Neonatal repair of atypical double outlet right ventricle.

BACKGROUND: A complex and rare form of double outlet right ventricle needs careful attention when choosing the optimal strategy for repair. AIM OF THE STUDY: To point out retrospectively what could have been done differently in our unique patient. METHODS: Primary repair was arranged in a neonate with double outlet right ventricle (of a non-committed ventricular septal defect type and lack of the outlet septum between the semilunar valves) with right aortic arch and dextro-malposition of great arteries. RESULTS: We managed to achieve intraventricular rerouting via a right ventricular incision concomitantly with the arterial switch maneuver. The patient is doing well with an excellent hemodynamic status. CONCLUSIONS: We considered that the radical approach we chose appeared to be sensible in this particular patient, although some other options could have been available.

A Case of Stanford Type A Acute Aortic Dissection With Preoperative Extensive Cerebral Infarction Successfully Treated Surgically.

Patients with organ malperfusion from acute aortic dissection (AAD) have poor outcomes, and the surgical indications for patients with AAD complicated by extensive cerebral infarction have not been established. Here, we report a successfully treated surgical case of a patient with cerebral infarction and Stanford type A, AAD. A 77-year-old man was admitted to the hospital with a chief complaint of left paresis. After confirming that there was no cerebral hemorrhage with a head computed tomography and an incision in the right neck, and the right internal carotid artery was ligated and closed, emergency surgery was performed with a 24 mm Triplex® raft. The ascending aorta was replaced, and a bypass was performed with a prosthetic graft from the right axillary artery. No cerebral hemorrhage or neurological issues were observed postoperatively, which indicates the possibility of surgical intervention as a treatment strategy for this disease.

Is two-staged repair for truncus arteriosus type A3 unpractical?

BACKGROUND: A complex and rare form of persistent truncus arteriosus needs careful attention when choosing the optimal strategy for repair. AIM OF THE STUDY: We herein describe our surgical strategy of a small infant having this malformation concomitantly with right aortic arch, unusual pulmonary artery branching and a left superior vena cava. METHODS: The patient underwent initially bilateral pulmonary arterial banding followed by the Rastelli type definitive repair. The pulmonary arteries were unified in front of the left superior vena cava, and the right ventricular outflow tract was readily reconstructed. RESULTS: The patient is doing well with an excellent hemodynamic status. CONCLUSIONS: We considered the two-stage approach was sensible in this particular patient.

Preoperative simulation for complex transposition of great arteries using a three-dimensional model.

We utilised a cast preoperatively prepared on the basis of the patient's computed tomography data to clarify unusual orientation of the great arteries (transposition of great arteries, coarctation of the aorta, and abnormally branching central pulmonary arteries) in a 2.2-kg neonate. The three-dimensional model was very useful for designing the surgical procedure - being easy to handle for real and precise simulation of the reparative manoeuvres.

Tuberculous peritonitis during pegylated interferon plus ribavirin combination therapy in a patient with chronic hepatitis C.

A woman in her 70s with fever and abdominal distension was referred to our hospital for investigation. She had just finished a course of pegylated interferon and ribavirin combination therapy for chronic hepatitis C. Abdominal computed tomography revealed peritoneal thickening and ascites. QuantiFERON(®)-TB Gold was positive, ascitic adenosine deaminase was high, and fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) showed diffuse accumulation in the peritoneum. Although these findings suggested tuberculous peritonitis, we did not detect Mycobacterium tuberculosis in any bacterial cultures, ascites, or other specimens. However, laparoscopic peritoneal biopsy demonstrated a large number of miliary white nodules in the parietal and visceral peritonea. Pathological examination of these nodules revealed epidermoid granuloma with giant Langhans' cells and caseous necrosis. Finally, the diagnosed of tuberculous peritonitis was established. It is important to consider tuberculosis in patients presenting with new symptoms while receiving interferon therapy.

Prevention of surgical adhesions with gelatine sealing sheet in a canine adhesion model.

OBJECTIVES: Although reoperation has been increasingly performed in cardiovascular surgery in recent years, preventing surgical adhesions remains an unsolved complication. Therefore, this study aimed to investigate whether gelatine sealing sheets are more effective than fibrin sealing sheets in preventing surgical adhesions. METHODS: Bilateral femoral arteries of 20 beagle dogs under general anaesthesia were pricked with syringe needles, and gelatine and fibrin sealing sheets were applied on the bleeding points to make canine adhesion models. The femoral artery was harvested after 4 and 12 weeks to evaluate adhesion formations. The adhesive grade was quantified by scoring the area and strength of adhesion tissues. Histological staining was performed to examine the structural features of surgical adhesions. RESULTS: Significantly fewer macroscopic adhesions were observed with gelatine sealing sheets than those with fibrin sealing sheets at 4 and 12 weeks postoperatively. Microscopically, CD3+ T lymphocytes at 4 and 12 weeks postoperatively in gelatine sealing sheets were significantly lower than those in fibrin sealing sheets. Microvessel density determined by CD34 at 4 and 12 weeks postoperatively in gelatine sealing sheets was also significantly lower than those in fibrin sealing sheets. CONCLUSIONS: The gelatine sealing sheets are more effective than the fibrin sealing sheets in preventing surgical adhesions. These findings suggest that the gelatine sealing sheet may help prevent adhesions and thus be a therapeutically effective biomaterial in vascular surgery.

Use of hydrocolloid dressing in infants requiring open chest management after cardiac surgery.

PURPOSE: Sternal splintage is known as an effective maneuver to stabilize hemodynamics during the immediate postoperative period, particularly in very sick infants. On the other hand, its wound management is not always straightforward. We employed dressing using a product made of a hydrocolloid material in such circumstances. This report describes our experience in utilizing the dressing in term of its potential advantages. MATERIALS AND METHODS: Six infants needed open chest management following complicated procedures for congenital heart disease. A polytetrafluoroethylene patch was fixed to augment the skin defect at the time of sternal splintage, and a hydrocolloid dressing was applied to entirely cover the wound including the suture line. RESULT: All patients survived their difficult circumstances. None of them suffered wound complications such as infection or healing problem during sternal splintage or subsequent to eventual chest closure. The dressing product was easy to handle with no adverse events associated with its material. CONCLUSIONS: It is reconfirmed that a dressing made of hydrocolloid material was of practical use for sealing the wound in infants requiring open chest management after cardiac surgery.

Cor Triatriatum Can Coexist With Common Pulmonary Venous Atresia.

Surgical treatment was very urgently carried out in an extremely cyanotic newborn with common pulmonary venous atresia. The diagnosis was confirmed during the procedure, and the common venous chamber was anastomosed to the left atrium through a transverse incision onto the right and the left atria. Unfortunately, pulmonary hypertension persisted during the postoperative course and even got worse gradually. Computed tomography eventually illustrated residual cor triatriatum. The initial atriotomy had been entirely above the diaphragm within the left atrium. Consequently, the abnormal structure had been overlooked. The patient is doing well 1 month after the surgical revision. Pulmonary hypertension disappeared.

Improvement in Left Cardiac Function Following Mitral Valve Repair: Analyses Based on Cardiac Magnetic Resonance Imaging.

AIM: This study aimed to evaluate the structural and functional changes of left-sided cardiac chambers by cardiac magnetic resonance imaging (CMRI) in patients with chronic mitral regurgitation after mitral valve repair (MVR). PATIENTS AND METHODS: Among 103 patients who underwent MVR, 21 showed normal left ventricular (LV) function; their pre- and postoperative left atrial (LA) and LV functions were examined by CMRI. RESULTS: LV end-diastolic volume, LV end-systolic volume, and LV mass significantly were reduced postoperatively (p<0.01) and postoperative LV ejection fraction tended to decrease. LA volume parameters also significantly decreased postoperatively (p<0.01). The conduit function positively affected the LV filling volume postoperatively (p<0.01); however, no effect on the booster pump function was noted (p=0.01). CONCLUSION: Restoration of LA and LV functions after a successful MVR was not associated with structural improvement in LA and LV.

Copeptin concentration following cardiac surgery as a prognostic marker of postoperative acute kidney injury: a prospective cohort study.

BACKGROUND: Copeptin, the C-terminal portion of the arginine vasopressin precursor, is a novel candidate biomarker. This study investigated the prognostic value of copeptin levels following cardiac surgery for the occurrence of postoperative acute kidney injury. METHODS: We studied 23 patients who underwent cardiac surgery between January 2018 and December 2019. The primary endpoint was postoperative acute kidney injury onset. Copeptin levels were measured before, right after, and daily for 7 days. The patients were divided into two groups according to the copeptin levels: low (values <43.7 pmol/L) and high (values ≥43.7 pmol/L). Correlations between copeptin levels and variables, such as central venous pressure, were assessed by bivariate analysis. RESULTS: The high copeptin group exhibited significantly higher levels of arginine vasopressin and cortisol following surgery, compared to those of the low copeptin group. The copeptin concentration following surgery was correlated to central venous pressure (P=0.03) and norepinephrine administered dose (P=0.008). Also, the copeptin levels right after surgery robustly predicted the onset of postoperative acute kidney injury (area under the receiver operating characteristic curve of 0.83, P=0.004). CONCLUSIONS: Elevated copeptin levels in patients following cardiac surgery predicted postoperative acute kidney injury development. Therefore, the copeptin concentration after surgery could represent a promising clinical biomarker of the postoperative cardiac outcome.

Midterm results and risk factors of functional single ventricles with extracardiac total anomalous pulmonary venous connection.

OBJECTIVES: To evaluate the clinical outcomes of surgical repair of an extracardiac total anomalous pulmonary venous connection (TAPVC) in a functional single-ventricle (f-SV) strategy. METHODS: This was a retrospective analysis of 48 consecutive cases of extracardiac TAPVC repair, from 1998 to 2015. Demographic and clinical variables were as follows: median age, 24 (range 0-744) days; median weight, 3.1 (range 2.0-9.6) kg; type of TAPVC-supracardiac, 21 patients, infracardiac, 8, and mixed, 19; right atrial isomerism, 45 patients; pulmonary atresia, 24 patients; and obstructed TAPVC, 30 patients. Concomitant procedures included systemic-to-pulmonary shunting in 15 patients, pulmonary artery banding in 12, ventricle-to-pulmonary artery shunting in 2, a Norwood procedure in one, a bidirectional Glenn procedure in 16, and a Fontan procedure in 1. RESULTS: The 1- and 5-year cumulative survival rates were 66.0% and 58.0%, respectively. Of the 28 survivors, 22 (78.6%) underwent Fontan completion and 4 (14.3%) a bidirectional Glenn procedure, and 1 (3.6%) was awaiting a bidirectional Glenn procedure. Recurrent pulmonary venous stenosis (PVS) was observed in 17 patients, with a 1- and 5-year rates of freedom from recurrent PVS 59.8% and 53.5%, respectively. Of the 20 post-operative deaths, only 4 were PVS related. Only pre-operative pulmonary atresia was identified as an independent risk factor of mortality after TAPVC repair. CONCLUSIONS: The midterm surgical outcomes of f-SV with extracardiac TAPVC were acceptable. Moreover, among survivors, Fontan completion can be sufficiently expected. Further improvement, with the development of a comprehensive treatment strategy, is required for this patient group.

Long-term outcome of patients with right atrial isomerism after common atrioventricular valve plasty.

OBJECTIVES: To review long-term outcomes of patients with right atrial (RA) isomerism who underwent common atrioventricular valve (CAVV) plasty. METHODS: We retrospectively analysed 59 patients with RA isomerism operated on between January 2004 and April 2016. We divided patients into those with CAVV plasty (CAVV plasty (+), 29 patients) and without CAVV plasty (CAVV plasty (-), 30), and we compared the outcome between the groups. We further divided patients into those with CAVV plasty before bidirectional cavopulmonary shunt (BCPS) operation (group before BCPS, 13 patients) or CAVV plasty with or after BCPS (group with or after BCPS, 16), and we compared the outcome between these groups. We reviewed the outcomes of 7 neonatal patients who underwent CAVV plasty. RESULTS: Kaplan-Meier estimated survival rates at 10 years were 70 ± 10% and 69 ± 9% in the CAVV plasty (+) and CAVV plasty (-) groups, respectively ( P = 0.45). Kaplan-Meier estimated survival rates at 10 years were 47 ± 17% and 85 ± 10% in the group before BCPS and group with or after BCPS, respectively ( P = 0.01). Among 7 neonates in the group before BCPS, 4 are alive; Kaplan-Meier estimated survival rates at 1 year and 5 years were 60 ± 20% and 30 ± 24%, respectively. CONCLUSIONS: Patients who underwent CAVV plasty with or after BCPS had good outcomes; the outcome of patients with CAVV plasty was the same as that of those without CAVV plasty. Treatment for patients who require CAVV plasty before BCPS, especially neonates, is challenging.

Modification of hemi-Fontan operation for patients with functional single ventricle and anomalous pulmonary venous connection to the superior vena cava: mid-term results.

OBJECTIVES: Fontan candidates with mixed totally anomalous pulmonary venous connection often have postoperative pulmonary venous obstruction after cavopulmonary anastomosis. Because some pulmonary venous obstructions have no intimal hypertrophy at reoperation, we considered such pulmonary venous obstructions to be caused by 3D deformities arising from dissection or mobilization of the vessels, and hypothesized that keeping the pulmonary venous branches in a natural position could avoid such obstruction. Here, we evaluated a modified hemi-Fontan strategy consisting of minimal dissection with no division of vessels and patch separation between systemic and pulmonary venous flow. METHODS: We retrospectively reviewed clinical records of infants with a functional single ventricle and supracardiac anomalous pulmonary venous connection who had undergone this procedure between 2002 and 2012. RESULTS: Nine infants underwent this procedure (median age, 5.6 months; range 3.2-30), all with right atrial isomerism and several pulmonary venous branches directly and separately connecting to the superior vena cava. In 5 patients, all pulmonary veins drained into the superior vena cava; in 1, the right pulmonary veins drained into the superior vena cava and in 3, a pulmonary venous branch drained into the superior vena cava. The median follow-up was 6.9 years (0.8-13 years). Three patients underwent reoperation for postoperative pulmonary venous obstruction caused by intimal hypertrophy; however, we confirmed no pulmonary venous obstruction caused by 3D deformities on the pulmonary venous branches connecting separately to the superior vena cava. Although 2 patients were effectively relieved from pulmonary venous obstruction, 1 died due to recurrent pulmonary venous obstruction. There was no late death and no sinus-node dysfunction. Eight patients underwent successful Fontan operation and catheterization. The median interval from the Fontan operation to the latest catheterization was 3.7 years (0.9-3.7 years). The median arterial oxygen saturation was 94% (91-97%) and the central venous pressure was 12 mmHg (8-14 mmHg); no deficiency of pulmonary arteries and veins was noted. CONCLUSIONS: For patients with functional single ventricle and anomalous pulmonary venous connections to the superior vena cava, our novel strategy of second-stage palliation could avoid postoperative pulmonary venous obstruction caused by 3D deformities, but may not eliminate pulmonary venous obstruction caused by intimal hypertrophy.

Experimental use of crosslinked gelatin glue for arterial hemostasis in cardiovascular surgery.

BACKGROUND: Anastomotic needle hole bleeding is a frequently encountered problem in cardiovascular surgeries. OBJECTIVE: To examine the feasibility of crosslinked gelatin glue as an anastomotic needle hole sealant in comparison with fibrin glue. METHODS: The in vitro burst water pressures were measured for gelatin and fibrin glue sealed needle holes of expanded polytetrafluoroethylene (ePTFE) or collagen coated woven polyester grafts. For in vivo investigations, abdominal aorta-ePTFE graft anastomoses of heparinized beagle dogs were sealed by gelatin or fibrin glue and hemostatic efficacy was judged. The implanted sites were re-examined 4 weeks postoperatively. RESULTS: The in vitro burst water pressures of gelatin glue sealed needle holes of both grafts were higher than those sealed by fibrin glue. For in vivo canine studies, hemostasis was successful for all gelatin glue applied suture lines, but not two out of three fibrin glue treated sites when 3-0 polypropylene suture was employed. Although adhesions of surrounding tissues were intense for all sites 4 weeks postoperatively, inflammation was more severe for the fibrin glue group compared to those of gelatin glue. CONCLUSIONS: Gelatin glue was found to be an effective and safe sealant for accomplishing hemostasis of anastomotic needle holes of vascular grafts.