An Alternative Non-Conduit Repair Strategy for Tetralogy of Fallot With Short Segment Pulmonary Atresia.

Tetralogy of Fallot (TOF) with pulmonary atresia is a subset in which it becomes imperative to use an artificial conduit in most cases. The atresia of the pulmonary artery can occur at various levels and be of variable lengths. For long segment pulmonary atresia, a right ventricle to pulmonary artery conduit is unavoidable in patients otherwise suitable for complete bi-ventricular repair with no major aortopulmonary collaterals, based on McGoon and Nakata indices. However, for patients with membranous pulmonary atresia and short segment atresia of the main pulmonary artery, we describe an alternative technique that avoids the use of handmade conduits or bovine jugular vein grafts and utilizes the concept of a monocusp with restoration of continuity from the right ventricular infundibulum to the distal main pulmonary artery. A seven-year-old girl diagnosed with TOF and pulmonary atresia underwent a right ventriculotomy with ventricular septal defect closure. The narrowed outflow tract was widened, and an anastomosis was made directly between the right ventricle and the pulmonary artery. A monocusp was fashioned from autologous pericardium, and the pulmonary artery was reconstructed using bovine pericardium. In TOF with pulmonary atresia, conventional surgery typically uses a valved conduit to connect the right ventricular outflow tract (RVOT) to the pulmonary artery. However, in cases like ours, direct anastomosis is possible due to a long confluent pulmonary segment. This alternative technique eliminates the need for an artificial conduit and may prevent associated problems. It also allows for potential growth of the neo-annulus and pulmonary segment. The risk of reoperation remains due to possible monocusp failure.

Choice of valve substitutes.

Infective endocarditis often necessitates surgical intervention, and the choice of valve substitute remains a topic of controversy and highly debatable due to the wide range of available options and recent technical advancements. This manuscript reviews the different valve substitutes in the context of infective endocarditis, including mechanical and bioprosthetic valves, homografts, xenografts, and tissue-engineered valves. The patient's age, sex, demographic location, intellectual quotient, comorbidities, available options, and the experience of the surgeon should all be taken into consideration while choosing the best valve substitute for that individual. While valve repair and reconstruction are preferred whenever feasible, valve replacement may be the only option in certain cases. The choice between mechanical and bioprosthetic valves should be guided by standard criteria such as age, sex, expected lifespan, associated comorbidities, and anticipated adherence to anticoagulation therapy and accessibility of medical facilities for follow-up. For patients with severe chronic illness or a history of intracranial bleeding or associated hematological disorders, the use of mechanical prostheses may be avoided. Homografts and bioprosthetic valves provide an alternative to mechanical valves, thereby decreasing the necessity for lifelong anticoagulation after surgery and diminishing the likelihood of bleeding complications. The manuscript also discusses specific valve substitutes for different heart valves (aortic, mitral, pulmonary, tricuspid positions) and highlights emerging techniques such as the aortic valve neocuspidization (Ozaki procedure) and tissue-engineered valves. Ultimately, the ideal valve substitute in IE should be evidence based on a comprehensive elucidation of clinical condition of the patient and available options.

Surgery compared to fibrinolytic therapy for symptomatic left-sided prosthetic heart valve thrombosis (SAFE-PVT): Rationale and design of a randomized controlled trial.

BACKGROUND: Left-sided mechanical prosthetic heart valve thrombosis (PVT) occurs because of suboptimal anticoagulation and is common in low-resource settings. Urgent surgery and fibrinolytic therapy (FT) are the two treatment options available for this condition. Urgent surgery is a high-risk procedure but results in successful restoration of valve function more often and is the treatment of choice in developed countries. In low-resource countries, FT is used as the default treatment strategy, though it is associated with lower success rates and a higher rate of bleeding and embolic complications. There are no randomized trials comparing the two modalities. METHODS: We performed a single center randomized controlled trial comparing urgent surgery (valve replacement or thrombectomy) with FT (low-dose, slow infusion tissue plasminogen activator, tPA) in patients with symptomatic left-sided PVT. The primary outcome was the occurrence of a complete clinical response, defined as discharge from hospital with completely restored valve function, in the absence of stroke, major bleeding or non-CNS systemic embolism. Outcome assessment was done by investigators blinded to treatment allocation. The principal safety outcome was the occurrence of a composite of in-hospital death, non-fatal stroke, non-fatal major bleed or non-CNS systemic embolism. Outcomes will be assessed both in the intention-to-treat, and in the as-treated population. We will also report outcomes at one year of follow-up. The trial has completed recruitment. CONCLUSION: This is the first randomized trial to compare urgent surgery with FT for the treatment of left-sided PVT. The results will provide evidence to help clinicians make treatment choices for these patients. (Clinical trial registration: CTRI/2017/10/010159).

Comparison of Multiple Injection Costotransverse Block and Erector Spinae Plane Block for Post-Sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective Randomized Comparative Study.

OBJECTIVE: The aim of this study was to evaluate the efficacy of ultrasound-guided multiple injection costotransverse block (MICB) and compare it with erector spinae plane block (ESPB) for poststernotomy pain relief in pediatric cardiac surgical patients. DESIGN: A prospective, randomized, double-blind, comparative study. SETTING: At a single institution tertiary referral cardiac center. PARTICIPANTS: A total of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy. INTERVENTIONS: Children were allocated randomly to 1 of the 3 following groups: ESPB (group 1), MICB (group 2), or Control (group 3). Participants in groups 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl/tramadol was used for rescue analgesia. MEASUREMENTS AND MAIN RESULTS: The modified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours postextubation. After all exclusions, 84 patients were analyzed. The MOPS score was found to be significantly lower in ESPB and MICB groups compared to the control group until 10 hours postextubation (p < 0.05), with no statistically significant difference at the 12th hour (p = 0.2198). The total intraoperative fentanyl consumption (p = 0.0005), need for fentanyl supplementation on incision (p < 0.0001), and need for rescue opioid requirement in the postoperative period (p = 0.034) were significantly lower in both the ESPB and MICB groups than the control group. There were no statistically significant differences in both primary and secondary outcomes between the ESPB and MICB groups. CONCLUSION: Ultrasound-guided MICB was effective and comparable to ESPB for post-sternotomy pain management in pediatric cardiac surgical patients.