Early Bidirectional Glenn Procedure as Initial Surgical Palliation for Functionally Univentricular Heart with Common Arterial Trunk.

We report an unusual case of a 2-month-old baby with a diagnosis of common arterial trunk and double outlet right ventricle with a remote type ventricular septal defect. Taking into consideration the physiologic moment and anatomic findings of the patient, we planned and successfully performed a bidirectional Glenn procedure as its first palliative procedure.

The Lugones Procedure for Scimitar Syndrome Repair Through Right Axillary Thoracotomy: Not Only a Cosmetically Superior Approach.

Several surgical strategies to deal with scimitar syndrome have been described over the years. Among them, the technique described by Lugones and coworkers in 2014 has gained attention due to its simplicity, reproducibility and excellent results. Following the original report of the procedure, the defect is usually repaired through a midline sternotomy. Here, we describe an alternative approach using a right axillary thoracotomy, which not only exhibits superior cosmetic results but allows for an excellent view of all relevant anatomic structures.

Early Extubation in a Pediatric Cardiac Surgery Program Located at High Altitude.

BACKGROUND: Early extubation is performed either in the operating room or in the cardiovascular intensive care unit during the first 24 postoperative hours; however, altitude might possibly affect the process. The aim of this study is the evaluation of early extubation feasibility of patients undergoing congenital heart surgery in a center located at 2,691 m (8,828 ft.) above sea level. MATERIAL AND METHODS: Patients undergoing congenital heart surgery, from August 2012 through December 2018, were considered for early extubation. The following variables were recorded: weight, serum lactate, presence or not of Down syndrome, optimal oxygenation and acid-base status according to individual physiological condition (biventricular or univentricular), age, bypass time, and ventricular function. Standardized anesthetic management with dexmedetomidine-fentanyl-rocuronium and sevoflurane was used. If extubation in the operating room was considered, 0.08 mL/kg of 0.5% ropivacaine was injected into the parasternal intercostal spaces bilaterally before closing the sternum. RESULTS: Four hundred seventy-eight patients were operated and 81% were early extubated. Mean pre- and postoperative SaO2 was 92% and 98%; postoperative SaO2 for Glenn and Fontan procedures patients was 82% and 91%, respectively. Seventy-three percent of patients who underwent Glenn procedure, 89% of those who underwent Fontan procedure (all nonfenestrated), and 85% with Down syndrome were extubated in the operating room. Reintubation rate in early extubated patients was 3.6%. CONCLUSION: Early extubation is feasible, with low reintubation rates, at 2,691 m (8,828 ft.) above sea level, even in patients with single ventricle physiology.

Norwood Procedure in a Patient With Hypoplastic Left Heart Syndrome, Right Aortic Arch, and Right Descending Aorta.

We describe the surgical treatment of a patient with hypoplastic left heart syndrome and right aortic arch.

Outcomes of the Non-fenestrated Fontan Procedure at High Altitude.

BACKGROUND: Although high altitude has been considered a risk factor for the Fontan operation, and an indication for fenestration, there is a paucity of data to support its routine use. Fenestration, with its necessary right to left induced shunt, together with the lower partial pressure of oxygen found with progressive altitude, can significantly decrease hemoglobin oxygen saturation, and therefore, it would be desirable to avoid it. OBJECTIVE: To analyze immediate and medium-term results of the non-fenestrated, extracardiac, Fontan procedure at high altitude. METHODS: Retrospective analysis of data from consecutive patients who underwent non-fenestrated, extracardiac, Fontan procedure at two institutions located in Mexico City at 2,312 m (7,585 ft) and 2,691 m (8,828 ft) above sea level. High altitude was not considered a risk factor. RESULTS: Thirty-nine patients were included, with a mean age of 6.7 years. Mean preoperative indexed pulmonary vascular resistance was 1.7 Wood units. Seventy-nine percent of the patients extubated in the operating room. There was one in-hospital death (2.56%) and one at follow-up. Median chest tube drainage time was 6.5 and 6 days for the right and left pleural spaces. Median oxygen saturation at discharge was 90%. At a median follow-up of six months, all survivors, except one, had good tolerance to daily life activities. CONCLUSIONS: The present study shows good short- and medium-term results for the non-fenestrated, extracardiac, Fontan operation at altitudes between 2,300 and 2,700 m and might favor this strategy over fenestration to improve postoperative oxygen saturation. Further studies to examine the long-term outcomes of this approach need to be considered.

A Novel Private-Public Hybrid Model for Treatment of Congenital Heart Disease in Mexico.

Mortality after surgery for congenital heart disease (CHD) in Mexico is significantly higher than in high-income countries due to structural, medical, and financial factors. In Mexico, public hospitals have a large volume of patients but inadequate quality control systems, whereas private hospitals, although having higher quality control systems, have an insufficient number of patients to build programs of excellence. We describe the creation of a novel hybrid private-public program in Mexico that leverages the advantages of both sectors while establishing an integrated multidisciplinary unit that has allowed us to improve the quality of care for patients with CHD.

Seguridad de la re-esternotomía media en el tratamiento paliativo de pacientes con corazón univentricular / Safety of repeat median sternotomy in the palliative treatment of patients with a univentricular heart

Resumen: Objetivo: Describir la morbimortalidad operatoria relacionada a re-esternotomía media en pacientes con corazón univentricular en el Instituto Nacional de Pediatría. Método: Estudio de serie de casos retrospectiva, descriptiva y analítica del año 2001 al 2016. Resultados: Se encontraron 65 pacientes que requirieron 76 procedimientos. Hubo 59 primeras re-esternotomías, con promedio de edad de 36 meses (4-176 meses) y peso 12.2 kg (3.2-21.5 kg); se realizaron 40 procedimientos de Glenn y 19 procedimientos de Fontan. Se practicaron 17 segundas re-esternotomías, con promedio de edad de 89 meses (48-156 meses) y 22.7 kg de peso (14.4-41 kg), en quienes se realizaron 17 procedimientos de Fontan. Hubo dos lesiones en primeras re-esternotomías, una lesión a la coronaria derecha con cambios electrocardiográficos, y una apertura incidental de la aurícula derecha que causó hipotensión. Reportamos una muerte secundaria a lesión de la aorta con sangrado masivo durante una segunda re-esternotomía, lo que representa una morbimortalidad del 3.9%. Conclusiones: Concluimos que la re-esternotomía es un procedimiento seguro en nuestro centro.

Abstract: Objective: To establish the morbidity and mortality of patients with univentricular hearts who underwent a repeat median sternotomy at the Instituto Nacional de Pediatría. Method: A retrospective review was performed on the clinical charts of all patients who under-went a repeat median sternotomy from 2001 to 2016. Results: Sixty-five patients underwent 76 surgeries by repeat median sternotomy. Fifty-nine patients had a first repeat median sternotomy, with a mean age of 36 months (range: 4-176 months) and a mean weight of 12.2 kg (range: 3.2-21.5 kg). Forty patients had a Glenn procedure, and 19 patients had a Fontan procedure. There were 17 patients with a second repeat median sternotomy, with a mean age of 89 months (range 48-156 months), and a mean weight of 22.7 kg (14.4-41 kg). A Fontan procedure was performed on all these 17 patients. A section of the right coronary artery with electrocardiographic changes and a right atrium tear that caused hypotension occurred during first repeat sternotomy. An aortic tear occurred during a second repeat sternotomy with massive bleeding and subsequent death. This represents 3.9% of re-entry injuries. Conclusion: It is concluded that repeat median sternotomy is a safe procedure.

Identificación de un patrón tromboelastográfico en niños sometidos a cirugía cardiaca con exposición prolongada a circulación extracorpórea / Identification of a thromboelastographic pattern in children undergoing cardiac surgery with prolonged exposure to cardiopulmonary bypass

Background: Point-of-care thromboelastography is used for guiding peri-operative haemostatic therapy. Objective: To identify a thromboelastographic pattern in children with prolonged cardiopulmonary bypass exposure. Material and methods: A cohort study of 62 patients undergoing prolonged cardiopulmonary bypass was performed. Patients with preexisting coagulopathy, use of drugs known to interfere with clotting, hematocrit > 60%, weight < 3 kg, or hepatic disease were excluded. The thromboelastography study was conducted at the point of care. Results: Baseline and rewarming reaction time values were 8.24 ± 6.35 and 7.66 ± 2.15min, respectively (p = 0.102). Baseline and rewarming angle values were 64.88 ± 13.08 and 54.67 ± 8.98 degrees, respectively (p < 0.001). Baseline and rewarming maximum amplitude values were 64.54 ± 12.31 and 43.14 ± 12.47 mm, respectively (p = 0.001). The same trend was observed when the cohort was divided into patients under and over 3 years of age, and patients under and over 10 kg of body weight. Discussion: This study suggests the existence of a thromboelastographic pattern independent of age or weight in patients undergoing paediatric cardiac surgery with prolonged cardiopulmonary bypass exposure, characterised by a reduction of angle and maximum amplitude values, with no change in reaction time.

Introducción: La tromboelastografía se emplea para la orientación en el manejo de la coagulación perioperatoria en el sitio de atención. Objetívo: Identificar un patrón de coagulación en niños sometidos a tiempos prolongados en circulación extracorpórea así como su asociación con edad y peso. Material y Métodos: Realizamos un estudio de cohorte en 62 pacientes sometidos a circulación extracorpórea prolongada. Excluimos pacientes con coagulopatía pre - existente, empleo de medicamentos interfiriendo con la coagulación, hematocrito > 60%, peso < 3 Kg o con enfermedad hepática. El estudio de tromboelastografía fue realizado en el sitio de atención. Resultados: Los valores para el tiempo de Reacción basales y durante recalentamiento fueron: 8,24 +/- 6,35 y 7,66 +/- 2,15 minutos respectivamente (p= 0,102). Los valores para el Ángulo basales y durante recalentamiento fueron: 64,89 +/- 13,08 y 54,67 +/- 8,98 grados (p< 0,001). Los valores para Amplitud Máxima basales y durante recalentamiento fueron: 64,54 +/-12,31 y 43,14 +/- 12,47 mm respectivamente (p = 0,001). Dividiendo la cohorte en pacientes menores o mayores a 3 años o bien en menores o mayores a 10 Kg se observó el mismo comportamiento. Discusión: Este estudio sugiere la existencia de un patrón tromboelastográfico independiente de la edad o peso en pacientes sometidos cirugía cardiaca pediátrica con permanencia prolongada en circulación extracorpórea caracterizado por reducción en los valores de ángulo y amplitud máxima, sin modificación en el tiempo de reacción.

[Safety of repeat median sternotomy in the palliative treatment of patients with a univentricular heart]. / Seguridad de la re-esternotomía media en el tratamiento paliativo de pacientes con corazón univentricular.

OBJECTIVE: To establish the morbidity and mortality of patients with univentricular hearts who underwent a repeat median sternotomy at the Instituto Nacional de Pediatría. METHOD: A retrospective review was performed on the clinical charts of all patients who underwent a repeat median sternotomy from 2001 to 2016. RESULTS: Sixty-five patients underwent 76 surgeries by repeat median sternotomy. Fifty-nine patients had a first repeat median sternotomy, with a mean age of 36 months (range: 4-176 months) and a mean weight of 12.2 kg (range: 3.2-21.5 kg). Forty patients had a Glenn procedure, and 19 patients had a Fontan procedure. There were 17 patients with a second repeat median sternotomy, with a mean age of 89 months (range 48-156 months), and a mean weight of 22.7 kg (14.4-41 kg). A Fontan procedure was performed on all these 17 patients. A section of the right coronary artery with electrocardiographic changes and a right atrium tear that caused hypotension occurred during first repeat sternotomy. An aortic tear occurred during a second repeat sternotomy with massive bleeding and subsequent death. This represents 3.9% of re-entry injuries. CONCLUSION: It is concluded that repeat median sternotomy is a safe procedure.

Preservación de hepatocitos en soluciones de UW y HTK con adición de fluorocarbonos / Hepatocyte preservation in UW and htk solutions with hydrocarbon addiction

Antecedentes: una de las limitantes del trasplante de hepatocitos es la corta supervivencia de los hepatocitos aislados. Objetivo: este estudio evalúa la utilidad de los fluorocarbonos adicionados a la solución de Universidad de Wisconsin (UW) y a la solución de Histidina-Triptófano-Ketoglutarato (HTK) en la preservación de hepatocitos. Método: se aislaron hepatocitos de ratas Fisher con la técnica de digestión por colagenasa, con una viabilidad mayor a 85 por ciento de acuerdo a la técnica de exclusión de azul de tripano. Se suspendieron 1.2 x 10 8 un volumen total de 20 mL de: HTK (HTK), HTK con perfluoro-n-octano (HTK+ PFC), UW (UW), UW con perfluoro-n-octano(UW-PFC) y medio E. Williams como grupo control (GC). Las cinco muestras de cada grupo se almacenaron a 4 ºC durante 40 horas. Se realizaron determinaciones de viabilidad celular, formación de vesículas de membrana grandes y LDH extracelular a las: 0, 12, 24 y 36 horas. Resultados: la viabilidad de los hepatocitos fue menor en la solución UW comparada con el resto de los grupos de estudio a las 12 horas y 24 horas (p < 0.05 para ambas), pero a las 36 horas no existió diferencia entre los grupos. La presencia de vesículas de membranas grandes fue menor en la solución de UW + PFC que en el resto de las soluciones de estudio, pero esta diferencia sólo alcanzó significancia estadística al comparar soluciones con o sin fluorocarbonos en ninguno de los tiempos de estudio. Conclusiones: la adición de fluorocarbonos en la solución de UW disminuye la formación de vesículas de membrana grandes (daño irreversible), mejorando la viabilidad de los hepatocitos. Sin embargo, la adición de fluorocarbonos a cada solución no incrementa el tiempo de preservación con una viabilidad superior al 50 por ciento más allá de 24 horas.