Transannular bovine jugular vein monocusp for the reconstruction of severe right ventricular outflow tract obstruction.

Objective: Severe right ventricular outflow tract obstruction in tetralogy of Fallot and variants necessitates the use of transannular patch in a significant proportion of children undergoing repair. We have used a Contegra monocusp together with delamination of native leaflet tissue in order to create a functioning pulmonary valve. Methods: In total, 18 (2017-2022) consecutive Contegra monocusp implantations were included. Median age and weight were 3.65 [2.00; 9.43] months and 6.12 [4.30; 8.22] kg, respectively. Nine of 18 patients had undergone palliation. Native pulmonary leaflet tissue was recruited to create a single posterior cusp. Contegra monocusp selection was based on the goal to achieve a neoannulus of Z value ≈ 0. Monocusp sizes implanted were 16 [14; 18] mm. Patch plasty of left pulmonary artery (LPA) (9), right pulmonary artery (RPA) (2), and both LPA-RPA (5) were often performed. Results: All patients survived the operation and were discharged home in good health. Median ventilation time and hospital stay were 2 [1; 9] and 12.5 [9; 54] days, respectively. Follow-up duration was 30.68 [3.47; 60.47] months and 100% complete. One patient with well-corrected right ventricular outflow tract died 9.4 months postoperatively, possibly of aspiration. One child with membranous pulmonary atresia needed reoperation (conduit insertion) at 3.5 months of follow-up. Five needed catheter interventions: supravalvar stent (2), LPA stent (3), and RPA stent (1), most of them in the earlier half of the experience. Pulmonary annulus changed from preoperative -3.91 [-5.98; -2.23] to -0.10 [-1.44; 1.92] at discharge; growing proportionally to -0.13 [-3.52; 2.73] at follow-up. Kaplan-Meier freedom from composite dysfunction was 79.25 (95% confidence interval, +13.68%, -31.44%) at 36 months. Conclusions: Recruitment of native leaflets, optimal Contegra monocusp, and commissuroplasty provide an easily replicable technique for achieving a competent, proportionally growing neopulmonary valve. Longer follow-up is needed to determine its impact on delaying a pulmonary valve replacement.

Surgical correction of partial anomalous left superior pulmonary venous connection to the innominate vein.

Partial anomalous pulmonary venous connection is reported to occur in 0.4 to 0.7% of children. Only 3% of these cases involve an anomalous left-sided pulmonary venous connection to the innominate vein [1]. In this video tutorial, we present the technique of reimplantation of the partial anomalous left superior pulmonary venous connection to the left atrial appendage through a median sternotomy and with a cardioplegic heart. We debate the merits of our strategy with respect to our ultimate goal of achieving long-term patency.

Repair of a remote pericommissural anomalous left coronary artery from the pulmonary artery.

We demonstrate a classic trapdoor technique to correct a late-presenting remote pericommissural anomalous left coronary artery from the pulmonary artery. The merits of the technique compared to alternative techniques are explained. The impact of late diagnosis on left ventricular function as well as on papillary muscle ischemia-induced mitral regurgitation is evident. The child's recovery without the need for a temporary ventricular assist device supports the efficacy of  the technique, despite the residual mitral regurgitation.

Two-stage repair of interrupted aortic arch type A: Arch reconstruction and pulmonary artery banding without CPB through a left thoracotomy.

Treatment of interrupted aortic arch (IAA) is inherently challenging. Single-stage complete repair has become the norm in contemporary practice.  While palliation, in general, has fallen out of favor, a 2-stage approach to correcting selected type A IAA appears to be a productive, safe, and effective option, considering the neonatal age at repair. In this video tutorial, we demonstrate our preferred technique for neonatal aortic arch repair and pulmonary artery banding, which constitute the first stage of the 2-stage repair. Key steps of stage 1 repair are demonstrated and the arguments supporting our approach are presented. This approach significantly reduces morbidity and results in a well-palliated ventricular septal defect (VSD).  We also briefly discuss stage 2 of the repair, which is a straightforward VSD closure and pulmonary artery debanding procedure when the child is older and more resilient.

Left ventricular unloading during extracorporeal membrane oxygenation - Impella versus atrial septal defect: A simulation study.

BACKGROUND: Atrial septal defect and Impella have been proposed for left ventricular unloading in venoarterial extracorporeal membrane oxygenation patients. This work aims at evaluating the haemodynamic changes in venoarterial extracorporeal membrane oxygenation patients after Impella implantation or atrial septal defect realization by a simulation study. METHODS: A lumped parameter model of the cardiovascular system was adapted to this study. Atrial septal defect was modelled as a resistance between the two atria. Venoarterial extracorporeal membrane oxygenation and Impella were modelled starting from their pressure-flow characteristics. The baseline condition of a patient undergoing venoarterial extracorporeal membrane oxygenation was reproduced starting from haemodynamic and echocardiographic data. The effects of different atrial septal defect size, Impella and venoarterial extracorporeal membrane oxygenation support were simulated. RESULTS: Impella caused an increment of mean arterial pressure up to 67%, a decrement in mean pulmonary arterial pressure up to 8%, a decrement in left ventricular end systolic volume up to 11% with a reduction up to 97% of left ventricular cardiac output. Atrial septal defect reduces left atrial pressure (19%), increases right atrial pressure (22%), increases mean arterial pressure (18%), decreases left ventricular end systolic volume (11%), increases right ventricular volume (33%) and decreases left ventricular cardiac output (55%). CONCLUSION: Impella has a higher capability in left ventricular unloading during venoarterial extracorporeal membrane oxygenation in comparison to atrial septal defect with a lower right ventricular overload.