Handmade Bicuspid Valved Polytetrafluoroethylene Conduit for Right Ventricular Outflow Tract Reconstruction.

Background: Excellent outcomes of right ventricle to pulmonary artery conduits with polytetrafluoroethylene (PTFE) valves have been reported. The purpose of this study was to analyze the short-term results of our handmade PTFE bicuspid valved conduit (VC) for right ventricular outflow tract reconstruction. Methods: Between September 2019 and May 2023, bicuspid PTFE-VC was implanted in 17 patients at a median age of 2.5 years (range, 3 months to 13.6 years). The PTFE-VC was fashioned from a commercially available PTFE tube graft (14 mm in three patients, 16 mm in three patients, 18 mm in one patient, 20 mm in three patients, and 22 mm in seven patients) and 0.1 mm thick PTFE membrane for the leaflet material. Valve function was assessed by echocardiogram after the implantation. The conduit reoperation and the conduit dysfunction were analyzed. There were no early deaths, but there was one late death. Results: There were no postoperative in-hospital deaths. Follow-up echocardiograms were available for 14 of 17 patients. The median follow-up was 21 months (range, 7-49 months). Conduit stenosis was none or trivial in 11 patients while it was mild in two and moderate in one patient and severe in 0 patients. Conduit insufficiency was mild or trivial in all 14 patients. By the end of the study period, freedom from reoperation/reintervention was 100%. There were no episodes of aneurysmal dilatation of the conduit or endocarditis. Conclusions: Handmade bicuspid PTFE VC shows good short-term outcome, with no significant valve dysfunction and no reintervention. A longer follow-up is necessary to evaluate the long-term advantages of using the handmade bicuspid PTFE VC.

Anomalous right coronary artery from the pulmonary artery in an infant with tetralogy of Fallot.

An anomalous right coronary artery from the pulmonary artery (ARCAPA) is a rare congenital anomaly that does not have the typical presentation of the more common anomalous left coronary artery. We present an infant with tetralogy of Fallot with atypical findings on the preoperative echocardiogram. A cardiac computerized tomographic (CT) scan showed ARCAPA. This was confirmed intraoperatively and repaired successfully. Close attention to coronaries on echocardiography and a low threshold for additional imaging can successfully diagnose ARCAPA in the presence of additional congenital heart defects.

Redo-ALCAPA Repair With Left Subclavian Artery-to-Left Main Coronary Bypass for Left Coronary Atresia.

Different surgical techniques have been described for the primary repair of anomalous left coronary artery arising from the pulmonary artery (ALCAPA); however, very few techniques are described for management of coronary artery occlusion following ALCAPA repair. We present a case of a 7-year-old girl with left main coronary atresia status-post left coronary button transfer for ALCAPA in infancy. She underwent redo-sternotomy and left subclavian artery-to-left main coronary artery bypass plus mitral valve repair and had an uneventful postoperative course.

Single-Stage Unifocalization and Intracardiac Repair Using Two Tube Grafts.

Unifocalization of the major aortopulmonary collaterals (MAPCAs) followed by intracardiac repair with ventricular septal defect (VSD) closure and restoration of right ventricle-to-pulmonary artery continuity is the ultimate treatment goal in a case of VSD with pulmonary atresia and MAPCAs. It may be achieved in a single stage or may require multiple surgeries. We present a case of a 2-year-old boy with VSD with pulmonary atresia who underwent single-stage unifocalization of MAPCAs through the midline followed by intracardiac repair using 2 polytetrafluoroethylene tube grafts: one for unifocalization and other as a bicuspid valved right ventricle-to-pulmonary artery conduit.

Fontan procedure on deep hypothermic circulatory arrest: Short-term results and technique.

Background: Various operative strategies are described for the Fontan procedure. In this study, we describe our short-term results and technique of Fontan procedure on cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). Methods: This was a retrospective study of 32 patients, median age of 6 years (4-19 years) and median weight of 20 kg (13-51 kg), who underwent Fontan procedure on CPB and DHCA from July 2016 to July 2021. Results: The median CPB time was 125 min (77-186 min), the median DHCA time was 42 min (27-50 min), and the median Fontan pressure was 14 mmHg (10-18 mmHg). The median time to extubation was 4 h (1-20 h), the duration of chest tube drainage was 8 days (5-24 days), and the median intensive care unit stay was 4 days (3-8 days). The presence of heterotaxy was associated with longer duration of pleural drainage (P = 0.01). There was no operative mortality and no major adverse events such as seizures, gross neurological deficits, or arrhythmias in the postoperative period. Conclusions: Fontan procedure can be safely performed on CPB and DHCA with good operative results. This operative strategy may be used in special circumstances like in patients with situs and systemic venous anomalies and those requiring repair of a complex intracardiac defect. Long-term follow-up will be required to evaluate if this strategy has any impact on the neurodevelopmental outcome and the long-term sequelae of Fontan.

Giant Right Atrial Aneurysm in an Infant.

Right atrial aneurysm (RAA) is a rare congenital anomaly with a diverse clinical spectrum. We present a case of antenatal detection of a giant RAA. The infant had 3 episodes of staring spells presumed to be thrombo-embolic phenomena originating from the RAA. The infant underwent successful RAA resection with preservation of the right coronary artery that was displaced from its usual position due to invagination of the RAA in the subepicardial space of the right atrio-ventricular groove.

Neo-cusp Reconstruction Procedure for Aortic Regurgitation Induced by Transcatheter Occluder Device for Ventricular Septal Defect Closure.

Aortic regurgitation after transcatheter device closure of a perimembranous ventricular septal defect is a known complication. We present the case of an 11-year-old boy with severe aortic valve regurgitation due to cusp perforation complicating previous device closure of a ventricular septal defect. The patient underwent successful aortic valve repair (neo-cusp reconstruction technique) by replacement of a cusp and shaving off of a rim of the device 5 years after device closure.

Valved reverse Potts shunt in a case of pulmonary hypertension due to pulmonary veno-occlusive disease.

Idiopathic pulmonary hypertension has a predictably morbid natural history with an absence of a uniformly successful treatment strategy. We describe our palliative surgical strategy in a symptomatic teenager. A 16-year-old girl, with a recent diagnosis of severe suprasystemic pulmonary hypertension, with severe right ventricular dysfunction, presented with syncope and World Health Organization functional class 4 symptoms. Blood and imaging work up revealed changes suggestive of pulmonary veno-occlusive disease. She failed to improve with oral pulmonary vasodilators and was listed for heart and lung transplant. Pending the transplant, a 10-mm handmade valved tube graft was placed between descending thoracic aorta and the proximal left pulmonary artery, on cardiopulmonary bypass. She had an uneventful recovery period with an early improvement in her symptoms. She was discharged home on aspirin and oral pulmonary vasodilators. At last follow up, 4 months post procedure, her functional capacity and right ventricular function had improved. The valved Potts shunt proved to be helpful in improving her symptomatology and as a bridge to transplant.

How to do it: repair of anomalous left coronary artery from pulmonary artery (ALCAPA) with coronary button transfer and Lecompte maneuver.

An alternative technique of coronary button transfer and Lecompte maneuver for anomalous left coronary artery (ALCAPA) arising from left lateral pulmonary sinus is described. This technique was used by us successfully in four patients aged 6 months to 3.5 years, weighing from 4.7 to 16 kg. The importance of trapdoor technique and Lecompte maneuver is discussed.

Surgical management of univentricular heart with total anomalous pulmonary venous drainage and intrapulmonary vertical vein.

We report a patient with univentricular heart, heterotaxy syndrome with total anomalous pulmonary venous connection, and an intrapulmonary vertical vein draining into the left superior vena cava who underwent a successful bidirectional Glenn shunt without cardiopulmonary bypass. A polytetrafluoroethylene tube interposition graft was used between the superior vena cava and the pulmonary artery. This condition is unusual and physiologic palliation, rather than anatomic correction as described in this report, may be appropriate for managing this condition.

An alternative technique for the atrial switch operation for transposition of the great arteries in an unoperated adult patient.

We report a 26-year-old patient with d-transposition of great arteries, intact ventricular septum, and an atrial septal defect. The relevant literature on late natural survivors with this condition is reviewed and the technical aspects of an alternative technique for accomplishing a successful atrial switch in this situation are discussed.

Temporary sternotomy wound closure with blood bag.

Many situations are encountered in cardiac surgery, especially paediatric cardiac surgery, which are associated with significant myocardial oedema. In such cases it is inadvisable or impossible to close the sternum primarily. Here we describe a simple and inexpensive technique of temporary sternotomy wound closure with a sterile blood bag.

Primary Arterial Switch Operation for TGA/IVS and Regressed Left Ventricle: How and When to Use Left Ventricular Assist Device.

PURPOSE: Numerous attempts have been made to extend the boundaries of arterial switch operation (ASO) in children presenting late with transposition of great arteries with intact ventricular septum (TGA/IVS) and regressed left ventricle (rLV). Many children tolerate the delayed ASO uneventfully, whereas others need mechanical circulatory support (MCS) to sustain the systemic circulation while the left ventricle undergoes retraining. DESCRIPTION: In this article, we describe six consecutive children with TGA/IVS and rLV who underwent primary ASO. RESULTS: Three were managed medically, while three required MCS in the form of Centrimag left ventricular assist device (LVAD). All patients survived the operation and were discharged home in a stable condition. CONCLUSIONS: Primary ASO can be safely performed in children with TGA/IVS and rLV, provided the center has MCS options. Supporting the rLV with LVAD is feasible and can be achieved safely.

Early experience with pediatric cardiac transplantation in a limited resource setting.

BACKGROUND: Pediatric heart transplantation is a now a well-established and standard treatment option for end stage heart failure for various conditions in children. Due to logistic issues, it is not an option for in most pediatric cardiac centres in the third world. AIM: We sought to describe our early experience in the current era in India. METHODS: This is a short term retrospective chart review of pediatric patients who underwent heart transplantation at our centre. Mean/Median with standard deviation /range was used to present data. RESULTS: Twenty patients underwent orthotopic heart transplant between January 2016 and June 2019. The median age at transplant was 12.4years (range 3.3 to 17.3 years). The median weight was 23.2kg (range 10-80kg). The mean donor/recipient weight ratio was 1.62± 0.84. The mean ICU stay was 12.1days. The mean follow up post transplant was 2.03± 0.97years (range 10 days-3.57years). The 1 month and the 1 year survival was 100%. Biopsies were positive for significant rejection in 7 patients (35%). At the time of last follow-up, 3 patients (15%) had expired. The major post transplant morbidities were mechanical circulatory support (n=3), hypertension with seizure complex (n=3), post transplant lympho-proliferative disorder (n=1), pseudocyst of pancreas (n=1), coronary allograft vasculopathy (n=3) and systemic hypertension (n=7). All surviving patients (n=17) were asymptomatic at last follow up. CONCLUSION: The results suggest acceptable short term outcomes in Indian pediatric patients can be achieved after heart transplantation in the current era. Significant rejection episodes and coronary allograft vasculopathy need careful follow up.

Biventricular Repair in Interrupted Aortic Arch Type C With Aortic Atresia.

We report a case of interrupted aortic arch type C with aortic atresia and a ventricular septal defect with two well-developed ventricles, who underwent a successful single-stage biventricular repair with the modified Yasui procedure and arch reconstruction. Angiography done during conduit revision showed bilateral brachiocephalic trunks with high branching. The child is doing well six years after the initial operation.

Use of Left Ventricular Assist Device After Arterial Switch Operation in Late Presenting D-Transposition of Great Arteries-A Technique for Retraining the Regressed Left Ventricle.

The preferred approach for patients with D-transposition of the great arteries with an intact ventricular septum (DTGA/IVS) is the arterial switch operation (ASO). In those patients presenting late, with regressed left ventricle (LV), successful LV preparation is of paramount importance to achieve this goal. We present a toddler with DTGA/IVS who underwent ASO followed by successful left ventricular retraining with postoperative left ventricular assist device support with CentriMag centrifugal pump.

Virtual three-dimensional model for preoperative planning in a complex case of a double outlet right ventricle.

A 3-year-old child with a complex variant of double outlet right ventricle achieved a successful biventricular repair after detailed delineation of the intracardiac anatomy on multimodality imaging. A virtual three-dimensional (3D) model based on computed tomography was used successfully in the absence of an actual 3D-printed model. This case report seeks to highlight and hence increase the utilization of the virtual 3D model in resource-limited settings.

HeartWare Ventricular Assist Device as a Bridge-to-Transplant in a Small Boy with Complicated Kawasaki Disease.

We report a case of HeartWare ventricular assist device (HVAD) implant as a Bridge-to-Transplant in the smallest and the youngest known patient, a 32-month-old boy (body surface area of 0.66 m2) with known Kawasaki disease and giant coronary artery aneurysms. The disease course was complicated by coronary thromboembolism resulting in acute myocardial infarction, ventricular fibrillation, and cardiac arrest. After short-term support with extracorporeal membrane oxygenation for 7 days and long-term support with an HVAD for 5 months, he underwent heart transplantation and is doing well 2 months after the transplant.

Endoscopic Repair of Recurrent Tracheoesophageal Fistula With an Atrial Septal Occluder Device.

A 32-year-old woman presented with recurrent trachea-esophageal fistula. Although she had undergone open repair three times in her first year of life, a residual small leak was left. In the past 2 years she had experienced several lower respiratory tract infections and she had lost 5 kilograms in the past 2 months. Recent argon plasma coagulation cauterization and clipping of the fistula had failed, so an alternative technique with placement of an atrial septal occluder device was used to obliterate the fistula. A follow-up barium swallow showed no more communication to the tracheobronchial tree, and endoscopy demonstrated epithelialization. At her 3-year follow-up visit she was asymptomatic.

Unusual left ventricular pseudoaneurysm in a child after disseminated bacterial infection.

Left ventricular pseudoaneurysms are rare in children. A six-year-old boy developed left ventricular pseudoaneurysm despite successful control of sepsis. The pseudoaneurysm was diagnosed by two-dimensional echocardiography and detailed by computed tomography. The child underwent successful surgical correction with partial excision and plication of the aneurysmal sac.