Impact of right ventriculotomy on cardiac function after pulmonary valve sparing repair of tetralogy of Fallot and double outlet right ventricle with pulmonary stenosis.

OBJECTIVES: Pulmonary valve-sparing repair of tetralogy of Fallot and double outlet right ventricle with pulmonary stenosis has the advantage of reduced incidence of late pulmonary valve regurgitation and better-preserved cardiac function. However, a right ventriculotomy is sometimes necessary in order to adequately relieve subvalvular pulmonary stenosis. We aimed to compare postoperative cardiac function and patients' symptoms between pulmonary valve-sparing repair with and without right ventriculotomy. MATERIALS AND METHODS: We retrospectively collected data from electronic medical records of Ramathibodi Hospital from 1st January 2013 to 31st October 2023. Patients diagnosed with tetralogy of Fallot and double outlet right ventricle with pulmonary stenosis who underwent pulmonary valve-sparing repair were included. Patients who underwent other types of repairs and whose medical record data were significantly missing were excluded. Demographic data, operative, and postoperative details were collected and reviewed. RESULTS: There were 49 patients included in our study with 10 patients undergoing pulmonary valve-sparing repair with and the other 39 without right ventriculotomy. Before-discharge echocardiographic parameters were generally similar between both groups (tricuspid annular plane systolic excursion = 0.9 versus 0.89 cm, P = 0.737; pressure gradient across pulmonary valve across pulmonary valve = 24 versus 19 mmHg, P = 0.275; left ventricular end-systolic volume index = 17.84 versus 19.19 ml/m2, P = 0.437; left ventricular end-diastolic volume index = 63.79 versus 61.13 ml/m2, P = 0.436). Patients' symptoms were also not statistically different. There was no early and late death up to the end date of our study. CONCLUSIONS: Right ventriculotomy in pulmonary valve-sparing repair did not result in worse postoperative cardiac function and symptoms. This suggested that the previously thought-to-be hazardous incision could be strongly considered if mandated.

Heterotopically-placed right ventricle-to-pulmonary artery conduit does not negatively affect outcomes.

OBJECTIVES: Since the introduction of surgical implantation of conduit for right ventricle-to-pulmonary artery pathway reconstruction, there has been a number of studies on possible factors which might potentially affect conduit longevity, as well as patient's reintervention-free and overall survival. Still, no definite consensual agreement could be made thus far. We aimed to compare conduit longevity, reintervention-free survival, and overall survival between patients with congenital heart diseases indicated for operations involving right ventricle-to-pulmonary artery pathway reconstruction whose conduits were placed heterotopically to those with orthotopically placed ones. MATERIALS AND METHODS: We retrospectively collected data from electronic medical records of Ramathibodi hospital from 1st January 2005 to 31st December 2022. Patients with congenital heart diseases whose operations involved reconstruction of right ventricle-to-pulmonary artery continuity were included. Patients whose medical record data were significantly missing were excluded. Demographic data, operative, and postoperative details were collected and reviewed. RESULTS: There were 67 patients included in our study, with 25 receiving orthotopic and the other 42 receiving heterotopic conduit implantation. Conduit dysfunction-free, reintervention-free, and overall survival were not statistically different between both groups. There was 1 early and no late death up to the end date of our study. CONCLUSIONS: Conduits placed on a heterotopic position did not result in worse longevity, reintervention-free survival, as well as overall survival when compared to conduits placed on an orthotopic position. This suggested that the less technically demanding heterotopic conduit placement could be recommended as an operation of choice for right ventricular outflow tract reconstruction.

Comparison of renal function between cyanotic and acyanotic congenital heart disease in children and adolescent.

BACKGROUND: Glomerular and tubular dysfunction can be found in congenital heart disease (CHD) especially in older children and adults. OBJECTIVE: To evaluate the prevalence renal dysfunction and to compare glomerular and tubular function between cyanotic and acyanotic CHD in children and adolescent. Correlations among clinicalfactors, urinary glomerular and tubular markers for kidney injury were also determined. MATERIAL AND METHOD: Renal function was determined by estimated glomerular filtration rate, urine protein/creatinine, urine microalbumin/creatinine, FE Na+, FE Mg2, and urine NAG/creatinine in children and adolescent with CHD. RESULTS: Forty-six patients, 15 cyanotic (group 1), and 31 acyanotic CHD (group 2), were studied. Only the differences of urine NAG/creatinine (median, 3.59 vs. 1.64 unit/gram creatinine; p = 0.008), FE Mg2+ (mean, 5.03 +/- 3.61% vs. 2.48 +/- 1.8%; p = 0.019), and urine protein/creatinine between the two groups were statistically significant (0.16 vs. 0.08; p = 0.001). No significant differences of clinical features, BUN, creatinine, eGFR, diastolic blood pressure, FE Na+, and urine microalbumin/creatinine were found between the two groups. Significantly higher prevalence ofabnormal biochemical markers in group 1 compared to those of group 2:86.6% vs. 43.38% (p = 0.02) for FE Mg2+; 46.6% vs. 9.67% (p = 0.008) for urine NAG/creatinine; 46.6% vs. 6.45% for significant proteinuria (p = 0.003); and 40% and 9.67% (p = 0.042) for microalbuminuria, respectively. The authors found moderate correlation between hemoglobin and functional class of the patients (r = 0.58) and highly negative correlation between oxygen saturation and functional class (r = -0.716). The relationships among other clinical or biochemical makers showed only low correlations. CONCLUSION: Cyanotic CHD patients had more prevalence and higher abnormal biochemical markers for renal dysfunction than those of acyanotic CHD. Their urine protein/creatinine, FE Mg2 and urine NAG/creatinine were higher than those of acyanotic CHD. Only low correlation among biochemical markers was found

Overall 5-year survival rate and disease-free survival after segmentectomy versus lobectomy in patients with non-small cell lung cancer.

Objectives: Anatomical lobectomy has always been the standard operative treatment of early-stage non-small cell lung cancer. However, there have been emerging evidences suggesting that a subanatomical resection, such as segmentectomy, may yield the same treatment results, even in patients with higher-stage non-small cell lung cancer. This study aimed to compare overall 5-year survival rate and disease-free survival between lobectomy and segmentectomy in patients with non-small cell lung cancer. Methods: The retrospective study included 380 patients who underwent surgery for non-small cell lung cancer at Ramathibodi Hospital between 1st January 2016 and 31st December 2020. Of 380 patients, 307 patients underwent lobectomy, while the other 73 patients underwent segmentectomy. Operative, admission, and follow-up data were collected from electronic medical records. Missing data were collected by telephone calls to patients or their relatives in deceased cases. Overall and disease-free survival were analyzed. Results: Median overall 5-year survival time after lobectomy and segmentectomy seemed to be different but not statistically significant (18.5 months versus 5.8 months, p = 0.127). Median disease-free survival time after lobectomy and segmentectomy was also similar (8.6 months versus 4.5 months, p = 0.511). Two deaths occurred during perioperative period, one from lobectomy group due to acute massive pulmonary embolism (0.3%) and the other from segmentectomy group due to acute exacerbation of chronic obstructive pulmonary disease with respiratory failure (1.4%). Conclusion: Lobectomy and segmentectomy result in similar overall 5-year survival rate and disease-free survival between these two comparison groups. Therefore, segmentectomy may be a potential alternative for operative treatment of non-small cell lung cancer. However, a larger and randomized-controlled trial may be needed to further validate these results.

Clinical Characteristics and Outcomes of Children With Extracorporeal Membrane Oxygenation in a Developing Country: An 11-Year Single-Center Experience.

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a lifesaving procedure for patients with refractory cardiac or respiratory failure. The indications for ECMO are growing, and it is increasingly being used to support cardiopulmonary failure in children. However, the risks and benefits of ECMO should be weighed before deploying it on the patients. The objectives of this study were to identify the mortality risk factors and to determine the ECMO outcomes. Methods: The retrospective chart reviews were done for all patients aged 1 day-20 years old receiving ECMO between January 2010 and December 2020. Results: Seventy patients were enrolled in the study. The median age was 31.3 months. The incidence of VA and VV ECMO was 85.7 and 14.3%, respectively. The most common indication for ECMO was the failure to wean off cardiopulmonary bypass after cardiac surgery. Pre-existing acute kidney injury (OR 4.23; 95% CI 1.34-13.32, p = 0.014) and delayed enteral feeding (OR 3.85, 95% CI 1.23-12.02, p = 0.020), and coagulopathy (OD 12.64; 95% CI 1.13-141.13, p = 0.039) were associated with the higher rate of mortality. The rates of ECMO survival and survival to discharge were 70 and 50%, respectively. Conclusion: ECMO is the lifesaving tool for critically ill pediatric patients. Pre-existing acute kidney injury, delayed enteral feeding, and coagulopathy were the potential risk factors associated with poor outcomes in children receiving ECMO. However, ECMO setup can be done successfully in a developing country.

Magnetic resonance imaging assessment of aortic dilatation and distensibility in 269 patients with repaired tetralogy of Fallot.

PURPOSE: To determine the prevalence and degree of aortic dilatation (Adilatation), severity of aortic stiffness (Astiff), factors for Adilatation, and level of aortic root most sensitive to Astiff in patients with repaired tetralogy of Fallot (rTOF). MATERIALS AND METHODS: 269 patients with rTOF (mean age 14.9 ± standard deviation 5.0 years) were analyzed for Adilatation at annulus, sinus, sinotubular junction, and ascending aorta (aAo). Aortic size index was graded as Z score < 2, 2-2.99, 3-4.99 and ≥ 5. Aortic distensibility (aAdis) was categorized according to 4 aortic levels and dilatation severity. Factors for Adilatation and level of aortic root most sensitive to Astiff were analyzed. RESULTS: Sinus and aAo were the two most common sites of Adilatation, with a prevalence of 84% and 76%, respectively. A decreased aAdis was found (mean 5.38 ± 1.79 10-3 mmHg-1). aAdis only declined significantly at the sinus level (p = 0.009). Male sex, age-at-repair and aortic regurgitation were significant factors for Adilatation, with male sex as the strongest factor (odds ratio 2.94). There was a significant decline in aAdis at sinus level (p = 0.002) as Adilatation progressed. CONCLUSIONS: We observed a high prevalence of Adilatation and Astiff in patients with rTOF. Male sex is the strongest factor for Adilatation. The sinus is the most sensitive area for determining a negative aAdis effect.

Follow-up aortic dilatation in patients with repaired tetralogy of Fallot using cardiovascular magnetic resonance.

PURPOSE: The study sought to determine the rate of aortic expansion and correlation with somatic growth in patients with repaired tetralogy of Fallot (rTOF), and predictors for determining the annual growth rate of the aorta (Ao-AGR). METHODS: Ninety-four rTOF patients (mean age 14.5 ± 4.4 years) with two cardiac magnetic resonance tests (CMR) (median duration 52 months, interquartile range, IQR 24-71) were analyzed for aortic diameter (AoD) at the annulus, the sinus of Valsalva (SoV), the sinotubular junction, and the ascending aorta (AAo), and compared with the normal limit AoD (NL-AoD) values. The median age-at-repair was 60 months (IQR 36-84). Ao-AGR and its index (Ao-AGRI) were derived from changes of the AoD and AoD-index, respectively, divided by the duration between the two studies. Three potential predictors (baseline AoD, sex, and age-at-repair) for the progression of Ao-AGR were analyzed. RESULTS: There was a significant larger AoD than NL-AoD (p < 0.001). Slow aortic growth was encountered in 78-85 % of patients. The Ao-AGR was slow, the median AGR ranged from 0.37 mm (IQR 0.13-0.72) at annulus to 0.56 mm (IQR 0.22-0.91) at AAo. There was a regression in Ao-AGRI, ranged from -1.41 mm (IQR -1.94, -0.87) at annulus to -2.36 mm (IQR -3.09, -1.63) at SoV. The three predictors were not correlated with severity of Ao-AGR. CONCLUSION: Most adolescents with rTOF show significant aortic dilatation. There is a slow Ao-AGR with regression of Ao-AGRI, which may suggest that the rate of aortic growth is slower than the somatic growth. There are no significant predictors of the progression of Ao-AGR.

Transcatheter tricuspid valve-in-valve implantation for degenerative surgical bio-prosthesis using SAPIEN 3: A case series.

We evaluated early outcomes of transcatheter valve-in-valve (ViV) implantation in patients with degenerated bio-prosthesis in tricuspid position. Total of 5 patients were included in our case series. Baseline native tricuspid valve etiology were highly varied ranging from chest wall trauma, Ebstein anomaly, rheumatic heart disease, infective endocarditis and complex congenital heart disease. These differences also made patient comorbidities highly varied. Procedure details were also varied due to different clinical and technical challenges. All cases underwent successful Tricuspid VIV implantation with satisfactory hemodynamics results. All patients experienced improved clinical symptoms at follow up.

Current Status of Training and Certification for Congenital Heart Surgery Around the World: Proceedings of the Meetings of the Global Council on Education for Congenital Heart Surgery of the World Society for Pediatric and Congenital Heart Surgery.

The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve the quality of care for patients with Congenital Heart Disease worldwide. The purpose of this article is to summarize and document the present state of training and certification in congenital heart surgery around the world.

Simplified antegrade cerebral perfusion and myocardial protection during stage I Norwood procedure.

Several important modifications have been introduced in the intraoperative management of neonates with hypoplastic left heart syndrome during first-stage palliation. Among these, utilization of selective antegrade cerebral perfusion and interposition of a conduit between the right ventricle and pulmonary artery are currently favored by many centers. We briefly describe our current approach to the modified stage I Norwood procedure.

Aerosolized iloprost for postoperative pulmonary hypertensive crisis in children with congenital heart disease.

INTRODUCTION: Pulmonary hypertensive crisis (PHC) is a significant contributor to the morbidity and mortality of surgery for congenital heart defect. Management of such a potentially fatal complication has been evolving for the past decades. Inhaled iloprost has been reported as an alternative treatment for this condition. We evaluated the use of aerosolized iloprost as a rescue therapy for PHC in children undergoing congenital heart surgery. METHODS: In this clinical study, 12 high risk children were monitored in order to identify postoperative PHC after congenital heart repair. Factors being monitored included pulmonary artery pressure, systemic blood pressure, left atrial pressure, transcutaneous oximetry and heart rate. PHC was defined as an acute rise in pulmonary pressure which causes cardiopulmonary compromise as reflected by desaturation and hypotension. Despite conventional medical treatment to prevent postoperative PHC, children with PHC were therefore administered with aerosolized iloprost (0.5 microg/kg). RESULT: Eight of the 12 children had one or more episodes of PHC, secondary to the pulmonary vasoreactivity. All responded to the aerosolized iloprost treatment, as demonstrated by a fall in their mean pulmonary pressure from 47.9 + or - 14.9 to 30.2 + or - 7.9 mmHg (p=0.012) and a rise in the arterial saturation from 82.2 + or - 16.7 to 93.4 + or - 11.5 % (p=0.012) while mean systemic blood pressure tended to increase from 59.4 + or - 12.1 to 64 + or - 10.3 mmHg (p=0.16). CONCLUSION: In medical setting with limited access to the nitric oxide, inhaled iloprost is consider to be an effective alternative treatment for postoperative PHC in children undergoing congenital heart surgery.

Pacing in preterm with hydrops fetalis due to congenital complete heart block.

Hydrops fetalis due to congenital complete heart block (CCHB) is a rare condition. The outcome of the preterm fetus with hydrops fetalis due to CCHB is poor, and is frequently associated with significant morbidity and mortality. The management of this condition is difficult. We report our experience in a hydropic preterm using staged pacing by applying left ventricular epicardial pacing with a temporary pacemaker and subsequently, left ventricular epicardial pacing with a permanent pacemaker.

Leucocyte depletion in cardiopulmonary bypass: a comparison of four strategies.

Leucocytes have been shown to play a fundamental role in the pathophysiology of inflammation. This prospective, randomized, controlled study was designed to identify the most advantageous leucocyte depletion technique in terms of reduction in systemic inflammatory response syndrome and myocardial ischaemia reperfusion injury associated with cardiopulmonary bypass (CPB). Forty consecutive patients undergoing elective coronary artery bypass graft (CABG) surgery were randomly allocated to one of four groups. The four groups consisted of a control group, a systemic leucocyte depletion (SLD) group, a cardioplegic leucocyte depletion (CLD) group and a total leucocyte depletion (TLD) group. There were 10 patients in each group. Lactoferrin (marker of neutrophil activation) and troponin-I (marker of myocardial ischaemia reperfusion injury) were measured at six time points: post induction, 5 min on CPB, 5 min before releasing the aortic crossclamp, 15 min after releasing the clamp and 1 and 24 hours after the discontinuation of CPB. Plasma lactoferrin levels increased rapidly in every group after the commencement of CPB, subsequently reached a peak after releasing the aortic crossclamp and gradually declined after the discontinuation of CPB. The lowest lactoferrin concentration was observed in the TLD (range 2.15-141.9 ng/mL) and CLD groups (7.469-114.6 ng/mL). Regarding myocardial injury, plasma cardiac troponin-I levels did not differ significantly between groups; but troponin-I concentrations rose dramatically after releasing the aortic crossclamp in all groups. Nevertheless, the CLD group had the lowest troponin-I level (1.37-5.55 ng/mL). In conclusion, it is believed that myocardial ischaemia is probably a major contributor to the inflammatory response. Although there is no clear statistical significance shown in this pilot study, the data tend to support the cardioplegic leucocyte depletion strategy as the optimal method for attenuating neutrophil activation and myocardial ischaemia reperfusion injury.