastelli repair for transposition of the great arteries.

OBJECTIVE: Our purpose was to describe the outcome of the Rastelli repair in D -transposition of the great arteries and to determine the risk factors associated with unfavorable events. METHODS: From March 1973 to April 1998, 101 patients with D -transposition of the great arteries and ventricular septal defect underwent a Rastelli type of repair. Median age and weight were 3.1 years (10th to 90th percentiles 0.3-9.9 years) and 12.8 kg (5.9-28.2). Pulmonary stenosis was present in 73 patients and pulmonary atresia in 18; 10 patients had no left ventricular outflow tract obstruction. RESULTS: There were 7 early deaths (7%) and no operative deaths in the last 7 years of the study. Risk factors for early death, by univariable analysis, included straddling tricuspid valve (P =.04) and longer aortic crossclamping times (P =.04). At a median follow-up of 8.5 years, there were 17 late deaths and 1 patient had undergone heart transplantation. Forty-four patients had reoperations for conduit stenosis, 11 for left ventricular outflow tract obstruction, and 28 had interventional catheterization to relieve conduit stenosis. Nine patients had late arrhythmias, and there were 5 sudden deaths. Overall freedom from death or transplantation (Kaplan-Meier) was 82%, 80%, 68%, and 52% at 5, 10, 15, and 20 years, respectively. Freedom from death or reintervention (catheterization or surgical treatment) was 53%, 24%, and 21% at 5, 10, and 15 years of follow-up, respectively. CONCLUSIONS: The Rastelli repair can be performed with low early mortality. However, substantial late morbidity and mortality are associated with conduit obstruction, left ventricular outflow tract obstruction, and arrhythmia.

Emergency ligation of anomalous left coronary artery arising from the pulmonary artery.

We report two cases of successful emergency ligation of anomalous left coronary artery arising from the pulmonary artery (ALCAPA) in patients with previous cardiac arrest. Both patients had regained marginal cardiac output after cardiopulmonary resuscitation and had maximal doses of inotropic support. The ALCAPA ligation was then performed as a life-saving procedure in the absence of any kind of mechanical circulatory support.

Five- to fifteen-year follow-up of fresh autologous pericardial valved conduits.

OBJECTIVE: Evaluate long-term results of autologous pericardial valved conduits in the pulmonary outflow. METHODS: Between June 1983 and October 1993, 82 conduits were placed in the outflow of the venous ventricle. Patients who received homografts (n = 2 patients), heterografts (n = 3 patients), and valveless conduits (n = 19 patients) and those patients who died within 90 days after the operation were excluded. Fifty-four survivors of pulmonary outflow reconstruction with fresh autologous pericardial valved conduits were followed up from 5 to 15 years (mean, 7.47 +/- 2.8 years). Diagnosis include d -transposition of great arteries (n = 16 patients), L -transposition of great arteries (n = 14 patients), tetralogy of Fallot, pulmonary atresia with ventricular septal defect (n = 11 patients), truncus arteriosus (n = 10 patients), and double-outlet ventricle (n = 3 patients). Implantation age ranged from 0.25 to 24 years (mean, 5.2 +/- 4.2 years). Median conduit diameter was 16 mm. Two-dimensional echocardiographic Doppler evaluations were made yearly; 9 patients underwent cardiac catheterization. Reintervention for stenosis was indicated when the pressure gradient exceeded 50 mm Hg. RESULTS: Three late deaths were unrelated to the conduit. Thirty-five autologous pericardial valved conduits increased in diameter (1-7 mm), remained unchanged in 15 patients, and reduced 1 to 2 mm in 4 patients. The median diameter was 18 mm at the last evaluation (P =.0001). Eight patients required conduit-related reoperation 3 to 8 years after the implantation. Two patients underwent balloon dilation of the autologous pericardial valved conduit. No conduit had to be replaced. Freedom from reintervention at 5 and 10 years was 92% and 76%, being 100% at 10 years for conduits larger than 16 mm at time of implantation. CONCLUSIONS: Autologous pericardial valved conduits show excellent long-term results and compare favorably with other conduits.

Forty-one years of surgical experience with congenital supravalvular aortic stenosis.

OBJECTIVE: Several techniques for symmetric reconstruction of the aortic root in congenital supravalvular aortic stenosis have been developed, but it remains unclear whether these prove superior to patch enlargement of the noncoronary sinus alone. We reviewed our experience with surgical treatment of supravalvular aortic stenosis and investigated the impact of the surgical technique on long-term results. METHODS AND RESULTS: Seventy-five patients underwent operations to treat congenital supravalvular aortic stenosis at our institution between 1957 and 1998. Surgical procedures included patch enlargement of the noncoronary sinus only (n = 34), inverted bifurcated patch plasty (n = 35), and 3-sinus reconstruction of the aortic root (n = 6). There were 7 early deaths. Among those who survived the operation, 100% were alive at 5 years, 96% were alive at 10 years, and 77% were alive at 20 years. According to time-related analysis diffuse stenosis of the ascending aorta proved a risk factor for both survival and reoperation (P <.01 for each). Patients with multiple-sinus reconstructions of the aortic root accounted for only 2 of the 14 reoperations and none of the late deaths (both P <.001). Residual gradients were lower after multiple-sinus reconstruction of the aortic root (median 10 mm Hg vs 20 mm Hg for patch enlargement of the noncoronary sinus only, P =. 008), as was the prevalence of moderate aortic regurgitation at follow-up (3% vs 22%, P =.05). CONCLUSIONS: Results of operations for supravalvular aortic stenosis improved greatly after the introduction of more symmetric reconstructions of the aortic root. Multiple-sinus reconstructions (inverted bifurcated patch plasty and 3-sinus reconstruction) resulted in superior hemodynamics and were associated with reductions in both mortality rate and need for reoperation.

Experience with one and a half ventricle repair.

OBJECTIVE: This article presents a 10-year experience with one and a half ventricle repair for right ventricular hypoplasia or dysfunction. METHODS: From November 1986 to December 1996, 30 patients (mean age 6.7 +/- 8.5 years, range 4 months-40 years) with functionally abnormal right ventricles underwent a bidirectional Glenn shunt as part of the repair. Diagnoses included pulmonary atresia with intact ventricular septum (n = 15), Ebstein anomaly (n = 5), levotransposition of the great arteries (n = 3), pulmonary stenosis with right ventricular hypoplasia (n = 2), tetralogy of Fallot (n = 3), dextrotransposition of the great arteries (n = l), and Uhl anomaly (n = l). Concomitantly performed cardiac procedures included atrial septal defect closure (n = 27), fenestration of the atrial septum (n = 2), right ventricular cavity augmentation (n = 8), right ventricular outflow tract enlargement (n = 6), transannular patch (n = 13), modified Blalock-Taussig shunt closure (n = 16), tricuspid replacement (n = 3), tricuspid repair (n = 2), Rastelli procedure (n = 3), tricuspid commissurotomy (n = 2), and double switch (n = l). RESULTS: There were 2 early deaths (6.6%) and 1 late death. Mean early postoperative superior vena caval pressure was 14. 12 +/- 3.55 mm Hg and mean right atrial pressure was 10.3 +/- 5.16 mm Hg. Early oxygen saturation in the operating room with an inspired oxygen fraction of 1 was 97.2 +/- 2.5; oxygen saturation was 92.3 +/- 4.8 on room air at discharge. Mean oxygen saturations were 93.6% +/- 3.6% at 1 year of follow-up (P =.10) and 93.5% +/- 4. 1% at 5 years (P =.12). Overall survival was 90% at 5 years, and 21 patients (77%) were in New York Heart Association class I, 5 (18%) were in class II, and 1 (2.7%) was in class III. CONCLUSION: This procedure provides a valid alternative for correction of right ventricle hypoplasia or dysfunction. Early and intermediate follow-up results compare favorably with those of the Fontan procedure, but long-term follow-up is needed.

Preoperative management of congestive heart failure in neonates: the closed hood.

In this study we report the results of the use of a closed hood with no external administration of CO2 to increase pulmonary vascular resistance by lowering the inspired fraction of oxygen (FiO2) and raising the inspired fraction of carbon dioxide (FiCO2) in patients with congenital heart disease and increased pulmonary blood flow. Between December 1995 and May 1996, 9 neonates (F:5, M:4) were admitted. Each study patient was assigned to clinical classes using a 1 to 4 classification. Ages ranged between 2 and 30 days (mean 18), weight between 2.25 and 3.65 kg (mean 2.89). A plastic hood, closed on the top with a plastic membrane and with the gas entrance open to room air was placed over the head of the patients. Patients increase pCO2 by rebreathing their own expired CO2. After 24 h of the onset of the treatment the media of points of congestive heart failure 1 to 4 classification decrease from a mean of 4 to a mean of 2.28+/-0.44 (p=0.001). A statistically significant improvement in symptoms and lowering of PO2 and pH while raising pCO2 has been demonstrated in this study.

Cavo atriopulmonary anastomosis via a nonprosthetic medial tunnel.

A surgical technique is described to perform a total bypass of the venous ventricle (TBPVV) via a cavo atriopulmonary anastomosis wherein a medial atrial tunnel is constructed using autologous tissue. The procedure offers the advantage of maintaining low atrial pressure at the sinus node area without the use of prosthetic material. It also represents a good method for conversion of a bidirectional Glenn to a TBPVV avoiding surgical damage of the sinus node area.

Long-term follow-up of autologous pericardial valved conduits.

BACKGROUND: The aim of this study was to evaluate the long-term results of the use of an autologous pericardial valved conduit in the outflow tract of the venous ventricle in congenital heart malformations. METHODS: Fifty-one patients were followed up for a period of 12 to 120 months; 30 for more than 36 months and 13 for more than 72 months. All were evaluated clinically and by two-dimensional and Doppler echocardiography. Eight patients were recatheterized. Postoperative evaluation included serial measurement of pressure gradients and the conduit's diameter at the proximal, valvular, and distal levels. Reoperation because of stenosis was indicated when the gradient across the right ventricular outflow was greater than 50 mm Hg. The reoperation rate in relation with postoperative time, diameter of the autologous pericardial valved conduit at the time of implantation, and malformation was statistically analyzed. RESULTS: In 27 patients the conduit increased its diameter 1 to 7 mm. In 20 patients the diameter remained unchanged, whereas a reduction was noted in 4. Conduit survival free of reoperation for the whole group was 89.9% at 5 years. Conduit survival free of reoperation was 100% at 5 and 7 years for conduits larger than 16 mm at the time of implantation. It was 95% (standard deviation = 4.8%) at 5 years and 72.3% at 7 years for those 16 mm or less. For patients operated after January 1, 1986 (technical modification), conduit survival free of reoperation was 95.4% at 7 years postoperatively. CONCLUSIONS: These results compare favorably with those of other available conduits.

Morphological characterization of carotid artery stenoses by ultrasound duplex scanning.

Ulcerations and intraplaque hemorrhages are thought to play an important role in the development of neurological deficits in carotid artery stenoses. To assess the ability of duplex scanning to predict plaque morphology we compared different sonographic criteria (plaque border, plaque density, plaque structure) with the morphological findings in 169 consecutive carotid endarterectomies (144 cases with diameter reduction greater than 50%). Two percent of the sonograms were inadequate, and 20% showed poor image quality. Regular plaque borders revealed a smooth or at most minimally ulcerated surface in 92%. Grossly ulcerated stenoses, however, were only found in 27% of the irregular plaques. Moreover, the plaque border was nonvisible in 35% of all cases. Simple, fibro-atheromatous plaques were found to be echogenic in 72% and echolucency was present in 80% of the stenoses with relevant intraplaque hemorrhage. In conclusion, duplex scanning proved to be capable of detecting smooth, fibro-atheromatous stenoses with high accuracy. Ulcerations, however, cannot be predicted reliably, and intraplaque hemorrhage cannot be differentiated from atheromatous debris.

[Determination of the degree of stenosis in carotid artery stenoses: ultrasound and i.v. DSA in comparison to surgical findings]. / Bestimmung des Stenosierungsgrades bei Karotisstenosen: Ultraschall und i.v. DSA im Vergleich zum Operationsbefund.

The specimens from 116 consecutive carotid thrombendarterectomies were taken as "gold standard" to evaluate the accuracy of ultrasound methods (duplex scanning + extra-/transcranial Doppler sonography) and intravenous digital subtraction angiography (i.v. DSA) in carotid artery stenoses. In 65 cases, in which the specimens could be gauged reliably, sonography estimated the degree of stenosis in 85% within a range of +/- 10%, in 97% within +/- 20% i.v. DSA was accurate in 52 respectively in 94%. High-grade stenoses were correctly assessed by ultrasound in 90%, by i.v. DSA in 64%. Sonography identified 4/10 kinkings and coilings of the carotid artery, i.v. DSA 9/10. Current available ultrasound methods enable estimation of the diameter reduction of carotid artery stenoses with low deviations. I.v. DSA seems to be less reliable, but can be used favourably as a complementary method to sonography.