Exercise performance after univentricular palliation.

BACKGROUND: The optimal timing, need for primary/staged procedure in patients undergoing univentricular palliation, is debatable. AIMS: We performed this study to assess the exercise performance of patients undergoing various forms of univentricular palliation. SETTING AND DESIGN: This was a retrospective, prospective comparative study conducted at a multispecialty tertiary referral center. PATIENTS AND METHODS: Between January 2012 and June 2015, 117 patients undergoing either bidirectional Glenn (BDG) (n = 43) or Fontan (total cavopulmonary connection [TCPC]) (n = 74) underwent exercise testing. STATISTICAL ANALYSIS: Comparisons between subgroups for continuous data were made with Student's t-test if normally distributed and Wilcoxon rank-sum test otherwise. Tests between subgroups for qualitative data were made with Pearson's Chi-square test. RESULTS: Patients who underwent BDG with open antegrade pulmonary blood flow (APBF) had higher saturations (oxygen saturation [SpO2]) compared to those without it (87.5 ± 5.0% vs. 81.1 ± 4.8%; P = 0.0001). However, we found no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC (n = 42) patients demonstrated better exercise capacity (15.0 ± 7.7 vs. 11.2 ± 6.2 min; P = 0.02) and increased SpO2 on exercise (87.0 ± 8.0% vs. 83.4 ± 7.6%; P ≤ 0.05) compared to lateral tunnel TCPC (n = 32). Fenestrated TCPC (n = 30) patients had higher exercise capacity reflected by higher metabolic equivalents (METs) consumption (6.4 ± 2.3 vs. 5.2 ± 2.0 METs, P = 0.02), fewer pleural effusions (7.0 ± 3.2 vs. 9.2 ± 6.2 days, P ≤ 0.05), and lower hospital stay (9.5 ± 4.0 vs. 12.7 ± 7.7 days, P = 0.04) compared to nonfenestrated TCPC (n = 44) patients. CONCLUSIONS: We observed no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC patients had better exercise capacity but longer postoperative hospital stay and pleural effusions than patients with lateral tunnel Fontan. Fenestrated TCPC patients seemed to fare better than nonfenestrated ones. Patients undergoing TCPC had better exercise capacity than patients undergoing BDG alone.

Bidirectional Glenn on cardiopulmonary bypass: A comparison of three techniques.

OBJECTIVE: To analyze the intraoperative and early results of the bidirectional Glenn (BDG) procedure performed on cardiopulmonary bypass (CPB) using three different techniques. METHODS: Between September 2013 and June 2015, 75 consecutive patients (mean age 42 ± 34.4 months) undergoing BDG were randomly assigned to either technique I: open anastomosis or technique II: superior vena cava (SVC) cannulation or technique III: intermittent SVC clamping. We monitored the cerebral near infrared spectrophotometry (NIRS), SVC pressure, CPB time, intensive care unit (ICU) stay, and neurocognitive function. RESULTS: Patients in technique III had abnormal lower NIRS values during the procedure (57 ± 7.4) compared to techniques I and II (64 ± 7.5 and 61 ± 8.0, P = 0.01). Postoperative SVC pressure in technique III was higher than other two groups (17.6 ± 3.7 mmHg vs. 14.2 ± 3.5 mmHg and 15.3 ± 2.0 mmHg in techniques I and II, respectively = 0.0008). CPB time was highest in technique II (44 ± 18 min) compared to techniques I and III (29 ± 14 min and 38 ± 16 min, P = 0.006), respectively. ICU stay was longer in technique III (30 ± 15 h) compared to the other two techniques (22 ± 8.5 h and 27 ± 8.3 h in techniques I and II, respectively = 0.04). No patient experienced significant neurocognitive dysfunction. CONCLUSION: All techniques of BDG provided acceptable results. The open technique was faster and its use in smaller children merits consideration. The technique of intermittent clamping should be used as a last resort.

Atrial switch procedure in children more than 5 years of age: mid-term results.

OBJECTIVES: In developing countries, where patients present late, the atrial switch operation is still a preferred palliation for d-transposition of great arteries (d-TGA). In this report, we present our experience in patients with d-TGA who were 5 years of age or older. METHODS: Twenty-seven patients underwent an atrial switch procedure between January 2004 and December 2014. The standard technique consisted of a combination of the Senning and Mustard's repair with Schumacker's in situ modification for construction of the pulmonary venous baffle. RESULTS: The median age was 8 years (mean: 9.42 ± 4.9, range: 5-26 years). Anatomical variations were dextrocardia (n = 3), situs inversus (n = 3), juxtaposed atrial appendages (n = 4) and left superior vena cava (n = 6). Median aortic cross-clamp and bypass times were 63 and 105 min, respectively. The median ventilator support duration was 15 h (mean: 13.7 ± 4.3, range: 6-24 h). The median intensive care unit stay was 2 days (mean: 2.38 ± 0.69, range: 2-4 days). The median hospital stay was 6 days (mean: 6.3 ± 1.7, range: 4-12 days). There were no early or late deaths. The median follow-up duration was 46 months (mean: 55.15 ± 34.71, range: 1-124 months). There were no deaths or re-operations. One patient had mild systemic venous obstruction after 4 years; one underwent embolization of aortopulmonary collaterals after 5 years. The event-free survival rate at 124 months was 90.9 ± 6.13% (95% CI: 68.3-97.65). CONCLUSIONS: The atrial switch operation using the described technique is low risk, carries acceptable results and is a valuable management option in older patients with d-TGA and a regressed LV.

Extraanatomic Bypass to Supraceliac Abdominal Aorta for Complex Thoracic Aortic Obstruction.

BACKGROUND: The standard surgical treatment of coarctation of the aorta is through a left posterolateral thoracotomy. However, when a concomitant cardiac procedure is required or the conventional approach is not possible or is hazardous, extraanatomic bypass to the supraceliac abdominal aorta may be advantageous. We discuss our technique and report the long-term results. METHODS: Between January 1986 and January 2015, 25 patients (16 males, 9 females) underwent extraanatomic bypass to the supraceliac abdominal aorta for various lesions of the arch and the descending thoracic aorta. Extraanatomic bypass to the supraceliac abdominal aorta was performed for patients in whom balloon dilatation was not feasible due to associated arch hypoplasia (n = 9), long-segment thoracic aorta narrowing due to nonspecific aortoarteritis (n = 3), or isolated long-segment coarctation of the aorta (n = 3). Patients who needed concomitant cardiac procedures, such as aortic valve replacement (n = 4), ascending aortic aneurysm repair (n = 2), or coronary artery bypass grafting (n = 1), and in whom balloon dilatation had failed, also underwent extraanatomic bypass to the supraceliac abdominal aorta. Extraanatomic bypass was also performed in 3 patients with recurrent coarctation after surgical repair and in whom balloon dilation was not feasible or unsuccessful. RESULTS: There were no early or late deaths. The peak-to-peak gradients between the upper limb and the lower limb decreased from 59.3 ± 16.3 mm Hg to 2.0 ± 2.8 mm Hg (p < 0.0001). The mean follow-up was 96.6 ± 92.6 months (range, 1 to 240 months; median, 54 months). Doppler interrogation of the lower limb arterial system after a mean follow-up of 86.4 ± 85.2 months showed an unobstructed flow pattern. The ankle-brachial pressure index improved from a preoperative value of 0.60 ± 0.07 to 1.04 ± 0.11 (p < 0.0001). Systolic blood pressure decreased significantly compared with preoperative values (153.9 ± 18.9 vs 122.8 ± 10.2, p < 0.0001). Three patients continued to receive antihypertensive medication due to persistent mild hypertension. CONCLUSIONS: Extraanatomic bypass to the supraceliac abdominal aorta provides effective palliation for complex aortic obstructions. It is easy and quick to perform, avoids fatal complications, and is well tolerated in all age groups.

Atrial Switch Operation in a Late Presenter With d-Transposed Great Arteries, Juxtaposed Atrial Appendages, and Bilateral Superior Caval Veins.

A 26-year-old patient with d-transposition of great arteries (d-TGA), bilateral superior vena cava, and juxtaposed atrial appendages underwent a successful atrial switch operation. It is extremely uncommon to encounter a previously unpalliated patient with d-TGA at this age. Unusual morphologic features in this patient necessitated technical modifications to successfully accomplish an atrial switch procedure.

Repair of Concomitant Double Orifice Mitral and Tricuspid Valves.

The coexistence of double orifice mitral and tricuspid valves is rare. We report a five-year-old boy with double orifice mitral and tricuspid valves requiring surgical correction of hemodynamically significant mitral and tricuspid stenosis.

Thrombus in the Proximal Aorta: Cardiopulmonary Bypass Strategy and Surgical Management.

De novo noninfective thrombus formation in the ascending aorta is rare. We report two cases of ascending aortic thrombus, their surgical management, and cardiopulmonary bypass strategy.

Conventional versus adjustable pulmonary artery banding: which is preferable?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'whether conventional pulmonary artery banding (PAB) or adjustable PAB might be the superior intervention?' Using the PubMed search, 51 papers were found, of which seven papers represented the best evidence to answer the clinical question. We included only those papers that actually compared conventional PAB with adjustable PAB, and excluded those that studied only one of these interventions. Four studies qualified (one prospective and three retrospective) and analysed data in human patients, while three were experimental studies in animals. The end points in the prospective human study were death, debanding and follow-up to intracardiac repair. The three retrospective studies compared the incidence of early deaths, inotropic support, need for mechanical ventilatory support, reoperations and intensive care unit and hospital stay. Out of the four studies in humans, three studies noted a significant reduction in early deaths from 23 to 1.8%, 77 to 0% and 15 to 0% in conventional vs adjustable PAB. Need for early reoperations reduced from 18 to 3.5% and from 35 to 0% in 2 studies. Similarly, there was a reduction in the ventilatory times and the intensive care unit and hospital stay. The three experimental animal studies demonstrated that a much more reliable preparation of the ventricle was achieved with the use of an adjustable PAB. The results of all the seven studies led us to conclude that adjustable PAB provides superior early outcomes; reduces early mortality, need for inotropes and need for reintervention; and provides equivalent or superior band gradients when compared to conventional PAB. The use of the adjustable PAB was found to result in significant haemodynamic improvement by progressively reducing the pulmonary artery pressures and left-to-right shunt. The adjustable PAB was found to improve early survival and also made delayed repair feasible in a better clinical state, with reduced mortality and morbidity.

Is sternotomy superior to thoracotomy for modified Blalock-Taussig shunt?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is sternotomy approach superior to a thoracotomy approach for a modified Blalock-Taussig shunt procedure? More than 58 papers were found using the search as described below, of which 11 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Three of seven papers compared the sternotomy and thoracotomy approaches. The operative approach was a significant predictor of shunt failure. The criterion used to define early shunt failure was either the complete occlusion during hospitalization or the need to return to the operating room for a second shunt. The studies that compared the thoracotomy and sternotomy approaches observed increased shunt failure rates in the thoracotomy group. The sternotomy approach was associated with advantages like less pulmonary artery distortion, ease of technical performance, cosmetic advantage of a single sternotomy incision, ease of ligation of patent ductus, less phrenic nerve injury, less collateral formation in chest wall adhesions and less thoracotomy induced scoliosis. However, other papers studied either the sternotomy approach only or the thoracotomy approach and drew conclusions regarding risk factors for operative morbidity and mortality. We conclude that the sternotomy approach is beneficial to neonates and infants undergoing modified Blalock-Taussig shunt when compared with the conventional thoracotomy approach.