Combined procedure using a double flap as a surgical option for coarctation of the aorta with delayed diagnosis.

Simple coarctation of the aorta is repaired in an infant by direct end-to-end anastomosis of the aorta or subclavian flap aortoplasty. However, some cases are not detected until late childhood. For school-age patients, greater consideration must be given to risks such as postoperative limb ischemia and the potentially harmful effects of any artificial material on future growth. Here, we describe our technique for these patients, in whom the value of direct anastomosis is uncertain, to minimize the amount of synthetic graft material used while achieving successful anatomical repair.

How do we treat severely prolapsed true ectopia cordis?

Ectopia cordis is an extremely rare condition where the heart displaces outside the thoracic cavity. Treating this, especially when accompanied by congenital heart diseases and severe protrusion, is challenging. Here, we present a case of successful treatment involving intracardiac repair and delayed sternal closure using local skin flaps.

Clinical Prognosis of Vocal Cord Paralysis After Cardiothoracic Surgery in Infants.

We aimed to clarify the long-term outcomes and prognosis of vocal cord paralysis (VCP) after cardiothoracic surgery in infants as well as the usefulness of laryngeal ultrasound (LUS) as screening for VCP. Overall, 967 infants aged 1-year-old or younger who underwent cardiothoracic surgery between 2008 and 2022 were included in this study. We divided the patients into two groups based on the period on whether they underwent screening without or with LUS and compared the incidence of VCP between the groups. There were no differences in the patients' preoperative characteristics between the two periods, whereas the incidence of VCP was significantly higher in period 2 than in period 1 (11.0% vs. 3.2%, p < 0.0001). The incidence of VCP among the procedures, including aortic arch repair, was > 50% and significantly increased from period 1 to period 2. The sensitivity and specificity of LUS was 87% and 90%, respectively. Symptoms of VCP improved in 92% of patients. Repeated flexible laryngoscopy revealed that the residual rate of VCP was 68%, 52%, and 48% at 6, 12, and 24 months, respectively. In conclusion, symptoms of postoperative VCP improved in most cases; however, paralysis persisted in half of the patients. As a screening method, LUS is useful for evaluating postoperative VCP. A more accurate understanding of VCP is needed to improve postoperative outcomes.

Regression of oesophageal varices in total anomalous pulmonary venous connection.

The coexisting of oesophageal varices with total anomalous pulmonary venous connection is extremely rare but contains a potential leading to a lethal haemorrhage. The fate of the oesophageal varices after total anomalous pulmonary vein connection repair remains largely unknown. We herein report a case with infracardiac type total anomalous pulmonary venous connection with remarkable oesophageal varices. In the present case, of note, the oesophageal varices were completely regressed after total anomalous pulmonary venous connection repair without any intervention. This case might help a surgical team reduce the hesitation to repair the total anomalous pulmonary venous connection regardless of oesophageal varices, a potentially fatal condition.

Efficacy of Short-Term Oral Prednisolone Treatment in the Management of Pericardial Effusion Following Pediatric Cardiac Surgery.

A standard treatment for pericardial effusion without cardiac tamponade after pediatric cardiac surgery has not been established. We evaluated the efficacy of short-term oral prednisolone administration, which is the initial treatment for postoperative pericardial effusion without cardiac tamponade at our institution. Between October 2008 and March 2020, 1429 pediatric cardiac surgeries were performed at our institution. 91 patients required postoperative treatment for pericardial effusion. 81 were treated with short-term oral prednisolone. Pericardial effusion was evaluated using serial echocardiography during diastole. Pericardial drainage was performed for patients with circumferential pericardial effusion with a maximum diameter of ≥ 10 mm or signs of cardiac tamponade. Short-term oral prednisolone treatment was administered to patients with circumferential pericardial effusion with a maximum diameter of < 10 mm or localized pericardial effusion with a maximum diameter of ≥ 5 mm. Patients with localized pericardial effusion with a maximum diameter of < 5 mm were observed. Prednisolone (2 mg/kg/day) was administered orally for 3 days, added as needed. Short-term oral prednisolone treatment was effective in 71 cases and 90% of patients were regarded as responders. The remaining patients were deemed non-responders who required pericardial drainage. Overall, 55 responders were deemed early responders whose pericardial effusion disappeared within 3 days. There were no cases of deaths, infections, or recurrence of pericardial effusion. The amount of drainage fluid on the day of surgery was higher in the non-responders. In conclusion, short-term oral prednisolone treatment is effective and safe for treating pericardial effusion without cardiac tamponade after pediatric cardiac surgery.

Histopathology of anastomotic stenosis after total anomalous pulmonary vein connection.

We report a case of a 10-month-old girl who was diagnosed with pulmonary vein stenosis after total anomalous pulmonary vein connection repair and underwent release of an anastomotic stenosis. Histopathological examinations of the resected anastomotic tissue revealed intimal hyperplasia at the anastomotic site. Predominant lesion cells were identified as myofibroblasts and had the characteristics of fibroblasts and synthetic smooth muscle cells. These cells could be a useful target for preventing anastomotic stenosis after total anomalous pulmonary vein connection repair.

Prophylactic Opening of the Pleural Cavity for Postoperative Drainage is a Risk Factor for Prolonged Pleural Effusion After a Fontan Operation.

Postoperative prolonged pleural effusion (PPE) remains a confounding problem after a Fontan operation. We aimed to describe the risk factors for PPE after a Fontan operation and to clarify the impact of prophylactic opening of the pleural cavity (POPC) for drainage tube insertion on PPE. We retrospectively reviewed the medical charts of 50 consecutive patients who underwent a Fontan operation at our institution. POPC for postoperative drainage was performed based on each surgeon's preference. Patients were divided into three groups for analysis: group A (n = 12), no opening; group B (n = 14), unilateral opening; and group C (n = 24), bilateral opening. At the time of surgery, the median age of our patient group was 26 months, with a median body weight of 10.5 kg. The volume of pleural effusion tended to be lower in group A than in groups B and C (p = 0.08). The median duration of drainage was significantly shorter (p = 0.03) in group A (3 days) than in group B (4 days) or C (5 days). Overall, 12 patients required chest tube drainage for ≥ 7 days. Multivariate analysis revealed POPC (p = 0.01) and postoperative water balance (p = 0.03) as independent predictors of PPE. POPC and postoperative water balance are risk factors for PPE after a Fontan operation. Therefore, avoiding POPC for postoperative drainage may reduce the risk of postoperative pleural effusion and morbidities associated with PPE after a Fontan operation.

Efficacy of Artificial Chordal Reconstruction for Idiopathic Severe Mitral Regurgitation Due To Chordal Rupture in Infancy.

Early surgical intervention is required for sudden onset, severe mitral regurgitation (MR) due to chordal rupture in infants with normal development younger than 1 year. The condition has been recognized as idiopathic. However, the surgical options in children are limited because of their size and somatic growth. We sought to examine the efficacy of mitral valve plasty by artificial chordal reconstruction for these infants in mid-to-long term. From August 2005 through June 2012, 8 consecutive patients aged 1-7 months underwent mitral valve plasty by chordal reconstruction using expanded polytetrafluoroethylene sutures for MR, owing to leaflet prolapse. The geometric parameters of the diameter of the mitral annulus (D1), the long axis of the left ventricular (LV) chamber (D2), and the length of the papillary muscle including the reconstructed chordae (D3) were measured, as well as MR grade (0-4) and LV end-diastolic dimension, at each time point. The parameters were compared with those in the control group that included Kawasaki disease patients without cardiac lesions and healthy children (n = 51). Mean follow-up period was 5.8 (2.8-9.6) years. Freedom from reoperation was 100%. MR grades were 3.9 ± 0.4 preoperatively, 2.4 ± 0.9 at discharge, and 1.4 ± 0.6 at the latest. Postoperative MR was improved within 1 year in 5 of 6 patients who had grade 2 or higher regurgitation. LV end-diastolic dimensions were 109% (% of normal), 113%, and 107% at discharge, 3, and 5 years, respectively. Geometric configuration indicated by the D1/D2 ratio did not significantly change with time. The length of the papillary muscle including reconstructed chordae (D3) strongly correlated with body surface area (r(2) = 0.65), which seemed to be equivalent to that in the control group. In conclusion, postoperative mitral valve function and geometry was preserved. This procedure with a low morbidity should be an option for pediatric patients with acute severe MR.

[Clinical Experience of Beating Heart Atrial Septostomy Using a Device for Coronary Artery Anastomosis Site Creator].

BACKGROUND: Intra-atrial communication was mandatory for several congenital cardiac diseases, such as pulmonary atresia with intact ventricular septum (PA/IVS), and either sided aortoventricular valve atresia. We assessed whether the new methods of atrial septal defect(ASD)creation was effective. METHODS: We experienced 4 cases of the surgical atrial septostomy performed under on-pump beating. We used a new device, a circular punch out defect creator. RESULTS: All cases were alive. The mean ASD diameter was enlarged from 4.37 mm to 5.55 mm and the mean ASD shunt flow was significantly decreased from 1.47 m/s to 1.11 m/s. CONCLUSIONS: We performed the surgical atrial septostomy using an aortic puncher under beating heart effectively and safely.

Efficacy and haemodynamic effects of vacuum-assisted closure for post-sternotomy mediastinitis in children.

OBJECTIVES: Post-sternotomy mediastinitis is a significant morbidity with controversial management. Vacuum-assisted closure (VAC) has been used to treat mediastinitis, with many reports documenting its efficacy and feasibility, particularly in adults. However, its use is not prevalent in the paediatric population because of concerns that it may deteriorate haemodynamics. This study aimed to evaluate outcomes and effects of VAC on the haemodynamics of paediatric patients with post-sternotomy mediastinitis. METHODS: Six patients were treated with VAC between April 2005 and March 2013. We retrospectively investigated their profiles, clinical outcomes and haemodynamic changes, including mean blood pressure (MBP), mean heart rate (MHR), urinary output, amount of diuretics and vasoactive-inotropic score (VIS), before and after VAC initiation. RESULTS: The median age and body weight of patients were 6.4 months and 4.5 kg, respectively. Three patients (50%) had single ventricular physiology. The median VAC duration was 12 days. One patient died of pulmonary venous obstruction after mediastinitis was cured. The average MBPs in every 8-h period were examined, and there were no significant changes (P = 0.773); the average MHRs were examined in the same manner and they decreased significantly after initiation of VAC (P = 0.032). Only 2 patients required vasoactive agents. The VIS did not change in 1 patient and decreased in the other. The mean amount of diuretics administered and urinary output per body weight did not change significantly (P = 0.395 and 0.273, respectively). CONCLUSIONS: In conclusion, the haemodynamics of children were not significantly affected by the negative pressure of VAC, indicating that this therapy may be safe and effective for post-sternotomy mediastinitis, even in small children with complex cardiac anomalies.

Right ventricular myxoma obstructing the pulmonary artery during early childhood.

Primary cardiac tumors are uncommon during infancy and childhood. Myxomas originating in the right ventricle are even less common in pediatric patients. A 2-year-old girl was referred to our hospital under a diagnosis of right ventricular tumor. The aim of the operation was extirpation of the tumor. Perioperative cardiac arrest occurred when the tumor obstructed the pulmonary artery. After promptly establishing cardiopulmonary bypass, the tumor was removed from the right ventricular outflow tract. The patient was discharged on the 13th postoperative day without complications.

An effective vacuum-assisted closure treatment for mediastinitis with aortic arch replacement.

Little experience exists with the vacuum-assisted closure (VAC) therapy in the high-risk group of patients with perigraft abscess containing a large amount of prosthetic vascular grafts. We report our experience in the VAC therapy for patients with mediastinitis after aortic arch replacement. Between February 2003 and December 2006, five patients with a mean age of 72.2 years developed postoperative mediastinitis after aortic arch replacement, and were treated with the VAC system. In all the patients the mediastinal fluid and tissue examinations turned out to be negative for microbiological cultures, and successful closure of the midline incision was achieved with concomitant omental transfer after a mean duration of 22.6 days of VAC treatment. Four of the five patients survived to discharge and have been free from recurrent sign of mediastinal or graft infection at long-term follow-up. Our study indicates that the VAC treatment may reduce early mortality of life-threatening deep sternal wound infection complicated by a prior aortic arch replacement and become a preferred therapeutic option for the patients to whom another replacement is too risky.

Trial of new vascular clips for aortic anastomosis in a canine model.

OBJECTIVES: We created a new vascular clip designed for aortic surgery. The purposes of this investigation were to examine surgical applicability in a clinically relevant aortic replacement model and to assess biomechanical strength of the clipped anastomosis and serial histologic changes in the clipped anastomotic site. METHODS: Twenty-one beagles underwent descending thoracic aortic replacement. Distal anastomosis was performed with the new clips, mimicking the cuffed anastomosis technique, and proximal anastomosis was carried out by conventional suture anastomosis. Tissue specimens of the anastomotic sites were harvested at 1, 3, 6, and 12 months postoperatively for examination. RESULTS: There was no significant difference in the time required to carry out clip anastomosis (12.2 +/- 1.3 minutes) and suture anastomosis (13.7 +/- 0.9 minutes; P = .38). Neither type of anastomotic site was disrupted by raising the intraluminal pressure to 280 mm Hg. Microscopically, the areas of aortic wall compressed by vascular clips appeared as hyalinized areas adjacent to surrounding collagen fibers, with no significant infiltration of inflammatory cells. Identical histologic changes were observed at the site of the sutured anastomosis. The media at the clipped anastomosis site was significantly thinner than that at the sutured anastomosis site at 1 month after the operation. However, there was no significant difference in the thickness of the media at 3 months. CONCLUSIONS: The new vascular clips were effective in this clinically relevant model, with appropriate biomechanical strength, and the anastomotic sites underwent similar histologic changes to those observed after suture anastomosis.

Midterm results of mitral valve repair with artificial chordae in children.

OBJECTIVE: We have used artificial chordal replacement with expanded polytetrafluoroethylene sutures for mitral valve repair in children and reported favorable early clinical results. In this article we evaluate the midterm results of mitral valve repair with expanded polytetrafluoroethylene sutures in 39 children. METHODS: From April 1995 through September 2003, mitral valve repair with chordal replacement using expanded polytetrafluoroethylene sutures was performed in 39 patients. In all patients the preoperative grade of mitral regurgitation was moderate or more because of prolapse of the anterior mitral leaflet. The mean age and body weight at the time of the operation were 4.7 +/- 5.3 years (range, 1 month to 17.8 years) and 14.4 +/- 12.2 kg (range, 3.9-54.4 kg), respectively. The number of expanded polytetrafluoroethylene sutures ranged from 1 to 3 (mean, 1.4). The mean follow-up period and body weight at the latest follow-up were 5.0 +/- 2.3 years (range, 1.1-8.5 years) and 25.7 +/- 16.4 kg (range, 6.9-73 kg), respectively. RESULTS: There were no operative or late deaths. Only one patient required mitral valve replacement, which occurred 17 days after repair. Two patients underwent redo mitral valve repair 2 and 5 years after initial repair, respectively. The actuarial freedom from reoperation at 5 and 8 years was 94.8% and 89.5%, respectively. At the latest follow-up, trivial or less mitral regurgitation was observed in 33 (84.6%) patients. CONCLUSIONS: Mitral valve repair with expanded polytetrafluoroethylene sutures in children demonstrated favorable midterm outcome. The procedure is safe and effective, with potential for patients' growth.