Permanent pacemaker implantation with hybrid endocardial perventricular approach in infancy: May be an alternative route in the absence of epicardial lead.

Despite the advancements in technology, establishing the optimal implantation technique for pediatric patients with a pacemaker (PM) indication remains challenging. Although the implantation of an epicardial PM is recommended, especially in children weighing less than 10 kg, transventricular placement of endocardial leads can be performed safely, offering a practical substitute for an epicardial pacing system, particularly in situations where a transvenous approach is unfeasible due to patient size, anatomical constraints or epicardial PM leads were not available as in our case.

Predictors of prolonged pleural effusion after Fontan operation.

Prolonged pleural effusion is a fairly common condition which has considerable impact on complicated and longer hospital stays after Fontan surgery. Identifying the patient population prone to have pleural effusions is still seeking for an answer. This study is to determine the variables that may predict prolonged pleural effusion according to the data of 69 patients who underwent Fontan operation between June 2018 and December 2020 and survived to date. Prolonged pleural effusion was defined as the need for a chest tube for more than 7 days. Two patient groups, with and without prolonged effusion, were compared in terms of pre-, peri-, and post-operative variables. The patients were subdivided into "high-risk" and "low-risk" groups based on the pre-operative catheterisation data. The most frequent main diagnosis was tricuspid atresia (n: 13, 19%). Among 69 patients, 28 (40%) had prolonged pleural effusion whereas 11 (16%) had effusions that lasted longer than 14 days. Ten patients among prolonged effusion group (35%) had pulmonary atresia coexistent with the main diagnosis. Fontan operation was performed in 6 patients (8.7%) over the age of 10, and 4 of these patients (67%) had prolonged pleural effusion. Among numerous variables, statistical significance between the two groups was achieved in pre-operative mean pulmonary artery pressure, post-operative albumin, C-reactive protein levels, length of hospital stay, duration of chest tube drainage, and amount of effusion per day. Early recognition and treatment strategies with routine medical protocol use remain to be the cornerstone for the management of post-operative prolonged pleural effusions after Fontan surgery.

Clinical Characteristics and Mid-term Follow-up in Children with Isolated Complete Atrioventricular Block.

BACKGROUND: Isolated complete atrioventricular block is a rare disease often associated with maternal autoantibodies. This study aimed to present the midterm data of patients at our clinic diagnosed with isolated complete atrioventricular block. METHODS: We evaluated 108 patients diagnosed with isolated complete atrioventricular block. Demographic data of the patients, electrocardiography, echocardiography, 24-hour Holter monitoring data, and follow-up and complications of the patients who underwent pacemaker implantation were evaluated retrospectively. RESULTS: The mean age of the patients at diagnosis was 5.51 ± 5.05 years. At the time of diagnosis, 74.8% of the patients had no symptoms associated with complete atrioventricular block. The most common symptom was fatigue. Pacemaker implantation was needed in 88 (81.4%) patients during follow-up. Significant bradycardia was the most common pacemaker implantation indication. The mean battery life was 5.41 ± 2.65 years. The battery replacement-free period of 68 patients who underwent pacemaker implantation and continued their follow-up was 4.18 ± 2.89 (0.1-10) years. Pacemaker-related complications developed in 8 patients during follow-up. Left ventricular dysfunction developed (dyssynchrony induced) in 3 patients at follow-up, and all were paced from the right ventricular anterior wall. Those patients underwent cardiac resynchronization therapy and their left ventricular dysfunction improved. CONCLUSION: Isolated complete atrioventricular block is a rare disease requiring careful clinical follow-up. Patients are often asymptomatic and significant bradycardia is the most common indication for pacemaker implantation. Left ventricular dysfunction is an important cause of morbidity, especially in patients with right ventricular anterior wall pacing. Physicians should be aware of left ventricular dysfunction during follow-up. Cardiac resynchronization therapy should be considered as a treatment option for left ventricular dysfunction.

Repair of complete atrioventricular canal defects: Early and midterm results and comparison of the left anterior leaflet augmentation technique with traditional technics.

BACKGROUND: Complete atrioventricular septal defects (CAVSD) include a variable spectrum of congenital malformations with different forms of clinical findings. We examined early and midterm outcomes, the need for reoperation, postoperative residual AV valve regurgitation, and other risk factors after various CAVSD repairs. METHODS: Between 2014 and 2018, we have performed 89 isolated CAVSD repairs. We retrospectively reviewed the patients' medical records. Patients were divided into three groups according to their repair techniques modified one patch repair (MP) (n = 16); two patch repair (TP) (n = 49); and left anterior leaflet augmentation (ALA) technique (n = 24). RESULTS: Eighty patients (89.8%) survived hospital discharge. Early mortality rates were three (18.8%) in the group MP, five (10.2%) in the group TP, and one (4.2%) in the group ALA. Thirteen patients died during the follow-up period. Late mortality rates were three (18.8%) in the group MP, four (16.6%) in the group ALA, and six (12.2%) in the group TP. The mean follow-up time was 35.9 ± 22.97 months (range: 0.3-77 months). The morbidity and mortality results were similar between-group TP and ALA but worse in the MP group. Low body weight (<4 kg) and younger age at surgery (<4 months) were found to be risk factors on mortality by univariate and multivariate analysis. Surgical technic was not found to be an independent risk factor. CONCLUSION: In our series, TP and ALA techniques had satisfactory results in early and midterm periods. Younger age and small bodyweight might increase early mortality and the need for reoperation.

First Harvest of Pediatric and Congenital Heart Surgery Multicenter Database in Turkey: Novel Application of Real-Time Online Reporting.

OBJECTIVES: A new congenital heart surgery database (CKCV) with real-time online reporting function was recently developed in Turkey. All standard international parameters were used, but Aristotle Comprehensive Complexity score was modified. In this study, the first analysis of the CKCV Database is reported. METHODS: The CKCV Database included 2307 procedures from 12 centers between January 2018 and March 2020. All parameters, including 10 real-time online reports, which represent the number of centers, number and mortality rates of all procedures, number of extracorporeal membrane oxygenation (ECMO) and results, details of postoperative complications, age-group statistics, analysis for priority status, mean intensive care and hospital stay durations of the procedures, results of Aristotle Basic, Modified Aristotle Comprehensive (MACC) and Society of Thoracic Surgeons-European Association (STAT) Score Categories, comparison of centers were analyzed. RESULTS: Most common 10 procedures were ventricular septal defect (VSD) repair (n = 273), tetralogy of Fallot (TOF) repair (n = 243), atrial septal defect (ASD) repair (n = 181), complete AVSD repair (n = 95), cavopulmonary anastomosis (n = 81), systemic to pulmonary shunt (n = 79), modified Fontan (n = 71), subaortic resection, (n = 66) PA banding (n = 66), and arterial switch operation (n = 66). Cardiopulmonary bypass was used in 84.6% of the procedures. Overall mortality rate was 6.0%. A total of 618 major and 570 minor complications were observed in 333 and 412 patients, respectively. According to six MACC categories, number of the patients and mortality rates were I (293; 0.3%); II (713; 1.4%); III (601; 3.3%); IV (607; 12%); V (84; 35.7%); and VI (9; 55.6%), respectively. Analysis of five STAT Categories showed 0.7, 3.8, 5.4, 14.9, and 54.7% mortality rates. CONCLUSIONS: CKCV Database has a great potential for nationwide quality improvement studies. Users could instantly analyze and compare their results to national and international aggregate data using a real-time online reporting function. This is the first multicenter congenital database study in Turkey.

Early postoperative arrhythmias in patients undergoing congenital heart surgery.

BACKGROUND: This study aims to evaluate early postoperative arrhythmias in children undergoing congenital cardiac surgery. METHODS: A total of 670 pediatric patients (355 males, 315 females; median age: 4 months; range, 1 day to 18 years) who underwent cardiac surgery due to congenital heart defects between December 2018 and November 2019 were included. The rate of postoperative arrhythmias, diagnosis, potential risk factors, and management strategies were evaluated. Multivariate regression analysis was used to identify significant factors of development of postoperative arrhythmias. RESULTS: Tachyarrhythmia was detected in 54 patients (8.1%), and the most common tachyarrhythmia was junctional ectopic tachycardia. Medical treatment was required in 25/38 (66%) of junctional ectopic tachycardia patients. Amiodarone was initiated in 18, dexmedetomidine in five, and flecainide + amiodarone in two of the patients. Different degrees of atrioventricular block were observed in 30 patients (4.5%). In 12 patients, permanent pacemakers were implanted during hospitalization. Age at the time of surgery under one-year-old, high inotropic scores, prolonged operation time, and high Aristotele"s scores were independent risk factors associated with early postoperative arrhythmia (p<0.05). The most common operations associated with early postoperative arrhythmia were left ventricular outflow tract, (6/20, 30%), complete atrioventricular septal defect (13/53, 24%), and tetralogy of Fallot (20/134, 14%) surgeries. CONCLUSION: Cardiac arrhythmias are common in the early period after congenital heart surgery in children. The diagnosis and frequency of arrhythmias may vary according to different surgical procedures.

Univentricular Pulmonary Artery Banding: How Tight is Tight Enough for Successful Progress?

We investigated the effects of intraoperative parameters measured during pulmonary artery banding operations and pre-discharge parameters on the completion of Fontan procedures. Fifty consecutive patients with single-ventricle anomalies and unrestricted pulmonary blood flow who underwent a PAB operation in and were discharged from our hospital were retrospectively analyzed. Patients who underwent a Fontan operation, a Glenn shunt operation, or who were eligible for a Fontan procedure were defined as the "successful group." Patients who needed rebanding prior to a bidirectional Glenn shunt, patients who were not eligible for a Glenn shunt, and those underwent a takedown due to high pulmonary arterial pressure after implantation of a Glenn shunt were defined as the "failure-to-progress group." The successful group included 34 (68%) patients and the failure-to-progress group included 16 (32%) patients. The median age was 2 months (IQR 1-4 months). There was a statistically significant difference between the groups in terms of systolic pulmonary arterial pressure, mean pulmonary arterial pressure, and pulmonary arterial pressure/systemic arterial pressure after PAB (P = 0.01, 0.03, and 0.03, respectively). While the median gradient before discharge was 60 mm Hg (IQR 50-70 mm Hg) in the successful group, it was 47.5 mm Hg (IQR 45-63.7 mm Hg) in the failure-to-progress group (P = 0.05). Mortality was observed in one (2.9%) patient in the successful group and five (31.2%) patients in the failure-to-progress group (P = 0.04). Successful pulmonary arterial banding increases long-term survival. Adequate targets should be determined, efforts should be made to achieve these targets, and patients should be followed up closely in terms of rebanding when the targets are not reached.

Early Results of Robotically Assisted Congenital Cardiac Surgery: Analysis of 242 Patients.

BACKGROUND: Robotic surgery is an alternative to traditional and minimally invasive cardiac procedures. The adaption of robotics in congenital cardiac surgery has remained limited, however. We analyzed the early outcomes of our single-center experience in robotically assisted congenital cardiac surgery. METHODS: From May 2013 to February 2020, 242 robotic operations were done for secundum atrial septal defects (74.7%), sinus venous atrial septal defects (16.1%), partial anomalous pulmonary venous connections (10.7%), widely patent foramen ovale (3.7%), ostium primum defects (2.5%), unroofed coronary sinus (1.2%), partial atrioventricular canal defects (2.5%), residual septal defects after failed percutaneous closure (1.2%), ventricular septal defect (0.4%), cor triatriatum sinister (0.4%), subvalvular aortic stenosis (0.4%), common atrium (0.4%), and double-chambered right ventricle (0.4%) using the da Vinci system. RESULTS: There was no mortality. Mean age was 30.9 ± 12.1 years, and 132 (54.5%) patients were female. Thirty (12.3%) patients were pediatric (median, 16 years; range, 12-17 years). Mean cardiopulmonary bypass and aortic clamping times were 89.5 ± 30.0 and 44.9 ± 22.3 minutes, respectively. We noted a steady decrease in operation times during the first year. Conversion to larger thoracic incisions was needed in 2 (0.8%) patients. The postoperative rates of stroke, cardiac events, pulmonary complications, and reexploration were 0.4%, 2.4%, 4.1%, and 0.8%, respectively. Mean hospital stay was 3.5 ± 1.1 days. CONCLUSIONS: Robotic technology can be utilized to perform suitable congenital cardiac procedures safely and effectively. With acceptable complication rates, robotic surgery can be an alternative to traditional, minimally invasive, and endoscopic approaches in adolescent and adult patients.

Evaluation of different lead types and implantation techniques in pediatric populations with permanent pacemakers: Single-center with 10 years' experience.

BACKGROUND: Permanent pacemaker (PM) implantation is performed for various indications and by different techniques in children; however, many problems with lead performance are encountered during follow-up. This study aims to evaluate the possible effects of different lead types and implantation techniques on pacing at early and midterm in children with a permanent PM. PATIENTS AND METHODS: Pediatric patients who underwent permanent PM system implantation at our tertiary cardiac surgery center between January 1, 2010 and January 1, 2020 were evaluated retrospectively. Patients were categorized in the epicardial pacing lead (EP), transvenous pacing lead (TP), and transvenous bipolar lumenless (Select Secure [SS]) lead groups according to the lead implantation technique and lead type with the same manufacturer. Groups were evaluated statistically for demographic features, pacing type and indication for implantation, lead electrical performance, lead failure, complications, and outcome. RESULTS: Over 10 years, 323 lead implantations were performed on 167 patients (96 males, median age 68 months [5 days-18 years]). Of 323 leads, 213 (66%) were EP, 64 (20%) were TP, and 46 (14%) were SS. Of the total, 136 of the leads were implanted in atria, and 187 were implanted in ventricles. Primary pacing indications were postoperative complete atrioventricular (AV) block (n = 95), congenital AV block (n = 71), sinus node dysfunction (n = 13), and acquired complete AV block (n = 1). Additional cardiac diseases were present in 115 patients (69%). No statistically significant difference was observed in gender, syndrome, or pacing indication (P > .05). Atrial and ventricular capture, threshold, sensing, and lead impedance measurements were not significantly different at the initial and follow-up periods (P > .05). The median follow-up duration was 3.3 years (6 months-10 years). Twenty lead failures were determined in 15 patients (EP: 14 lead failures in 10 patients; TP: two lead failures in two patients; and SS: four lead failures in three patients) during follow-up, and no statistically significant difference was found between groups (P = .466). The 5-year lead survival was 98% for TP, 95% for EP, and 90% for SS; the 10-year lead survival was 90% for TP, 70% for EP, and 70% for SS. There was no mortality related to chronic pacing or due to the procedure of implantation. CONCLUSIONS: Despite improvements in technology, lead failure is still one of the most critical problems during these patients' follow-up. Early to midterm lead survival rates of all three lead types were satisfactory.

The effects of Vasoactive-Ventilation-Renal score on pediatric heart surgery.

OBJECTIVE: The effects of Vasoactive-Ventilation-Renal (VVR) score on the evaluation of pediatric heart surgery results were investigated in this study. METHODS: This retrospective study included children younger than 18 years of age who were operated for congenital heart disease between was July 1st- December 31st 2018. Patients who needed ECMO support at the first postoperative 72 hours were not included in the study group. The postoperative initial, 24th and 48th-hour Vasoactive-Inotrope Score (VIS) and VVR scores of all patients were calculated in the intensive care unit (ICU). The effects of these scores on lengthy ICU duration (PCILOS, duration more than the upper 25th percentile) and to the hospital mortality (before 30 days) were evaluated. RESULTS: There were 340 patients in this study. The median age was 12 months (1 day-18 years), and the median weight was 7 kg (2.5 -82 kg). 18% of the patients had single ventricle physiology. Total correction was performed in 88% of the patients. Median RACHS 1 score was 2 (1-6). PCILOS was>112 hours and total mortality was 4%. The 0th hour VVR ICU c index=0.73 (CI: 0.70-0.77), mortality c index=0.77 (CI: 0.69-0.85). VVR at 24th hour ICU c index=0.75 (CI: 0.71-0.79), mortality c index=0.86 (CI: 0.81-0.91). VVR at 48th-hour ICU c index=0.87 (CI: 0.82-0.92), mortality c index=0.92 (CI: 0.87-0.97). The VVR score at 48th-hour was a strong indicator for the prediction of both LICU duration (odds ratio [OR]: -1.44; p=0.001) and hospital mortality (OR: -1.28; p=0.001). CONCLUSION: The postoperative VVR score can be a strong determinant for the prediction of early clinical results in congenital heart disease patients, which were considerably a heterogeneous group.

Short- and midterm outcomes of aortic arch reconstruction: Beating heart versus cardiac arrest.

OBJECTIVES: We aimed to compare the short- and midterm results of perfusion strategies used for arch reconstruction surgery. MATERIAL AND METHODS: One hundred and seventy-three consecutive patients who underwent aortic arch reconstruction surgery for transverse arcus hypoplasia between January 2011 and February 2020 were retrospectively analyzed. The patients were divided into two groups, as beating heart (BH) group and cardiac arrest (CA) group. RESULTS: The CA group comprised 60 (35%) patients and the remaining 113 (65%) patients were in the BH group. The median age of the patients was 30 (interquartile range: 18-95) days. The incidences of acute renal failure (ARF) and delayed sternal closure were higher in the CA group (p = .05, <.001, respectively). Balloon angioplasty was performed in 5 (2%) patients and reoperation was performed in 11 (6%) patients due to restenosis. There were no statistically significant differences between the two groups in terms of reoperation or reintervention rates (p = .44 and .34, respectively). CONCLUSIONS: Both strategies were associated with satisfactory midterm prevention of reintervention and reoperation. Given the lower incidence of ARF and delayed sternal closure in the postoperative period and similar midterm outcomes, we believe that the BH strategy is preferable.

A rare cause of abnormal pulmonary venous drainage: septum primum malposition.

OBJECTIVES: This study aimed to evaluate the clinical features of patients with septum primum malposition, imaging tools used for diagnosis, and their effects on the surgical approach. MATERIALS AND METHODS: Patients diagnosed with septum primum malposition in our paediatric cardiac centre between 1 January, 2015 and 1 January, 2019 were included in the study. In all patients, the age, reason for admission, transthoracic echocardiography, cardiac multidetector CT angiography findings, and subsequent surgical data were evaluated. RESULTS: Fifteen patients were diagnosed with septum primum malposition during the study period. The median age was 12 months (2 months-10 years). Six patients were left isomeric, and the rest were situs solitus; 80% of the patients (n = 12) had additional secundum atrial septal defect. There was cardiac pathology in 46% of the patients (n = 7) in addition to the abnormal pulmonary venous drainage, ventricular septal defect (n = 3), left ventricularhypoplasia (n = 2), cortriatriatum sinister (n = 2), double outlet right ventricle (n = 1), and atrioventricular septal defect (n = 1). There was bilateral superior caval vein in three patients, right-sided superior caval vein in 11 patients, and left-sided superior caval vein in one patient. All three patients with total abnormal pulmonary venous drainage were left atrial isomeric. There were differences between the results of transthoracic echocardiography and CT angiographies in two patients. The surgical strategy was changed in three patients after the preoperative diagnosis of septum primum malposition. CONCLUSION: Septum primum malposition should be kept in mind during the imaging of complex CHDs specifically during the segmental analysis of the pathologies with heterotaxy syndromes; it should be differentiated from other aetiologies of abnormal pulmonary venous drainage as accurate diagnosis would facilitate the ideal surgery in these complex pathologies requiring a detailed preoperative preparation.

Impact of additional annuloplasty on tricuspid valve and cardiac functions after atrial septal defect closure in adults.

BACKGROUND: Surgical indications for moderate to severe tricuspid regurgitation (TR) during atrial septal defect (ASD) closure are still unclear. Additional tricuspid valve annuloplasty (TVP) can be beneficial to avoid postoperative persistent TR. Therefore, we compared the results of surgical ASD closure with or without additional TVP in patients who presented with moderate-to-severe TR. METHODS: Between November 2009 and June 2016, 103 patients with ASD and moderate-to-severe TR underwent surgical ASD closure without (n = 76, group 1) and with additional TVP (n = 27, group 2). Clinical outcomes and echocardiographic data were analyzed. RESULTS: There was no mortality. Postoperative outcomes were similar despite significantly longer aortic clamping time in group 2 (P = .003). Mean TR grade, right atrial diameter, right ventricular end-diastolic diameter, pulmonary artery pressure, and Qp/Qs ratio decreased significantly in both groups (P < .05). Mean follow-up time was 5.3 months (range: 1 month-6.2 years) in group 1 and 6.1 months (range: 1 month-4.1 years) in group 2 (P = .66). Echocardiography results showed significant decrease in TR grade in both groups (P = .93). The incidence of persistent moderate to severe TR was higher in isolated ASD closure group (14.4% vs 3.7%, P = .086). Additional TVP provided greater regression in TR grade (-1.49 ± 0.9 vs -1.89 ± 0.8, P = .041). CONCLUSION: Despite TVP being associated with longer ischemic time, postoperative outcomes were comparable to ASD closure alone. Both approach demonstrated an effective decrease in TR, but TVP provided greater regression and lower incidence of persistent TR. Therefore, additional TVP should be considered in patients undergoing ASD closure with moderate-to-severe TR.

Parameters affecting pleural drainage and management strategy after Fontan operation.

BACKGROUND: Prolonged pleural drainage is a common complication after undergoing the Fontan procedure. Although various protocols have been described, there is no definitive consensus for how to treat this complication. MATERIALS AND METHODS: Our primary aim was to determine the effect of the management strategy protocol on the duration of drainage and length of hospital stay. Our secondary aim was to determine the parameters affecting the need for prolonged drainage after the Fontan procedure. Ninety-two consecutive patients who underwent the Fontan procedure were retrospectively analyzed. A protocol-based postoperative management strategy was adopted in July 2018. Group 1 (n = 48) consisted of patients that underwent the procedure before the protocol was implemented. Group 2 (n = 44) consisted of patients that underwent the procedure after the protocol was implemented. RESULTS: The mean age was 5 years (interquartile range [IQR], 4.0-6.9); the mean body weight was 17.3 kg (IQR, 15.1-21.8). Statistically significant differences were found between the groups in terms of total drainage, duration of pleural drainage, prolonged drainage, and length of hospital stays (LOHS) (P = .05, P = .04, P = .04, P = .04, respectively). The multivariate analysis results showed that the application of the protocol was the only factor impacting prolonged drainage (OR, 2.46, 95% CI lower-upper: 1.03-5.86, P = .04). CONCLUSION: Standardization and strict application of the medical treatment within a specific protocol without being affected by doctor-, nurse-, or patient-based factors increases the success rate of this procedure. After implementing the changes in the medical management strategy, total drainage and duration of pleural drainage and LOHS decreased, and the costs associated with these factors also decreased.

Epicardial Pacemaker in Neonates and Infants: Is There a Relationship Between Patient Size, Device Size, and Wound Complication?

We aimed to investigate the complications after epicardial pacemaker (PM) implantation in neonates and infants and their relationship with factors such as device size and patient size. Between May 2010 and July 2018, 55 patients under 1 year of age who underwent epicardial PM placement were retrospectively evaluated. PM-related complications requiring rehospitalization were determined as wound site problems requiring surgical intervention, battery pocket infection, battery pocket dehiscence without infection, PM removal, relocation of the PM system, and replacement of the PM system with another system. The patients were divided into three groups: < 3 kg, 3-5 kg and > 5 kg. Fifty-five patients underwent PM implantation, 43 (78.2%) because of postoperative atrioventricular block (AVB), 10 (18.2%) because of congenital AVB, and two (3.6%) with diagnoses of c-TGA and AVB. Five (9%) patients incurred 18 complications. No statistically significant difference was observed in complication development between the groups (p > 0.05). Single- or dual-chamber device implantation did not affect complication development (p > 0.05). Despite the role of factors such as low weight, low age, and device volume in the development of wound complications, the relationship between these factors and complications is not statistically significant. Therefore, our results are encouraging in terms of the use of dual-chamber PMs instead of single-chamber ones in heart diseases in which AV synchronization is important.

Use of extracorporeal membrane oxygenation in postcardiotomy pediatric patients: parameters affecting survival.

AIM: We aimed to investigate the risk factors affecting survival after extracorporeal membrane oxygenation use in pediatric postcardiotomy patients. METHODS: One hundred thirty-three consecutive patients who underwent surgery for congenital heart disease who needed extracorporeal membrane oxygenation support were retrospectively analyzed. RESULTS: In all, 3,082 patients were operated, of which 140 patients (4.54% of the total number of operations) needed extracorporeal membrane oxygenation. Eighty (60.1%) patients were successfully weaned and 51 (38.3%) patients were discharged. Of the 50 patients discharged during the mean follow-up period of 34.8 (0-192.4) months, 6 (12%) patients died. The extracorporeal membrane oxygenation support was instituted in 29 (21.8%) patients for extracorporeal membrane oxygenation cardiopulmonary resuscitation, in 44 (33.1%) patients due to the inability to be separated from cardiopulmonary bypass, in 19 (14.3%) patients due to respiratory failure, and in 41 patients due to low cardiac output syndrome. Eighty patients (60.2%) were successfully weaned from extracorporeal membrane oxygenation support. The remaining 53 (39.8%) patients died on extracorporeal membrane oxygenation. Mortality was observed in 29 (21.8%) of the 80 patients in the successful weaning group, while the remaining 51 (38.3%) patients were discharged from the hospital. Multivariate analysis showed that double-ventricular physiology increased the rate of successful weaning (odds ratio: 3.4, 95% confidence interval lower: 1.5 and upper: 8, p = 0.004) and prolonged extracorporeal membrane oxygenation durations were a risk factor in successful weaning (odds ratio: 0.9, 95% confidence interval lower: 0.8 and upper: 0.9, p = 0.007). The parameters affecting mortality were the presence of syndrome (odds ratio: 3.8, 95% confidence interval lower: 1.0 and upper: 14.9, p = 0.05), single-ventricular physiology (odds ratio: 5.3, 95% confidence interval lower: 1.8 and upper: 15.3, p = 0.002), and the need for a second extracorporeal membrane oxygenation (odds ratio: 12.9, 95% confidence interval lower: 1.6 and upper: 104.2, p = 0.02). While 1-year survival was 15.2% and 3-year survival was 12.1% in patients with single-ventricular physiology, the respective survival rates were 43.9% and 40.8%. CONCLUSION: Parameters affecting mortality after extracorporeal membrane oxygenation support in pediatric postcardiotomy patient group were the presence of a syndrome, multiple runs of extracorporeal membrane oxygenation, and single-ventricular physiology. Timing of extracorporeal membrane oxygenation initiation, appropriate patient selection, appropriate reintervention or reoperation for patients with correctable pathology, the use of an appropriate cannulation strategy in single-ventricle patients, management of shunt flow, and appropriate interventions to reduce the incidence of complications play key roles in improving survival.

Robotic repair of partial anomalous pulmonary venous connection: the initial experience and technical details.

This study reports our initial experience with robotic-assisted partial anomalous pulmonary venous connection (PAPVC) repair. From May 2013 through September 2018, 20 patients (12 male and 8 female) underwent robotic-assisted repair of a right-sided (n = 19) or a left-sided (n = 1) PAPVC. The mean age was 24.6 ± 9.4 years (range 14-44) and the mean body mass index was 22.3 ± 4.6. Seventeen patients had a right-sided supra-cardiac PAPVC with sinus venosus atrial septal defect, two had a right-sided cardiac PAPVC to the right atrium and one had a left-sided cardiac PAPVC to the coronary sinus. Associated anomalies included patent foramen ovale (n = 2) and left persistent superior vena cava (n = 1). All patients were operated on successfully. No conversion to mini-thoracotomy or sternotomy was needed. Cardiopulmonary bypass and aortic clamping times were 114.8 ± 17.3 (range 90-150) and 66.5 ± 15.8 (range 44-90) minutes, respectively. Repair techniques included the single-patch repair with baffle through right atriotomy (n = 16), the 2-patch repair (n = 1) using lateral transcaval incision and intracardiac re-routing (n = 3). The mean ventilation time was 4.2 ± 1.2 h and hospital stay was 3.1 ± 0.1 days. No phrenic nerve injury, sinus node dysfunction, re-exploration or blood transfusion was noted. No residual shunting or venous obstruction was found on echocardiograms. Follow-up was a mean of 1.7 years (range 3-36 months). There was no follow-up mortality. Totally, endoscopic robotic-assisted PAPVC repair is a feasible procedure in selected adult patients. It is a less invasive alternative to traditional incisions, mini-thoracotomy and endoscopic approaches. In the future, new generation robotic devices may offer an alternative for younger patients with this pathology.

Predictors of a complicated course after surgical repair of tetralogy of Fallot.

BACKGROUND: In this study, we aimed to evaluate the patient and surgical factors affecting prolonged hospital stay and major adverse events after surgical repair of tetralogy of Fallot and to identify the predictors of a complicated course after surgical repair. METHODS: A total of 170 consecutive patients (96 males, 74 females; median age 12 months; range, 1 to 192 months) who underwent surgical repair of tetralogy of Fallot between January 2015 and April 2018 were retrospectively reviewed. A mechanical ventilation duration of >24 h, an intensive care unit stay of >3 days, and a hospital stay of >7 days were considered as prolonged. Unplanned reoperation, complete heart block requiring a permanent pacemaker implantation, renal failure, diaphragmatic paralysis, neurological deficit, sudden circulatory arrest, need for extracorporeal membrane oxygenation, and death were considered as major adverse events. RESULTS: The median time to hospital discharge was 8.0 (range, 5.0 to 40.0) days. Higher preoperative hematocrit levels prolonged the length of hospital stay (odds ratio: 1.12, 95% confidence interval 1.1-1.2, p<0.001). A total of 28 major adverse events were observed in 17 patients (10%). Lower pulmonary artery annulus Z-score (odds ratio: 0.5, 95% confidence interval 0.3-0.9, p=0.01) and residual ventricular septal defects (odds ratio: 54.6, 95% confidence interval 1.6-1,874.2, p=0.03) were found to increase mortality. Residual ventricular septal defect was also a risk factor for major adverse events (odds ratio: 12.4, 95% confidence interval 1.5-99.9, p=0.02). CONCLUSION: Preoperative and operative factors such as high preoperative hematocrit, low preoperative oxygen saturation, low pulmonary annulus Z-score, Down syndrome, residual ventricular septal defects, and the use transannular patch were found to be associated with prolonged length of hospital stay, prolonged mechanical ventilation, prolonged intensive care unit stay, and increased development of major adverse events.