Selective Antegrade Cerebral Perfusion With or Without Additional Lower Body Perfusion During Aortic Arch Reconstruction in Infants.

BACKGROUND: Aortic arch reconstruction is often challenging, especially in infants, owing to its high postoperative complication risks. This study aimed to compare the effectiveness between selective antegrade cerebral perfusion (SACP) alone and SACP in combination with continuous lower body perfusion with descending aortic cannulation (DAC) in preserving renal function, and to determine the influence of perfusion strategy on the postoperative course of infants who underwent aortic arch reconstruction. MATERIAL AND METHODS: A total of 121 infants who underwent aortic arch reconstruction between January 2008 and December 2018 were included in the analysis. Patients (median age: 29 days, range: 3-270 days) were divided into the following groups: those who underwent repair with SACP (SACP group, 79 patients) and those who underwent additional lower body perfusion (DAC group, 42 patients). RESULTS: Three (7.1%) and nine (11.4%) patients died in the DAC and SACP groups, respectively (P = .54). The SACP group had more patients requiring renal replacement therapy (P = .002) and higher incidence of second stage acute kidney injury (AKI) development (Kidney disease improving global outcomes (KDIGO) criteria; P = .032). The SACP group had higher frequency of open chest postoperatively than the DAC group (P = .011). The DAC group had lower vasoactive inotropic score (VIS) at the first postoperative day (P < .001) and shorter intensive care unit length of stay (P = .050). There was no difference in neurological complications between the groups (P = .061). High VIS was associated with early mortality (odds ratio [OR]: 1.79 [1.33-2.41], P < .001) and AKI (OR: 1.60 [1.35-1.91], P < .001). The DAC perfusion strategy with minimal hypothermia was associated with lower risk of AKI (OR: 0.91 [0.84-0.98], P = .016). CONCLUSION: Antegrade cerebral perfusion with continuous lower body perfusion via DAC could effectively be used for improving early postoperative results among infants undergoing procedures that include aortic arch reconstruction.

Double Arterial Cannulation in the Critical Management of Neonatal Aortic Arch Obstruction With Closed Ductus Arteriosus.

The neonatal management of critical aortic arch obstruction in association with an arterial duct that remains closed or significantly constricted requires urgent surgical repair, with a postoperative focus on resolving the impaired function of compromised organs. Here, we present two neonatal cases illustrating the use of the dual arterial cannulation perfusion method in the complete repair of interrupted aortic arch and critical coarctation of the aorta with nonfunctional ductus arteriosus. We suggest that dual arterial cannulation, which provides total body perfusion (with the exception of cardiac perfusion during cardioplegic arrest of the heart), may be a good alternative to other perfusion strategies in cases of absent ductal blood flow, as this method allowed us to avoid the further development of severe multiple organ failure.

Does mitral valve repair matter in infants with ventricular septal defect combined with mitral regurgitation?

OBJECTIVES: This study aimed to assess mitral valve function after repair of ventricular septal defect (VSD) combined with mitral regurgitation (MR) in the mid-term follow-up period, to evaluate the clinical utility of simultaneous mitral valve repair (MVR). METHODS: From June 2005 to March 2014, 60 patients with VSD and MR underwent surgical treatment. After performing propensity score analysis (1:1) for the entire sample, 46 patients were selected and divided into 2 groups: those with VSD closure and MVR (VSD + MVR, 23 patients) and those with VSD closure without mitral valve intervention (VSD only, 23 patients). The follow-up period ranged from 12 to 48 months (median 32 months; interquartile range 28-40 months). RESULTS: There was no postoperative mortality in either group. There was no significant difference in the duration of the postoperative period between groups (ventilation time, P = 0.49; inotropic support, P = 0.50). Mean cardiopulmonary bypass time and aortic cross-clamping time were significantly longer in the 'VSD + MVR' group (cardiopulmonary bypass, P = 0.023; aortic cross-clamp, P < 0.001). There was no significant difference in regurgitation area (P = 0.30) and MR grade (P = 0.76) between groups postoperatively. There was no significant difference in freedom from MR ≥ 2+ between groups (log-rank test, P = 0.28). In the 'VSD + MVR' group, 12-, 36- and 42-month freedom from MR ≥ 2+ values were 100%, 59 ± 10.4% [95% confidence interval (CI) 36.1-76.2%] and 44 ± 15% (95% CI 15.8-69.7%), respectively, while in the 'VSD only' group, these values were 100%, 54.5 ± 10.6% (95% CI 32-72.3%) and 54.5 ± 10.6% (95% CI 30-72.3%), respectively. The only significant risk factor for recurrent MR ≥ 2+ during the follow-up period was mild residual MR in the early postoperative period (P = 0.037). CONCLUSIONS: In infants with VSD combined with MR, simultaneous MVR has no benefits simultaneous MVR provided no advantage over that of isolated VSD closure. We found that the presence of mild residual MR in the early postoperative period predisposes the development of MR ≥ 2+ in follow-up period.

Risk Factors For Unfavorable Outcomes After Bidirectional Cavopulmonary Anastomosis.

BACKGROUND: Bidirectional cavopulmonary anastomosis (BCPA) is an important preliminary step toward the Fontan procedure; thus, understanding of risk factors for morbidity and mortality after BCPA may ultimately promote improved rates of success with Fontan completion and general survival. This study evaluated survival and predictors of unfavorable outcomes in patients after BCPA. METHODS: Clinical data of 157 patients who underwent BCPA from 2003 to 2015 at a single center were retrospectively analyzed. RESULTS: Three-year and nine-year survival after BCPA were 87.1% ± 2.8% and 85.8% ± 2.9%, respectively. Freedom from unfavorable outcomes (mortality, BCPA takedown, nonsuitability for Fontan procedure) was 83.8% ± 3.1% at three years and 73.5% ± 4.8% at nine years. Multivariate proportional hazards regression analysis revealed that total anomalous pulmonary venous connection (TAPVC; hazard ratio [HR]: 3.74, 95% confidence interval [CI]: 1.35-10.36; P = .01) and increased mean pressure in BCPA circuit (HR: 1.17, 95% CI: 1.02-1.34; P = .03) were independent risk factors for unfavorable outcomes. Postoperative mean pressure in BCPA circuit in patients with poor outcomes was median 16 mm Hg (interquartile range [IQR]: 14-18 mm Hg) versus median 14 mm Hg (IQR: 12-15.5 mm Hg) in patients with favorable outcomes ( P < .01). Preoperative (HR: 1.87, 95% CI: 1.20-2.91; P < .01) and postoperative atrioventricular valve regurgitation (AVVR; HR: 2.22, 95% CI: 1.24-3.94; P < .01) were also associated with unfavorable outcome in univariate Cox regression. CONCLUSIONS: Elevated mean pressure in the BCPA circuit is the main predictor of unfavorable outcome; therefore, thorough preoperative examination and careful patient selection are critical points for successful intermediate-stage and later Fontan completion. Total anomalous pulmonary venous connection and insufficient correction of AVVR worsen the prognosis in this patient group.

Bidirectional cavopulmonary anastomosis with additional pulmonary blood flow: good or bad pre-Fontan strategy.

Objectives: This study aimed to evaluate the influence of preserved additional pulmonary blood flow (APBF) on survival after bidirectional cavopulmonary shunt (BCPS) and completion of Fontan circulation. Methods: From March 2003 and April 2015, 156 patients with a single ventricle underwent BCPS. After performing propensity score analysis (1:1) for the entire sample, 50 patients with APBF (APBF group) were matched with 50 patients without APBF (no-APBF group). Results: Age ( P = 0.90), sex ( P = 0.57), weight ( P = 0.75), single ventricle morphology ( P = 0.87), type of neonatal palliative procedure ( P = 0.52), saturation ( P = 0.35), ejection fraction ( P = 0.90), Nakata index ( P = 0.70) and mean pulmonary artery pressure ( P = 0.72) were not significantly different between the groups. No significant survival difference was demonstrated ( P = 0.54). One and 4-year survival rates were both 89.1% ± 4.6% in the APBF group and 87.2% ± 4.9% and 83.4% ± 5.9%, respectively, in the no-APBF group. There was no significant difference in rates of Fontan completion ( P = 0.24), which was achieved in 22 patients from the APBF group (55.0%) and 26 patients from the no-APBF group (65.0%). However, Fontan completion occurred significantly earlier in the no-APBF group ( P < 0.01). In this group, Fontan procedure was performed before 36 months of inter-stage period in 45.9% ± 8.5% of cases (95% CI 31.0-63.7%) compared to only 13.3 ± 5.6% (95% CI 5.8-29.1%) in the APBF group. Conclusions: Our study demonstrates that APBF does not affect survival after BCPS or Fontan completion rate. APBF allows postponing the Fontan procedure without a negative effect on clinical status.

Perventricular device closure of ventricular septal defect using a video-assisted thoracoscopic approach.

We describe a new technique of perventricular closure of a perimembranous ventricular septal defect on a beating heart using transesophageal echocardiography guidance and video-assisted thoracoscopy. Ventricular septal defects were closed successfully, and no shunts, rhythm disorders, or valve incompetence developed during the short hospital stay. This procedure is safe and effective for selected patients. These early and mid-term results encourage further evaluation.

Surgical off-pump closure of perimembranous ventricular septal defects.

OBJECTIVE: To present our first experience in perventricular closure of ventricular septal defect, which is in our opinion, an important adjunct to current ventricular septal defect treatment options. BACKGROUND: Surgical closure under cardiopulmonary bypass is the treatment of choice for a perimembranous ventricular septal defect. Percutaneous techniques have technical limitations. To date, an off-pump approach and device deployment through the wall of the right ventricle is not widespread and has only been reported from China and Germany. We think this approach is promising in selected patients. METHODS: In July 2012, 7 pediatric patients with an isolated perimembranous ventricular septal defect (age range, 4 months to 8 years, mean 2.5 years, all female) with a body weight of 5 to 27 kg, mean 12.7 kg, underwent minimally invasive perventricular device closure. RESULTS: In all patients, the ventricular septal defect was occluded successfully based on transesophageal echocardiographic confirmation. There were no cases of occluder dislocation noted in the operating room or in the postoperative period. No residual shunts were observed. There was no transient or persistent rhythm disorder in any of the patients. All patients were discharged 4-5 days postoperatively, in excellent physical condition. CONCLUSIONS: The described off-pump approach showed excellent results. It offers such advantages as avoidance of the morbidity associated with cardiopulmonary bypass, significantly shorter hospital stay and therefore reduced costs, and a cosmetic advantage.