Toward More Granular Guidelines in AAOCA: Associating Anatomical Details With Specific Surgical Strategies.

Patients with anomalous aortic origin of a coronary artery (AAOCA) require imaging to clarify the multiple potential anatomic sites of obstruction (fixed or dynamic). Once repaired, the pathway of blood to the myocardium must not encounter: (1) intrinsic ostial stenosis, (2) obstruction from compression or distortion near the commissure or the intercoronary pillar, (3) stenosis where the artery exits the aortic wall (due to an acutely angled "take-off"), (4) compression due to a pathway between the great vessels, (5) stenosis or compression along an intramural course, or (6) compression due to an intramuscular (intraseptal/intraconal) course. Detailed anatomic evaluation of each of these locations allows the surgeon to select an appropriate repair strategy, and each of these abnormal anatomic features should be "matched" with a particular surgical correction. We speculate that the most common surgical repair, unroofing with or without tacking, is often inadequate, as in isolation, it may not allow for correction with a large orifice from the appropriate sinus, without an interarterial course. While the evidence base is insufficient to call these recommendations formal guidelines, these recommendations should serve as a basis for further validity testing, and ultimate evolution to more granular guidelines on AAOCA management.

Passive high-frequency microrheology of blood.

Indicative of various pathologies, blood properties are under intense scrutiny. The hemorheological characteristics are traditionally gauged by bulk, low-frequency indicators that average out critical information about the complex, multi-scale, and multi-component structure. In particular, one cannot discriminate between the erythrocytes contribution to global rheology and the impact of plasma. Nevertheless, in their fast stochastic movement, before they encounter each other, the erythrocytes probe the subtle viscoelasticity of their protein-rich environment. Thus, if these short time scales can be resolved experimentally, the plasma properties could be determined without having to separate the blood components; the blood is practically testing itself. This microrheological description of blood plasma provides a direct link between the composition of whole blood and its coagulability status. We present a parametric model for the viscoelasticity of plasma, which is probed by the erythrocytes over frequency ranges of kilohertz in a picoliter-sized volume. The model is validated both in vitro, using artificial hemo-systems where the composition is controlled, as well as on whole blood where continuous measurements provide real-time information. We also discuss the possibility of using this passive microrheology as an in vivo assay for clinically relevant situations where the blood clotting condition must be observed and managed continuously for diagnosis or during therapeutic procedures at different stages of hemostatic and thrombotic processes.

Joint programmes in paediatric cardiac surgery: an update and descriptive analysis.

OBJECTIVE: Joint programmes are an alternative model that may aid in improving congenital cardiac surgery outcomes while avoiding the potential resource and accessibility challenges that could result from regionalisation. This study aims to characterise current joint programmes, identify factors that are associated with joint programme success and failure, and gauge attitudes within the profession regarding joint programmes as an alternative. METHODS: A multiple choice survey with 23 standard questions for all programmes and additional 42 additional questions for each participant hospital in a joint programme was addressed to paediatric cardiac surgeons in the United States of America. Questions were designed to qualitatively and quantitatively characterise congenital cardiac surgery joint programmes. RESULTS: Of the 34 unique congenital cardiac surgery programmes identified in this survey, 14 have participated in a joint programme and 50% of those joint programmes existed for more than 10 years. Most joint programmes (86%) participate or participated in a model where the hospital participants are engaged in a "mother-daughter" relationship in both perception and case volume distribution. In three out of four defunct joint programmes, there were case complexity limitations placed on partner institutions, but the now independent partner institutions operate with no limitation on complexity. Most (71%) hospital participants in a joint programme felt that the joint programme produced better outcomes than two separate programmes; however, among those who participate or have participated in a joint programme, only 18% felt that joint programmes were the optimal model for delivery of congenital cardiac surgical care.

Gravity Venous Drainage and the 3/8-Inch Venous Line: What Would Poiseuille Do?

The 1/2″ venous line has long been the drainage tubing diameter of choice for adult patients undergoing cardiac surgery. However, several programs use a smaller diameter venous line when used in conjunction with kinetic-assisted venous drainage or vacuum-assisted venous drainage. In 2014, our perfusion team made an institution-wide effort to miniaturize the cardiopulmonary bypass (CPB) circuit for children. One of our changes was the transition to a 3/8″ diameter venous line for drainage, even in our larger patients (up to 80 kg). We reviewed the current literature on this topic and delineated the various parameters required to be able to use the 3/8″ venous line with gravity drainage with the aim of using it on patients up to 115 kg with the appropriate venous reservoir. We have successfully used the 3/8″ venous line in more than 40 of our larger patients (35-90 kg) without the need for assisted venous drainage. We were able to reduce CPB prime from 625 ± 118 to 425 ± 52 mL before retrograde autologous priming (RAP)/venous autologous priming (VAP). The prime was further reduced to 325 ± 66 mL after RAP/VAP. Homologous blood utilization was reduced from 217 ± 311 mL to 27 ± 77 mL. Both results were statistically significant. We hypothesize that taking into account two of the parameters of Poiseuille's law, namely length and diameter, it is possible to safely drain large children and mid-size adults via gravity venous drainage and the 3/8″ venous line. This technique allows reducing prime volume, simplifies CPB circuits with increased safety and potentially reduces the need for homologous blood transfusion.

The Novel Use of a Low Prime Modified Ultrafiltration Apparatus in a 13-kg Jehovah's Witness Patient: A Case Report.

Modified ultrafiltration (MUF) is used in neonates and infants to reduce volume overload and increase oxygen-carrying capacity post cardiopulmonary bypass (CPB). In addition, it decreases edema, attenuates complementation activation and immunogenic response to CPB. Hemodilution in the pediatric patient has always been a challenge, countered in part by miniaturization of CPB circuits. We describe a case in which we maintained an acceptable hematocrit level greater than 24%, considered the nadir below which the adverse effects of hemodilution can become evident. We performed this by the novel use of an intravenous warming device (enFlow, Vyaire Medical, Mettawa, IL) to reduce the prime volume of our MUF circuit by more than 50%. We present the case and discuss the advantages and disadvantages of using a low-prime MUF circuit. We were able to conduct "bloodless" CPB, with the use of acute normovolemic hemodilution, miniaturization of the CPB and MUF circuits.

Bloodless Heart Surgery for an 11-kg Infant of the Jehovah's Witness Faith Undergoing Second Repair for Complete Atrioventricular Canal.

Bloodless pediatric cardiac surgery is the intent of most surgical centers especially in the Jehovah's Witness population where it is a desire not to administer blood products because of religious belief. It is a tremendous feat, considering that most pediatric cardiovascular prime volumes are more than 20% of the patient's estimated blood volume (EBV). We report on our bloodless strategy for a 2-year old Jehovah's Witness with trisomy 21 and complete atrioventricular canal repair, who underwent atrial septal defect and ventricular septal defect patch closure, pulmonary artery debanding, and pulmonary arterioplasty. We modified our circuit to reduce our prime volume to approximately 10% of the EBV and removed 200 mL of the patient's blood before surgery as acute normovolemic hemodilution. We did not alter our institutional standards for transfusion of blood and blood products. The post cardiopulmonary bypass (CPB) hematocrit was 30%. We conclude that bloodless CPB surgery can be performed safely in Jehovah's Witness patients with a carefully planned interdisciplinary approach.

Experimental Study of Anisotropic Stress/Strain Relationships of Aortic and Pulmonary Artery Homografts and Synthetic Vascular Grafts.

Homografts and synthetic grafts are used in surgery for congenital heart disease (CHD). Determining these materials' mechanical properties will aid in understanding tissue behavior when subjected to abnormal CHD hemodynamics. Homograft tissue samples from anterior/posterior aspects, of ascending/descending aorta (AA, DA), innominate artery (IA), left subclavian artery (LScA), left common carotid artery (LCCA), main/left/right pulmonary artery (MPA, LPA, RPA), and synthetic vascular grafts, were obtained in three orientations: circumferential, diagonal (45 deg relative to circumferential direction), and longitudinal. Samples were subjected to uniaxial tensile testing (UTT). True strain-Cauchy stress curves were individually fitted for each orientation to calibrate Fung model. Then, they were used to calibrate anisotropic Holzapfel-Gasser model (R2 > 0.95). Most samples demonstrated a nonlinear hyperelastic strain-stress response to UTT. Stiffness (measured by tangent modulus at different strains) in all orientations were compared and shown as contour plots. For each vessel segment at all strain levels, stiffness was not significantly different among aspects and orientations. For synthetic grafts, stiffness was significantly different among orientations (p < 0.042). Aorta is significantly stiffer than pulmonary artery at 10% strain, comparing all orientations, aspects, and regions (p = 0.0001). Synthetic grafts are significantly stiffer than aortic and pulmonary homografts at all strain levels (p < 0.046). Aortic, pulmonary artery, and synthetic grafts exhibit hyperelastic biomechanical behavior with anisotropic effect. Differences in mechanical properties among vascular grafts may affect native tissue behavior and ventricular/arterial mechanical coupling, and increase the risk of deformation due to abnormal CHD hemodynamics.

The Impact of Roller Pump vs. Centrifugal Pump on Homologous Blood Transfusion in Pediatric Cardiac Surgery.

Centrifugal pumps are considered to be less destructive to blood elements (1) when compared to roller pumps. However, their large prime volumes render them unsuitable as arterial pumps in heart lung machine (HLM) circuitry for children. In November of 2014, the circuit at Arnold Palmer Hospital, a Biomedicus BP-50 with kinetic assist venous drainage (KAVD) and 1/4″ tubing was converted to a roller pump in the arterial position with gravity drainage. Vacuum-assisted venous drainage (VAVD) was mounted on the HLM as a backup, but not used. Tubing was changed to 3/16″ in the arterial line in patients <13 kg. A retrospective study with a total of 140 patients compared patients placed on cardiopulmonary bypass (CPB) with Biomedicus centrifugal pumps and KAVD (Centrifugal Group, n = 40) to those placed on CPB with roller pumps and gravity drainage (Roller Group, n = 100). Patients requiring extra-corporeal membrane oxygenation (ECMO)/cardio-pulmonary support (CPS) or undergoing a hybrid procedure were excluded. Re-operation or circulatory arrest patients were not excluded. Prime volumes decreased by 57% from 456 ± 34 mL in the Centrifugal Group to 197 ± 34 mL in the Roller Group (p < .001). There was a corresponding increase in hematocrit (HCT) of blood primes and also on CPB. Intraoperative homologous blood transfusions also decreased 55% from 422 mL in the Centrifugal Group to 231 mL in the Roller Group (p < .001). The Society of Thoracic Surgeons--European Association for Cardio-Thoracic Surgery (STAT) categorized intubation times and hospital length of stay (LOS) for all infants showed a trend toward reduction, but was not statistically significant. Overall mortality was 5% utilizing the centrifugal configuration and 0% in the roller pump cohort. We demonstrated that the transition to roller pumps in the arterial position of the HLM considerably reduced our priming volume and formed a basis for a comprehensive blood conservation program. By maintaining higher HCTs on CPB, we were able to reduce intraoperative homologous blood transfusions.

Mathematical modeling of patient-specific ventricular assist device implantation to reduce particulate embolization rate to cerebral vessels.

Stroke is the most devastating complication after ventricular assist device (VAD) implantation, with an incidence of 14%-47% despite improvements in device design and anticoagulation. This complication continues to limit the widespread implementation of VAD therapy. Patient-specific computational fluid dynamics (CFD) analysis may elucidate ways to reduce this risk. A patient-specific three-dimensional model of the aortic arch was generated from computed tomography. A 12 mm VAD outflow-graft (VAD-OG) "anastomosed" to the aorta was rendered. CFD was applied to study blood flow patterns. Particle tracks, originating from the VAD, were computed with a Lagrangian phase model and percentage of particles entering the cerebral vessels was calculated. Twelve implantation configurations of the VAD-OG and three particle sizes (2, 4, and 5 mm) were considered. Percentage of particles entering the cerebral vessels ranged from 6% for the descending aorta VAD-OG anastomosis, to 14% for the ascending aorta at 90 deg VAD-OG anastomosis. Values were significantly different among all configurations (X(2) = 3925, p < 0.0001). Shallower and more cephalad anastomoses prevented formation of zones of recirculation in the ascending aorta. In this computational model and within the range of anatomic parameters considered, the percentage of particles entering the cerebral vessels from a VAD-OG is reduced by nearly 60% by optimizing outflow-graft configuration. Ascending aorta recirculation zones, which may be thrombogenic, can also be eliminated. CFD methods coupled with patient-specific anatomy may aid in identifying the optimal location and angle for VAD-OG anastomosis to minimize stroke risk.

Research Enterprise of the Congenital Heart Surgeons' Society 2018 to 2023: History, Accomplishments, Transformation, and Challenges.

The history of the research arm of the Congenital Heart Surgeons' Society (CHSS) through 2017 was contained within two prior publications that covered CHSS history in general. The present article is the first to focus explicitly on the research enterprise, with emphasis on the period 2018 to 2023. During this time, the challenges of continuing to build multiple cohorts with lifelong follow-up and to transform the enterprise to a premiere research organization became manifest. Although continuing its commitment to produce impactful research results and to educate the Kirklin/Ashburn Fellow, the research team devoted considerable effort to defining the problems of cohort relevance, workflow, data management, long-term patient follow-up, CHSS member engagement, and the regulatory burden. The team wrote a proposal outlining ways to solve the challenges. A major change from a single-institution "Data Center" to a two-institution Center for Research & Quality (CRQ) was made, assuring increased faculty members and resources. The proposed changes to structure and process began execution in mid-2022. A second Kirklin/Ashburn Fellowship position was created. Between 2018 and 2022, the CRQ produced 17 publications and launched five new research initiatives. This article chronicles the exciting five-year period in which the CHSS research enterprise began a transformation with the intent to become the premiere research organization in the world in the specialty of congenital cardiac surgery.

Invited Commentary: Notwithstanding the Significance of Anatomy in Anomalous Aortic Origin of a Coronary Artery, Physiology Is Important, Too.

The management strategies for anomalous aortic origin of a coronary artery (AAOCA) are based on anatomy, symptoms, and stress tests for evidence of ischemia. These strategies remain associated with low levels of evidence. Stress tests for ischemia or ventricular dysfunction, the only widely used physiological tests, are not adequately reliable. Additional physiological metrics are needed to build reliable strategies. Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are physiological measurements that are used in assessing acquired coronary artery disease (CAD). In this commentary, we describe FFR and iFR and review studies supporting their utility in assessing CAD. We describe a few small studies of their use in assessing AAOCA. Finally, we comment on the unique features of AAOCA that mandate further investigation on how to conduct and interpret FFR/iFR measurements. Even at a point where we understand how to do this, determining the effectiveness of these measurements in improving outcomes and guiding management will require lengthy and challenging trials. A collective effort of institutions that manage AAOCA will be essential.

Mycotic Pseudoaneurysm: Rare Complication of a Norwood/Sano Graft Stump.

The Sano variant of the stage 1 Norwood procedure is commonly performed as initial palliation for hypoplastic left heart syndrome. We present a case of a 2-year-old who developed a mycotic pseudoaneurysm of the Sano graft and discuss the importance of imaging and operative management of this rare presentation. Localization and full description of the lesion require compulsive, often multimodality imaging.

Persistent Hypoxia After Blunt Thoracic Trauma due to Flail Tricuspid Valve Leaflet and Patent Foramen Ovale.

Structural cardiac injury after blunt trauma is uncommon but usually life-threatening. While tricuspid injury is very rare and potentially lethal, the right heart can accommodate larger volumes and higher pressures in acute tricuspid insufficiency and facilitate initial stabilization prior to definitive valvular repair. ECMO may be used to ameliorate resulting right heart failure. The traumatic force required to cause cardiac structural injury is also associated with pulmonary complications related to pneumothorax, hemothorax, effusion, acute pain secondary to rib fractures, and pulmonary contusions causing hypoxia. We present an unusual case of hypoxia in a trauma patient caused by acute tricuspid regurgitation with pre-existing patent foramen ovale.

A dynamic Norwood mortality estimation: Characterizing individual, updated, predicted mortality trajectories after the Norwood operation.

Objective: Post-Norwood mortality remains high and unpredictable. Current models for mortality do not incorporate interstage events. We sought to determine the association of time-related interstage events, along with (pre)operative characteristics, with death post-Norwood and subsequently predict individual mortality. Methods: From the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort, 360 neonates underwent Norwood operations from 2005 to 2016. Risk of death post-Norwood was modeled using a novel application of parametric hazard analysis, in which baseline and operative characteristics and time-related adverse events, procedures, and repeated weight and arterial oxygen saturation measurements were considered. Individual predicted mortality trajectories that dynamically update (increase or decrease) over time were derived and plotted. Results: After the Norwood, 282 patients (78%) progressed to stage 2 palliation, 60 patients (17%) died, 5 patients (1%) underwent heart transplantation, and 13 patients (4%) were alive without transitioning to another end point. In total, 3052 postoperative events occurred and 963 measures of weight and oxygen saturation were obtained. Risk factors for death included resuscitated cardiac arrest, moderate or greater atrioventricular valve regurgitation, intracranial hemorrhage/stroke, sepsis, lower longitudinal oxygen saturation, readmission, smaller baseline aortic diameter, smaller baseline mitral valve z-score, and lower longitudinal weight. Each patient's predicted mortality trajectory varied as risk factors occurred over time. Groups with qualitatively similar mortality trajectories were noted. Conclusions: Risk of death post-Norwood is dynamic and most frequently associated with time-related postoperative events and measures, rather than baseline characteristics. Dynamic predicted mortality trajectories for individuals and their visualization represent a paradigm shift from population-derived insights to precision medicine at the patient level.

The Academic Impact of Congenital Heart Surgeons' Society (CHSS) Studies.

PURPOSE: We reviewed all 64 articles ever published by The Congenital Heart Surgeons' Society (CHSS) Data Center to estimate the academic impact of these peer-reviewed articles. MATERIALS AND METHODS: The Congenital Heart Surgeons' Society has performed research based on 12 Diagnostic Inception Cohorts. The first cohort (Transposition) began enrolling patients on January 1, 1985. We queried PubMed to determine the number of publications that referenced each of the 64 journal articles generated by the datasets of the 12 Diagnostic Inception Cohorts that comprise the CHSS Database. Descriptive summaries of the data were tabulated using mean with standard deviation and median with range. RESULTS: Sixty-four peer-reviewed papers have been published based on the CHSS Database. Fifty-nine peer-reviewed articles have been published based on the 12 Diagnostic Inception Cohorts, and five additional articles have been published based on Data Science. Excluding the recently established Diagnostic Inception Cohort for patients with Ebstein malformation of tricuspid valve, the number of papers published per cohort ranged from 1 for coarctation to 11 for transposition of the great arteries. The 11 articles generated from the CHSS Transposition Cohort were referenced by a total of 111 articles (median number of references per journal article = 9 [range = 0-22, mean = 10.1]). Overall, individual articles were cited by an average of 11 (mean), and a maximum of 41 PubMed-listed publications. Overall, these 64 peer-reviewed articles based on the CHSS Database were cited 692 times in PubMed-listed publications. The first CHSS peer-reviewed article was published in 1987, and during the 35 years from 1987 to 2022, inclusive, the annual number of CHSS publications has ranged from 0 to 7, with a mean of 1.8 publications per year (median = 1, mode = 1). CONCLUSION: Congenital Heart Surgeons' Society studies are widely referenced in the pediatric cardiac surgical literature, with over 10 citations per published article. These cohorts provide unique information unavailable in other sources of data. A tool to access this analysis is available at: [https://data-center.chss.org/multimedia/files/2022/CAI.pdf].

Norwood operation versus comprehensive stage II after bilateral pulmonary artery banding palliation for infants with critical left heart obstruction.

OBJECTIVE: To determine patient characteristics and outcomes after Norwood versus comprehensive stage II (COMPSII) for infants with critical left heart obstruction who had prior hybrid palliation (bilateral pulmonary artery banding ± ductal stent). METHODS: From 23 Congenital Heart Surgeons' Society institutions (2005-2020), 138 infants underwent hybrid palliation followed by either Norwood (n = 73, 53%) or COMPSII (n = 65). Baseline characteristics were compared between Norwood and COMPSII groups. Parametric hazard model with competing risk methodology was used to determine risk and factors associated with outcomes of Fontan, transplantation, or death. RESULTS: Infants who underwent Norwood versus COMPSII had a higher prevalence of prematurity (26% vs 14%, P = .08), lower birth weight (median 2.8 vs 3.2 kg, P < .01) and less frequent ductal stenting (37% vs 99%; P < .01). Norwood was performed at a median age of 44 days and median weight of 3.5 kg, versus COMPSII at 162 days and 6.0 kg (both P < .01). Median follow-up was 6.5 years. At 5 years after Norwood and COMPSII, respectively; 50% versus 68% had Fontan (P = .16), 3% versus 5% had transplantation (P = .70), 40% versus 15% died (P = .10), and 7% versus 11% are alive without transition, respectively. For factors associated with either mortality or Fontan, only preoperative mechanical ventilation occurred more frequently in the Norwood group. CONCLUSIONS: Higher prevalence of prematurity, lower birth weight, and other patient-related characteristics in the Norwood versus COMPSII groups may influence differences in outcomes that were not statistically significant for this limited risk-adjusted cohort. The clinical decision regarding Norwood versus COMPSII after initial hybrid palliation remains challenging.

Hybrid palliation versus nonhybrid management for a multi-institutional cohort of infants with critical left heart obstruction.

OBJECTIVE: To compare patient characteristics and overall survival for infants with critical left heart obstruction after hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) versus nonhybrid management (eg, Norwood, primary transplantation, biventricular repair, or transcatheter/surgical aortic valvotomy). METHODS: From 2005 to 2019, 1045 infants in the Congenital Heart Surgeons' Society critical left heart obstruction cohort underwent interventions across 28 institutions. Using a balancing score propensity analysis, 214 infants who underwent hybrid palliation and 831 infants who underwent nonhybrid management were proportionately matched regarding variables significantly associated with mortality and variables noted to significantly differ between groups. Overall survival between the 2 groups was adjusted by applying balancing scores to nonparametric estimates. RESULTS: Compared with the nonhybrid management group, infants who underwent hybrid palliation had lower birth weight, smaller gestational age, and higher prevalence of in-utero interventions, noncardiac comorbidities, preoperative mechanical ventilation, absent interatrial communication, and moderate or severe mitral valve stenosis (all P values < .03). Unadjusted 12-year survival after hybrid palliation and nonhybrid management, was 55% versus 69%, respectively. After matching, 12-year survival after hybrid palliation versus nonhybrid management was 58% versus 63%, respectively (P = .37). Among matched infants born weighing <2.5 kg, 2-year survival after hybrid palliation versus nonhybrid management was 37% versus 51%, respectively (P = .22). CONCLUSIONS: Infants born with critical left heart obstruction who undergo hybrid palliation have more high-risk characteristics and anatomy versus infants who undergo nonhybrid management. Nonetheless, after adjustment, there was no significant difference in 12-year survival after hybrid palliation versus nonhybrid management. Mortality remains high, and hybrid palliation confers no survival advantage, even for lower-birth-weight infants.

Computational fluid dynamics in congenital heart disease.

Computational fluid dynamics has been applied to the design, refinement, and assessment of surgical procedures and medical devices. This tool calculates flow patterns and pressure changes within a virtual model of the cardiovascular system. In the field of paediatric cardiac surgery, computational fluid dynamics is being used to elucidate the optimal approach to staged reconstruction of specific defects and study the haemodynamics of the resulting anatomical configurations after reconstructive or palliative surgery. In this paper, we review the techniques and principal findings of computational fluid dynamics studies as applied to a few representative forms of congenital heart disease.

Alternative anticoagulation during cardiovascular procedures in pediatric patients with heparin-induced thrombocytopenia.

Patients with heparin-induced thrombocytopenia (HIT) that require anticoagulation for cardiovascular procedures represent a challenging and high-risk group. Bivalirudin and argatroban have been successfully used as alternative anticoagulants in adult patients with HIT. There have been few experiences published involving the pediatric population and controversy exists regarding the properties and optimal dosing of these drugs. This report describes the experience of managing two pediatric patients with HIT that underwent cardiovascular procedures requiring anticoagulation. Bivalirudin was used in both cases for anticoagulation during cardiopulmonary bypass, while argatroban was used without complications during cardiac catheterization. A description of perfusion and anticoagulation protocols is included.

Congenital Left Main Coronary Atresia: Rare Cause of Sudden Cardiac Arrest.

A 13-month-old male sustained cardiac arrest under general anesthesia and was found to have left main coronary artery atresia with collateralization from the right coronary artery. After protracted recovery, the patient underwent coronary ostioplasty. Postoperative imaging confirmed patency of the newly established artery without stenosis. At 12 months, no changes in the vessel were noted. Ventricular function remains mildly decreased and stable.