A Valved Expanded Polytetrafluoroethylene Conduit can Acquire Endothelium After Implantation.

We demonstrate histopathology, neointimal proliferation, and neo-endothelialization in an explanted valved expanded polytetrafluoroethylene (ePTFE) conduit 40 months postimplantation that was void of calcification and inflammation, confirmed by CD-31 positivity on immunohistochemistry. Grossly, there was no distortion with preserved leaflets and lack of calcification. Good biocompatibility, nonreactivity, and low antigenicity, combined with neointimal and endothelial layer generation within the conduit might explain the low infection rates and minimal thrombogenicity. These findings support the use of handmade, valved ePTFE conduits as an economically viable option as a right ventricle to pulmonary artery conduit.

Harlequin effect and central veno-arterial extracorporeal life support.

"Harlequin effect" may be observed in the watershed region of a patient with pulmonary dysfunction, receiving peripheral veno-arterial extracorporeal membrane oxygenation via the femoral vessels. In such cases, retrograde oxygenated blood from the peripheral inflow cannula converges with the antegrade deoxygenated blood ejected from the left ventricle. This occurs when the left ventricle is ejecting significantly but the recovery of pulmonary function lags behind. Herein, we describe the occurrence of "Harlequin effect" in the setting of central veno-arterial extracorporeal membrane oxygenation that ensues due to the persistence of right ventricular dysfunction in the presence of an interatrial communication. This results in right to left shunting at the atrial level while weaning the patient from extracorporeal life support.

The Role of Shunt Occlusion During Extracorporeal Life Support.

INTRODUCTION: The current recommendation for systemic to pulmonary artery shunt (SPS) patients requiring extracorporeal life support (ECLS) is to keep the shunt open, maintaining a higher pump flow. The practice in our center is to totally occlude the shunt while on ECLS, and we are presenting the outcome of this strategy. METHODS: This is a retrospective analysis of patients who underwent SPS for cyanotic congenital heart disease with decreased pulmonary blood flow and required postoperative ECLS between January 2016 and December 2020. ECLS indication was excessive pulmonary blood flow, leading to either refractory low cardiac output syndrome (LCOS) or cardiac arrest. All patients had their shunts totally occluded soon after ECLS establishment. RESULTS: Of the 27 SPS patients who needed postoperative ECLS (13 refractory LCOS, 14 extracorporeal cardiopulmonary resuscitation), wherein the strategy of occluding the shunt on ECLS initiation was followed, 16 (59.3 %) survived ECLS weaning and eight (29.6%) survived to discharge. CONCLUSION: Increased flow to maintain systemic circulation for a SPS patient while on ECLS is an accepted strategy, but it should not be applied universally. A large subset of SPS patients, who require ECLS either due to cardiac arrest or refractory LCOS due to excessive pulmonary flow, might benefit from complete occlusion of the shunt soon after commencement of ECLS, especially in cases with frank pulmonary edema or haemorrhage in the pre-ECLS period. A prospective randomized trial could be ethically justified for the subset of patients receiving ECLS for the indication of excessive pulmonary blood flow.

The Role of Shunt Occlusion During Extracorporeal Life Support

ABSTRACT Introduction: The current recommendation for systemic to pulmonary artery shunt (SPS) patients requiring extracorporeal life support (ECLS) is to keep the shunt open, maintaining a higher pump flow. The practice in our center is to totally occlude the shunt while on ECLS, and we are presenting the outcome of this strategy. Methods: This is a retrospective analysis of patients who underwent SPS for cyanotic congenital heart disease with decreased pulmonary blood flow and required postoperative ECLS between January 2016 and December 2020. ECLS indication was excessive pulmonary blood flow, leading to either refractory low cardiac output syndrome (LCOS) or cardiac arrest. All patients had their shunts totally occluded soon after ECLS establishment. Results: Of the 27 SPS patients who needed postoperative ECLS (13 refractory LCOS, 14 extracorporeal cardiopulmonary resuscitation), wherein the strategy of occluding the shunt on ECLS initiation was followed, 16 (59.3 %) survived ECLS weaning and eight (29.6%) survived to discharge. Conclusion: Increased flow to maintain systemic circulation for a SPS patient while on ECLS is an accepted strategy, but it should not be applied universally. A large subset of SPS patients, who require ECLS either due to cardiac arrest or refractory LCOS due to excessive pulmonary flow, might benefit from complete occlusion of the shunt soon after commencement of ECLS, especially in cases with frank pulmonary edema or haemorrhage in the pre-ECLS period. A prospective randomized trial could be ethically justified for the subset of patients receiving ECLS for the indication of excessive pulmonary blood flow.

Coronavirus disease 2019 convalescent children: outcomes after congenital heart surgery.

BACKGROUND: Children with exposure to coronavirus disease 2019 in recent times (asymptomatic or symptomatic infection) approaching congenital heart surgery programme are in increasing numbers. Understanding outcomes of such children will help risk-stratify and guide optimisation prior to congenital heart surgery. OBJECTIVE: The objective of the present study was to determine whether convalescent coronavirus disease 2019 children undergoing congenital heart surgery have any worse mortality or post-operative outcomes. DESIGN: Consecutive children undergoing congenital heart surgery from Oct 2020 to May 2021 were enrolled after testing for reverse transcription-polymerase chain reaction or rapid antigen test and immunoglobulin G antibody prior to surgery. Convalescent coronavirus disease 2019 was defined in any asymptomatic patient positive for immunoglobulin G antibodies and negative for reverse transcription-polymerase chain reaction or rapid antigen test anytime 6 weeks prior to surgery. Control patients were negative for any of the three tests. Mortality and post-operative outcomes were compared among the groups. RESULTS: One thousand one hundred and twenty-nine consecutive congenital heart surgeries were stratified as convalescence and control. Coronavirus disease 2019 Convalescent (n = 349) and coronavirus disease 2019 control (n = 780) groups were comparable for all demographic and clinical factors except younger and smaller kids in control. Convalescent children had no higher mortality, ventilation duration, ICU and hospital stay, no higher support with extracorporeal membrane oxygenation, high flow nasal cannula, no higher need for re-intubations, re-admissions, and no higher infections as central line-associated bloodstream infection, sternal site infection, and ventilator-associated pneumonia on comparison with coronavirus disease 2019 control children. CONCLUSIONS: Convalescent coronavirus disease 2019 does not have any unfavourable outcomes as compared to coronavirus disease 2019 control children. Positive immunoglobulin G antibody screening prior to surgery is suggestive of convalescence and supports comparable outcomes on par with control peers.

Branch Pulmonary Artery Jailing During Patent Ductus Arteriosus Stenting: Recruitment and Immediate Outcomes.

BACKGROUND: Branch pulmonary artery (PA) occlusion during patent ductus arteriosus (PDA) stenting procedure is the main reason why branch PA origin stenosis was considered as a contraindication for PDA stenting. This study was designed to assess the incidence of branch PA jailing during PDA stenting for cyanotics with duct-dependent pulmonary circulation and its immediate outcome. METHODS: All the completed PDA stenting patients in our hospital between April 2017 and June 2019 were retrospectively analyzed for branch PA jailing and its outcome. RESULTS: Of 63 completed PDA stenting, there was branch PA jailing in 13 (20.6%) patients, all successfully recruited either by strut dilatation or by surgery. The median duration of ventilation was 16 (interquartile range [IQR]: 8-22) hours for jailed patients and 17.5 (IQR: 5.25-34.25) hours for nonjailed patients (P = .978). Median intensive care unit [ICU] stay was 69 (IQR: 47.75-96) hours for jailed patients and 79.5 (IQR: 66.75-135.25) hours for nonjailed patients (P = .394). Procedural mortality was 1 (7.6%) for jailed patients and 3 (6%) for nonjailed patients. Since all the jailed pulmonary arteries were recruited, there was proportionate growth of branch PA till the most recent follow-up. CONCLUSION: Jailing of branch PA does not increase the ventilation duration, ICU stay, or mortality risk if recruited immediately. Proportionate growth of branch PAs can be achieved in spite of jailing, if addressed aggressively. Branch PA stenosis should not be considered as a contraindication for PDA stenting.

Staged Hybrid Approach for Ductal Origin of the Pulmonary Artery in a Low Birth Weight Neonate.

Early recruitment of a discontinuous branch pulmonary artery will give the best long-term outcome for congenitally disconnected pulmonary arteries. This may be achieved using a staged approach. Even in low birth weight neonates, a hybrid approach with the first stage consisting of transcervical (via the common carotid artery) patent ductus arteriosus stenting can be performed to recruit the pulmonary artery where conventional treatment strategies may not be feasible or may be associated with higher risk.

Veno-arterial extracorporeal membrane oxygenation: Special reference for use in 'post-cardiotomy cardiogenic shock' - A review with an Indian perspective.

The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve 'milieu intérieur'. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.

Hybrid approach for aortic embolization of Amplatzer duct occluder.

Embolization of the patent ductus arteriosus (PDA) device is a known adverse event of percutaneous PDA closure, which can lead to complications. Embolization can occur into the pulmonary artery or into the aorta. Device embolization can be moderate adverse event (when retrieved percutaneously) or major adverse event (when retrieved surgically). We are describing a hybrid approach for aortic embolization of PDA device when the percutaneous retrieval fails, where device retrieval and PDA ligation can be done through thoracotomy incision, thus decreasing the complications.

Hybrid Approach for Embolized Right Ventricular Outflow Tract Stent.

Displacement and embolization of the stent is one of the major complications of right ventricular outflow tract (RVOT) stenting. Since embolized stents cannot be retrieved percutaneously as they cannot be crimped into pre-stenting state (unlike duct occluders and septal devices, which can be pulled back into the sheath), surgery remains the gold standard treatment. We describe a hybrid approach for the retrieval of the embolized RVOT stent, which will decrease morbidity when compared to the standard surgical approach that is otherwise required.

Improved Technique for Interventional Extracardiac Fontan.

We have previously reported a simple technique for preparatory staging and subsequent interventional completion of an extracardiac Fontan procedure that anatomically and hemodynamically closely mimics a standard extracardiac Fontan. We describe herein modifications that simplify the original procedural sequence and that may allow wider application. Percutaneous completion can be achieved even without a radiofrequency probe, using electrocautery. Fenestration is also easy to perform if there is a clinical indication.

Late Complication of Amplatzer Duct Occluder: Erosion and Pseudoaneurysm.

We are presenting a delayed complication of an Amplatzer duct occluder (ADO) in which a patient presented with increasing hemoptysis owing to ADO eroding the vessel wall and forming a pseudoaneurysm that communicated with the left main bronchus. Although ADO is considered as the safest for catheter-based patent ductus arteriosus closures, isolated complication as reported can occur. Just like atrial septal defect device closures, which were considered safe initially and found to be having an erosion incidence of 0.1% to 0.3%, this case could represent an isolated event (the index case) or a long-term complication occurring at a very low incidence.

Functional status and survival after prolonged intensive care unit stay following cardiac surgery.

OBJECTIVES: The clinical outcomes of patients discharged after prolonged postoperative intensive care unit (ICU) stay following cardiac surgery are unclear. The aim of this study was to assess survival and functional status in patients whose ICU stay exceeded 5 or 10 days in a tertiary cardiac surgical unit. METHODS: Patients undergoing adult cardiac surgery between October 2008 and October 2010 who stayed in an ICU for 5-10 days (Group A) or >10 days (Group B) were studied. Demographics, operative details and postoperative data were prospectively collected. The follow-up of all patients was performed by telephone questionnaire. Functional status was assessed using the Karnofsky performance score by only one investigator for uniformity of scoring. For those patients who could not be contacted, the electronic patient records and data from the UK Office for National Statistics were reviewed to determine mortality. RESULTS: Between 2008 and 2010, 2250 patients underwent adult cardiac surgery. Of these, 108 (4.7%) patients stayed >5 days (Group A, n = 53 and Group B, n = 55) in the ICU, having undergone various adult cardiac surgical procedures. The mean logistic EuroSCORE was 13 (range 1.5-86) for Group A and 16 (range 1-78) for Group B (P = 0.11). The mean ICU stay was 7 (range 6-8 days) for Group A and 21 (range 10-78 days) for Group B. Death in ICU occurred in 7 (13%) Group A patients and 11 (20%) Group B patients (P = 0.34). The median follow-up of patients who survived to the hospital discharge was 30 (range 13-38 months). Of the 90 survivors discharged from the hospital, there were 13 (25%) late deaths in Group A and 26 (47%) in Group B (P = 0.02). All survivors were contacted for the assessment of their functional status. The mean Karnofsky scores for Group A and Group B were 87 (range 70-100%) and 77.3% (range 40-100%), respectively, indicating satisfactory functional status. CONCLUSIONS: Patients who have a prolonged ICU stay following cardiac surgery have high early and late mortalities. However, the functional status of the survivors is satisfactory after 1 year and beyond.