Advantages of a mini right axillary thoracotomy for congenital heart defect repair in children.

OBJECTIVES: The mini right axillary thoracotomy is an alternative surgical approach to repair certain congenital heart defects. Quality-of-life metrics and clinical outcomes in children undergoing either the right axillary approach or median sternotomy were compared. METHODS: Patients undergoing either approach for the same defects between 2018 and 2020 were included. Demographic details, operative data, and outcomes were compared between both groups. An abbreviated quality of life questionnaire based on the Infant/Toddler/Child Health Questionnaires focused on the patient's global health, physical activity, and pain/discomfort was administered to all parents/guardians within two post-operative years. RESULTS: Eighty-seven infants and children underwent surgical repair (right axillary thoracotomy, n = 54; sternotomy, n = 33) during the study period. There were no mortalities in either group. The right axillary thoracotomy group experienced significantly decreased red blood cell transfusion, intubation, intensive care, and hospital durations, and earlier chest tube removal. Up to 1 month, parents' perception of their child's degree and frequency of post-operative pain was significantly less after the right axillary thoracotomy approach. No difference was found in the patient's global health or physical activity limitations beyond a month between the two groups. CONCLUSIONS: With the mini right axillary approach, surrogates of faster clinical recovery and hospital discharge were noted, with a significantly less perceived degree and frequency of post-operative pain initially, but without the quality of life differences at last follow-up. While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of certain congenital heart lesions is a safe alternative to median sternotomy.

Mini right axillary thoracotomy for congenital heart defect repair can become a safe surgical routine.

OBJECTIVE: Owing to its obvious cosmetic appeal, minimal invasive repair of congenital heart defects (CHDs) through the mini right axillary thoracotomy is becoming routine in many centres. Besides cosmesis, and before becoming a new norm, it is important to establish its outcomes as safe compared to repairs through traditional median sternotomy. METHODS: Between 2013 and 2021, 116 consecutive patients underwent defect repairs through mini right axillary thoracotomy. Patient, operative data, and hospital outcomes were compared to contemporary mini right axillary thoracotomy and sternotomy series. RESULTS: There was no mortality or need for approach conversion (mean age 4.3 years, range 0.17-17, mean weight 18.6 kg, range 4.8-74.4) in 118 repairs for atrial septal defect, ventricular septal defect, partial anomalous pulmonary venous return, partial atrioventricular canal with mitral cleft, scimitar syndrome, double-chambered right ventricle, cor triatriatum, and tricuspid valve repair. Protocol included on-table extubation, achieved in 97 children, with 23 outliers leading to 0.7 average hours of mechanical ventilation (range 0-66 hours), indwelling chest drain time of 2.6 days (range 1-9 days), intensive care stay of 1.8 days (range 1-10 days), and hospital stay of 3.9 days (range 2-18 days). Late revisions were required in one patient after scimitar repair for scimitar vein stenosis at 2 weeks, and in another for repair of superior caval vein stenosis after a Warden operation at 2 months; reoperations (5/116 = 4.3%) were successfully performed through the same mini right axillary incision. CONCLUSIONS: While providing obvious cosmetic advantages, the minimally invasive right axillary thoracotomy approach for the surgical repair of common CHDs yields excellent results and is safe compared to the benchmark median sternotomy approach.

Results of international assistance for a paediatric heart surgery programme in a single Ukrainian centre.

BACKGROUND: Surgery for CHD has been slow to develop in parts of the former Soviet Union. The impact of an 8-year surgical assistance programme between an emerging centre and a multi-disciplinary international team that comprised healthcare professionals from developed cardiac programmes is analysed and presented.Material and methodsThe international paediatric assistance programme included five main components - intermittent clinical visits to the site annually, medical education, biomedical engineering support, nurse empowerment, and team-based practice development. Data were analysed from visiting teams and local databases before and since commencement of assistance in 2007 (era A: 2000-2007; era B: 2008-2015). The following variables were compared between periods: annual case volume, operative mortality, case complexity based on Risk Adjustment for Congenital Heart Surgery (RACHS-1), and RACHS-adjusted standardised mortality ratio. RESULTS: A total of 154 RACHS-classifiable operations were performed during era A, with a mean annual case volume by local surgeons of 19.3 at 95% confidence interval 14.3-24.2, with an operative mortality of 4.6% and a standardised mortality ratio of 2.1. In era B, surgical volume increased to a mean of 103.1 annual cases (95% confidence interval 69.1-137.2, p<0.0001). There was a non-significant (p=0.84) increase in operative mortality (5.7%), but a decrease in standardised mortality ratio (1.2) owing to an increase in case complexity. In era B, the proportion of local surgeon-led surgeries during visits from the international team increased from 0% (0/27) in 2008 to 98% (58/59) in the final year of analysis. CONCLUSIONS: The model of assistance described in this report led to improved adjusted mortality, increased case volume, complexity, and independent operating skills.

Fontan completion in reverse order out of necessity: secondary Glenn after primary extracardiac inferior cavopulmonary artery connection.

The primary extracardiac inferior cavopulmonary connection is an unusual novel palliation for single-ventricle physiology, which we first performed in the setting of unfavourable upper-body systemic venous anatomy for a standard bi-directional Glenn, and in lieu of leaving our patient with shunt-dependent physiology. After an initial 16-month satisfactory follow-up, increasing cyanosis led to the discovery of a veno-venous collateral that was coiled, but, more importantly, to impressive growth of a previously diminutive superior caval vein, which allowed us to perform completion Fontan with a good outcome. Performing the single-ventricle staging in a reverse manner, first from below with a primary inferior cavopulmonary connection, followed by Fontan completion from above with a standard superior caval vein bi-directional Glenn, is also possible when deemed necessary.

CHD and respiratory syncytial virus: global expert exchange recommendations.

BACKGROUND: Palivizumab is the standard immunoprophylaxis against serious disease due to respiratory syncytial virus infection. Current evidence-based prophylaxis guidelines may not address certain children with CHD within specific high-risk groups or clinical/management settings. METHODS: An international steering committee of clinicians with expertise in paediatric heart disease identified key questions concerning palivizumab administration; in collaboration with an additional international expert faculty, evidence-based recommendations were formulated using a quasi-Delphi consensus methodology. RESULTS: Palivizumab prophylaxis was recommended for children with the following conditions: <2 years with unoperated haemodynamically significant CHD, who are cyanotic, who have pulmonary hypertension, or symptomatic airway abnormalities; <1 year with cardiomyopathies requiring treatment; in the 1st year of life with surgically operated CHD with haemodynamically significant residual problems or aged 1-2 years up to 6 months postoperatively; and on heart transplant waiting lists or in their 1st year after heart transplant. Unanimous consensus was not reached for use of immunoprophylaxis in children with asymptomatic CHD and other co-morbid factors such as arrhythmias, Down syndrome, or immunodeficiency, or during a nosocomial outbreak. Challenges to effective immunoprophylaxis included the following: multidisciplinary variations in identifying candidates with CHD and prophylaxis compliance; limited awareness of severe disease risks/burden; and limited knowledge of respiratory syncytial virus seasonal patterns in subtropical/tropical regions. CONCLUSION: Evidence-based immunoprophylaxis recommendations were formulated for subgroups of children with CHD, but more data are needed to guide use in tropical/subtropical countries and in children with certain co-morbidities.

When the bi-directional Glenn is an unfavourable option: primary extracardiac inferior cavopulmonary connection as an alternative palliation.

The superior cavopulmonary anastomosis - bi-directional Glenn - is the standard palliation for single ventricle physiology. When upper body systemic venous anatomic concerns such as superior caval vein stenosis, hypoplasia, or inadequate collateral tributaries are present, a Glenn may be precluded or have a high risk of poor outcome. A primary inferior cavopulmonary connection with an extracardiac conduit is an alternative palliation that provides a generous pathway for pulmonary blood flow, with the additional benefit of including hepatic venous return. We report a case of primary extracardiac inferior cavopulmonary connection in a patient unsuitable for Glenn, with successful post-operative outcome and early follow-up.

Alternative strategies in newborns and infants with major co-morbidities to improve congenital heart surgery outcomes at an emerging programme.

INTRODUCTION: Debilitating patient-related non-cardiac co-morbidity cumulatively increases risk for congenital heart surgery. At our emerging programme, flexible surgical strategies were used in high-risk neonates and infants generally considered in-operable, in an attempt to make them surgical candidates and achieve excellent outcomes. MATERIALS AND METHODS: Between April, 2010 and November, 2013, all referred neonates (142) and infants (300) (average scores: RACHS 2.8 and STAT 3.0) underwent 442 primary cardiac operations: patients with bi-ventricular lesions underwent standard (n=294) or alternative (n=19) repair/staging strategies, such as pulmonary artery banding(s), ductal stenting, right outflow patching, etc. Patients with uni-ventricular hearts followed standard (n=96) or alternative hybrid (n=34) staging. The impact of major pre-operative risk factors (37%), standard or alternative surgical strategy, prematurity (50%), gestational age, low birth weight, genetic syndromes (23%), and major non-cardiac co-morbidity requiring same admission surgery (27%) was analysed on the need for extracorporeal membrane oxygenation, mortality, length of intubation, as well as ICU and hospital length of stays. RESULTS: The need for extracorporeal membrane oxygenation (8%) and hospital survival (94%) varied significantly between surgical strategy groups (p=0.0083 and 0.028, respectively). In high-risk patients, alternative bi- and uni-ventricular strategies minimised mortality, but were associated with prolonged intubation and ICU stay. Major pre-operative risk factors and lower weight at surgery significantly correlated with prolonged intubation, hospital length of stay, and mortality. DISCUSSION: In our emerging programme, flexible surgical strategies were offered to 53/442 high-risk neonates and infants with complex CHDs and significant non-cardiac co-morbidity, in order to buffer risk and achieve patient survival, although at the cost of increased resource utilisation.

The expression of CD39 on regulatory T cells is genetically driven and further upregulated at sites of inflammation.

Regulatory T cells (Tregs) use different mechanisms to exert their suppressive function, among them the conversion of ATP to adenosine initiated by the ectonucleotidase CD39. In humans, the expression of CD39 on Tregs shows a high interindividual variation, and is especially high at sites of inflammation, like the synovia of patients with arthritis. How CD39 expression is regulated, and the functional consequences of different levels of CD39 expression is not known. We show here that stimulation of CD39(-) Tregs results in a modest upregulation of CD39, which cannot explain the high levels observed in many donors. Moreover, CD39(+) Tregs are present in naïve compartments such as cord blood and thymus, and the individual frequency of CD39(+) Tregs remains stable over time, suggesting inherent regulation of CD39 expression. Indeed, we show that a single nucleotide polymorphism in the CD39 gene determines expression levels in Tregs. CD39(+) Tregs suppress T cell proliferation and inflammatory cytokine production more efficiently than CD39(-) Tregs. Accordingly, Tregs from donors with the GG (high CD39) genotype have a higher capacity to suppress IFN-γ and IL-17 production by effector cells than Tregs from AA (low CD39) donors. Our study demonstrates that the expression of CD39 in Tregs is primarily genetically driven, and this may determine interindividual differences in the control of inflammatory responses.

Age-related reoperation rate after the Ross procedure: a report from the German Ross Registry.

BACKGROUND AND AIM OF THE STUDY: An increasing number of young adult patients are choosing bioprostheses for aortic valve replacement (AVR). In this context, the Ross operation deserves renewed consideration as an alternative biological substitute. After both the Ross procedure and bioprosthetic AVR, reoperation rates remain a concern and may be related to age at surgery. Herein are reported details of freedom from reoperation after the Ross procedure for different age groups. METHODS: The reoperation rates of 1,925 patients (1,444 males, 481 females; mean age 41.2 ± 15.3 years) from the German Ross registry with a mean follow up of 7.4 ± 4.7 years (range: 0.00-18.51 years; total 12,866.6 patient-years) were allocated to three age groups: group I < 40 years; group II 40-60 years; and group III > 60 years. RESULTS: At 10 years (respectively 15 years) of follow up, freedom from reoperation was 86% (76%) in group I, 93% (85%) in group II, and 89% (83%) in group III. CONCLUSION: There is some evidence that, at least during the first 10 and 15 years after AVR, the Ross procedure provides a significantly lower reoperation rate in young adult and middle-aged patients aged < 60 years. This information may be of interest to the patients' or physicians' decision-making for aortic valve surgery.

Repairing the tricuspid valve in congenital heart diseases other than Ebstein's.

The tricuspid valve is being increasingly recognised as an important safeguard to the heart with congenital heart disease. Both structural anomalies of the valve and functional burdens from other malformations of the right heart can lead to major haemodynamic consequences both upstream and downstream. The indications to surgically intervene on the tricuspid valve are evolving and vary depending on the malformation. The extant surgical techniques and their applications to corresponding frequent congenital anomalies of the tricuspid valve are reviewed.

Partial mechanical circulatory support in children.

Partial mechanical support devices are capable of partially unloading only one ventricle, often the systemic one, in the setting of acute circulatory failure. They are rarely used in the pediatric population, as the mode of circulatory failure in patients with congenital heart disease often involves biventricular or a predominantly right ventricular component. The devices include intra-aortic balloon pumping, Impella, TandemHeart, and CentriMag. They are rarely used as a bridge-to-recovery, but more often as a bridge-to-decision, or bridge-to-conversion to full mechanical support systems, such as extracorporeal membrane oxygenation or ventricular assist devices. Currently, lack of availability of more complete support devices, cost issues, or lack of infrastructure and personnel may still be indications to continue using partial mechanical support as opposed to more complete forms of biventricular circulatory support.

Pediatric mechanical circulatory support: future directions.

The field of extracorporeal support is moving forward rapidly. New technology, improved experience with a variety of patients, and successful outcomes in groups previously excluded from extracorporeal life support are increasing the use of this technique in patient support. Although initial reports of outcome are encouraging, they are often taken from single-center reports or large databases without specific detail to answer many of the relevant questions or for eras that do not reflect the effects of new technology. Collaboration between investigators, rigorous scientific data collection and analysis, and careful short- and long-term outcomes for patients receiving extracorporeal life support are imperative to avoid improper use of this high-resource, high-cost technology and to establish the efficacy of new devices and techniques. Bleeding and thrombosis remain devastating complications and efforts to reduce complications and improve anticoagulation regimens or eliminate the need for anticoagulation would be of major benefit to the field.

Minimal invasive approaches for pediatric & congenital heart surgery: safe, reproducible, more cosmetic than through sternotomy, and here to stay.

Minimal invasive approaches through small thoracic incisions for the isolated repair of the most common congenital heart defects have been around for decades. However, the lack of belonging in established surgical training curriculums compared to the traditional median sternotomy, the requirement for more technical expertise and a certain learning curve, has limited their use, being routinely performed only by certain surgeons in specialized centers. More recently, through cumulated and increasingly mediatized shared experience, remote teaching potential through universally accessible surgical videos and simulation, the approach has gained traction and acceptance, and even established itself as the new norm in many centers. In this review, we present technically focused aspects of our own experience and protocols which have evolved over time, along with a brief overview of the literature pertaining to other right thoracic approaches, and some comparison to established results using the traditional median sternotomy. An increasing body of literature, produced more frequently and across all continents, seems to suggest that repairs of congenital heart defects through a minimal invasive right thoracic approach are becoming the new norm, as they are reported to be safe and reproducible, with excellent surgical results, and an obvious superior and more desirable cosmetic result. This comes at a cost of additional training and learning curve by surgeons, who are not offered the technique as part of their standard professional training curriculum.

Minimally invasive insertion of an equine stented pulmonary valve with a built-in sinus portion in a sheep model.

OBJECTIVES: This study evaluated the feasibility of inserting a new equine stented-valve with a sinus portion in a lamb survival model, through a minimally invasive thoracotomy with right ventricular access without cardiopulmonary bypass. BACKGROUND: Extant surgical or percutaneous methods for inserting biological valves in the right outflow tract have drawbacks and limitations. METHODS: A decellularized equine valved jugular vein, sutured to a self-expanding stent with a sinus portion, was placed through a minimal right thoracotomy using a newly developed flexible hydraulic release device in seven lambs. The approach through the right ventricle into the pulmonary valve position is achieved on a beating heart. RESULTS: The stented valves were correctly positioned in the right outflow tract, were competent up to 6 months as confirmed by angiography and echocardiography, and were well-tolerated by the animals, with endothelialization of the valve demonstrated at 6 months. CONCLUSIONS: The newly developed hydraulic release system allowed for safe and reliable insertion of an equine stented-valve with a sinus portion, through a right transventricular approach on a beating heart, in a sheep survival model.

Past, present, and future of the arterial switch operation: historical review.

The arterial switch operation is the extant surgical correction after a long series of palliations attempted and/or successfully achieved for the treatment of discordant ventriculoarterial connections. As early as 1954, pioneers such as Mustard, Bailey, Kay, and Idriss led the way with at first disheartening failures, temporarily leading to abandoning the procedure. The first successful atrial baffle procedure in 1958 established itself as the procedure of choice for treating discordant ventriculoarterial connections, but tenacity, courage, and vision to pursue anatomic correction finally led to the first successful arterial switch in 1975 by Jatene. After a decade to perfect surgical technique and timing indications for the various anatomic subtypes, the new era of the neonatal arterial switch since the late 1980s set the very high standards that we all know and expect today. Despite excellent early and long-term survival, important residual lesions are increasingly being recognised. Expected anatomic residuals include supravalvar pulmonary stenosis, neoaortic valve insufficiency, and coronary ostial stenosis. Reinterventions and rare, but challenging surgical reoperations address these residual findings with satisfactory outcomes. Quality of life into young adulthood is satisfactory, but functional problems include reduced exercise capacity, diffuse coronary insufficiency, and neurodevelopmental shortcomings, of which the true incidence and potential clinical implications are still unknown. The arterial switch is a spectacular anatomic correction for a once lethal condition and currently the best surgical solution for patients with discordant ventriculoarterial connections. It is, however, far from a true cure; closer and ongoing follow-up for future care will continue to be required.

Major adverse cardiac and cerebrovascular events after the Ross procedure: a report from the German-Dutch Ross Registry.

BACKGROUND: The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients. METHODS AND RESULTS: One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years. CONCLUSIONS: Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.

Results of Less Than 5-mm Right Ventricle-Pulmonary Artery Conduits in Single Ventricle Palliation.

BACKGROUND: Our programmatic approach to single ventricle (SV) neonatal palliation has evolved to using smaller-size right ventricle to pulmonary artery (RV-PA) conduits for pulmonary blood flow. Therefore, we sought to compare the early outcomes of less than 5-mm versus 5-mm RV-PA conduits in SV patients undergoing neonatal palliation. METHODS: We performed a retrospective review of SV patients who had neonatal palliation with either a less than 5-mm or 5-mm RV-PA connection, constructed using a waterproof, breathable fabric membrane graft (Gore-Tex, Flagstaff, AZ). Data before, during, and after surgery were analyzed using SPSS software. RESULTS: A total of 26 patients in group 1 (n = 11; <5 mm) and group 2 (n = 15; 5 mm) were operated on, with a mean follow-up of 13 months. Statistical differences (P ≤ .05) were noted with renal near-infrared spectroscopy (mean, 56 versus 44), and oxygen saturation at discharge (mean, 80% versus 85%) in groups 1 and 2, respectively. We found no significant difference in patient weight, peak lactate, cerebral near-infrared spectroscopy, length of intubation, length of hospitalization, or need for RV-PA conduit intervention after stage 1 along with age, branch PA sizes, or need for PA plasty at bidirectional Glenn between groups. CONCLUSIONS: Our early results of less than 5-mm conduits support further exploration into the tailoring of the RV-PA conduit size for each patient. A smaller-diameter conduit may improve systemic cardiac output and net oxygen delivery. Larger patient cohorts and longer follow-up with assessment of pulmonary artery growth are warranted to guide clinical practice.

Perioperative Anomalous Pulmonary Venous Return Evaluation With Low-Dose Cardiac Computed Tomography.

BACKGROUND: Low-dose multidetector computed tomographic angiography (MDCTA) is playing an increasingly larger role in the diagnosis of anomalous pulmonary venous return (APVR). Despite advances in new computed tomographic (CT) techniques with radiation dose reduction, there are limited studies describing radiation dose parameters to allow routine use of cardiac CT in infants and children with APVR. This study compares cardiac CT findings with intraoperative findings and describes comprehensive radiation exposure parameters. METHODS: A retrospective analysis of 27 patients compared MDCTA and intraoperative or cardiac catheterization findings of the pulmonary venous anatomy. RESULTS: A total of 32 MDCTA studies were performed on these 27 patients. Of the 28 studies with subsequent intervention, MDCTA accurately diagnosed the anomalous pulmonary venous anatomy in 27 (96.4%) patients. Narrowing of the pulmonary venous confluence entrance to the coronary sinus was missed on cardiac CT in one patient due to motion artifact, but it was noted intraoperatively. Median estimated effective radiation dose was 0.98 mSv (range: 0.39-3.2 mSv), and mean estimated effective radiation dose was 1.1 ± 0.68 mSv. Median total dose length product (DLP) was 25 mGy cm (range: 10-83 mGy cm), and mean total DLP was 28 ± 18 mGy cm. Median CTDI volume was 3.8 mGy (range: 2.5-14.6 mGy), and mean CTDI volume was 5.0 ± 3.2 mGy. CONCLUSIONS: We conclude that modern cardiac MDCTA is the best imaging modality to guide management in both preintervention and postintervention APVR patients. In this study, we describe comprehensive radiation exposure parameters in infants and children with APVR.

Do predictors exist for a successful withdrawal of preoperative prostaglandin E(1) from neonates with d-transposition of the great arteries and intact ventricular septum?

Prostaglandin E(1) (PGE(1)) is given to neonates with d-transposition of the great arteries (d-TGA) to reduce cyanosis by reopening and maintaining the patency of the ductus arteriosus. To avoid side effects, this medication can be stopped for hemodynamically stable patients after balloon atrial septostomy (BAS). A consecutive series of neonates with d-TGA and an intact ventricular septum (IVS) presenting from 2000 through 2005 was analyzed retrospectively to search for side effects of PGE(1) and to identify predictors for a safe preoperative withdrawal. The medication was stopped for hemodynamically stable patients with transcutaneous oxygen saturations higher than 80% after BAS and reinitiated for patients with an oxygen saturation lower than 65%. Patients successfully weaned were compared with those who had failed weaning in terms of atrial septal defect (ASD) size, ductus arteriosus size, and the transcutaneous oxygen saturation. Prostaglandin E(1) was initiated for all 43 neonates with d-TGA. The median maintenance dose of PGE(1) was 0.00625 µg/kg/min (range, 0.00313-0.050 µg/kg/min) for a median duration of 6 days (range, 1-12 days). For 16 patients, PGE(1) was preoperatively withdrawn but then had to be reinitiated for 7 of the 16 patients. No predictors for a successful weaning of PGE(1) were found based on ASD size, ductus arteriosus size, or oxygen saturation. The adverse effects of PGE(1) were apnea in 10 patients and fever in 19 patients. Neither seizures nor necrotizing enterocolitis was documented. Prostaglandin E(1) was successfully withdrawn for a minority of hemodynamically stable patients with d-TGA. No predictors for a successful weaning could be identified. Because apnea and fever are common side effects, withdrawal of PGE(1) after BAS may improve patient safety and comfort. In this patient group, if PGE(1) withdrawal was not well tolerated, it could be safely reinitiated. There were no serious side effects of PGE(1.).

First experience with a new drug-eluting balloon for the treatment of congenital pulmonary vein stenosis in a neonate.

Paclitaxel-eluting balloons are a new and innovative method in the treatment of in-stent stenosis and small vessel disease in adult cardiac pathology. The treatment of congenital pulmonary vein stenosis is difficult to manage, and results in a high mortality rate due to residual or recurrent stenosis. We report the first case of treatment for neonatal pulmonary vein restenosis with a paclitaxel-eluting balloon.