Revisiting the central aortopulmonary shunt procedure.

Background: In this study, we present our experience with the central aortopulmonary shunt technique with interposing a polytetrafluoroethylene graft between main pulmonary artery (end-to-end) and the ascending aorta (side-to-side) in a variety of cyanotic congenital heart defects. Methods: Between January 2019 and June 2022, a total of 10 patients (6 males, 4 females; mean age: 4.3±2.8 months; range, 5 days to 10 months) with hypoplastic central pulmonary arteries who underwent central aortopulmonary shunt procedure were retrospectively analyzed. Demographic characteristics, preoperative, operative, and postoperative data of the patients were recorded. The Nakata indices of the patients were also noted before the procedure, as well as before the second stage of palliation or definitive repair. Results: Four (40%) patients were operated as the first-step palliation for univentricular circulation. Six (60%) patients had well-developed ventricles and were palliated to be treated with total correction. The median follow-up after the procedure was 12 (range, 8 to 16) months. The mean systemic arterial saturation level at room air was 89.3±2.9% during follow-up. No mortality was observed in any patient. Conclusion: A central aortopulmonary shunt procedure provides a reliable antegrade blood flow with a relatively non-challenging surgical technique that offers sufficient growth for the hypoplastic and confluent central pulmonary arteries with a very low risk of shunt thrombosis and overflow.

Early outcomes of fenestrated intra-extracardiac Fontan procedure: Insights, experiences, and expectations.

BACKGROUND: Intraextracardiac Fontan procedure (FP) aimed to combine the advantages of lateral tunnel and extracardiac conduit modifications of the original technique. Herein, we present our early outcomes in patients with intraextracardiac fenestrated FP. METHODS: A retrospective analysis was performed to evaluate intraextracardiac fenestrated Fontan patients between 2014 and 2021. Seventeen patients were operated on with a mean age and body weight of 9.1 ± 5.5 years and 28.6 ± 14.6 kg. RESULTS: Sixteen patients (94%) were palliated as univentricular physiology with hypoplasia of one of the ventricles. One patient (6%) with well-developed two ventricles with double outlet right ventricle and complete atrioventricular septal defect had straddling of the chordae prohibiting a biventricular repair. All of the patients had cavopulmonary anastomosis before Fontan completion, except one case. Fenestration was performed in all cases. Postoperative mean pulmonary artery pressures and arterial oxygen saturation levels at follow-up were 10 ± 2.4 mmHg and 91.3 ± 2.7%, respectively. Mean duration of pleural drainage was 5.4 ± 2.3 days. All of the fenestrations are patent at a mean follow-up period of 4.8 ± 7.7 years, except one case. Any morbidity and mortality were not encountered. CONCLUSIONS: Early outcomes of intraextracardiac fenestrated FP are encouraging. This procedure may improve the results in a patient population who should be palliated as univentricular physiology, especially in cases with complex cardiac anatomy.

Fontan procedure in patients with preoperative mean pulmonary artery pressure over 15 mmHg.

BACKGROUND: Several factors affect the long-term outcome of Fontan procedure, but a high pulmonary artery pressure is still one of the most important limitation for proceeding to a Fontan circulation. Herein, we present our experience in Fontan patients with high preoperative pulmonary artery pressures. METHODS: A retrospective analysis was performed to evaluate Fontan patients with a preoperative pulmonary artery pressure >15 mmHg between 2009 and 2020. Sixteen patients were operated on with a mean preoperative pulmonary artery pressure of 17.5 ± 2.1 mmHg. RESULTS: Mean age at the time of Fontan procedure was 7.8 ± 5.6 years. All the patients had stage 2 cavopulmonary anastomosis before Fontan completion, with a mean interstage period of 4 ± 2.6 years. Fontan completion was achieved with a polytetrafluorethylene tubular conduit, two of which were intra-extracardiac. Fenestration was performed in five (31%) cases. Postoperative pulmonary artery pressures and arterial oxygen saturation levels were 11.2 ± 2.8 and 97.8 ± 2 mmHg, respectively. Mean duration of pleural drainage was 3.9 ± 5.3 days. Any morbidity and mortality were not encountered during a mean follow-up period of 4.8 ± 7.7 years. CONCLUSIONS: The midterm results of stage 3 Fontan completion in patients with pulmonary artery >15 mmHg are encouraging. Not only the mean pulmonary artery pressure but also the pulmonary vascular resistance may be helpful in order to identify the high risk patients before Fontan completion.

A better approach for left ventricular training in transposition of the great arteries and intact interventricular septum: Bidirectional cavopulmonary anastomosis and pulmonary artery banding.

OBJECTIVE: Management of the patients with transposition of the great arteries and intact ventricular septum may be challenging beyond the newborn period. Herein, we would like to present our alternative strategy for training the left ventricle in these patients. METHODS: Six patients with transposition of the great arteries and intact ventricular septum were evaluated in our clinic. Two of them were palliated with Glenn procedure and pulmonary banding as a definitive treatment strategy at other centers. Four patients were operated on and a bidirectional cavopulmonary anastomosis in combination with pulmonary artery banding was performed (stage-1: palliation and ventricular training) in our center. In four out of these six patients, arterial switch operation was performed with takedown and direct re-anastomosis of the superior vena cava to right atrium after an interstage period of 21-30 months (stage-2: anatomical repair). RESULTS: Any mortality was not encountered. The left ventricular mass indices increased from 18-32 to 44-74 g/m2 in patients undergoing the anatomical repair. All of the patients were uneventfully discharged following the second stage. The mean follow-up period was 20 months (9-32 months) following stage 2. All of the patients are doing well with trivial neoaortic regurgitation and normal biventricular function. CONCLUSIONS: Bidirectional cavopulmonary anastomosis with pulmonary artery banding may be a promising left ventricle training approach in ventriculoarterial discordance when compared to the traditional pulmonary artery banding with concomitant systemic-to-pulmonary artery shunt procedures which still carry a significant interstage morbidity and mortality.

Double Switch Procedure and Surgical Alternatives for the Treatment of Congenitally Corrected Transposition of the Great Arteries.

BACKGROUND: We present our experience with the double switch operation in sixteen patients with congenitally corrected transposition of the great arteries. METHODS: We enrolled 16 patients with congenitally corrected transposition of the great arteries operated by a single surgeon between 1995 and 2015. The mean age was 25 months (range 4 to 72 months) and the mean body weight was 8.9 kg (range 4.3 to 19 kg) at the time of operation. RESULTS: We encountered seven patients with moderate to severe tricuspid regurgitation, five of which had Ebstein anomaly. We performed a combination of atrial and arterial switch procedures in 11 cases, one of which had a concomitant coarctation of the aorta that was repaired along with the double switch procedure. Atrial switch and the Rastelli procedures were performed in three cases with concomitant pulmonary stenosis. A combination of arterial switch, Hemi-Mustard procedure, and bidirectional cavopulmonary anastomosis was performed in two cases. During a mean follow-up period of 67 months (range three months to 18 years), we encountered one early postoperative mortality related to intracerebral bleeding. All but one of the patients are now in NYHA class I-II. CONCLUSIONS: Congenitally corrected transposition of the great arteries is a rare congenital cardiac anomaly in which the results of the anatomical repair with double switch operation appear to be superior to that achieved by a physiological repair.

Mid-Term Results of Congenital Supravalvar Mitral Ring Resection.

BACKGROUND: Supravalvar mitral ring is a rare congenital anomaly leading to left ventricle inflow obstruction. We present our surgical experience and mid-term results in patients operated for supravalvar mitral ring and associated congenital heart defects. MATERIALS AND METHODS: A retrospective analysis was performed in order to evaluate the cases surgically treated with the diagnosis of supravalvar mitral ring between 2001 and 2014. Ten patients were identified, seven of whom had accompanying congenital heart defects. Median age at the operation was 4.5 years. RESULTS: Ventricular septal defects were encountered in half of the cases. Two of the patients had mitral annular hypoplasia, another two had the components of Shone's complex. The mean preoperative gradient across the supravalvar mitral ring decreased from 14.1 ± 4.2 mmHg to 4.6 ± 2.2 mmHg. All patients are alive and remain in a good clinical condition after a mean follow-up of five years. CONCLUSION: Supravalvar mitral ring is a surgically treatable cause of left ventricular inflow obstruction. Although residual gradients may be encountered in patients with mitral annular hypoplasia, surgical resection of the ring is encouraged.

Modified Single Versus Double-Patch Technique for the Repair of Complete Atrioventricular Septal Defect.

OBJECTIVES: We present our single center results of two commonly used surgical techniques, the modified single-patch and double-patch technique for the repair of the complete atrioventricular septal defect. METHODS: We enrolled 49 patients with complete atrioventricular septal defect who were operated by a single surgeon between 2004 and 2014. The modified single-patch technique was performed in 32 cases (group S), whereas the defect was repaired with the double-patch technique in 17 patients (group D). RESULTS: The mean age at the time of operation was 7.7 ± 8.6 (range 1-48) months and 9.9 ± 12.5 (range 1.5-48) months, in groups S and D, respectively. Mean body weight was 6.7 ± 3 (range 3.5-15.5) kilograms and 7.2 ± 3.8 (range 4.3-14.5) kilograms in groups S and D, respectively. Cross-clamp and cardiopulmonary bypass times were shorter in the modified single-patch group (65.6 ± 16.3 vs. 98.7 ± 19.8 minutes, p = 0.0001; 88.9 ± 23.3 vs. 128.9 ± 28.0 minutes, p = 0.0001). Postoperative atrioventricular valve function was improved in both groups. Mean follow-up period was 4.4 ± 3.2 (range 1.2-9.9) years. One patient in each group underwent reoperation for left atrioventricular valve insufficiency. We encountered two early and one late mortalities in modified single-patch group. One early mortality was experienced in the unmodified group. CONCLUSIONS: The modified single-patch and two-patch techniques have comparable results; however, the modified single-patch technique is performed with significantly shorter cross-clamp and cardiopulmonary bypass times, therefore we have adopted this technique on a routine basis for the treatment of the complete atrioventricular septal defect in our institute.

Surgical correction of cor triatriatum sinister in the paediatric population: mid-term results in 15 cases.

OBJECTIVES: Cor triatriatum sinister (CTS) is a rare developmental cardiac abnormality resulting in left ventricular inflow obstruction. In this report, we aimed to present our mid-term results of early childhood patients operated for CTS and associated cardiac abnormalities. METHODS: We enrolled 15 patients with CTS who were operated by a single surgeon between 2001 and 2013. A retrospective analysis was performed in order to determine the demographics, operative and postoperative results of the patients. The median age was 14 months and the median body weight was 8.2 kg at the time of operation. RESULTS: Fourteen patients had concomitant cardiac pathology. Three of the patients had atrial septal defect and 1 of the patients had partial abnormal pulmonary venous connection, whereas 4 of the patients had both. In 2 cases of complete atrioventricular septal defect, 1 case with ventricular septal defect, 1 case with patent ductus arteriosus, 1 case with double outlet right ventricle and another case with tetralogy of Fallot, complete repair was performed together with membrane resection in the left atrium (LA). The mean preoperative left atrial gradient was 13.3 mmHg, whereas the mean LA pressure at the first postoperative year was 4.2 mmHg. There was 1 case with early mortality due to septic multiorgan failure secondary to pneumonia. CONCLUSIONS: CTS is a rare congenital cardiac anomaly in which the results of the corrective surgery are encouraging. Early and long-term outcomes may be variable according to the associated congenital heart defects.

Evaluation of intravenous paracetamol administration on postoperative pain and recovery characteristics in patients undergoing laparoscopic cholecystectomy.

PURPOSE: In this study, the effects of intravenous paracetamol treatment on early postoperative period analgesia and recovery characteristics after laparoscopic cholecystectomy have been evaluated. METHODS: Forty patients whose American Society of Anesthesiologists physical status I or II underwent laparoscopic cholecystectomy and randomly divided into 2 equal groups. In the first group, 1 g paracetamol was given to the patients intravenously after intubation before start of the surgery in 15 minutes. The 100 mL 0.9% NaCl was infused intravenously for the control group in 15 minutes. Postoperative pain was evaluated and recovery characteristics were evaluated. RESULTS: Verbal and visual pain scores of the paracetamol group were significantly lower than control group (P<0.05). First morphine requirement and total administered morphine dose and duration of staying in recovery room were significantly decreased in the paracetamol group (P<0.05). CONCLUSIONS: Beside its effective analgesic properties, paracetamol administration during per operative period supports effective and faster recovery.

Effects of pneumoperitoneum and positioning on respiratory mechanics in chronic obstructive pulmonary disease patients during Nissen fundoplication.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the effects of pneumoperitoneum and patient positioning on respiratory mechanics and blood gases in chronic obstructive pulmonary disease (COPD) patients during laparoscopic Nissen fundoplication. METHODS: After the approval of the Ethical Committee, 32 patients were divided into 2 groups as COPD patients (n=16) and normal patients (n=16). Dynamic respiratory compliance (Cdyn), airway resistance, and peak inspiratory pressure were monitored. Measurements were made in 5 time points: after intubation (intubation), Trendelenburg position (Trendelenburg), during laparoscopic Nissen fundoplication surgery after pneumoperitoneum with the Fowler position (Fowler), right before the desufflation with Fowler position (Fowler-end), and after the desufflation in supine position (supine). Samples of arterial blood gases were collected at the same periods. RESULTS: At all periods, there was a significant decrease in Cdyn and arterial oxygen pressure in 2 groups. Although pneumoperitoneum did not exist during Trendelenburg position, the Cdyn (38+/-13 mL cm H2O(-1)) found to be significantly decreased in COPD patients. In 2 groups, the lowest Cdyn value detected during the Fowler-end period was 43+/-8 mL cm H2O(-1) in control group and 34+/-11 mL cm H2O(-1) in COPD group. Whereas the pH decreased at Fowler, Fowler-end, and supine period, arterial carbon dioxide pressure increased (P<0.05). There was no difference for the other parameters. CONCLUSIONS: In COPD patients, Trendelenburg position has negative effect on respiratory mechanics. Pneumoperitoneum and other positions have similar effect on respiratory mechanics in COPD and control patients.

Neuromuscular effects of cisatracurium in morbidly obese patients.

Obesity is associated with significant changes in body composition and function that may alter the pharmacodynamics and pharmacokinetics of various drugs. In this study, we investigated the neuromuscular effects of cisatracurium in morbidly obese as compared to control group of normal body weight patients. In the morbidly obese group (n = 20), corrected weight was used to calculate the drug doses. In the control group (n = 20), the dose was calculated on ideal body weight (IBW). 0.15 mg/kg(-1) cisatracurium was administered as the neuromuscular blocker. Neuromuscular effects were recorded at T0 (onset time), T1 (appearance of first stimulus of TOF), T25 (25% recovery of T1) and T25-75 (time of T25 to T75, recovery time). T0 was determined as 177 +/- 23 s and 168 +/- 19 s in the morbidly obese, and control group, respectively. T25 was determined as 46 +/- 7 min and 56 +/- 8 min, in the morbidly obese and control group, respectively (p < 0.05). T25-75 was determined as 11 +/- 5 min and 14 +/- 6 min in the morbidly obese and control group, respectively (p < 0.05). Intubation conditions were determined as good in 13, excellent in 7 patients in the morbidly obese group, and as good in 4 and excellent in 16 patients in the control group (p < 0.05). As different neuromuscular effects of cisatracurium were detected, we conclude that ne uromuscular agents must be monitored in the morbidly obese patients.

The effects of pneumothorax on the respiratory mechanics during laparoscopic surgery.

Pneumothorax is rare but can be a severe complication of laparoscopic surgery. Diagnosis of pneumothorax in laparoscopy includes the sudden increase in end-tidal carbon dioxide (EtCO(2)) with a decrease in compliance and an abnormal increase in airway pressure. By these case reports, we recommend the simultaneous monitoring of airway pressures, dynamic compliance, and particularly, EtCO(2) for an immediate diagnosis and prompt treatment of pneumothorax.

Effect of pneumoperitoneum on the level of plasma potassium.

The purpose of this study was to find out the impact of acute respiratory acidosis on serum potassium level during laparoscopy. The study was performed on ninety patients who underwent laparoscopic surgery. Ventilation parameters were kept constant throughout the study. Samples for assessment of blood gases were collected in the following sequence: before pneumoperitoneum, a the 20th minute of pneumoperitoneum, at the 60th minute of pneumoperitoneum, and after extubation. The systolic, diastolic pressures and heart rate were recorded simultaneously. Before pneumoperitoneum, heart rate, systolic and diastolic pressures were reduced according to baseline values. With the induction of pneumoperitoneum, both systolic and diastolic pressures returned to the baseline levels except the heart rate. There was a statistically significant increase in potassium level (Control: 3.49 mEq.L(-1), determined high level: 3.75 mEq.L(-1)). Electrolytes, especially potassium, should be monitored during laparoscopy utilizing CO2 pneumoperitoneum and when necessary, ventilatory parameters should be adjusted.

Effect of intra-abdominal pressure level on gastric intramucosal pH during pneumoperitoneum.

The present study was designed to examine the effect of intra-abdominal pressure level on gastric intramucosal pH using gastric tonometry during pneumoperitoneum. One hundred patients were prospectively randomized into 5 equal groups (N = 20 each). Intra-abdominal pressure levels were 8, 10, 12, 14, and 16 mm Hg in groups I, II, III, IV, and V, respectively. Intramucosal pH measurement was done 2 times: 30 minutes following insufflation and 1 hour after the ending of the surgery. In the first and second measurements, intramucosal pH values were found as 7.39 +/- 0.02 and 7.36 +/- 0.03 in group I; 7.41 +/- 0.03 and 7.38 +/- 0.03 in group II; 7.37 +/- 0.03 and 7.37 +/- 0.03 in group III; 7.36 +/- 0.03 and 7.37 +/- 0.03 in group IV; and 7.39 +/- 0.03, 7.36 +/- 0.03 in group V, respectively. Statistical significance was not found in the comparison of these values within the groups and between the groups (P > 0.005, for each). In conclusion, intra-abdominal pressure between 8 and 16 mm Hg did not cause significant difference in gastric intramucosal pH.

Effects of sevoflurane, propofol and position changes on respiratory mechanics.

This study was designed to investigate the effects of propofol, sevoflurane and position changes on respiratory mechanics. Forty patients scheduled for thyroid surgery were divided randomly into two groups; those receiving sevoflurane (group S) (n=20), and those receiving TIVA propofol (group P) (n=22). Dynamic compliance (Cdyn), peak inspiratory pressure (PIP), and respiratory resistance (Rr) values were recorded with a VenTrak respiratory monitor (Novometrix Inc. USA) at three time instances. The first measurement was done immediately after the beginning of ventilation and before the inhalation agent was initiated (Induction). Second measurement was done after 5 minutes of thyroid position (Thyroid) (ventilation with 1 MAC sevoflurane concentration or propofol infusion at the rate of 6 mg/kg/h). The third measurement was performed 5 minutes after end of surgery in the supine position (Supine) Blood gases were measured at the three time instances. Respiratory mechanics did not change in the P group (51 +/- 13, 46 +/- 11, 48 +/- 10 mL/cmH2O) at Induction, Thyroid and Supine positions). In the S group, dynamic compliance measurements showed changes statistically significant in the supine position (52 +/- 6 mL/cmH2O)) when compared to Induction (47 +/- 9 mL/cmH2O) and Thyroid position (47 +/- 6 mL/cmH2O) measurements (p<0.05). When the groups were compared with each other, there was no significant difference whatsoever at all periods (p>0.05). His concluded that sevoflurane, propofol and position changes exhibit similar effects on respiratory mechanics and blood gases at described dose and concentration.

Effects of intraperitoneal and extraperitoneal carbon dioxide insufflation on blood gases during the perioperative period.

The aim of this study was to evaluate the effects of intraperitoneal and extraperitoneal CO2 insufflation on blood gases during and after laparoscopic surgery. Forty patients were included in this study. Twenty patients underwent elective laparoscopic cholecystectomy with intraperitoneal insufflation (intraperitoneal group) and 20 patients underwent laparoscopic inguinal hernia repair with extraperitoneal insufflation (extraperitoneal group). Arterial blood gases were analyzed at four points: 10 minutes after induction, 10 minutes after insufflation, 10 minutes after desufflation, and 30 minutes after the operation in the recovery room. PaCO2 values in the intraperitoneal group at the four points were 36.8 +/- 4, 39.6 +/- 5.9, 40.7 +/- 4.4, and 42.3 +/- 4.8 mm Hg; in the extraperitoneal group, 35.8 +/- 3.9, 37.4 +/- 4, 42.8 +/- 6.6, and 46.2 +/- 5.9 mm Hg. In the extraperitoneal group, there was a significant increase in postoperative PaCO2 compared to the desufflation PaCO2. In our study, extraperitoneal CO2 insufflation caused increases in PaCO2 values that started perioperatively and continued in the postoperative period.

Effects of sevoflurane versus TIVA on gastric intramucosal pH and hemodynamic status in colon cancer surgery.

BACKGROUND: Gastric tonometry is a minimally invasive device by which the adequacy of splanchnic blood flow is assessed indirectly. Patients undergoing major abdominal surgery are under the risk of developing splanchnic ischemia. The aim of this study was to compare gastric intramucosal pH and hemodynamic effects between sevoflurane and TIVA achieved by propofol. METHODS: Forty patients of ASA I-II were studied. Twenty patients received sevoflurane (Group S) and 20 patients received TIVA by propofol (Group P). Continuous measurements were made at four intervals: (a) 30 minutes before the starting of the surgery, (b) at the first hour of the surgery, (c) at the second hour of the surgery, (d) at the first hour after ending of the surgery. The mean arterial pressure, heart rate, SpO2, EtCO2, body temperature, central venous pressure, urine output, intramucosal and arterial pH were monitored. RESULTS: There were no significant differences between two groups regarding the studied parameters. CONCLUSIONS: Sevoflurane and propofol did not cause any significant difference in hemodynamic effects and splanchnic circulation measured by gastric tonometry in ASA I-II patients operated on for colon cancer.

Influence of the patient positioning on respiratory mechanics during pneumoperitoneum.

The aim of this study was to evaluate the effect of patient positioning during laparoscopic cholecystectomy on respiratory mechanics and arterial blood gases. Thirty patients of ASA I were included. Ventilation was controlled mechanically. Tidal volume and ventilator frequency were kept unchanged throughout the operation. Intra-abdominal pressure was kept constant at 12 mmHg. Ventrak respiratory system was used for measuring respiratory mechanics. The airway resistance (Raw), the dynamic compliance (Cdyn), and the peak inspiratory pressure (PIP) were monitored. Measurements were made in five intervals: "a" after induction of general anesthesia, "b" after insufflation, "c" in the Trendelenburg position of 40 degree, "d" in the Fowler position of 40 degree, and "e" after desufflation. Samples of arterial blood gases were collected while the respiratory mechanics were being recorded. The mean arterial pressure (MAP) and heart rate (HR) were also monitored. In our study, during intervals "c" and "d", PCO2, was increased and pH decreased. With the initiation of insufflation, Cdyn, PIP, and Rawx, were altered (P < 0.05). The patient positioning had a significant effect on respiratory mechanics. After desufflation only Cdyn changed (P < 0.05). Although HR remained in normal limits, MAP increased during pneumoperitoneum (P < 0.05). We conclude that blood gas changes and respiratory mechanics were affected by the duration of pneumoperitoneum and patient positioning. The Fowler position had the least influence on respiratory mechanics.