ABSTRACT
INTRODUCTION: Surgical repair of aortic arch hypoplasia in children requires a "dry" surgical field with reliable end-organ protection. Perfusion strategies commonly involve deep hypothermic circulatory arrest (DHCA) and variations of the continuous perfusion techniques, such as selective antegrade cerebral perfusion (SACP) and full-flow perfusion with double aortic cannulation (DAC). We aimed to evaluate the end-organ protection in the surgery of aortic arch hypoplasia in newborns and infants using DHCA and DAC. MATERIALS AND METHODS: 66 newborns and infants with aortic arch hypoplasia and biventricular anatomy were enrolled in this prospective study. Patients were randomly assigned into two groups according to the perfusion strategy - DHCA (n = 33); and DAC (n = 33). Primary endpoint: acute kidney injury (AKI), graded according to the KDIGO score. Secondary endpoints: neurological sequelae (pre- and postoperative MRI), in-hospital mortality. RESULTS: The lowest temperature was 32 (28; 34)°Ð¡ in the DAC group and 23 (20; 25)°Ð¡ in the DHCA group. The patients with DAC had lower incidence of AKI (6 patients (18.2%) versus 19 patients (57.6%); p = .017). In the multivariate analysis, the inotropic index at 48 h was identified as a risk factor, increasing the risk of AKI by 4%. The DHCA group was associated with a 3.8-fold increase in the risk of AKI. There was no difference in hospital mortality between the DAC and DHCA groups (1 patient (3%) versus 3 patients (9.1%); p = .61). Neurological sequelae by MRI scan were observed in 18 patients (54.5%) in the DHCA group compared to 5 patients (15.15%) in the DAC group (p = .026). The only risk factor identified in the multivariate analysis for neurological lesions on MRI scan was the DHCA group, which increased the risk by 8.8 times. CONCLUSIONS: Surgical reconstruction of the aortic arch hypoplasia using the method of full-body perfusion reduces the incidence of neurological lesions and renal complications requiring renal replacement therapy compared with the deep hypothermic circulatory arrest in neonates and infants.
ABSTRACT
The literature review is devoted to transcatheter pulmonary valve replacement. The authors summarize the indications, clinical data and current capabilities of transcatheter pulmonary valve replacement. The authors also overviewed modern valves for transcatheter pulmonary artery replacement. Effectiveness of transcatheter pulmonary valve implantation has been substantiated. Various studies comparing the outcomes of different valve systems for endovascular implantation were analyzed. The authors concluded the prospects for transcatheter pulmonary valve implantation.
Subject(s)
Cardiac Surgical Procedures , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Pulmonary Valve , Humans , Cardiac Catheterization , Heart Valve Prosthesis Implantation/adverse effects , Prosthesis Design , Pulmonary Valve/surgery , Replantation , Treatment OutcomeABSTRACT
OBJECTIVE: To assess the early and long-term results after the Norwood procedure and to identify predictors of aortic recoarctation and arterial hypertension. MATERIAL AND METHODS: We have operated on 2789 infants in the department of congenital heart diseases of the Meshalkin National Medical Research Center between January 2015 and December 2018. The current single-center prospective cohort study included 39 (1.4%) patients with hypoplastic left heart syndrome who underwent the Norwood procedure. RESULTS: In-hospital mortality was 15.3% (n=6). An inter-stage mortality was 10.2% (n=4). Recoarctation of the aorta and Sano shunt stenosis in inter-stage period occurred in 8 (24.2%) and 4 patients (12.1%), respectively. Body mass <3 kg was the only risk factor of recoarctation (OR 7.08, 95% CI 1.17; 42.79, p=0.033). We found no risk factors of Sano shunt stenosis. There were no signs of recoarctation and Sano shunt dysfunction in the early postoperative period. Arterial hypertension developed in 14 (48.3%) patients. We found the correlation between systolic blood pressure and ventricular ejection fraction (ß coefficient -0.88, 95% CI -1.33; -0.44, p=0.001). The only risk factor of arterial hypertension was increased stiffness of the aorta. CONCLUSION: The early and inter-stage mortality are still the issues after the Norwood procedure. Postoperative reduced ejection fraction of single ventricle is one of the most common complications that could be related with residual arterial hypertension.
Subject(s)
Hypertension , Norwood Procedures , Constriction, Pathologic/etiology , Humans , Hypertension/etiology , Infant , Norwood Procedures/adverse effects , Norwood Procedures/methods , Prospective Studies , Retrospective Studies , Treatment OutcomeABSTRACT
We aimed to compare the safety and efficacy of 3 perfusion methods primarily used in aortic arch reconstruction in infants, namely, deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and double arterial cannulation. Forty-five infants with aortic arch obstruction and biventricular anatomy were enrolled in this pilot prospective study (ClinicalTrials.gov registration number: NCT02835703). Patients were randomly assigned into 3 groups according to the perfusion strategy (deep hypothermic circulatory arrest, nâ¯=â¯15; selective antegrade cerebral perfusion, nâ¯=â¯15; double arterial cannulation, nâ¯=â¯15). The primary composite endpoint was the incidence of adverse events in the early postoperative period (acute kidney injury [KDIGO criteria], new brain magnetic resonance imaging (MRI) findings, and in-hospital mortality). The secondary endpoints were intensive care unit length of stay, vasoactive-inotropic score index, and cardiopulmonary bypass duration. All patients underwent aortic arch reconstruction under cardiopulmonary bypass and were monitored with near-infrared spectroscopy during surgery. No significant differences in the baseline characteristics and cardiopulmonary bypass duration were observed among the groups. The incidence of unfavorable events was lower in the double arterial cannulation group (Pâ¯=â¯0.041). Acute kidney injury was observed in 8, 6, and 5 patients from the deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and double arterial cannulation groups, respectively (Pâ¯=â¯0.64). Twelve patients from the deep hypothermic circulatory arrest group had new brain MRI findings (Pâ¯=â¯0.019). There were 5 in-hospital deaths with no significant difference among the groups (Pâ¯=â¯0.70). The "head" and "lumbar" values on near-infrared spectroscopy during aortic arch reconstruction were significantly higher in the selective antegrade cerebral perfusion and double arterial cannulation groups than in the deep hypothermic circulatory arrest group. Patients in the double arterial cannulation group had a significantly lower vasoactive-inotropic score index 24 hours postoperatively than the deep hypothermic circulatory arrest group (Pâ¯=â¯0.03). Vasoactive-inotropic score index >12 was found to be a risk factor for acute kidney injury and early mortality. Continuous regional perfusion during aortic arch reconstruction decreases the risk of new brain MRI findings in infants and the need for postoperative inotropic support. Although values of near-infrared spectroscopy during the procedure were significantly higher with continuous perfusion strategies, these methods do not reduce the acute kidney injury incidence compared to that with deep hypothermic circulatory arrest. Double arterial cannulation significantly reduces the need for inotropic support.
Subject(s)
Aorta, Thoracic , Aortic Coarctation , Aorta, Thoracic/diagnostic imaging , Aorta, Thoracic/surgery , Aortic Coarctation/diagnostic imaging , Aortic Coarctation/surgery , Cerebrovascular Circulation , Circulatory Arrest, Deep Hypothermia Induced/adverse effects , Humans , Infant , Infant, Newborn , Perfusion/adverse effects , Prospective Studies , Treatment OutcomeABSTRACT
AIM: To describe single-center evolution of the procedure and to evaluate the results of thoracoscopic clipping of patent ductus arteriosus (PDA) with diameter over 3,0 mm in term infants weighting over 4,0 kg. MATERIAL AND METHODS: Thoracoscopic clipping of PDA has been performed in 140 patients for the period from March 2012 to March 2018 in Meshalkin National Medical Research Center. Mean age was 4.0 years (range 3 months - 13 years), mean body mass index - 15.4±2.2 kg/m2. INCLUSION CRITERIA: PDA size 3.5-10 mm, Qp/Qs >1,3/1,0, weight 4.0-40 kg. Mean PDA size was 4.6±0.9 mm (range 3.5-8.0 mm), mean pulmonary artery pressure - 34.3±5.8 mm Hg, mean systemic/pulmonary flow Qp/Qs - 1.6±0.3. All patients underwent successful PDA closure through four-port technique under endotracheal general anesthesia and no need for pleural drainage. RESULTS: Mean procedure time was 24.5±15.5 min. In 29 (20,7%) cases we used titanium clips, in 11 (79.3%) - polymer locking ligating clips. There was 1 conversion to mini-thoracotomy. There were no deaths, bleeding or any other life-threatening complications. 94 (67.1%) patients were weaned from ventilator within operating theatre, in other 46 (32.9%) patients mean ventilation time in ICU was 1.3±1.0 hours. In-hospital postoperative complications: pneumothorax - 2 (1.4%) cases, recurrent laryngeal nerve dysfunction - 1 (0.7%), false croup - 1 (0.7%). There were 2 residual leakages in 2 (1.4%) patients in 10 and 6 months after titanium clip deployment. Both of them underwent transcatheter closure using the coil. Considering these cases all following patients underwent PDA closure by polymer locking ligating clips with no cases of residual leakage. CONCLUSION: Thoracoscopic PDA closure by polymer locking ligating clip is safe and effective technique for surgical management of PDA with diameter over 3.0 mm in term infants weighting over 4.0 kg.
Subject(s)
Ductus Arteriosus, Patent/surgery , Thoracoscopy/methods , Adolescent , Cardiac Catheterization , Child , Child, Preschool , Humans , Infant , Ligation , Surgical Instruments , Surgical Stapling , Thoracoscopy/instrumentation , Treatment OutcomeABSTRACT
AIM: To evaluate effectiveness and safety of various methods of cerebral and visceral protection during aortic arch surgery in infants. MATERIAL AND METHODS: Retrospective analysis included 60 patients after aortic arch repair followed by different cerebral protection technique who have been assessed for neurological status and visceral injury in early and long-term postoperative period. Aortic arch surgery with deep hypothermic circulatory arrest for congenital diseases was performed in 26 patients (group 1) and antegrade unilateral selective cerebral perfusion in 34 patients (group 2). RESULTS: Cerebral complications occurred in 28.5% of patients of the 1st group and in 7.9% of patients of the 2nd group. CONCLUSION: Odds ratio for neurological event is significantly lower in group 2: 0.17 (0.06-0.69; p=0.02). However, there were more patients with renal dysfunction in this group compared with group 1: 58.7% vs. 23.7% (p=0.02).
Subject(s)
Aorta, Thoracic , Kidney Diseases , Nervous System Diseases , Postoperative Complications , Vascular Malformations/surgery , Vascular Surgical Procedures , Aorta, Thoracic/abnormalities , Aorta, Thoracic/diagnostic imaging , Aorta, Thoracic/surgery , Cerebrovascular Circulation , Circulatory Arrest, Deep Hypothermia Induced/methods , Female , Humans , Infant , Infant, Newborn , Kidney Diseases/diagnosis , Kidney Diseases/etiology , Kidney Diseases/mortality , Kidney Diseases/prevention & control , Male , Nervous System Diseases/diagnosis , Nervous System Diseases/etiology , Nervous System Diseases/mortality , Nervous System Diseases/prevention & control , Outcome and Process Assessment, Health Care , Postoperative Complications/diagnosis , Postoperative Complications/mortality , Postoperative Complications/prevention & control , Siberia/epidemiology , Vascular Malformations/diagnosis , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/methodsABSTRACT
Congenital aneurysms and diverticula of the left ventricle represent a rare group of anomalies in the spectrum of congenital heart disease. Although natural histories of these anomalies are considerably different and characterized by different rates of lifethreatening events, similarity of their clinical presentation and diagnostic criteria do not allow to differentiate this anomalies at routine examination. Data on etiology, methods of diagnosis and treatment published by various authors is controversial. In this review we present relevant aspects of etiology, pathophysiology and treatment strategy of patients with left ventricular diverticula and congenital aneurysms.
Subject(s)
Diverticulum , Heart Aneurysm , Heart Defects, Congenital , Heart Ventricles , HumansSubject(s)
Cardiac Surgical Procedures , Tetralogy of Fallot/surgery , Ventricular Dysfunction, Right , Cardiac Surgical Procedures/adverse effects , Cardiac Surgical Procedures/methods , Disease Management , Humans , Practice Guidelines as Topic , Ventricular Dysfunction, Right/diagnosis , Ventricular Dysfunction, Right/etiology , Ventricular Dysfunction, Right/physiopathology , Ventricular Dysfunction, Right/therapy , Ventricular Remodeling/physiologyABSTRACT
Congenital left ventricular diverticulum is an extremely rare heart defect. Here, we report a case of successful endoventriculoplasty using a Dacron patch in an infant who was followed up for one year.