The use of "2-octyl cyanoacrylate" as skin adhesive in pediatric and congenital cardiac surgery.

AIM: The aim of this paper was to evaluate the safety and cost-effectiveness of "2-octyl-cyanoacrylate" as skin adhesive in congenital heart surgery. METHODS: From April 2010 to December 2011, we collected data from 300 patients who underwent cardiac surgery for congenital heart disease. We divided our population into 3 groups: group-1 (N.=100):"2-octyl-cyanoacrylate" has been used to replace the intra-dermal suture line; group-2 (N.=100):"2-octyl-cyanoacrylate" has been utilized as a barrier ("add-on measure") in addition to the intra-dermal suture line, group-3 (N.=100) with a standard intra-dermal suture line. RESULTS: Median age of patients was 1.36 years. One-hundred and thirty-nine patients were younger than 12 months and 56 older than 16 years. There were 11 wound dehiscence (3.6%) (2 in group-1 and 9 in group-3, P=0.001) and 1 superficial wound infection (group-1). Six patients (2%) required surgical wound revision (2 in group-1 and 4 in group-3, P=NS). Wound complication was significantly associated to delayed sternal closure (3/12 patients, 25% versus 13/288 patients, 4.5%) (P=0.04). Median cost (intra-/postoperative) for wound treatment was lower in group-1 and 2 (19±5.5 and 23.9±7.4 € respectively) when compared to Group-3 (26.7±3.2) (P<0.0001). CONCLUSION: The use of "2-octyl-cyanoacrylate" proved to be safe and effective; the "add-on measure" strategy provided the best cost-effective solution.

One-and-a-half ventricle repair as a surgical alternative to Fontan revision in an adult.

We report a case of a young man with hypoplastic right ventricle, who presented with recurrent untreatable arrhythmias after a Bjork Fontan procedure in infancy. He underwent one-and-a-half ventricle repair as an alternative surgery to Fontan revision.

One-and-a-half ventricle repair in adult patients: a word of caution.

OBJECTIVES: The "one-and-a-half ventricle repair" (1.5 VR) is applied to several congenital heart diseases with hypoplastic right ventricle (RV), with good functional and clinical results in infants and children, but feasibility in adult population is being explored. MATERIALS AND METHODS: This is a retrospective analysis of medical records of all adult patients undergoing 1 + 1/5 VR between 2000 and 2012. RESULTS: Five patients (M/F = 4/1, mean age of 42.3 years, range 29-66.8) underwent 1 + 1/5 VR. Underlying diagnoses were Ebstein's anomaly (EA) in three, hypoplastic RV and tricuspid valve (TV) in two. Mean TV annulus Z-score was -3.0; mean pulmonary vascular resistance was 1.6 WU/m(2) . Eleven associated procedures were performed simultaneously to 1.5 VR. There were no operative deaths. All patients were discharged home alive and in good clinical condition on anticoagulation regimen. At a mean follow-up of 8.6 ± 5.2 years, there was one cerebral stroke-related death; two patients experienced major complications. Two patients are in NYHA Class I, one is in NYHA Class II, and the last in NYHA Class III on a transplant list. CONCLUSIONS: The one-and-a-half ventricle repair in adult patients is feasible with low mortality. However, advanced age-associated co-morbidities and prolonged chronic RV preoperative dysfunction may jeopardize long-term results when compared to children.

The use fibrinogen/thrombin-coated equine collagen patch in children requiring reoperations for congenital heart disease. A single center clinical experience.

AIM: The aim of this study was to evaluate the efficacy and cost-effectiveness of fibrinogen/thrombin-coated collagen patch (FTCCP)(TachoSil®) during intraoperative hemostasis in patients with congenital heart disease, who required a reoperation during childhood. METHODS: We reviewed data on the intraoperative blood product requirements and hospital costs of children (age <16 years) who underwent a reoperation for treating their congenital heart disease between January 2009 and December 2011. RESULTS: One-hundred and seventeen patients were included. Median age at surgery was 2.1 years (range 3 days-14.1 years). Main causes of intraoperative bleeding were: 1) reinforcement of suture lines (106 patients, 90.6%); 2) lung lesions (5 patients, 4.2%); 3) epicardial lesions (3 patients, 2.6%); and 4) chest wall lesions (3 patients, 2.6%). At logistic regression the amount of packed red blood cells (PRBC) requirement was significantly higher in patients with preoperative cyanosis (P=0.008, OR=3.85) and in patients who required the use of cardiopulmonary bypass (P=0.005, OR=21.19). The use of FTCCP (N.=90 patients) as first line treatment was significantly associated with a lower PRBC requirement (P=0.0003, OR=0.1) which in addition to the avoidance of other hemostatic/sealant agents, leads to lower hospital cost. CONCLUSION: FTCCP is an effective hemostatic agent which can be safely used during the hemostasis of children requiring reoperations for their congenital heart malformations. When used as first line treatment, with specific indications, FTCCP limited the intraoperative PRBC requirement and the use of other hemostatic/sealant agents thus reducing hospital costs.

Effect of Vacuum on Venous Drainage: an Experimental Evaluation on Pediatric Venous Cannulas and Tubing Systems.

INTRODUCTION: To observe how vacuum assisted venous drainage (VAVD) may influence the flow in a cardiopulmonary bypass circuit with different size of venous lines and cannulas. METHODS: The experimental circuit was assembled to represent the cardiopulmonary bypass circuit routinely used during cardiac surgery. Wall suction was applied directly, modulated and measured into the venous reservoir. The blood flow was measured with a flow-meter positioned on the venous line. The circuit prime volume was replaced with group O date expired re-suspended red cells and Plasmalyte 148 to a hematocrit of 28% to 30%. RESULTS: In an open circuit with gravity siphon venous drain, angled cannulae drain more than straight ones regardless the amount of suction applied to the venous line (16 Fr straight cannula (S) drains 90 ml/min less than a 16 Fr angled (A) with a siphon gravity). The same flow can be obtained with lower cannula size and higher suction (i.e. 12 A with and -30 mmHg). Tables have been created to list how the flow varies according to the size of the cannulas, the size of the venous tubes, and the amount of suction applied to the system. CONCLUSIONS: Vacuum assisted venous drainage allows the use of smaller cannulae and venous lines to maintain a good venous return, which is very useful during minimally invasive approaches. The present study should be considered as a preliminary attempt to create a scientific-based starting point for a uniform the use of VAVD.

European Contegra multicentre study: 7-year results after 165 valved bovine jugular vein graft implantations.

OBJECTIVE: The valved bovine conduit "Contegra" for RVOT reconstruction became available for clinical use within a 100 % source data monitored and echo core lab controlled prospective European Multicentre Study, carried out from 1999 to 2006. We present the results of this study. METHODS: A total of 165 Contegras were implanted in 8 centres. The mean patient age was 3.9 years (2 days - 18 years, median 2.0). Total follow-up was 687 patient years. Diagnoses included: tetralogy of Fallot (64 patients, 39 %), truncus arteriosus (50, 30 %), double outlet right ventricle (16, 10 %), aortic valve disease/Ross procedure (11, 7 %), pulmonary valve atresia (10, 6 %), transposition of the great arteries (10, 6 %), 4 other malformations (2 %). Previous procedures were: 82 patients (50 %) - none; 37 (22 %) - valved conduit implantation; 14 (8 %) aortopulmonary shunt; 6 (4 %) catheter intervention. Follow-up appointments which included standardised echocardiography investigations were scheduled at 1, 3, 6, and 12 months, then annually. We evaluated freedom from death, explantation, intervention, stenosis, insufficiency, and degeneration. Results were stratified by age, diagnosis group and conduit size. RESULTS: The 5-year freedom-from rates were: explantation - 90 % (for patients aged 1 to 10 years) and 68 % (for younger patients); endocarditis - over 92 %; catheter intervention - 74 % (patients with congenital malformations); stenosis - 75 % and more (any group); insufficiency - 50 % (12 and 14 mm diameter conduits); any event - 13 % (patients under 1 year), 58 % (1 to 10 years), 82 % (> 10 years). Trace or mild insufficiency was a frequent, but not progressive finding. Mild calcification was detected in only 8 examinations. CONCLUSIONS: The performance of the Contegra conduit compares well with that of homografts when used to reconstruct paediatric right ventricular outflow tracts.

Prolonged ECMO support for virus-induced cardiorespiratory failure early after cardiac surgery.

Extracorporeal membrane oxygenation (ECMO) after cardiac surgery is a rescue for life-threatening respiratory or circulatory failure. Although ECMO support for short periods (<10 days) represents an effective means of respiratory and cardiac support, treatment for longer periods remains controversial. We describe successful long-term use of ECMO support (48 days) for acquired virus-induced respiratory failure complicated by circulatory collapse following heart surgery.

Performance of the pulmonary autograft in four infants after the Ross procedure.

Pulmonary valve autografts have proven to be valid aortic valve substitutes in children. The objective of this study is to evaluate the performance of the pulmonary autograft (PAG) in systemic position and its adjustment to growth in four infants who underwent a Ross operation. Between April 1998 and January 2000, four infants whose aortic valve anatomy and function were judged unsuitable for a valve-sparing operation underwent successful Ross operation. All patients were followed postoperatively with echocardiograms to evaluate the function and the dimensional changes of the PAG within the systemic circulation. The PAG adjustments to growth were compared to the growth of the pulmonary root of healthy patients matched for body surface area, with the purpose to evaluate the effects of the systemic pressure on the pulmonary vascular wall, as a passive dilatation process versus a true and active structural adaptation. Median follow-up was 53 months (range, 48-65). There were no early deaths or reoperations. All patients were asymptomatic and in stable hemodynamic conditions. The PAG annulus grew according to body surface area without dilatation. PAG valve regurgitation was present but mild in three patients. Trans-PAG peak gradients were not significant. The PAG diameter at the level of the sinuses of Valsalva and sinotubular junction increased rapidly and steadily in all patients during follow-up compared to controls. The Ross operation in infants provides acceptable immediate surgical and hemodynamic results. However, significant midterm increases in PAG sinuses and sinotubular junction diameters require close and continued observation.

Surgical outcome for congenital heart malformations in the adult age: a multicentric European study.

Congenital heart diseases are currently treated in the pediatric age. However, a conspicuous number of patients requires treatment in the adult age. This study has been undertaken by members of the European Congenital Heart Surgeons Association with the aim of evaluating the impact of cardiac surgery in this particular age group. We have collected data from 1,247 patients who underwent 1,287 operations during a 5-year period between January 1, 1997 and December 31, 2001. Patients were divided into three groups: (1) palliative procedures (4.4%), operation performed to improve patients' clinical status without restoring normal anatomy or physiology; (2) repair (79.3%), operation performed to achieve an anatomic or physiologic repair with separation of the pulmonary from the systemic circulation (included in this group are also Fontan-type repair and one and a half ventricle repair); (3) reoperation (16.3%), all the reoperations performed after repair (either anatomic or physiologic). Hospital mortality (within 30 days) was 2.4% (range, 0% to 15.3% in different centers). Kaplan-Meier estimates shows a 94% survival at 4 years, which is higher for repair (95%) as compared with reoperations (92%) or palliations (88%). Surgery for congenital heart disease in the adult age is a safe, beneficial, and low-risk treatment that modifies patients' natural history by improving their clinical status.

The Aristotle score: a complexity-adjusted method to evaluate surgical results.

OBJECTIVES: Quality control is difficult to achieve in Congenital Heart Surgery (CHS) because of the diversity of the procedures. It is particularly needed, considering the potential adverse outcomes associated with complex cases. The aim of this project was to develop a new method based on the complexity of the procedures. METHODS: The Aristotle project, involving a panel of expert surgeons, started in 1999 and included 50 pediatric surgeons from 23 countries, representing the EACTS, STS, ECHSA and CHSS. The complexity was based on the procedures as defined by the STS/EACTS International Nomenclature and was undertaken in two steps: the first step was establishing the Basic Score, which adjusts only the complexity of the procedures. It is based on three factors: the potential for mortality, the potential for morbidity and the anticipated technical difficulty. A questionnaire was completed by the 50 centers. The second step was the development of the Comprehensive Aristotle Score, which further adjusts the complexity according to the specific patient characteristics. It includes two categories of complexity factors, the procedure dependent and independent factors. After considering the relationship between complexity and performance, the Aristotle Committee is proposing that: Performance = Complexity x Outcome. RESULTS: The Aristotle score, allows precise scoring of the complexity for 145 CHS procedures. One interesting notion coming out of this study is that complexity is a constant value for a given patient regardless of the center where he is operated. The Aristotle complexity score was further applied to 26 centers reporting to the EACTS congenital database. A new display of centers is presented based on the comparison of hospital survival to complexity and to our proposed definition of performance. CONCLUSION: A complexity-adjusted method named the Aristotle Score, based on the complexity of the surgical procedures has been developed by an international group of experts. The Aristotle score, electronically available, was introduced in the EACTS and STS databases. A validation process evaluating its predictive value is being developed.

[Thoracoscopy: the pediatric experience in Padua]. / Toracoscopia: esperienza pediatrica a Padova.

INTRODUCTION: Thoracoscopy is an important option in the treatment of many thoracic pathologies; its use in children, however, is still limited. We have retrospectively evaluated the thoracoscopic activity in our pediatric surgery department in the last six years. METHODS AND PROCEDURES: Video-Assisted Thoracoscopy (VATS) has been routinely adopted in our institutions since 1997. The data of 115 patients who have undergone VATS were reviewed and analysed. RESULTS: There were 47 males and 68 females. Mean age at surgery was 66.08 (SD: 58.23) months. Mean body weight at surgery was 21.85 (SD: 16.26) Kg. The patients were divided in four groups according to the pathologies: Patent Ductus Arteriosus (PDA) (n = 95), Pleural Empyema (n = 14), Mediastinal Mass (n = 3) and Lung Disease (n = 3). Complicances were seen in two patients in the PDA group (one laryngeal nerve paralysis and one chylothorax) and one in the pleural empyema group (post-operative bleeding which required blood transfusion). CONCLUSIONS: VATS can be performed safely and with minimal morbidity. In our experience, early and late complications turned out to be quite low. This survey would support on-going development of thoracoscopy in children.

Surgical treatment of complete A-V canal defects in children before 3 months of age.

OBJECTIVES: Surgical repair of complete A-V canal defects (CAVCD) is a well established procedure which is currently performed in infancy. The aim of this study is to evaluate surgical results of correction in early infancy in comparison to older age. METHODS: From January 1985 to March 2001, 119 consecutive patients (age range 27 days to 83 months, mean 6.7 months) underwent repair of CAVCD in our Institution. Forms with unbalanced ventricles in association with Fallot's tetralogy or heterotaxia were excluded from this series. Fifty-eight patients (49%) underwent correction before 3 months of age (Group A), and 61 patients (51%) after 3 months (Group B). Surgical repair was accomplished with a double patch technique in 100 patients (84%). Associated surgical lesions were treated simultaneously in 48 patients (40%). RESULTS: There were 11 operative deaths (<30 days) (two in Group A (3.4%) and nine in Group B (15%)) (P = 0.05). The remaining patients were discharged home in good haemodynamic condition. Reoperation for postoperative left A-V incompetence occurred in five patients in Group A and in eight patients in Group B. There were eight late deaths (three in Group A and five in Group B), of which four were non-cardiac related. At a mean follow-up time of 80 months (range 2-184 months) 100 patients are asymptomatic and well, and free from oral medication. Echocardiographic examination showed absent or mild residual left A-V valve incompetence in 91 patients (49 in Group A and 42 in Group B) and moderate left A-V valve incompetence in nine patients (four in Group A and five in Group B). Kaplan-Meier survival estimates at 10 years were 90% for Group A and 75% for Group B. Kaplan-Meier freedom from reoperation at 10 years was 89% for Group A and 84% for Group B. CONCLUSIONS: Our data demonstrate that repair of CAVCD under 3 months of age is the ideal approach to this malformation with a lower mortality rate at operation compared to older patients. Logistic analysis showed that an operative age >3 months is, compared to an age < or =3 months, an incremental risk factor for hospital mortality with an odds ratio of 4.8 (95% confidence limit 1-23.5) (P = 0.05). In the long term, freedom from reoperation for left A-V valve incompetence is higher when compared to children repaired at an older age.

Surgical treatment of complex cardiac anomalies: the 'one and one half ventricle repair'.

OBJECTIVE: One and one half ventricle repair is a surgical option for congenital cardiac anomalies characterised by right ventricle (RV) hypoplasia and/or dysplasia. METHODS: From March 1994 to March 2001, eight patients (mean age 9.1 years, range 7 months to 35 years) with hypoplastic and/or dysplastic RV underwent correction of their intracardiac anomaly in association with a BCPS (one and one half ventricle repair). Preoperative diagnoses included: Ebstein's anomaly of tricuspid valve (TV) in two, inlet ventricular septal defect (VSD) in association with straddling/overriding TV in two patients, pulmonary atresia-intact ventricular septum in one, tertralogy of Fallot in association with complete atrioventricular canal defect in one, truncus arteriosus in one and heterotaxy syndrome with VSD and anomalous systemic venous return in one. Four patients underwent previous surgery which included: main pulmonary artery (MPA) banding in two patients, pulmonary valvotomy, central shunt and right ventricular outflow tract reconstruction in one, pulmonary artery separation from truncus arteriosus and modified Blalock-Taussig shunt in one, and MPA closure in one. Two patients underwent a bidirectional cavo-pulmonary shunt before the one and a one half ventricle repair. Associated cardiac lesions were treated simultaneously. RESULTS: There were no hospital deaths. All the patients were discharged home in good clinical conditions. There were no late deaths or reoperations. At mean follow-up of 29.8 months (range 8 months to 7.3 years) all the patients are alive and in good general conditions. MPA percutaneous balloon dilation was performed in two patients at 33 and 4 months, respectively, both after MPA reconstruction (which was previously ligated) and dilation of the left pulmonary artery branch in one patient, repeated twice at 10 and 14 months from repair, for a hypoplastic left pulmonary artery after truncus arteriosus repair. CONCLUSIONS: Surgical treatment of congenital cardiac anomalies in the presence of a hypoplastic and or a dysplastic RV by means of one and one half ventricle repair has the advantage of reducing the surgical risk for biventricular repair, and compared to the Fontan circulation, it maintains a low right atrium pressure, a pulsatile pulmonary blood flow and improves the systemic oxygen saturation. Short and medium-term results are promising. Longer follow-up is needed, to prove the efficacy of such a repair, in the long term.

Surgical treatment of complex cardiac anomalies: the 'one and one half ventricle repair'.

OBJECTIVE: One and one half ventricle repair is a surgical option for congenital cardiac anomalies characterised by right ventricle (RV) hypoplasia and/or dysplasia. METHODS: From March 1994 to March 2001, eight patients (mean age 9.1 years, range 7 months to 35 years) with hypoplastic and/or dysplastic RV underwent correction of their intracardiac anomaly in association with a BCPS (one and one half ventricle repair). Preoperative diagnoses included: Ebstein's anomaly of tricuspid valve (TV) in two, inlet ventricular septal defect (VSD) in association with straddling/overriding TV in two patients, pulmonary atresia-intact ventricular septum in one, tertralogy of Fallot in association with complete atrioventricular canal defect in one, truncus arteriosus in one and heterotaxy syndrome with VSD and anomalous systemic venous return in one. Four patients underwent previous surgery which included: main pulmonary artery (MPA) banding in two patients, pulmonary valvotomy, central shunt and right ventricular outflow tract reconstruction in one, pulmonary artery separation from truncus arteriosus and modified Blalock-Taussig shunt in one, and MPA closure in one. Two patients underwent a bidirectional cavo-pulmonary shunt before the one and a one half ventricle repair. Associated cardiac lesions were treated simultaneously. RESULTS: There were no hospital deaths. All the patients were discharged home in good clinical conditions. There were no late deaths or reoperations. At mean follow-up of 29.8 months (range 8 months to 7.3 years) all the patients are alive and in good general conditions. MPA percutaneous balloon dilation was performed in two patients at 33 and 4 months, respectively, both after MPA reconstruction (which was previously ligated) and dilation of the left pulmonary artery branch in one patient, repeated twice at 10 and 14 months from repair, for a hypoplastic left pulmonary artery after truncus arteriosus repair. CONCLUSIONS: Surgical treatment of congenital cardiac anomalies in the presence of a hypoplastic and or a dysplastic RV by means of one and one half ventricle repair has the advantage of reducing the surgical risk for biventricular repair, and compared to the Fontan circulation, it maintains a low right atrium pressure, a pulsatile pulmonary blood flow and improves the systemic oxygen saturation. Short and medium-term results are promising. Longer follow-up is needed, to prove the efficacy of such a repair, in the long term.

Arterial switch operation after left ventricular retraining in the adult.

Retraining the morphological left ventricle in transposition of the great arteries has been successfully reported in infancy, while older age seems to be a contraindication. A 23-year-old woman with ¿S,D,D¿ transposition of the great arteries and ventricular septal defect developed severe right systemic ventricular dysfunction 22 years after Mustard procedure and ventricular septal defect closure. Hemodynamic investigation revealed moderate pulmonary hypertension and preserved left ventricular function. A pulmonary artery band was applied to obtain a left-right ventricular pressure ratio of 0.91. Her postoperative course was characterized by biventricular failure, treated effectively with inotropic support. Six months later, she underwent a Mustard baffle takedown and arterial switch procedure. Her postoperative course was uneventful. She was discharged home on postoperative day 15. At 24-months follow-up, she is in excellent clinical condition; echocardiographic evaluation shows good left ventricular function (ejection fraction: 0.69) with left ventricular volume within normal limits (70 ml/m2). Our experience demonstrates that, despite adult age, a staged arterial switch operation can be performed successfully in selected patients when left ventricular function is preserved.

Repair of congenital mitral valve dysplasia in infants and children: is it always possible?

OBJECTIVES: Surgical management of congenital malformation of the mitral valve (MV) in the pediatric age group remains a therapeutic challenge for the wide spectrum of the morphological abnormalities and the high incidence of associated cardiac anomalies. We reviewed our experience so as to assess whether MV conservative surgery is always advisable and its results are superior to MV replacement. METHODS: Thirty-four consecutive children (20 male and 14 female) with a mean age of 5.9 years (range 45 days-18 years) treated surgically for congenital MV disease between January 1987 and June 1999. Four patients (11.7%) were under 12 months of age, while 21 patients (62%) were younger than 5 years. Twenty-two patients presented with MV incompetence (or prevalent incompetence), while 12 presented with stenosis (or prevalent stenosis). Associated cardiac lesions were present in 22 patients (62.8%). RESULTS: Mitral valve reconstruction was possible in all. There were no operative deaths. Three patients required reoperation for MV restenosis (a re-repair in one and MV replacement with mechanical prosthesis in two) 4 months, 27 months and 5.6 years after repair with no operative deaths. There was only one late death for prosthetic valve thrombosis. Follow-up data reveal that the 33 surviving patients are asymptomatic and well 4 months-12 years (mean 72 months) after surgery. At 12 years, actuarial survival and freedom from reoperation are 96.8 and 85.9%, respectively. Echocardiography performed in all of them shows no or mild incompetence or stenosis in 26 (78%), while residual moderate MV incompetence persists in six. CONCLUSIONS: Our experience indicates that MV reconstructive procedures in infants and children with congenital MV dysplasia may be effective and reliable with low mortality and low incidence of reoperation rate. Mitral valve repair should always be attempted, especially in infants, despite the frequent severity of MV dysplasia, to avoid the drawbacks of the currently available prostheses.

Surgical closure of apical ventricular septal defects through a right ventricular apical infundibulotomy.

BACKGROUND: We present a new understanding of the anatomic position of apical ventricular septal defects and its surgical relevance. These defects occur between the left ventricular apex and the infundibular apex, rather than between the left and right ventricular apices. Often a sizable apical recess, the infundibular apex lies anteriorly and inferiorly to the moderator band and is the most leftward part of the right ventricle. METHODS: Four patients (2 boys and 2 girls) with a mean age of 109 days (range, 48 to 217 days) underwent patch closure through an apical infundibulotomy, which allowed complete visualization of the muscular apical ventricular septal defect. RESULTS: There were no early or late deaths at operation. No significant residual shunt at ventricular level was detected by postoperative two-dimensional and Doppler echocardiography. Intraoperative comparison of right atrial and pulmonary arterial blood samples showed a difference of less than 5%. At a mean follow-up of 18 months, all the patients are asymptomatic and growing well. CONCLUSIONS: The successful outcome of these 4 patients indicates that surgical closure of apical ventricular septal defects can be achieved safely and completely in early infancy through a limited right ventricular apical infundibulotomy. Long-term follow-up of these and similar patients is needed to provide further evaluation of this approach.