The Effect of the Presence of Barrier during Resternotomy in Congenital Heart Surgery.

Background: Reoperation is an important cause of morbidity and mortality in congenital heart surgery. The aim of this study was to assess whether the presence of barrier during resternotomy affected the outcomes of infants and children who underwent congenital heart surgery. Methods: A total of 110 (7.6%) patients who underwent reoperations among 1445 consecutive patients between February 2018 and June 2023 were evaluated. The patients were divided into two groups: those with barrier (n = 72) and those without barrier (n = 38). Demographic, intraoperative and postoperative data were retrospectively analyzed. Results: Among the 110 patients, the age at reoperation was 10.1 ± 1.4 years in the group with barrier and 10.9 ± 2.8 years in the group without barrier. There were no statistically significant differences in the age at surgery, preoperative saturation, interval since preceding surgery (years), and aortic cross clamp time (minutes) between the groups. However, there were significantly higher rates of injuries during dissection (p = 0.001) and adverse events (p = 0.002) during dissection in the non-barrier group. One patient in the group without barrier underwent reoperation but subsequently died. Conclusions: The usage of any barrier in front of the right ventricle can decrease the incidence of adverse events, morbidity and mortality.

Efficiency of Minimized Circuits of a Heart Roller Pump on Systemic Inflammatory Response Syndrome and Multiorgan Effects in a Rat Model.

BACKGROUND: The aim of this study is to compare the effects of tubing length on systemic inflammatory response syndrome and myocardial protection in a rat model of cardiopulmonary bypass (CPB) from a histological standpoint. METHODS: Twelve adult male Wistar Albino rats weighing >180 g were randomly selected and divided into 2 groups. In 1 group, the pump lines were kept 1 m shorter than standard. The right jugular vein and tail artery were cannulated using a 16-gauge catheter. Animals received 500 IU/kg intravenous heparin. Cardiac index and rectal temperature were set at 2.4 mL and 36°C, respectively. Total line volume was maintained at 8 mL. A roller pump was adjusted to supply a blood flow of 6 to 28 mL/min (mean 10 mL/min), similar to the typical cardiac output of rats. CPB duration was 15 minutes throughout the experiment. After sacrifice, tissue samples were collected from heart, liver, and kidney for histomorphologic examination. RESULTS: All histochemical and histomorphologic analyses, performed by 2 blinded researchers, revealed band loss in cardiomyocytes, mononuclear (MNL) cell infiltration, and impaired fibrillar organization in the standard-line group. Additionally in that group, sinusoidal dilatation in the liver, low-level congestion, focal necrosis, and periportal MNL infiltration were noted. In the shorter-line group, on the other hand, MNL cell infiltration, band loss in myofibrils, and cardiomyocyte degeneration were rarely observed. Higher liver congestion and lower MNL cell infiltration were observed in the shorter-line group. No significant differences were found in kidney samples. CONCLUSION: In a shorter-line roller pump test model, less multiorgan damage and fewer systemic inflammatory responses were observed. It may be applicable to keep CPB lines as close to the table as possible, especially in pediatric cardiac surgery cases.

Assessment of Tricuspid Valve Detachment Efficiency for Ventricular Septal Defect Closure: A Retrospective Comparative Study.

BACKGROUND: The aim of this study was to investigate the efficiency of tricuspid valve detachment (TVD) during the surgical treatment of perimembranous ventricular septal defects (VSDs) and to compare the early and mid-term results to patients without TVD in terms of tricuspid insufficiency. METHODS: A total of 170 patients who had undergone surgical closure of perimembranous VSDs between November 2012 and January 2019 were included in this study, of whom 50 had an additional TVD procedure during the surgery. All patients were examined by transthoracic echocardiography before and after the operation with regular intervals, and the tricuspid valve function was then evaluated. RESULTS: There was no significant difference between subgroups with an unchanging degree of TVR, however, the result was also similar among those who had a decreased degree of TVR at any level (p = 0.271, p = 0.451). At the end of the study, all patients were in New York Heart Association class I. CONCLUSIONS: We suggest that, in appropriate patients, VSD closure can be safely performed with an additional TVD application through an incision of the septal leaflet of the tricuspid valve without impairing the valve function or reducing the growth potential of the valve at midterm follow-up.

The assessment of thoracal approaches in the treatment of aortic coarctation.

OBJECTIVES: The optimal choice of surgery in coarctation of the aorta (CoA) remains controversial but it needs to be individualised. However, in most conditions, a surgical approach through thoracotomy maintains adequate exposure to create aortic patency. This study aimed to assess the efficiency and reliability of thoracal approaches in the treatment of CoA by examining the mid- and late-term outcomes, and determining the predictive factors for re-intervention. METHODS: Patients who underwent CoA repair through thoracotomy between September 2015 and February 2023 were included in the study, except for those with complex cardiac diseases. Medical records were retrospectively analysed and peri-operative course, follow-up findings on echocardiogram and physical examinations were obtained. The complication rate, postoperative arch gradient, need for antihypertensive medication use, and freedom from re-intervention were evaluated and then compared in terms of age at surgery. RESULTS: Overall, 98 patients including 50 neonates were reviewed. The most common surgical method was extended end-to-end anastomosis, performed in 53 patients. The median follow-up time was 4.6 years. There was one death in hospital and one late mortality in the cohort. Eight complications were observed in the cohort but all recovered well. Overall, 13 re-interventions, six redo surgeries and seven balloon angioplasties were carried out in 12 patients. Ten of the re-interventions were carried out within the first year of the initial surgery. One- and three-year freedom from re-intervention rates were 89.5 and 86.4%, respectively. However, there was no significant predictive factor for re-intervention. Comparisons according to the age at surgery did not differ, except for intensive care unit stay. The need for hypertensive medication was initially in 14 (14.2%) patients and then reduced to eight (8%) patients. The mean peak residual gradient on postoperative examination was 9 mmHg. CONCLUSION: Thoracotomy provided feasible surgical access that led to satisfactory results with a low complication rate, negligible residual gradient, low incidence of hypertension and excellent rate for freedom from re-intervention in the treatment of CoA.

Ventricular septal defect closure using radial incision of the tricuspid valve for exposure: is it really necessary?

AIM: To evaluate the effects of radial incision of the tricuspid valve in patients who had undergone ventricular septal defect (VSD) closure. METHODS: Overall 173 patients were included in this study between 2012 and 2019. In 44 individuals, a tricuspid valve radial incision (TVRI) was included in the surgical process. RESULTS: There were no mortalities. The demographic data did not differ between the groups. The mean ages of the TVRI and non-TVRI groups were 2.92 ± 3.88 and 2.69 ± 2.80 years, respectively. There were no significant differences between the groups in terms of mean duration of cardiopulmonary bypass aortic cross-clamp, postoperative intubation time and intensive care unit stay. Mild tricuspid valve regurgitation was detected in only two patients in the TVRI and six patients in the non-TVRI groups. There was no tricuspid valve stenosis and all patients were in New York Heart Association functional class 1. CONCLUSION: This technique, which can facilitate exposure and closure of VSDs, did not compromise the tricuspid valve function at mid-term, therefore proving to be safe.

Prevalence and Localization of Hibernating Myocardium Among Patients with Left Ventricular Dysfunction.

OBJECTIVE: This study evaluated how much of the myocardium was hibernating in patients with left ventricle dysfunction and/or comorbidities who planned to undergo either surgical or interventional revascularization. Furthermore, this study also identified which irrigation areas of the coronary arteries presented more scar and hibernating tissue. METHODS: At rest, Tc-99m MIBI SPECT and cardiac F-18 FDG PET/CT images collected between March 2009 and September 2016 from 65 patients (55 men, 10 women, mean age 64±12) were retrospectively analyzed in order to evaluate myocardial viability. The areas with perfusion defects that were considered metabolic were accepted as hibernating myocardium, whereas areas with perfusion defects that were considered non-metabolic were accepted as scar tissue. RESULTS: Perfusion defects were observed in 26% of myocardium, on average 48% were associated with hibernation whereas other 52% were scar tissue. In the remaining Tc-99m MIBI images, perfusion defects were observed in the following areas in the left anterior descending artery (LAD; 31%), in the right coronary artery (RCA; 23%) and in the Left Circumflex Artery (LCx; 19%) irrigation areas. Hibernation areas were localized within the LAD (46%), LCx (54%), and RCA (64%) irrigation areas. Scar tissue was also localized within the LAD (54%), LCx (46%), and RCA (36%) irrigation areas. CONCLUSION: Perfusion defects are thought to be the result of half hibernating tissue and half scar tissue. The majority of perfusion defects was observed in the LAD irrigation area, whereas hibernation was most often observed in the RCA irrigation area. The scar tissue development was more common in the LAD irrigation zone.

Requirement for repetitive surgical approaches at supravalvular aortic stenosis.

Supravalvular aortic stenosis, which is a rare congenital cardiac anomaly, is associated with several lesions and has a progressive nature. Herein, we report a five-year-old girl with bicuspid aorta who underwent initial Doty operation at the age of nine months. A combined redo Doty operation and an aortic valve commissurotomy were performed two years later. Due to the rapidly progressing aortic regurgitation and both valvular and supravalvular gradient, a repeated surgery was required at the age of five years and an aortic homograft was successfully inserted with an annulus enlargement and the patient was discharged uneventfully. In conclusion, although Doty repair yields satisfactory results in most patients, certain cases with identified risk factors may require reoperations due to the progressive nature of the disease. Therefore, these patients should be kept under a close follow-up lifelong.

Long-Term Assessment of Left Ventricular Ejection Fraction and Mitral Regurgitation Following Takeuchi Repair.

OBJECTIVE: This study aimed to evaluate the early operative outcomes and to compare the left ventricle and mitral valve functions after initial Takeuchi repair in patients with anomalous left coronary arising from pulmonary artery (ALCAPA). METHODS: Fourteen patients (5 males, 9 females; mean age 4.3 years, ranging from 25 days to 34 years) who were operated for ALCAPA between 2007 and 2018 were included in this study. Data were evaluated retrospectively based on our medical records. RESULTS: Hospital mortality rate was 7.1% (n=1). Thirteen surviving patients were kept in follow-up mean 4.3±3.05 years. When compared to preoperative measurements, both left ventricular ejection fraction (LVEF), (P=0.007) and mitral regurgitation (MR) (P=0.001) significantly improved before discharge. Moreover, LVEF values were improved in the late follow-up, considering early postoperative outcomes, and this alteration was significant (P=0.014). Nevertheless, alteration in the degree of MR among patients did not differ in the long-term follow-up (P=0.180). There was no late-term mortality or need for reoperation among patients. CONCLUSION: Although some centers prefer to direct implantation in ALCAPA, Takeuchi procedure can be accepted as a reliable method that provides satisfactory long-term results, considering that it aids to improve left ventricle ejection fraction and reduced mitral valve regurgitation.

Our experience on Bentall procedure in an adult patient with Baraitser-Winter syndrome.

Baraitser-Winter syndrome is a very rare genetic disorder caused by cytoplasmic actin-encoding genes defects. Although most patients have similar phenotype, concomitant cardiac anomalies widely vary. In addition to well-described congenital heart diseases, aortic aneurysms occur due to underlying actin gene mutation in these patients in the further years. Herein, we present a 26-year-old male case who underwent Bentall procedure with the diagnosis of new-onset aortic valve regurgitation and an ascending aorta aneurysm.

Surgical management of late-term pulmonary venous baffle stenosis after Senning operation.

Although pulmonary venous baffle stenosis is not a common late complication after the Senning operation, surgical treatment is vital, when interventional methods fail to correct the pathology. Our patient was admitted to hospital with recurrent epistaxis and exertional dyspnea 6.5 years after the Senning procedure. The gradient in the pulmonary venous baffle was measured as 34 to 35 mmHg via transthoracic echocardiography. During surgical treatment, the calcified and retracted polytetrafluoroethylene flap was completely excised and porcine pericardial xenograft was used to cover the pulmonary venous baffle. At the end of the procedure, no significant gradient was detected via transesophageal echocardiography.

Effects of carbon dioxide insufflation on anastomosis remodeling at a carotid artery site in rabbits.

INTRODUCTION: Use of carbon dioxide (CO2) insufflation (CDI) on the surgical field during heart surgery has become widespread, and in some units routine. AIM: To assess the effects of CDI on endothelial dysfunction in a carotid artery model in rabbits. MATERIAL AND METHODS: Twelve randomly selected rabbits were divided into two groups. Right carotid arteries of the animals were transected and sutured with running suture technique. Then, 1 l/min CO2 insufflation was initiated with a 45° angle. In the control group, the anastomotic field was irrigated with 0.1 ml/s flow of 0.9% saline. At day 28, the carotid artery segments were removed and prepared for histological specimens. RESULTS: In the cross-sections of the control group vessel samples, thickening of the tunica intima was observed. Scoring the quantity of endothelial nitric oxide synthase (e-NOS) and α-smooth muscle actin (α-SMA) positive staining revealed a nonsignificant difference between the experimental groups (p = 0.07). In the CO2 group, the intimal hyperplasia (p = 0.2) and the thickness of the tunica media (p = 0.2) were indistinguishable when compared to the control group. The mean luminal diameters and luminal areas of the experimental groups were all evaluated by histomorphometry and a significant differences was found between luminal areas (p = 0.016). On the other hand, no significant difference was found between mean luminal diameters (p = 0.055). CONCLUSIONS: Our study indicated that CDI can affect endothelial cell damage and the mean luminal diameters.

Effects of rivaroxaban on intimal hyperplasia and smooth muscle cell proliferation at the carotid artery anastomosis site in rabbits.

OBJECTIVE: This study aimed to assess the effect of new generation oral, direct factor Xa inhibitor rivaroxaban on intimal hyperplasia and smooth muscle cell proliferation at the carotid artery anastomosis site of rabbits. METHODS: In total, 14 New Zealand male rabbits weighing 3-3.5 kg were randomized into two groups. Group A (7 rabbits) served as the control group and received no medication. Rivaroxaban was perorally administered to group B (7 rabbits) mg/kg/day for 28 days. Following anesthesia induction, carotid arteries were dissected through a right neck incision. following heparinization at 100 IU/kg, vertical full thickness arteriotomy was performed, then was repaired continuously with 8-0 polypropylene. At day 28, all rabbits were sacrificed and the anastomosed carotid artery segments were analyzed using light microcopy. Hematoxylin-eosin and Masson's trichrome stained images were analyzed using a digital image analysis program, and lumen diameter, lumen area, intimal and medial thickness, and media areas were measured and results were compared. RESULTS: In the serial sections, the average lumen diameter of group B was higher than that of group A (p=0.001). The lumen areas of group B were also higher than those of group A (p=0.004). The intimal thickness of group B was lower than that of group A (p=0.001). When the section series were evaluated for media thickness, the thickness of group B was lesser than that of group A; the difference was statistically significant (p=0.002). CONCLUSION: This study may imply a potential midterm benefit of rivaroxaban following arterial anastomosis by reducing intimal proliferation and restenosis.

Long-term assessment of left ventricular ejection fraction and mitral regurgitation following takeuchi repair

Abstract Objective: This study aimed to evaluate the early operative outcomes and to compare the left ventricle and mitral valve functions after initial Takeuchi repair in patients with anomalous left coronary arising from pulmonary artery (ALCAPA). Methods: Fourteen patients (5 males, 9 females; mean age 4.3 years, ranging from 25 days to 34 years) who were operated for ALCAPA between 2007 and 2018 were included in this study. Data were evaluated retrospectively based on our medical records. Results: Hospital mortality rate was 7.1% (n=1). Thirteen surviving patients were kept in follow-up mean 4.3±3.05 years. When compared to preoperative measurements, both left ventricular ejection fraction (LVEF), (P=0.007) and mitral regurgitation (MR) (P=0.001) significantly improved before discharge. Moreover, LVEF values were improved in the late follow-up, considering early postoperative outcomes, and this alteration was significant (P=0.014). Nevertheless, alteration in the degree of MR among patients did not differ in the long-term follow-up (P=0.180). There was no late-term mortality or need for reoperation among patients. Conclusion: Although some centers prefer to direct implantation in ALCAPA, Takeuchi procedure can be accepted as a reliable method that provides satisfactory long-term results, considering that it aids to improve left ventricle ejection fraction and reduced mitral valve regurgitation.