Cyanoacrylate closure for arteriovenous fistula in the lower extremity with saphenous vein insufficiency.

A lower extremity arteriovenous fistula (AVF) is sometimes associated with venous disease following venous hypertension, especially when the saphenous vein is the main return route. This can cause venous dilation, leading to valve insufficiency. A complete cure can be difficult in cases with multiple vascular branches. We report three surgical cases of lower extremity AVF with saphenous vein insufficiency. All patients had saphenous vein insufficiency with long duration leg symptoms and underwent full-length occlusion of saphenous vein using cyanoacrylate closure. Substantial improvements in leg symptoms and appearance were observed immediately after surgery in all three patients. Cyanoacrylate closure could be a treatment option for lower extremity AVF.

Posterior aortic plication for tracheal compression by aortic dilatation in infants with congenital heart disease.

Two infants with congenital heart disease developed life-threatening airway obstruction due to progressive dilatation of the aorta. Both underwent posterior aortic plication with extracorporeal bypass (9 and 4 months of age). After surgery, the arterial diameter was adequately reduced with a smooth aortic route leading to a wide airway space. Both patients were weaned from the ventilator shortly after surgery and are currently asymptomatic.

Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography.

Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.

Fluorographic findings of diaphragmatic paralysis with spontaneous recovery.

BACKGROUND: Postoperative diaphragmatic paralysis is an unavoidable complication of cardiovascular surgery. Although diaphragmatic plication, as a surgical treatment, can be performed, spontaneous recovery is possible. We aimed to identify differences in fluorographic findings of diaphragmatic paralysis between pediatric patients with and without spontaneous recovery within 1 year of intrathoracic surgery. METHODS: Ten children, who had been followed-up for at least 1 year post-surgery and who had not received diaphragmatic plication were included and classified into those with or without spontaneous recovery. The presence or absence of the paradoxical movement of the diaphragm and mediastinum was evaluated based on fluorographic findings. Fisher's exact test was used to compare the presence or absence of paradoxical movement between the groups. RESULTS: Eight patients experienced spontaneous recovery. The mean ± standard deviation time to spontaneous recovery was 150 ± 114 days (range, 18-338 days). In the spontaneous recovery group, no patient had paradoxical movement of the mediastinum, and a significant between-group difference was observed in the presence of the paradoxical movement of the mediastinum (present/absent in patients with vs. without spontaneous recovery: 0/8 vs. 2/0, P = 0.02). There was no significant between-group difference in paradoxical movement of the diaphragm (present/absent in patients with vs. without spontaneous recovery: 1/7 vs. 2/0, P = 0.07). Pediatric patients without paradoxical movement of the mediastinum spontaneously recovered within 1 year of intrathoracic surgery. CONCLUSIONS: Pediatric patients without paradoxical movement of the mediastinum, based on fluorography findings, spontaneously recovered within 1 year of surgery. The timing of spontaneous recovery varied between cases.

Cor triatriatum sinister with left anomalous pulmonary venous drainage to innominate vein: what to do with the vertical vein?

We treated a surgical case of a 47-day-old male infant diagnosed with an unusual type of cor triatriatum sinister (CTS) with left anomalous pulmonary venous drainage to the innominate vein via a vertical vein. After preoperative hemodynamic assessment of pulmonary venous (PV) return, this patient underwent a resection of the fibromuscular membrane between the accessory and the true left atrial chambers, concomitant with vertical vein banding to facilitate a left PV return through a common pulmonary venous collector (CPVC). Catheterization three months after this surgery revealed no obstruction of the PV return to the mitral orifice as well as good growth of the CPVC as a left PV return pathway. The patient has been doing well on aspirin.

Comparison of sonographic findings between pediatric patients with mediastinitis and without mediastinitis after cardiovascular surgery.

PURPOSE: To compare the sonographic findings between pediatric patients with/without mediastinitis after cardiovascular surgery. METHODS: We included 18 pediatric patients with suspected mediastinitis after cardiovascular surgery who underwent ultrasound. They were divided into two groups according to the presence of mediastinitis, confirmed by positive bacterial culture from the mediastinum (number with/without mediastinitis = 5/13). The following sonographic findings were compared between the groups: (1) increased parasternal fat echogenicity and (2) retrosternal mediastinal fluid collection. Additionally, sex, age, and the interval between surgery and ultrasound examination were also compared. Fisher's exact and Mann-Whitney U tests were used for statistical comparisons. RESULTS: A significant difference was observed between patients with and without mediastinitis in the presence of increased fat echogenicity around the sternum (present/absent with mediastinitis vs. present/absent without mediastinitis: 5/0 vs. 3/10, respectively; P = 0.007) and retrosternal mediastinal fluid collection (5/0 vs. 2/11, respectively; P = 0.002). There was no significant difference in sex (male/female; 3/2 vs. 6/7; P > 0.999); age (months; 12.6 ± 9.4 (range, 1-22) vs. 6.9 ± 5.4 (range, 1-21); P = 0.336); and interval between surgery and ultrasound examination (days; 12.8 ± 7.2 (range, 6-20) vs. 19.1 ± 14.9 (range, 1-45); P = 0.443). CONCLUSION: Although our cohort was small, none of the patients without increased parasternal fat echogenicity or mediastinal fluid collection was diagnosed with mediastinitis. These sonographic findings may help identify the possible presence of mediastinitis. Ultrasound may be the modality of first choice to evaluate pediatric patients for mediastinitis after cardiovascular surgery.

Ultrasound evaluation of complications after cardiovascular surgery in pediatric patients: A case series.

In contrast to computed tomography, ultrasound can be performed without radiation exposure, repeatedly performed by the patients' bedside. Hence, in this case series, we describe the evaluation of complications including hematoma, superficialsurgical site infection, mediastinitis, and pseudoaneurysm associated mediastinitis using ultrasound in pediatric patients after cardiovascular surgery. To our knowledge, no previous reports have evaluated such complications using ultrasound. Ultrasound may be useful for the early diagnosis of these complications, and in the selection of subsequent examinations such as computed tomography, resulting in the early initiation of intervention.

Computed tomography findings of mediastinitis after cardiovascular surgery.

BACKGROUND: To our knowledge, no systematic study has been conducted on computed tomography (CT) imaging of mediastinitis in children post-cardiovascular surgery. We aimed to assess the CT findings of pediatric patients diagnosed with mediastinitis after cardiovascular surgery. METHODS: We included 28 pediatric patients with suspected mediastinitis after undergoing cardiovascular surgery and who underwent CT. Patients were divided into a group with mediastinitis requiring antibiotic therapy (n = 15) confirmed by positive bacterial culture from the mediastinum and a group without mediastinitis (n = 13). Fisher's exact test was used to compare the following CT findings between the two groups: (i) mediastinal fluid collection; (ii) free gas bubble within fluid collection; (iii) sternal destruction; and (iv) capsular ring enhancement. The enhancement extent was categorized into the following four grades: whole rim enhancement, >50% of the rim enhancement, <50% of the rim enhancement, and no rim enhancement. A receiver operating characteristic curve analysis was performed to establish a cut-off point for obtaining the maximum diagnostic accuracy. RESULTS: A significant difference was observed between patients, with and without mediastinitis in sternal destruction (73.6% vs 0%, P = <0.0001) and capsular ring enhancement (100.0% vs 38.5%, P = 0.0004). By using a cut-off grade of the whole rim enhancement, the estimated sensitivity and specificity for mediastinitis diagnosis were 100% and 92.3%, respectively. CONCLUSION: Computed tomography findings of sternal destruction and capsular ring enhancement were observed more in patients with mediastinitis than in those without mediastinitis, and should be assessed carefully to diagnose mediastinitis accurately in pediatric patients who have undergone cardiac surgery.

A Devised Option of Neonatal Palliation for Compromised Tetralogy of Fallot with Absent Pulmonary Valve Syndrome.

Neonatal primary repair of tetralogy of Fallot (TOF) with absent pulmonary valve (APV) syndrome is associated with high mortality rates. Our plan involves a staged repair that avoids one-stage intracardiac repair (ICR), with a first palliation that closes the main pulmonary orifice using an expanded polytetrafluoroethylene (ePTFE) patch, pulmonary arterioplication, and an adjustable Blalock-Taussig (BT) shunt. This strategy was used for a neonatal case with TOF/APV syndrome with hypoplastic left ventricle (LV). There was evidence of subsequent progressive increase in the LV size, and bronchial compression was relieved and an ICR was performed successfully at 9 months of age.

Three Dimensional Visualization of Human Cardiac Conduction Tissue in Whole Heart Specimens by High-Resolution Phase-Contrast CT Imaging Using Synchrotron Radiation.

BACKGROUND: The feasibility of synchrotron radiation-based phase-contrast computed tomography (PCCT) for visualization of the atrioventricular (AV) conduction axis in human whole heart specimens was tested using four postmortem structurally normal newborn hearts obtained at autopsy. METHODS: A PCCT imaging system at the beamline BL20B2 in a SPring-8 synchrotron radiation facility was used. The PCCT imaging of the conduction system was performed with "virtual" slicing of the three-dimensional reconstructed images. For histological verification, specimens were cut into planes similar to the PCCT images, then cut into 5-µm serial sections and stained with Masson's trichrome. RESULTS: In PCCT images of all four of the whole hearts of newborns, the AV conduction axis was distinguished as a low-density structure, which was serially traceable from the compact node to the penetrating bundle within the central fibrous body, and to the branching bundle into the left and right bundle branches. This was verified by histological serial sectioning. CONCLUSION: This is the first demonstration that visualization of the AV conduction axis within human whole heart specimens is feasible with PCCT.

Variability of Pulmonary Regurgitation in Proportion to Pulmonary Vascular Resistance in a Porcine Model of Total Resection of the Pulmonary Valve: Implications for Early- and Long-Term Postoperative Management of Right Ventricular Outflow Tract Reconstruction With Resulting Pulmonary Valve Incompetence.

INTRODUCTION: Pulmonary regurgitation (PR) is a major concern after right ventricular (RV) outflow tract surgery. We assessed the impact of physiological changes in pulmonary vasculature on hemodynamic severity of PR and RV function and their potential clinical implications for postoperative management using a porcine model with severe PR. MATERIALS AND METHODS: Eight porcine models of acute PR were established by means of resection of pulmonary valve on cardiopulmonary bypass. After separation from bypass and stabilization, blood flow in the main pulmonary artery was measured by a pulsed Doppler flowmeter, and RV systolic function was assessed on the basis of RV segment shortening (RVSS), which was analyzed by sonomicrometry. In the acute PR model, we verified the impact of pulmonary vascular resistance (Rp) on pulmonary regurgitant fraction (PRF) and RV function. Pulmonary vascular resistance was changed by manipulating the level of PaCo 2 and by inhalation of nitric oxide (NO). RESULTS: After bypass, the mean PRF was 40% ± 5%, and there was a deterioration of RV function. Under each ventilation condition (high CO2, low CO2, and NO 20 ppm), Rp was 836 ± 207 dyne × s × cm(-5), 499 ± 125 dyne × s × cm(-5), and 340 ± 102 dyne × s × cm(-5), respectively, and PRF was 60% ± 10%, 37% ± 5%, and 24% ± 4%, respectively, under each condition. They also showed a positive correlation in all animals. Cardiac output and RVSS were decreased by hypercapnia, while they were significantly improved after NO inhalation. CONCLUSIONS: This study indicates that low Rp after right ventricular outflow tract reconstruction (RVOTR) resulting in acute PR is advantageous in reducing the severity of PR and RV volume load. These findings may have clinical implications for early and long-term postoperative management of patients subjected to RVOTR with resulting pulmonary valve incompetence.

[Hemorrhagic Shock due to an Aortoesophageal Fistula in an Infant with a Double Aortic Arch；Report of a Case].

We experienced a case of a female infant with a double aortic arch (DAA) which formed an aortoesophageal fistula, leading to hemorrhagic shock. The patient had severe dyspnea at birth, and was intubated and tube-feeding was started through a nasogastric tube immediately after birth. A DAA was diagnosed by contrast-enhanced computed tomography. Due to abdominal organ malformation, we proceeded with abdominal surgery. Forty-nine days after birth, she suddenly developed massive hematemesis and went into hemorrhagic shock. The bleeding was stopped using an endoscope and was shown to have originated from the esophagus membrane. Compression of the esophageal wall by both the inserted nasogastric tube and vascular ring led to the development of ulceration, resulting in a fistula associated with massive hematemesis. An operation for a DAA was performed on the 53rd day after birth. The inferior side of the DAA was cut, to decompress the bronchus and esophagus and close the fistula. The patient's postoperative course was good and there was no further bleeding. In severe cases of a DAA who require respiratory intubation and tube feeding from a nasogastric tube it is important to carry out surgery as soon as possible.

Inflammatory response to hyperoxemic and normoxemic cardiopulmonary bypass in acyanotic pediatric patients.

BACKGROUND: Hyperoxemic management during cardiopulmonary bypass (CPB) is still common, and there is no consensus about physiologic oxygen tension strategy (normoxemic management) during pediatric CPB. In this study, we compared the postoperative conditions and measures of inflammatory response among patients with acyanotic congenital heart disease subjected to either hyperoxemic or normoxemic management strategy during CPB. METHODS: We studied 22 patients with a ventricular septal defect and pulmonary artery hypertension. The patients were divided into two groups. Group I (n=9) received normoxemic management (PaO2=100-150 mm Hg) and group II (n=13) received hyperoxemic management (PaO2=200-300 mm Hg) during CPB. There was no difference between groups with regard to age, body weight, duration of CPB, and aorta clamping time or preoperative pulmonary hypertension (pulmonary pressure/systemic pressure [Pp/Ps]). In each group, the blood samples to measure the cytokine levels were collected before and after the CPB. RESULTS: Although we observed no statistically significant differences in postoperative intubation time, alveolar-arterial oxygen difference, creatine kinase MB level, and pulmonary hypertension (Pp/Ps) between group I (10.7±13.4 hours, 197±132 mm Hg, 148±58.6 IU/L, 42.8%±22.1%, respectively) and group II (27.8±36.5 hours, 227±150 mm Hg, 151±72.6 IU/L, 50.4%±16.0%, respectively), levels of median interleukin 6 and tumor necrosis factor α were lower in group I (129.8 and 17.0 pg/mL, respectively) than that in group II (487.8 and 22.5 pg/mL, respectively). CONCLUSION: During the CPB in acyanotic pediatric patients, normoxemic management can minimize the systemic inflammatory response syndrome associated with CPB. We can apply this physiologic oxygen tension strategy to surgical advantage during heart surgeries in acyanotic pediatric patients.

Improved cardioprotection using a novel stepwise ischemic preconditioning protocol in rabbit heart.

BACKGROUND: The current commonly used cardiac ischemic preconditioning (IPC) protocol, involving three 5-min cycles of ischemia-reperfusion (I/R), may not be clinically beneficial because of its acutely deleterious effects on hemodynamics. This study attempted to assess the effects of a novel stepwise IPC scheme on cardiac function, infarct size, and arrhythmogenesis in a rabbit model of prolonged I/R. METHODS: Anesthetized open-chest rabbits were subjected to 60-min occlusion of a proximal branch of the left coronary artery followed by 180-min reperfusion. Animals were divided into five groups (n = 6 each): (1) control group (no IPC); (2) 2-min IPC group (three cycles of 2-min IPC); (3) 5-min IPC group (three cycles of 5-min IPC); (4) 10-min IPC group (three cycles of 10-min IPC); and (5) stepwise IPC group (2-, 5-, and 10-min I/R). RESULTS: Compared with control group, 2-, 5-, and 10-min IPC decreased arrhythmia score by 16%, 67%, and 33%, respectively. Remarkably, stepwise IPC resulted in a 78% reduction of arrhythmias. Stepwise IPC also produced the least ventricular infarct size when compared with 2-, 5-, and 10-min IPC groups (16.4% versus 39.3%, 28.1%, and 38.5%, P < 0.05). CONCLUSIONS: These results suggest that stepwise IPC has better cardioprotective effects against prolonged I/R injury and may serve as an acceptable approach to clinical revascularization procedures on the heart, including catheter-based and surgical approaches.

Left ventricular twist and untwist rate provide reliable measures of ventricular function in myocardial ischemia and a wide range of hemodynamic states.

Although rotational parameters by speckle tracking echocardiography (STE) have been previously compared to sonomicrometry and cardiac magnetic resonance imaging, few have examined the relationship between left ventricular (LV) rotational mechanics and intraventricular measures of load-independent contractility, LV stiffness, or ventriculoarterial coupling. The aim of this study was to compare the changes in LV rotational indices to intraventricular pressure-volume (PV) relationships under a range of inotropic states induced by pharmacological interventions, acute ischemia, and changes in preload. In nine pigs, simultaneous echocardiographic imaging and LVPV measurements were performed during pharmacologically induced high or low inotropy and during acute ischemia by ligation of the left anterior descending coronary artery (LAD). Maximal ventricular elastance (Emax), arterial elastance (Ea), ventricular-arterial coupling (Emax/Ea), dP/dt, tau, and other hemodynamic parameters were determined. Dobutamine and esmolol infusions led to inversely correlated changes in hemodynamic measurements of LV function. Apical but not basal rotation and diastolic rotation rate were decreased by esmolol and increased by dobutamine. The LV twist correlates well with Emax (r = 0.83) and Emax/Ea (r = 0.80). Apical diastolic rotation rate also correlates with dP/dtmin (r = -0.63), τ (r = -0.81), and LV stiffness (r = -0.52). LAD ligation decreased systolic and diastolic LV rotation in apical (P < 0.05), but not basal myocardium. Occlusion of the inferior vena cava, to reduce preload, increased apical rotation in systole and diastole. LV rotational parameters measured by STE provide quantitative and reproducible indices of global LV systolic and diastolic function during acute changes in hemodynamics.

Valvuloplasty of Persistent Truncus Arteriosus with Pentacuspid Truncal Valve Insufficiency / 日本心臓血管外科学会雑誌

A neonate, presenting with cyanosis, received the diagnosis of persistent truncus arteriosus with truncal valve stenosis with insufficiency. Her disease was classified as persistent truncus arteriosus Van Praagh type A1, or Collett and Edwards type I. At the age of 2 months, she underwent a modified Blalock-Taussig shunt, and her operative team was waiting for adequate body weight gain before performing further surgery. At the age of 1 year, however, she began to have repeated episodes of congestive heart failure due to severe tricuspid valve regurgitation and truncal valve insufficiency. When she reached 18 months of age, she underwent a definitive operation including a truncal valve plasty, VSD patch closure, and a right ventricular outflow tract reconstruction. Postoperative echocardiography 6 months after surgery showed a good truncal valve function with minimal regurgitaion. Truncal valve surgery is a challenging operation ; we report a successfully treated case, though the patient will require extensive follow-up.

[Modified Aubert procedure for transposition of the great artery with Planché type â ± coronary anatomy；report of a case].

Unusual coronary patterns such as single, intramural, and interarterial coronaries are the major risk factors for the arterial switch operation. Of the many approaches described, modified Aubert technique for coronary reconstruction is one of the flexible and safer procedure in complex coronary configulations. We report a successful modified Aubert operation for transposition of the great artery associated with Planché type Ⅱ coronary anatomy characterized by" single" and" interarterial" coronary arising from a posterior sinus. It is technically important to keep the sewing line of the coronary pouch away from the left margin of the coronary orifice. Since the interarterial coronary anatomy is a risk factor of future coronary events even after a successful Aubert procedure, a long-term follow up is important.