Is Porcine Small Intestinal Submucosal Extracellular Matrix (ECM) a Suitable Material for Right Ventricular Outflow Tract Reconstruction in Association With Pulmonary Valve Replacement?

Pulmonary valve replacement (PVR) with right ventricular outflow tract (RVOT) reconstruction is a common congenital cardiac operation. Porcine submucosal intestinal-derived extracellular matrix (ECM) patches have been used for RVOT reconstruction. We present 2 adult patients with Tetralogy of Fallot who underwent PVR with RVOT reconstruction utilizing ECM. Both cases required reoperation due to patch dehiscence causing a large paravalvular leak. One patient also had a pseudoaneurysm associated with ECM dehiscence. There may be a propensity for ECM dehiscence in this application and, based on these cases, we recommend avoidance of ECM in RVOT reconstruction with PVR. PVR patients repaired with ECM should be monitored for this complication.

Inferior vena cava syndrome caused by postoperative positional changes in the liver.

Inferior vena cava (IVC) compression is well reported in the literature with the most common etiology being secondary to malignancy in neighboring structures (liver, kidney, pancreas, etc.). We present a novel case of IVC compression secondary to altered liver position following nephrectomy. This case report describes the clinical course, patient evaluation, and procedural considerations of this unique case.

A telephone-based surgical transitional care program with improved patient satisfaction scores and fiscal neutrality.

BACKGROUND: Limited data exist regarding the downstream effects of surgical transitional care programs. We explored the impact of such programs on patient satisfaction and fiscal metrics. METHODS: A telephone-based surgical transitional care program enrolled patients undergoing complex abdominal surgery between 2015 to 2017. A matched cohort undergoing similar procedures between 2010 to 2015 were used as controls. Press Ganey scores were used to reflect patient satisfaction. Hospital costs, reimbursements, and margins were analyzed for index hospitalizations and readmissions within 90 days of surgery. RESULTS: There were 607 patients in the control group and 608 in the transitional care program; survey response rates were 37% and 35%, respectively. Transitional care patients rated their understanding of personal responsibilities in post-discharge care higher than controls (59% vs 69%, P = .02). Transitional care patients felt they received better educational materials about their condition or treatment (55% vs 68%, P < .01) and rated their global hospital experience higher (46% vs 57%, P = .02). The aggregate (index plus readmission) cost was greater for the transitional care ($22,814 vs $25,827, P < .01), but there was no difference in aggregate margin ($7,027 vs $4,698, P = .25). Multivariable adjustment yielded similar results for the aggregate cost (ref vs $2,232, P = .03) and margin (ref vs $1,299, P = .23). CONCLUSION: The use of this dedicated abdominal surgery transitional care program is associated with improved Press Ganey patient education and global rating scores. The cost to support this program did not adversely affect the hospital margin when considering all factors. These data support broader investment in patient centered initiatives that may significantly enhance patient experience.

Prophylactic Peritoneal Drainage is Associated with Improved Fluid Output after Congenital Heart Surgery.

Infants undergoing congenital heart surgery (CHS) with cardiopulmonary bypass (CPB) are at risk of acute kidney injury (AKI) and fluid overload. We hypothesized that placement of a passive peritoneal drain (PPD) can improve postoperative fluid output in such infants. We analyzed 115 consecutive patients, age birth to 60 days, admitted to the PICU after CHS with CPB between 2012 and 2018. Patients who needed postoperative ECMO were excluded. Linear and logistic regression models compared postoperative fluid balances, diuretics administration, AKI, vasoactive-inotropic scores (VIS), time intubated, and length of stay after adjusting for pre/operative predictors including STAT category, bypass time, age, weight, and open chest status. PPD patients had higher STAT category (p = 0.001), longer CPB times (p = 0.001), and higher VIS on POD 1-3 (p ≤ 0.005 daily). PPD patients also had higher AKI rates (p = 0.01) that did not reach significance in multivariable modeling. There were no postoperative deaths. Postoperative hours of intubation, hospital length of stay, and POD 1-5 fluid intake did not differ between groups. Over POD 1-5, PPD use accounted for 48.8 mL/kg increased fluid output (95% CI [2.2, 95.4], p = 0.043) and 3.41 mg/kg less furosemide administered (95% CI [1.69, 5.14], p < 0.001). No PPD complications were observed. Although PPD placement did not affect end-outcomes, it was used in higher acuity patients. PPD placement is associated with improved fluid output despite lower diuretic administration and may be a useful postoperative fluid management adjunct in some complex CHS patients.

A unique indication for the senning procedure: Atrioventricular discordance with ventriculoarterial concordance.

OBJECTIVE: We describe experience treating a patient with atrioventricular (AV) discordance with ventriculoarterial (VA) concordance, ventricular septal defect (VSD), and situs inversus. This is a rare congenital lesion in which closing the VSD would septate D-transposition physiology and performing an arterial switch and VSD closure would produce congenitally corrected transposition of the great arteries physiology. As such, it is the only lesion for which an isolated atrial switch (and VSD closure) remains the preferred correction. CASE: A term baby girl born with AV discordance/VA concordance, a large VSD, and situs inversus totalis was palliated with atrial septostomy on day of life 3 to allow for optimal mixing and pulmonary artery banding during the 6th week of life to control symptoms of pulmonary overcirculation and protect the pulmonary vasculature. At 8 months of age, she underwent complete repair with a Senning atrial switch procedure, VSD closure, and pulmonary artery debanding with pulmonary arterioplasty. RESULTS: The patient underwent corrective surgery with patch closure of the VSD, and the Senning atrial switch procedure resulting in a total anatomic correction. The patient was discharged on postoperative day 6 and is clinically doing well 12 months later. Follow-up transthoracic echocardiogram shows no pulmonary venous baffle obstruction, mild systemic venous baffle obstruction, and moderate pulmonary stenosis/pulmonary insufficiency. CONCLUSION: The isolated atrial switch is rarely employed as its outcomes are inferior to the arterial switch operation in the setting of the dextro-transposition of the great arteries. However, it remains the procedure of choice for AV discordance with VA concordance as it leads to physiologically corrected biventricular circulation.

Helpful sternal wound vacuum-assisted closure techniques in two open chest situations: Central extracorporeal membrane oxygenation and sternal infection.

BACKGROUND: Dressing open sternal wounds after cardiac surgery can be challenging. In cases where extracorporeal membrane oxygenation (ECMO) is required, the sternum is left open with cannulae traversing the wound, making it difficult to create a water-tight seal and maintain sterility. Patients with a deep sternal infection may also be left with an open sternum between the time of debridement and reconstruction; in such cases, stabilizing the dressing in an ambulatory patient can pose a challenge. METHODS: Two cases are reviewed, each highlighting the solutions to the problems mentioned above. RESULTS: In case 1, a patient with an open sternum and central ECMO, we describe construction of a dressing that achieves air seal and blood seal, and helps maintain the cannulae in a safe, stable position. In case 2, an ambulatory patient, we describe a modification of a recently published "Two Bridge Technique" that provides a stable dressing in three dimensions. CONCLUSION: Performance of specific techniques and attention to detail in complex situations can make a big difference in open sternum patients treated with temporary, vacuum-assisted dressings. Achieving vacuum and fluid seal is important for sterility, integrity of adjacent skin, and caregiver safety.

Loss of odor-induced c-Fos expression of juxtaglomerular activity following maintenance of mice on fatty diets.

Diet-induced obesity (DIO) decreases the number of OMP+ olfactory sensory neurons (OSN) in the olfactory epithelium by 25% and reduces correlate axonal projections to the olfactory bulb (OB). Whether surviving OSNs have equivalent odor responsivity is largely unknown. Herein, we utilized c-fos immediate-early gene expression to map neuronal activity and determine whether mice weaned to control (CF), moderately-high fat (MHF), or high-fat (HF) diet for a period of 6 months had changes in odor activation. Diet-challenged M72-IRES-tau-GFP mice were exposed to either a preferred M72 (Olfr160) ligand, isopropyl tiglate, or clean air in a custom-made Bell-jar infusion chamber using an alternating odor exposure pattern generated by a picosprizer™. Mice maintained on fatty diets weighed significantly more and cleared glucose less efficiently as determined by an intraperitoneal glucose tolerance test (IPGTT). The number of juxtaglomerular cells (JGs) decreased following maintenance of the mice on the MHF diet for cells surrounding the medial but not lateral M72 glomerulus within a 4 cell-column distance. The percentage of c-fos + JGs surrounding the lateral M72 glomerulus decreased in fat-challenged mice whereas those surrounding the medial glomerulus were not affected by diet. Altogether, these results show an asymmetry in the responsiveness of the 'mirror image' glomerular map for the M72 receptor that shows greater sensitivity of the lateral vs. medial glomerulus upon exposure to fatty diet.

Widowmaker Right Coronary Artery Treated With Drug-Eluting Stent Implantation.

We present a case of a single coronary artery system arising from the right sinus of Valsalva found to have an obstructive mid-vessel lesion with functional evidence of ischemia on stress testing. She was treated with a first-generation Cypher (Cordis, Johnson & Johnson, Hialeah, Florida) drug-eluting stent and remains asymptomatic at 14-year follow-up. (Level of Difficulty: Intermediate.).