Switching the Left and the Right Hearts: A Novel Bi-ventricle Mechanical Support Strategy with Spared Native Single-Ventricle.

End-stage Fontan patients with single-ventricle (SV) circulation are often bridged-to-heart transplantation via mechanical circulatory support (MCS). Donor shortage and complexity of the SV physiology demand innovative MCS. In this paper, an out-of-the-box circulation concept, in which the left and right ventricles are switched with each other is introduced as a novel bi-ventricle MCS configuration for the "failing" Fontan patients. In the proposed configuration, the systemic circulation is maintained through a conventional mechanical ventricle assist device (VAD) while the venous circulation is delegated to the native SV. This approach spares the SV and puts it to a new use at the right-side providing the most-needed venous flow pulsatility to the failed Fontan circulation. To analyze its feasibility and performance, eight SV failure modes have been studied via an established multi-compartmental lumped parameter cardiovascular model (LPM). Here the LPM model is experimentally validated against the corresponding pulsatile mock-up flow loop measurements of a representative 15-year-old Fontan patient employing a clinically-approved VAD (Medtronic-HeartWare). The proposed surgical configuration maintained the healthy cardiac index (3-3.5 l/min/m2) and the normal mean systemic arterial pressure levels. For a failed SV with low ejection fraction (EF = 26%), representing a typical systemic Fontan failure, the proposed configuration enabled a ~ 28 mmHg amplitude in the venous/pulmonary waveforms and a 2 mmHg decrease in the central venous pressure (CVP) together with acceptable mean pulmonary artery pressures (17.5 mmHg). The pulmonary vascular resistance (PVR)-SV failure case provided a ~ 5 mmHg drop in the CVP, with venous/pulmonary pulsatility reaching to ~ 22 mmHg. For the high PVR failure case with a healthy SV (EF = 44%) pulmonary hypertension is likely to occur as expected. While this condition is routinely encountered during the heart transplantation and managed through pulmonary vasodilators a need for precise functional assessment of the spared failed-ventricle is recommended if utilized in the PVR failure mode. Comprehensive in vitro and in silico results encourage this novel concept as a low-cost, more physiological alternative to the conventional bi-ventricle MCS pending animal experiments.

An experience in the COVID-19 pandemic period: Turkish Cardiovascular Surgery Online Board Exam 2020.

Background: The aim of this study was to provide information about the results of the Turkish Cardiovascular Surgery Board written exam, which was held online due to the pandemic. Methods: This cross-sectional study included a total of 41 cardiovascular surgeons and residents (39 males, 2 females) in November 21st, 2020 between 10:00 A.M. and 12:00 P.M. After the online exam was completed, data on participant information and answers to exam questions were obtained from the information system. Results: Of all participants, 39% were working in university hospitals. A total of 82.9% of the participants were specialists. The total mean score of the participants was 60.3±10.2 and 53.7% of them were declared successful-passed. Aortic surgery (63%), heart failure surgery (50%), and mitral valve surgery (50%) were the most incorrectly answered questions. Conclusion: With the online exam, the Board gained different experiences regarding exam planning and implementation. The Turkish Cardiovascular Surgery Board did not give up the Board exam during the pandemic period and conducted a reliable written exam with many participants.

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.

Association between caregivers' coping and children's psychiatric symptoms in the heart transplantation process: A pilot study.

Our aim was to investigate whether there is an association between caregivers' coping and children's psychiatric symptoms and quality of life in adolescent heart transplant (HTx) recipients and HTx candidates with left ventricular assist device (LVAD). Fourteen patients were recruited for this pilot study (HTx (n = 8), LVAD (n = 6)). Schedule for Affective Disorders and Schizophrenia for School Aged Children, Present and Lifetime Version (K-SADS) was administered to detect the psychiatric diagnosis of patients. Children's Depression Inventory (CDI), State-Trait Anxiety Inventory, and Pediatric Quality of Life Inventory (PedsQL) were completed by adolescents; Brief Coping Styles Inventory by their caregivers. Six of the participants had an internalizing disorder. Optimistic coping strategy score was significantly higher in the caregivers of adolescents without an internalizing disorder than caregivers of those with an internalizing disorder (U = 2.500, P = .005). Utilizing Spearman's correlation, caregivers' optimistic approach (rho = -0.736, P = .004), and self-confident approach (rho = -0.634, P = .020) had significant negative correlations with children's CDI scores. Moreover, caregivers' optimistic approach score had a significant positive correlation with children's PedsQL score (rho = 0.563, P = .045). According to our preliminary results, it seems that caregivers' optimistic and self-confident coping strategies may be associated with fewer internalizing symptoms and a better quality of life in adolescents in the HTx process. A future multicentered longitudinal study will be planned to assess the effect of caregivers' coping strategies on the psychological adjustment of these children.

Can urinary biomarkers predict acute kidney injury in newborns with critical congenital heart disease?

BACKGROUND: Congenital heart disease (CHD) is the most common congenital malformation group and is the leading cause of newborn mortality in developed countries. Most of the infants with CHD develop preoperative or postoperative acute kidney injury (AKI). Acute kidney injury may develop before the serum creatinine rise and oliguria. Urinary biomarkers such as kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), interleukin (IL)-18, and cystatin C may predict AKI in patients with critical CHD (CCHD) before the serum creatinine rise. In this study, we aimed to determine the AKI incidence among newborn patients with CCHD and investigate the predictivity of urinary biomarkers for AKI. METHODS: Newborns with a gestational age >34 weeks and birth weight >1500 g with a diagnosis of CCHD were enrolled in the study. Blood and urine samples were collected at birth, during the first 24-48 h, and in the preoperative and postoperative periods. RESULTS: A total of 53 CCHD patients requiring surgery during the neonatal period were enrolled in the study. The 24-48 h KIM-1 levels of the cases with exitus were higher (P = 0.007). The 24-48 h cystatin C and preoperative NGAL levels were higher in patients with postoperative AKI (P = 0.02). DISCUSSION: In newborns with CCHD, high KIM-1 levels may predict mortality, whereas high cystatin C and preoperative NGAL levels may be indicative of AKI. These biomarkers deserve further investigation in larger study populations.

Assessment of Tricuspid Valve Detachment Efficiency for Ventricular Septal Defect Closure: A Retrospective Comparative Study.

BACKGROUND: The aim of this study was to investigate the efficiency of tricuspid valve detachment (TVD) during the surgical treatment of perimembranous ventricular septal defects (VSDs) and to compare the early and mid-term results to patients without TVD in terms of tricuspid insufficiency. METHODS: A total of 170 patients who had undergone surgical closure of perimembranous VSDs between November 2012 and January 2019 were included in this study, of whom 50 had an additional TVD procedure during the surgery. All patients were examined by transthoracic echocardiography before and after the operation with regular intervals, and the tricuspid valve function was then evaluated. RESULTS: There was no significant difference between subgroups with an unchanging degree of TVR, however, the result was also similar among those who had a decreased degree of TVR at any level (p = 0.271, p = 0.451). At the end of the study, all patients were in New York Heart Association class I. CONCLUSIONS: We suggest that, in appropriate patients, VSD closure can be safely performed with an additional TVD application through an incision of the septal leaflet of the tricuspid valve without impairing the valve function or reducing the growth potential of the valve at midterm follow-up.

Long-term assessment of left ventricular ejection fraction and mitral regurgitation following takeuchi repair

Abstract Objective: This study aimed to evaluate the early operative outcomes and to compare the left ventricle and mitral valve functions after initial Takeuchi repair in patients with anomalous left coronary arising from pulmonary artery (ALCAPA). Methods: Fourteen patients (5 males, 9 females; mean age 4.3 years, ranging from 25 days to 34 years) who were operated for ALCAPA between 2007 and 2018 were included in this study. Data were evaluated retrospectively based on our medical records. Results: Hospital mortality rate was 7.1% (n=1). Thirteen surviving patients were kept in follow-up mean 4.3±3.05 years. When compared to preoperative measurements, both left ventricular ejection fraction (LVEF), (P=0.007) and mitral regurgitation (MR) (P=0.001) significantly improved before discharge. Moreover, LVEF values were improved in the late follow-up, considering early postoperative outcomes, and this alteration was significant (P=0.014). Nevertheless, alteration in the degree of MR among patients did not differ in the long-term follow-up (P=0.180). There was no late-term mortality or need for reoperation among patients. Conclusion: Although some centers prefer to direct implantation in ALCAPA, Takeuchi procedure can be accepted as a reliable method that provides satisfactory long-term results, considering that it aids to improve left ventricle ejection fraction and reduced mitral valve regurgitation.

Long-Term Assessment of Left Ventricular Ejection Fraction and Mitral Regurgitation Following Takeuchi Repair.

OBJECTIVE: This study aimed to evaluate the early operative outcomes and to compare the left ventricle and mitral valve functions after initial Takeuchi repair in patients with anomalous left coronary arising from pulmonary artery (ALCAPA). METHODS: Fourteen patients (5 males, 9 females; mean age 4.3 years, ranging from 25 days to 34 years) who were operated for ALCAPA between 2007 and 2018 were included in this study. Data were evaluated retrospectively based on our medical records. RESULTS: Hospital mortality rate was 7.1% (n=1). Thirteen surviving patients were kept in follow-up mean 4.3±3.05 years. When compared to preoperative measurements, both left ventricular ejection fraction (LVEF), (P=0.007) and mitral regurgitation (MR) (P=0.001) significantly improved before discharge. Moreover, LVEF values were improved in the late follow-up, considering early postoperative outcomes, and this alteration was significant (P=0.014). Nevertheless, alteration in the degree of MR among patients did not differ in the long-term follow-up (P=0.180). There was no late-term mortality or need for reoperation among patients. CONCLUSION: Although some centers prefer to direct implantation in ALCAPA, Takeuchi procedure can be accepted as a reliable method that provides satisfactory long-term results, considering that it aids to improve left ventricle ejection fraction and reduced mitral valve regurgitation.

Comparison Between Nomograms Used to Define Pediatric Aortic Arch Hypoplasia: Retrospective Evaluation Among Patients Less Than 1 Year Old with Coarctation of the Aorta.

Although various modalities are currently in use to define pediatric aortic arch hypoplasia (AAH), there is little uniformity among them. We aimed to determine the inter-rater strength of agreement of the nomograms in a survey of patients less than 1 year old, who had undergone coarctation of the aorta (CoA) repair with or without AAH. This retrospectively designed study comprised of 105 patients with CoA, who had been evaluated between 2008 and 2018 by means of a computed tomography angiogram. Through re-estimation of the aortic arch segmental diameters, the z scores were calculated using three nomograms (Cantinotti, Pettersen, Lopez). Along with a t test and Pearson's correlation coefficient, a linear regression analysis, Bland-Altman plots, and Cohen's kappa k value were used to evaluate inter-rater strength of agreement. The mean age and weight of the cohort was 73.3 ± 81.2 days and 4.2 ± 1.6 kg, respectively. Sixty-four (61%) patients were neonates. The z scores of the nomograms for each aortic arch segment were significantly different. Although there was a significantly positive correlation between the nomograms with their related aortic arch diameter, the differences in z scores revealed considerable deviations in the scatter plot diagrams. The mean difference of z scores was significantly different from the testing value of zero, which was also presented in Bland-Altman plots. None of the comparisons reached a kappa k value of > 0.9. The current nomograms do not reveal an acceptable level of agreement for the definition of the AAH. The question is which modality to rely on when deciding on the surgical approach and technique of CoA repair to address the hypoplastic aortic arch segment. Decisions about the surgical approach and the technique of repair warrant a reliable definition of AAH. It is high time that a consensus is reached in this regard.

Requirement for repetitive surgical approaches at supravalvular aortic stenosis.

Supravalvular aortic stenosis, which is a rare congenital cardiac anomaly, is associated with several lesions and has a progressive nature. Herein, we report a five-year-old girl with bicuspid aorta who underwent initial Doty operation at the age of nine months. A combined redo Doty operation and an aortic valve commissurotomy were performed two years later. Due to the rapidly progressing aortic regurgitation and both valvular and supravalvular gradient, a repeated surgery was required at the age of five years and an aortic homograft was successfully inserted with an annulus enlargement and the patient was discharged uneventfully. In conclusion, although Doty repair yields satisfactory results in most patients, certain cases with identified risk factors may require reoperations due to the progressive nature of the disease. Therefore, these patients should be kept under a close follow-up lifelong.

Excision of the atrial Wilms` tumor thrombus without sternotomy, atriotomy and cardiovascular By-pass.

Tekin A, Yagmur I, Ergün O, Ayik MF, Atay Y, Ulman I, Avanoglu A. Excision of the atrial Wilms` tumor thrombus without sternotomy, atriotomy and cardiovascular By-pass. Turk J Pediatr 2019; 61: 436-439. The treatment of atrial-extention Wilms` tumor thrombus is surgical excision after chemotherapy. Atriotomy with cardiovascular by-pass is the one of the most common method for this procedure. Herein, we aimed to present a case of Wilms` tumor with a tumor thrombus extending into the right atrium totally excised with retrohepatic cavatomy. A 3.5 year-old girl was admitted with the symptom of dysuria. The examinations revealed a mass consistent with Wilms` tumor in the middle and lower poles of the left kidney. Doppler ultrasound and Echocardiographic examinations showed a tumor thrombus extending into the right atrium and some pulmonary nodules which were interpreted to be metastasis. Wilms` tumor was histopathologically diagnosed by an open biopsy. After three courses of chemotherapy imaging studies revealed that the atrial axtention of the tumor thrombus persisted. The tumor thrombus was found to be fibrotic on the magnetic resonance imaging scan of the patient. Therefore, nephroureterectomy along with the excision of the tumor thrombus from the inferior vena cava was done with intraoperative continuous trans-esophageal echocardiography (TEE). The suprarenal and retrohepatic vena cava were exposed by dissecting and ligating all short hepatic veins and completely mobilizing the right lobe of the liver. The thrombus was dissected out via Vertical cavatomy at the retrohepatic level. TEE confirmed complete removal of the thrombus from the atrium; Vena cava was then repaired. There was no need for a blood transfusion, or cardiovascular by-pass (CPB) during the operation. Total exposure of the retrohepatic and subdiaphragmatic vena cava using transplantation techniques is an effective method for the excision of a tumor thrombus without sternotomy, atriotomy and CPB, avoiding possible intra- and postoperative complications in selected cases of Wilms` tumor with intraatrial thrombus extension. The case emphasises the importance of multidisciplinary communication and collaboration.

Blalock-Taussig Shunt Size: Should it be Based on Body Weight or Target Branch Pulmonary Artery Size?

The study aimed to revisit the in-hospital predictors of shunt thrombosis (ST) in the foreground of the pulmonary artery size in patients who received modified Blalock-Taussig shunt (mBTS) as the first-stage palliation. Data from 80 patients who received mBTS as their initial palliative procedure between February 2012 and January 2017 was retrospectively collected. The median age and weight of the patients at the time of their mBTS procedure was 4 days (IQR 2-22 days) and 3.2 kg (IQR 2.8-3.7 kg), respectively. Of the 80 patients in the study, 11 (13.8%) developed ST. The diameter and corresponding z scores of the pulmonary arteries were significantly lower in patients with ST. The median shunt size/shunted pulmonary artery size (S/PA) ratio was considerably higher in patients with ST. In logistic regression analysis, pulmonary artery hypoplasia (PAH) [odds ratio (OR) = 13.7 (0.06-0.21), p < 0.001], S/PA ratio ≥ 0.9 [OR = 8.1 (0.03-0.53), p = 0.03], prematurity [OR = 9.5 (0.05-0.33), p = 0.003], and shunt size/weight (S/W) ratio ≥ 1.3 [OR = 6.4 (0.04-0.67), p = 0.012] were found to have a significant impact on ST. The best combination of sensitivity and specificity of the S/W (0.73 and 0.75) and the S/PA ratio (0.73 and 0.80) were achieved at the cut-off value of 1.3 and 0.9, respectively. The Youden index of S/PA was 0.52. While the area under the curve (AUC) of the S/W ratio was 0.686 ± 0.12 (p = 0.049), the AUC of the S/PA ratio was 0.791 ± 0.08 (p = 0.002). In conclusion, instead of weight, considering the size of the target pulmonary artery and thereby, the S/PA ratio would be more instructive in determining shunt size. There were a high number of patients in our study who showed PAH having received a shunt size based on their body weight. By contrast, our results showed that the S/PA ratio of ≥ 0.9 would be a good predictor of in-hospital ST.

Correction to: Blalock-Taussig Shunt Size: Should it be Based on Body Weight or Target Branch Pulmonary Artery Size?

The original version of the article unfortunately contained an alignment error in Table 1. The correct version of Table 1 is given below.

A Retrospective Survey Comparing Suture Techniques Regarding the Risk of Permanent Epicardial Pacemaker Implantation After Ventricular Septal Defect Closure.

OBJECTIVE: The aim of this study is to compare the continuous and combined suturing techniques in regards to the needing epicardial pacing at the time of weaning from cardiopulmonary bypass (EP-CPB) and to evaluate permanent epicardial pacemaker (PEP) implantation in patients who had undergone surgical ventricular septal defect (VSD) closure. METHODS: This single-centre retrospective survey includes 365 patients who had consecutively undergone VSD closure between January 2006 and October 2015. RESULTS: The median age and weight of the patients were 15 months (range 27 days - 56.9 years) and 10 kg (range 3.5 - 100 kg), respectively. Continuous and combined suturing techniques were utilised in 302 (82.7%) and 63 (17.3%) patients, respectively. While 25 (6.8%) patients required EP-CPB, PEP was implanted in eight (2.2%) patients. Comparison of the continuous and combined suturing techniques regarding the need for EP-CPB (72% vs. 28%, P=0.231) and PEP implantation (87.5% vs. 12.5%, P=1.0) were not statistically significant. The rate of PEP implantation in patients with perimembraneous VSD without extension and perimembraneous VSD with inlet extension did not reveal significant difference between the suture techniques (P=1.0 and P=0.16, respectively). In both univariate and multivariate analyses, large VSD (P=0.001; OR 8.63; P=0.011) and perimembraneous VSD with inlet extension (P<0.001; OR 9.02; P=0.005) had a significant influence on PEP implantation. CONCLUSION: Both suturing techniques were comparable regarding the need for EP-CPB or PEP implantation. Caution should be exercised when closing a large perimembraneous VSD with inlet extension.

A retrospective survey comparing suture techniques regarding the risk of permanent epicardial pacemaker implantation after ventricular septal defect closure

Abstract Objective: The aim of this study is to compare the continuous and combined suturing techniques in regards to the needing epicardial pacing at the time of weaning from cardiopulmonary bypass (EP-CPB) and to evaluate permanent epicardial pacemaker (PEP) implantation in patients who had undergone surgical ventricular septal defect (VSD) closure. Methods: This single-centre retrospective survey includes 365 patients who had consecutively undergone VSD closure between January 2006 and October 2015. Results: The median age and weight of the patients were 15 months (range 27 days - 56.9 years) and 10 kg (range 3.5 - 100 kg), respectively. Continuous and combined suturing techniques were utilised in 302 (82.7%) and 63 (17.3%) patients, respectively. While 25 (6.8%) patients required EP-CPB, PEP was implanted in eight (2.2%) patients. Comparison of the continuous and combined suturing techniques regarding the need for EP-CPB (72% vs. 28%, P=0.231) and PEP implantation (87.5% vs. 12.5%, P=1.0) were not statistically significant. The rate of PEP implantation in patients with perimembraneous VSD without extension and perimembraneous VSD with inlet extension did not reveal significant difference between the suture techniques (P=1.0 and P=0.16, respectively). In both univariate and multivariate analyses, large VSD (P=0.001; OR 8.63; P=0.011) and perimembraneous VSD with inlet extension (P<0.001; OR 9.02; P=0.005) had a significant influence on PEP implantation. Conclusion: Both suturing techniques were comparable regarding the need for EP-CPB or PEP implantation. Caution should be exercised when closing a large perimembraneous VSD with inlet extension.

Early and mid-term outcomes after surgical repair of congenital supravalvular aortic stenosis with the Doty technique.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of the Doty surgical approach in pediatric patients with congenital supravalvular aortic stenosis (SVAS) by examining early and mid-term outcomes. METHODS: Surgical repair using the Doty technique was performed in a total of 10 pediatric patients with SVAS between January 2005 and July 2015 at this clinic. These patients were evaluated retrospectively. Demographic characteristics, echocardiographic findings, and clinical outcomes were analyzed. RESULTS: The mean patient age was 4.8±3.9 years. Williams-Beuren syndrome was diagnosed in 4 of the patients. Early mortality was observed in 1 patient with diffuse SVAS. At the final follow-up (mean follow-up: 3.7±1.2 years; range: 6-61 months), echocardiograms revealed a mean pressure gradient of 14±4.2 mmHg. Two patients displayed minimal aortic insufficiency during the follow-up period. No reoperation or reintervention was required. CONCLUSION: The Doty technique is an anatomically and technically effective surgical approach to treating SVAS.

Low-virulent chronic sternal osteomyelitis in children.

Sternal osteomyelitis is a fatal and serious complication of open heart surgery. Application of current surgical techniques and the use of prophylactic antibiotherapy have reduced the sternal wound infections and the development of osteomyelitis. As a treatment, many methods have been described, from wound dressing to partial sternal resection, although complete recovery cannot be achieved without rationale and long-term antibiotherapy. In this article, we discuss the clinical approach to three pediatric cases who were diagnosed with low-virulent chronic sternal osteomyelitis.

Correlation between serum lactate levels and outcome in pediatric patients undergoing congenital heart surgery.

BACKGROUND: This study aimed to investigate the correlation between perioperative arterial lactate levels and morbidity and mortality in children undergoing cardiac surgery. METHODS: A total of 236 patients who underwent open heart surgery due to congenital heart disease (121 males, 115 females; mean age 56.4 month (median: 42 month): range, 1 day to 204 month) between June 2014 and May 2016 were retrospectively analyzed. The arterial blood gas analysis results at baseline (after insertion of arterial cannula), during the cooling and warming-up phases in cardiopulmonary bypass, during the sternal closure, and at 0, 6, 12, and 24 hours in the postoperative intensive care unit stay were recorded. The patients were divided into two groups according to their lactate levels: Group 1 (lactate level <4.5 mmol/L, n=183) and Group 2 (lactate level ≥4.5 mmol/L, n=53). Correlation between the lactate groups and demographic data, intraoperative and postoperative variables, postoperative complications, and mortality were investigated. RESULTS: Sixty-nine patients (29.2%) had cyanotic heart disease. A total of 53 patients (22.5%) had lactate levels of ≥4.5 mmol/L. At least one complication occurred in 41% of the patients. Development of at least one complication (p=0.027) and mortality rate (p<0.001) were significantly higher in the patients with lactate levels of ≥4.5 mmol/L. Seventeen patients (7.2%) died in the postoperative period, and 15 of them had lactate levels of ≥4.5 mmol/L at least once within the first 24 hours. In terms of mortality, lactate levels of ≥4.5 mmol/L at any time, prolonged mechanical ventilation (>48 hours), and undergoing complex surgery (high the Risk-adjusted Classification for Congenital Heart Surgery-1 score, category 4-6) were the independent risk factors for mortality. CONCLUSION: Blood arterial lactate level of ≥4.5 mmol/L was found to be a risk factor for postoperative morbidity and mortality in pediatric patients undergoing congenital heart surgery.

The fate of a thoracoabdominal aortic bypass graft 10 years after surgery in a child with the middle aortic syndrome.

A 13-year-old boy who underwent thoracoabdominal aortic bypass when he was three years old for middle aortic syndrome was admitted with fatigue and need for an increased dose of antihypertensive mediations. The graft was patent, but there were stenoses at the juxta-proximal and juxta-distal anastomosis sites. A partial benefit was gained with endovascular stenting. Although postponement of surgery, until the child reaches full growth is preferred, surgery remains the inevitable treatment of choice in patients with middle aortic syndrome. In contrary, it is important to use the graft as large as possible during the initial operation to avoid patient-graft mismatch in the future.

Our experience on Bentall procedure in an adult patient with Baraitser-Winter syndrome.

Baraitser-Winter syndrome is a very rare genetic disorder caused by cytoplasmic actin-encoding genes defects. Although most patients have similar phenotype, concomitant cardiac anomalies widely vary. In addition to well-described congenital heart diseases, aortic aneurysms occur due to underlying actin gene mutation in these patients in the further years. Herein, we present a 26-year-old male case who underwent Bentall procedure with the diagnosis of new-onset aortic valve regurgitation and an ascending aorta aneurysm.