Comparative analysis of the effectiveness of coarctation surgery between neonates and infants.

OBJECTIVE: This study aimed to compare the effectiveness of resection and extended end-to-end anastomosis between neonate and infant patients with coarctation. METHODS: This study was designed retrospectively and included 41 neonate (<30 days) and infant (30 days to 1 year) patients who were operated on using the resection and extended end-to-end anastomosis technique for aortic coarctation. Preoperative aortic annulus diameters and Z scores, all aortic arch diameters and Z scores, the presence of hypoplastic aortic segment, and the presence of prematurity were reviewed in both groups. Subsequently, we investigated whether these parameters were statistically related to the residual gradient in the operation area, whether there was a need for early re-intervention, and what was the incidence of mortality in the early postoperative period. In addition, the aortic arch Z scores of the patients at 6 months postoperatively were examined. RESULTS: While the mean age (p<0.001), body weight (p<0.001), and proximal arch Z score (p=0.029) were found to be significantly lower in the neonate group than in the infant group, the total length of the intensive care unit stay (p=0.013) and the total length of hospital stay (p=0.017) were found to be significantly higher. In addition, significant enlargement was detected in the proximal arch, distal arch, and isthmus segments in both patient groups. CONCLUSION: The resection and extended end-to-end anastomosis is an equally effective technique that can provide a marked decrease in gradient in the coarctation area and a significant enlargement of the aortic arch segments in the early period after coarctation repair in both neonate and infant patients.

Comparative Analysis of Modified BT Shunt and Central Shunt in Pediatric Patients.

INTRODUCTION: Cyanotic congenital heart diseases constitute 40-45% of all congenital heart diseases. In patients who are not suitable for primary repair, modified BT (MBT) shunt and central shunt (CS) procedures are still frequently used. METHODS: This study included 62 pediatric patients who underwent MBT shunt or CS via median sternotomy. Patients' demographic, echocardiographic, operative, and postoperative data were collected retrospectively. The patients were classified as single ventricle and bi-ventricle according to their cardiac anatomy, and the presence of prematurity and heterotaxy was noted. Procedure details of the patients who underwent endovascular intervention prior to the surgery were investigated, and operation data were accessed from the surgery notes. Data regarding postoperative follow-ups were obtained and comparatively analyzed. RESULTS: Of the total 62 patients, 32 (51.6%) were newborns and 16 (25.8%) had a body weight < 3 kg. MBT shunt was applied to 48 patients (77.4%), while CS was applied to 14 patients (22.6%). There was no significant difference between the two surgical procedures in terms of requirement for urgent shunt or cardiopulmonary bypass, additional simultaneous surgical intervention, need for high postoperative inotropes, and in-hospital mortality (P>0.05). The rate of congestive heart failure in patients with in-hospital mortality was determined as 66.7% and it was significantly higher than in patients without heart failure (P<0.001). CONCLUSION: MBT shunt and CS are still frequently used in cyanotic patients. The use of small-diameter shunts, particularly when centrally located, can prevent the onset of congestive heart failure and lower mortality.

Comparative analysis of the effectiveness of coarctation surgery between neonates and infants

SUMMARY OBJECTIVE: This study aimed to compare the effectiveness of resection and extended end-to-end anastomosis between neonate and infant patients with coarctation. METHODS: This study was designed retrospectively and included 41 neonate (<30 days) and infant (30 days to 1 year) patients who were operated on using the resection and extended end-to-end anastomosis technique for aortic coarctation. Preoperative aortic annulus diameters and Z scores, all aortic arch diameters and Z scores, the presence of hypoplastic aortic segment, and the presence of prematurity were reviewed in both groups. Subsequently, we investigated whether these parameters were statistically related to the residual gradient in the operation area, whether there was a need for early re-intervention, and what was the incidence of mortality in the early postoperative period. In addition, the aortic arch Z scores of the patients at 6 months postoperatively were examined. RESULTS: While the mean age (p<0.001), body weight (p<0.001), and proximal arch Z score (p=0.029) were found to be significantly lower in the neonate group than in the infant group, the total length of the intensive care unit stay (p=0.013) and the total length of hospital stay (p=0.017) were found to be significantly higher. In addition, significant enlargement was detected in the proximal arch, distal arch, and isthmus segments in both patient groups. CONCLUSION: The resection and extended end-to-end anastomosis is an equally effective technique that can provide a marked decrease in gradient in the coarctation area and a significant enlargement of the aortic arch segments in the early period after coarctation repair in both neonate and infant patients.

Comparative Analysis of Modified BT Shunt and Central Shunt in Pediatric Patients

ABSTRACT Introduction: Cyanotic congenital heart diseases constitute 40-45% of all congenital heart diseases. In patients who are not suitable for primary repair, modified BT (MBT) shunt and central shunt (CS) procedures are still frequently used. Methods: This study included 62 pediatric patients who underwent MBT shunt or CS via median sternotomy. Patients' demographic, echocardiographic, operative, and postoperative data were collected retrospectively. The patients were classified as single ventricle and bi-ventricle according to their cardiac anatomy, and the presence of prematurity and heterotaxy was noted. Procedure details of the patients who underwent endovascular intervention prior to the surgery were investigated, and operation data were accessed from the surgery notes. Data regarding postoperative follow-ups were obtained and comparatively analyzed. Results: Of the total 62 patients, 32 (51.6%) were newborns and 16 (25.8%) had a body weight < 3 kg. MBT shunt was applied to 48 patients (77.4%), while CS was applied to 14 patients (22.6%). There was no significant difference between the two surgical procedures in terms of requirement for urgent shunt or cardiopulmonary bypass, additional simultaneous surgical intervention, need for high postoperative inotropes, and in-hospital mortality (P>0.05). The rate of congestive heart failure in patients with in-hospital mortality was determined as 66.7% and it was significantly higher than in patients without heart failure (P<0.001). Conclusion: MBT shunt and CS are still frequently used in cyanotic patients. The use of small-diameter shunts, particularly when centrally located, can prevent the onset of congestive heart failure and lower mortality.

Tetralogy of Fallot with double aortic arch and aortopulmonary window: a very rare trifecta.

Tetralogy of Fallot with an aortopulmonary window and double aortic arch is very rare. This complex coexistence may be over a wide clinical spectrum. Herein, we present an asymptomatic 8-day-old infant who was diagnosed as having tetralogy of Fallot, double aortic arch, and an aortopulmonary window using transthoracic echocardiography while being examined for microcephaly.

The anomalous drainage of the inferior vena cava into the left atrium.

BACKGROUND: Anomalies in systemic venous return most commonly involve a persistent left supe-rior vena cava draining into the left atrium. Anomalous drainage of the inferior vena cava (IVC) into the left atrium is a rare congenital vascular disorder. The diagnosis was confirmed as anoma-lous drainage of the right superior pulmonary vein and large atrial septal defect following echo-cardiography. Anomalous drainage of the inferior vena cave was confirmed with computed tomog-raphy (CT). We report a rare combination of drainage of the inferior vena cava associated with atrial septal defect (ASD) and partial anomalous pulmonary venous return. CASE: A 14-year-old girl was referred to our hospital for the evaluation of palpitations, hypoxia, exertional dyspnea, and cyanosis. Transthoracic echocardiography (TTE) revealed a large sinus venosus ASD and anomalous right superior pulmonary venous return. A cardiac CT demonstrated IVC drainage to the left atrium and an anomalous right superior pulmonary vein draining into the right atrium. CONCLUSIONS: In older patients with cyanosis, further imaging methods together with TTE will be useful in detecting additional cardiac anomalies. Patients with inferior vena cava opening to the left atrium are different from caval type ASD`s and should be surgically repaired using a patch. Corrective surgery involves repositioning of the interatrial septum via a patch.

Can Right Infra-Axillary Vertical Thoracotomy Make a Big Difference in Surgical Technique Preference?

AIM: Minimally invasive techniques in the surgical treatment of congenital heart diseases have gained popularity recently. Right infra-axillary vertical thoracotomy (RIAVT) is one of these techniques. The aim of this study is to investigate the postoperative morbidity and cosmetic results of the right infraaxillary thoracotomy technique and compare them with the results in the literature. METHOD: All patients who had undergone cardiac surgery using RIAVT at the Ankara City Hospital Pediatric Cardiovascular Surgery Clinic between 2019 and 2021 were enrolled in the study. Preoperative echocardiographic diagnoses, intraoperative surgical data and postoperative morbidity data of the patients was obtained. In addition, surgical incision length was measured and recorded for the evaluation of cosmetic outcome. This data was then compared with data from similar studies in the literature. RESULT: Between January 2019 and December 2021, 59 patients were operated on using RIAVT. Of the RIAVT patients, 45 (76%) were female and 14 (24%) were male. The mean weight of the patients was 22.38±12.48 kg. Although the youngest patient was a 5-month-old infant weighing 4 kg, the oldest one was 15-years-old weighing 57 kg. Isolated secundum atrial septal defect (ASD) repair (primary or patch) was performed in 47 patients. One (1) patient with Primum ASD and mitral cleft, 1 patient with secundum ASD and perimembranous ventricular septal defect (VSD) repair, nine patients with high venosum ASD and PAPVC, and one patient with a discrete subaortic membrane were operated on. The surgical incision length was between 4 to 5 cm. CONCLUSION: RIAVT is an important surgical alternative to median sternotomy in selected cases with certain pathologies. It can be performed safely in various congenital heart anomalies and provides excellent functional and cosmetic results in the long-term when compared to other surgical methods.

Ascending aortic pseudoaneurysm following Norwood Stage 1 surgery in an infant.

Pseudoaneurysms of the ascending aorta are rarely seen in paediatric patients. They may occur following complex cardiovascular surgery and are associated with a high risk of mortality due to their nature of spontaneous rupture. In this case report, we discuss a 1-year-old paediatric patient with an ascending aortic pseudoaneurysm following Norwood Stage 1 surgery with Sano modification for hypoplastic left heart syndrome and the patient's successful recovery following aneurysmectomy with Norwood Stage 2 operation.

Cost-effectiveness analysis of radiobasilic and brachiobasilic arteriovenous fistulas in hemodialysis patients.

We evaluated the cost and efficacy of radiobasilic and brachiobasilic arteriovenous fistula (AVF) methods in terms of forearm autogenous arteriovenous access in hemodialysis patients. We used a decision tree to compare the cost-effectiveness of proximal radiobasilic AVF (pRBAVF) and brachiobasilic AVF (BBAVF), considering the mean direct medical costs and patency rates. The overall mean cost of pRBAVF per patient (1767.59 Turkish lira [TL]) was lower than that of BBAVF (1877.99 TL). Also, the mean patency duration per patient was higher for pRBAVF (25.72 months) than BBAVF (20.21 months). The incremental cost-effectiveness ratio (ICER) showed that pRBAVF was 20.04-fold more effective than BBAVF. The monthly ICERs also favored pRBAVF, which was less costly and more effective. The pRBAVF provided clinical and economic benefits for hemodialysis patients requiring forearm autogenous arteriovenous access. pRBAVF was more effective in terms of patency than BBAVF, and was also less expensive.

A comparison of two different management plans for patients requiring both carotid endarterectomy and coronary artery bypass grafting.

BACKGROUND: Carotid endarterectomy (CEA) is a prophylactic operation that is used to mitigate the risk of stroke caused by embolism of atherosclerotic plaques in the carotid bifurcation. Previously, the large, multicentre, randomised, controlled GALA study found no significant differences in clinical outcomes between patients treated using general or local anaesthesia. While this study provided important insights into disease outcomes based on treatment modalities, it did not answer questions regarding the safety of CEA under local anaesthesia in patients at high risk for cardiovascular complications. Here, we examined the use of two different management plans in patients requiring both carotid endarterectomy and coronary artery bypass grafting (CABG), in terms of their effects on hospital mortality. METHODS: Thirty-four patients consecutively operated on in our cardiovascular department were included in this analysis. The patients were divided into two groups based on the anaesthetic management plan. The first group consisted of patients who underwent CEA and CABG under general anaesthesia in the same session (GA group); the second group consisted of patients who initially underwent CEA under cervical block anaesthesia followed by CABG under general anaesthesia in a separate session (CB-GA group). These two groups were compared in terms of postoperative complications and hospital mortality. RESULTS: The incidence of postoperative myocardial infarction was higher in the CB-GA group, with four patients experiencing postoperative myocardial infarction, compared to no patients in the GA group. CONCLUSIONS: For patients requiring CEA and CABG, performing both operations under general anaesthesia in the same session was safer than initially performing CEA under cervical block anaesthesia followed by CABG under general anaesthesia.

Midterm results of salvage surgery for autogenous dialysis access in aneurysmal arteriovenous fistulas.

Autologous arteriovenous fistulas are commonly constructed in patients undergoing hemodialysis for end-stage renal disease. However, they are associated with a high rate of aneurysm formation, and aneurysmal arteriovenous fistulas that have become symptomatic require surgical intervention. This study was performed to evaluate the midterm results of salvage surgery for autogenous dialysis access in patients with aneurysmal arteriovenous fistulas. Of 1326 arteriovenous fistula operations, 81 involving surgery for aneurysmal arteriovenous fistulas between January 2008 and January 2012 were included in this study. The database was searched to identify all complicated arteriovenous fistula patients undergoing surgery for vascular access. The number of complicated arteriovenous fistula surgeries, for example for aneurysms, was greater than the number of patients undergoing surgery to create a new arteriovenous fistula. We performed three different surgical procedures to treat arteriovenous-related aneurysms in our clinic: primary repair, resection and saphenous vein interposition, and resection and polytetrafluoroethylene (PTFE) interposition. We compared the patency rates at the 12- and 24-month follow-ups among these three techniques. The study population consisted of 24 cases of primary repair, 29 cases of resection and saphenous vein interposition, and 30 cases of resection and PTFE graft interposition. True aneurysms occurring in patients undergoing hemodialysis did not require treatment unless they were symptomatic. Arteriovenous access salvage therapy is recommended after the aneurysm has become symptomatic. Symptomatic arteriovenous fistula aneurysms can be treated by maintaining arteriovenous fistula continuity. Moreover, patient safety is ensured by long-term patency.

Management of congenital cardiac surgery during COVID-19 pandemic.

The new coronavirus infection, which was first seen in China in late December, 2019 and eventually became a worldwide pandemic, poses a serious threat to public health. After a high spike in the number of new COVID-19 infection cases following the increase in overall daily death toll in Turkey, Turkish Ministry of Health has taken immediate precautions to postpone elective surgeries in order to reduce the burden to the healthcare system which might be challenged. Whereas different areas of medicine were able to suspend their operative procedures during this period, this was not completely possible in paediatric cardiovascular surgery due to the severity and urgency of congenital heart disease patients requiring operation. Based on the guideline that was published by the Turkish Paediatric Cardiology and Cardiac Surgery Association, in which the patients requiring surgical intervention during the COVID-19 pandemic period are ranked according to the priority, directions were given regarding the operations that hereby, be delayed, we report our experience in 29 cases retrospectively, regarding the pre-operative evaluation of these patients, makings of an emergency operation decision, and strategies taken about intra-operative and post-operative management and arrangements during the pandemic period. In this article, we present crucial precautions that were applied in paediatric cardiovascular surgery and extensive list of cases in order to deliver highest level of the patient safety and protection for the surgical team.

Pentamidine in Pneumocystis jirovecii prophylaxis in heart transplant recipients.

Despite advances in transplantation techniques and the quality of post-transplantation care, opportunistic infections remain an important cause of complications. Pneumocystis jirovecii (P. jirovecii) is an opportunistic organism, represents an important cause of infections in heart transplantation patients. Almost 2% to 10% of patients undergoing cardiac transplantation have Pneumocystis pneumonia. Prophylaxis is essential after surgery. Various prophylaxis regimes had been defined in past and have different advantages. Trimethoprim/sulfamethoxazole (TMP/SMX) has a key role in prophylaxis against P. jirovecii. Generally, although TMP/SMX is well tolerated, serious side effects have also been reported during its use. Pentamidine is an alternative prophylaxis agent when TMP/SMX cannot be tolerated by the patient. Structurally, pentamidine is an aromatic diamidine compound with antiprotozoal activity. Since it is not effectively absorbed from the gastrointestinal tract, it is frequently administered via the intravenous route. Pentamidine can alternatively be administered through inhalation at a monthly dose in heart transplant recipients. Although, the efficiency and safety of this drug is well studied in other types of solid organ transplantations, there are only few data about pentamidine usage in heart transplantation. We sought to evaluate evidence-based assessment of the use of pentamidine against P. jirovecii after heart transplantation.

Radiobasilic Versus Brachiobasilic Transposition on the Upper Arm to Avoid Steal Syndrome.

BACKGROUND: Although the proximal radial artery has been reported as an alternative inflow to prevent steal syndrome, brachiobasilic fistula has been reported to be associated with steal syndrome in 10-20% of cases. We aimed to compare proximal radiobasilic arteriovenous fistula (AVF) with brachiobasilic AVFs on the upper arm in terms of steal syndrome and outcomes. MATERIAL AND METHODS: We used our institutional operative record database to identify 94 patients in whom brachiobasilic AVF (n=40) and radiobasilic AVF (n=54) were placed between January 2009 and December 2013. Postoperative complications such as steal syndrome, venous hypertension, and aneurysm were recorded. RESULTS: Steal syndrome was determined to occur less frequently in the radiobasilic AVF group (0% vs. 10%, P=0.03). The rates of other complications (bleeding, aneurysm, venous hypertension) between the 2 groups were similar, as were the patency rates. CONCLUSIONS: Radiobasilic AVF was effective in reducing steal syndrome, with similar early and late outcomes.

Regional cervical plexus blockage for carotid endarterectomy in patients with cardiovascular risk factors.

BACKGROUND: Carotid artery disease is not rare in cardiac patients. Patients with cardiac risk factors and carotid stenosis are prone to neurological and cardiovascular complications. With cardiac risk factors, carotid endarterectomy operation becomes challenging. Regional anesthesia is an alternative option, so we aimed to investigate the operative results of carotid endarterectomy operations under regional anesthesia in patients with cardiac risk factors. METHODS: We aimed to analyze and compare outcomes of carotid endarterectomy under regional anesthesia with cardiovascular risk groups retrospectively. Between 2006 and 2014, we applied 129 carotid endarterectomy ± patch plasty to 126 patients under combined cervical plexus block anesthesia. Patients were divided into three groups (high, moderate, low) according to their cardiovascular risks. Neurological and cardiovascular events after carotid endarterectomy were compared. RESULTS: Cerebrovascular accident was seen in 7 patients (5.55%) but there was no significant difference between groups (P > .05). Mortality rate was 4.76% (n = 6); it was higher in the high risk group and was not statistically significant (P = .180). Four patients required revision for bleeding (3.17%). We did not observe any postoperative surgical infection. CONCLUSION: Carotid endarterectomy can be safely performed with regional cervical anesthesia in all cardiovascular risk groups. Comprehensive studies comparing general anesthesia and regional anesthesia are needed.

Surgical treatment of post-infarct left ventricular pseudoaneurysm with on-pump beating heart technique.

Left ventricular pseudo-aneurysms develop when cardiac rupture is contained by pericardial adhesions or scar tissue due to myocardial infarction, surgery, trauma or infection. Left ventricular pseudo-aneurysms are uncommon, difficult to diagnose and prone to cardiac rupture. Urgent surgical repair is recommended. Here we report on a case of a large left ventricular pseudo-aneurysm on the anterolateral wall due to a previous anterior myocardial infarction, and its successful repair using the on-pump beating-heart technique.

Hybrid endovascular repair of thoracoabdominal aorta: early results.

BACKGROUND: Thoracoabdominal aortic aneurysms (TAAA) present a significant clinical challenge, as they are complex and require invasive surgery. In an attempt to prevent considerably high mortality and morbidity in open repair, hybrid endovascular repair has been developed by many authors. In this study, we evaluated the early-term results obtained from this procedure. METHODS: From November 2010 to February 2013, we performed thoracoabdominal hybrid aortic repair in 18 patients. The mean age was 68 years (12 men, 6 women). All of the patients had significant comorbidities. Follow-up computed tomography (CT) scans were performed at 1 week, 3 months, 6 months, and annually thereafter. RESULTS: All patients were operated on in a staged procedure and stent graft deployment was achieved. Procedural success was achieved in all cases. All patients were discharged with complete recovery. No endoleaks weres detected in further CT examination. CONCLUSION: Our results suggests that hybrid debranching and endovascular repair of extensive thoracoabdominal aneurysms represents a suitable therapeutic option to reduce the morbidity and mortality of TAAA repair, particularly in those typically considered at high risk for standard repair.

Validation of EuroSCORE II risk model for coronary artery bypass surgery in high-risk patients.

INTRODUCTION: Determining operative mortality risk is mandatory for adult cardiac surgery. Patients should be informed about the operative risk before surgery. There are some risk scoring systems that compare and standardize the results of the operations. These scoring systems needed to be updated recently, which resulted in the development of EuroSCORE II. In this study, we aimed to validate EuroSCORE II by comparing it with the original EuroSCORE risk scoring system in a group of high-risk octogenarian patients who underwent coronary artery bypass grafting (CABG). MATERIAL AND METHODS: The present study included only high-risk octogenarian patients who underwent isolated coronary artery bypass grafting in our center between January 2000 and January 2010. Redo procedures and concomitant procedures were excluded. We compared observed mortality with expected mortality predicted by EuroSCORE (logistic) and EuroSCORE II scoring systems. RESULTS: We considered 105 CABG operations performed in octogenarian patients between January 2000 and January 2010. The mean age of the patients was 81.43 ± 2.21 years (80-89 years). Thirty-nine (37.1%) of them were female. The two scales showed good discriminative capacity in the global patient sample, with the AUC (area under the curve) being higher for EuroSCORE II (AUC 0.772, 95% CI: 0.673-0.872). The goodness of fit was good for both scales. CONCLUSIONS: We conclude that EuroSCORE II has better AUC (area under the ROC curve) compared to the original EuroSCORE, but both scales showed good discriminative capacity and goodness of fit in octogenarian patients undergoing isolated coronary artery bypass grafting.

Single-stage aortic valve-sparing root replacement and extra-anatomic bypass for aortic arch interruption in an adult.

We describe the treatment of an extremely rare case of interrupted aortic arch, annuloaortic ectasia, and aortic regurgitation in a 34-year-old man who presented with dyspnea and palpitation. We performed a single-stage operation involving aortic root reconstruction and valve repair with concomitant extra-anatomic bypass from the ascending to the descending aorta with a Dacron tube graft. The patient made a full recovery. To the best of our knowledge, this is the first such report in the English medical literature.