Use of the novel curved GOKU balloon catheter for acute-angled lesions in palliative surgery for congenital heart disease: comparison with a conventional straight balloon.

Obstruction develops commonly at the acute-angled portion of the vessels following palliative surgery, such as systemic-pulmonary shunt (SP shunt), right ventricle-to-pulmonary artery shunt (RV-PA shunt) in the Norwood-Sano procedure for hypoplastic left heart syndrome, and cavopulmonary (Glenn) anastomosis. Although balloon angioplasty is a treatment option, dilation with existing straight balloons is sometimes ineffective and technically complicated because of balloon slippage and target vessel distortion. In this study, we investigated the effectiveness of a curved GOKU balloon catheter for balloon angioplasty in postoperative acute-angled lesions associated with palliative surgery for congenital heart disease. We reviewed patients who underwent balloon angioplasty for angled lesions complicated by SP shunt, RV-PA shunt, or Glenn anastomosis, using the novel curved GOKU or a conventional balloon catheter, such as a Sterling balloon catheter. We evaluated patients' backgrounds, balloon specifications, target lesion anatomical features and angles, and short-term outcomes. We evaluated 45 procedures in 18 patients. A curved GOKU was used in 20 procedures, and a Sterling balloon in 25 procedures. The angulation of the lesions at maximum balloon inflation was significantly smaller using a curved GOKU vs a Sterling balloon [70-120 (mean ± standard deviation, 97 ± 40) degrees vs 110-180 (149 ± 46) degrees, respectively; p < 0.001], while the original angle was similar between the groups. Patients' short-term outcomes with the curved GOKU were excellent, with a significantly better percent increase in minimum lumen diameter of 0-220% (92% ± 66%) vs 0-46% (18% ± 15%) with the Sterling balloon (p < 00.1) and with less frequent balloon slippage. The curved GOKU was more effective in balloon angioplasty for acute-angled lesions compared with a conventional straight balloon, likely because of better conformability to the lesion angle and slip resistance.

Percutaneous pulmonary artery debanding.

BACKGROUND: There is a paucity of data on palliative or total percutaneous pulmonary artery debanding (p-debanding), particularly with use of a stent. METHODS: Twelve p-debandings in eight patients were included in this study. Age at pulmonary artery banding (PAB) ranged from 3 days to 1 year (median, 13 days), while p-debanding was performed at 2-157 (7) months. The body weight at the p-debanding ranged from 3.2 to 22.2 (7.3) kg. We chose the balloon diameter of 30-50% to the circumference of the band for palliative, and larger than 50% for total p-debanding, respectively. In either way, the balloon diameter did not exceed 1.5 times the reference vessel diameter. Stent was implanted for palliative p-debanding in 2 patients. RESULTS: 1. The circumference of the band ranged from 16 to 23 (20) mm, while the balloon diameter ranged from 20-60 (40)% to that, where larger than 50% was used for 2 procedures intended total p-debanding. 2. PAB diameter increased from 2.5-4.7 (3.0) mm to 2.8-9.5 (4.5) mm (p<0.01), however, there was no significant change in the diameter in 2 procedures. In one patient, p-debanding was the definitive treatment associated with spontaneous near closure of muscular ventricular septal defect, in another patient of congenitally corrected transposition of the great arteries, severely depressed left ventricular ejection fraction was recovered following p-debanding. 3. Arterial oxygen saturation (SaO2) increased from 64-97 (80)% to 66-95 (90)% (p<0.01), while in 10 procedures of 6 patients where the indication of p-debanding was hypoxia, SaO2 increased in 8 procedures. There was no significant pulmonary hypertension following p-debanding. CONCLUSION: Palliative or total p-debanding using balloon and/or stenting is generally feasible and effective. A balloon diameter 35-50% to the band circumference in palliative, and more than 50% in total p-debanding, while in either way less than 1.5 times the reference vessel diameter, is safe.

Transcatheter closure of perimembranous ventricular septal defects with Amplatzer® duct occluder I; The first case report in Japan.

We report the first case of transcatheter perimembranous ventricular septal defect (pmVSD) closure in Japan where none of existing devices for VSD closure has been approved. The pmVSD was successfully closed with first generation Amplatzer® duct occluder (ADO-I; St Jude Medical, St Paul, MN, USA). The procedure was performed under general anesthesia with transesophageal echocardiographic and fluoroscopic guidance. The left ventricular volume overload after the procedure was remarkably improved and no major complications occurred. ADO-I can be a safe and effective option for transcatheter pmVSD closure. The incidence of heart block may be less than reported with the original device. .

Percutaneous pulmonary debanding for an infant complicated by spontaneously closing muscular ventricular septal defect: A case report and in vitro study.

Pulmonary artery banding (PAB) is a standard operation for various congenital heart defects complicated by pulmonary hypertension (PH) and judged unsuitable for primary intracardiac repair. We report successful percutaneous pulmonary artery debanding in a baby complicated by muscular ventricular septal defect (VSD), that was initially large and multiple, but closed spontaneously later. The 5-month-old boy was referred to our hospital on day 3, diagnosed as having aortic coarctation (CoA), with multiple muscular VSDs and severe PH. On day 6, he underwent CoA repair and PAB using expanded polytetrafluoroethylene (ePTFE), while the muscular VSDs were left open. We planned percutaneous pulmonary debanding at the age of 5 months, as the muscular VSDs had become small. After dilation with a Mustang® (Boston Scientific, Marlborough, Massachusetts, United State) balloon (12 mm diameter) there was a persistent waist indicating a residual narrowing. Use of an extra-high pressure balloon, Conquest® (Medicon, Osaka, Japan) balloon of the same size, completely eliminated the waist. In in vitro experiments, the Mustang® partially tore the ePTFE, while a Conquest® of the same diameter completely opened the band. The mechanism of debanding was tearing of the ePTFE by the knot of the suture thread. Percutaneous pulmonary debanding to avoid unnecessary surgery is feasible in such a patient if the VSD becomes small. .

Static balloon atrial septostomy for the purpose of left heart intervention in postoperative adult CHD.

Background and purposeStatic balloon atrial septostomy is a widely accepted intervention for children with CHD. Successful surgical palliation is creating increasing numbers of adult CHD patients who need subsequent left heart intervention requiring transseptal access. In these patients, the interatrial septum is usually thick and fibrotic because of a previous open heart surgery or catheter intervention, and conventional transseptal puncture may be unsuccessful. Static balloon atrial septostomy to access the left atrium may facilitate intervention via the interatrial septum in such situations. The purpose of this study was to investigate the usefulness and the safety of static balloon atrial septostomy, and the evolution of an iatrogenic atrial septal defect post procedure in adult CHD. METHODS: We retrospectively reviewed six procedures in five adults with CHD and collected demographic characteristics, details of the procedures, clinical outcome, and size changes of the iatrogenic atrial septal defect. RESULTS: The mean age at the time of the procedure was 35 years. The intended primary interventions were pulmonary vein isolation, stenting for pulmonary vein obstruction, and catheter ablation for focal atrial tachycardia. All static balloon atrial septostomies were effective, and the left heart interventions were successfully achieved via transseptal sheaths. There were no major complications associated with the static balloon atrial septostomy. There were no adverse clinical outcomes related to iatrogenic atrial septal defect, and the size of the defects regressed over time in all cases. CONCLUSIONS: Static balloon atrial septostomy can be a safe and useful technique in adult CHD patients needing left heart procedures. The thick interatrial septum found in postoperative patients may reduce the risk of persistent iatrogenic atrial septal defect.

Stent unzipping using an ultra-high-pressure balloon: in vitro and animal experiments.

As a child grows, limitations to the maximum dilatable stent diameter (MDD) will result in stenosis associated with size mismatch. If an implanted stent can be intentionally fractured along its length, a process called "unzipping," it may eventually be redilated to adult vessel size. Few studies have addressed how a stent can be unzipped using an ultra-high-pressure balloon (UHB) with the smallest balloon diameter. Eleven commercially available stents, three Liberté stents (LS), six genesis renal stents (GS), and two express vascular SD stents (ES), were tested for in vitro unzipping. In addition, using eight stents, we investigated whether a balloon that had unzipped the stent in vitro would work similarly in the vessel of a pig. Finally, we assessed the histological influence of the unzipped stent on the surrounding tissue. In a bench test, LS, GS, and ES were consistently unzipped by a balloon whose diameter was ≥ 1.5, 2.18, and 1.66 times that of MDD, respectively. In animal experiments, LS, GS, and ES were predictably unzipped with balloons of 1.50, 1.81, and 1.66 times the MDD, respectively. After unzipping, the unzipped strut did not damage the surrounding tissue histologically. Use of a UHB enabled unzipping of the stent with a balloon diameter less than two times the MDD enables implantation of a larger stent in the unzipped small stent by incremental steps.

Novel curved balloon catheter for dilating postoperative angled lesions associated with congenital heart disease.

OBJECTIVES: This study aimed to analyze the surface stress generated by a novel curved balloon and assess its efficacy for treating angular lesions associated with congenital heart disease. BACKGROUND: Obstructions at the anastomosis of aortopulmonary shunts and cavopulmonary connections may occur postoperatively. Catheter interventions are often performed for such lesions; however, acute angulation may cause balloon slippage or inappropriate stress on the vessel wall. METHODS: We dilated the curved balloon in a curved vessel model and measured the resultant wall stress and its distribution. Clinical evaluations were performed using this balloon in angled lesions. RESULTS: In the curved vessel model, curved balloons generated uniform stress on the lesser and greater curvatures (curved type, lesser/greater = 0.343 MPa/0.327 MPa; P = 0.61), whereas straight balloons caused disproportionate stress (straight type, lesser/greater = 0.358 MPa/0.254 MPa; P = 0.19). However, the difference in average stress was not statistically significant. Furthermore, the stress was uniform along the entire length of the curved balloon, but differed between the mid and end portions of the straight balloon. Curved balloon dilations were performed for 10 lesions in 7 patients. The curved balloon conformed well to the angulated lesion without slipping. The median percent change in the minimal lumen diameter (MLD) was 64% (range, 0-206%). In 5 lesions, MLD increased by ≥50%. Oxygen saturation increased by 5% (0-9%). CONCLUSIONS: Although further clinical evaluation is necessary, this novel curved balloon may be a reasonable alternative in angled lesions, providing better conformability and preventing excessive stress to the vessel wall adjacent to the stenosis.

Atrionatriuretic peptide improves left ventricular function after myocardial global ischemia-reperfusion in hypoxic hearts.

Atrionatriuretic peptide (ANP) is reported to be useful for attenuating myocardial ischemia-reperfusion injury and improving left ventricular function after reperfusion. However, ANP may be either ineffectual or harmful in cases where the myocardium has been chronically hypoxic since birth. This can be a result of the concomitant high levels of cyclic guanosine monophosphate (cGMP) produced within the myocardium. This study aimed to verify the validity of using ANP to improve left ventricular function after myocardial ischemia-reperfusion injury. For this purpose, a cyanotic congenital disease model that was developed using isolated rat hearts was used. Hearts were obtained from Sprague-Dawley rats that were housed from birth until 6 weeks of age either in a hypoxic environment with 13-14% FiO(2) (hypoxic group) or in ambient air (normoxic group). These hearts were subjected to 30min of normothermic global ischemia followed by 30min of reperfusion using the Langendorff technique. Left ventricular functional recovery in hearts administered ANP (0.1µM) into the reperfusion solution was compared with those hearts that were not administered ANP in both hypoxic (without ANP: n=6, with ANP: n=6, with ANP and HS-142-1[an antagonist of ANP]: n=6) and normoxic hearts (without ANP: n =6, with ANP: n=6). In the hypoxic hearts, ANP administration improved the percent recovery of the left ventricular developed pressure (76.3±9.2% without ANP vs. 86.9±6.7% with ANP), maximum first derivative of the left ventricular pressure (82.4±1.1% without ANP vs. 95.8±6.5% with ANP), and heart rate (85.6±4.7% without ANP vs. 96.1±5.2% with ANP) after reperfusion. The improvement and recovery of these cardiac functions were closely related to significantly increased levels of postischemic cGMP release after ANP administration. The effect of ANP was blocked by HS-142-1. The improvements observed in the hypoxic group were similar to those found in the normoxic group. ANP administration during reperfusion improved left ventricular function after myocardial acute global ischemia-reperfusion equally in both the chronically hypoxic and age-matched normoxic groups.

Impact of chronic cyanosis and reoxygenation on the microheterogeneity of the myocardial blood flow: digital radiographic study in neonatal rats.

PURPOSE: This study sought to show the heterogeneity of myocardial blood flow in the chronically hypoxic infantile myocardium and its response to reoxygenation using a novel type of digital radiography. METHODS: Newborn rats were housed in a hypoxic chamber or in a normal chamber (controls). After 4 or 8 weeks, the control rats were ventilated with normoxic conditions, and the rats housed under hypoxia were ventilated with either hypoxic (cyanotic group) or normoxic conditions (reoxygenation group). Desmethylimipramine labeled with tritium (HDMI) was injected into the left ventricle, and both ventricular free walls were sectioned and sliced from the subepicardium to the subendocardium at 10 mm thickness. The within-layer distribution of HDMI density was measured by digital radiography, and its spatial heterogeneity (i.e., flow heterogeneity) was quantified by the coefficient of variation (CV) of flows. RESULTS: There were no differences in the CV between the groups in either ventricle at 4 weeks of age and no differences in the right ventricle at 8 weeks of age. There was a trend toward a higher left ventricular CV in the cyanotic group than in the control group at 8 weeks of age (0.637 ± 0.099 vs. 0.510 ± 0.060, P = 0.06). At 8 weeks of age, the CV was lower in both ventricles in the reoxygenation group than in those of the control and cyanotic groups. CONCLUSION: The chronically hypoxic infantile myocardium exhibits regional flow heterogeneity similar to that observed in the normal myocardium in both ventricles and exhibits reduced flow heterogeneity in response to reoxygenation.

Evaluation of the appropriate root pressure for maintaining heartbeat during an aortic cross-clamp for primary repair of the aortic arch in premature infants with associated cardiac anomalies.

We developed a new cardiopulmonary bypass (CPB) method to minimize myocardial damage during aortic arch reconstruction. In this method, coronary flow and heartbeat were stabilized by maintaining the aortic root pressure with an adjusted preload of the ventricle during aortic cross-clamping. This study was performed to determine the appropriate root pressure to maintain the heartbeat without causing deterioration of ventricular function. Study 1. Under partial CPB, the ascending aorta was cross-clamped in 6 pigs (group 1). Experimental data at various systolic aortic root pressures was analysed to determine the appropriate root pressure. Study 2. In group 2 (control, n＝6), the aorta was not clamped, while in group 3 (n＝6), the aorta was cross-clamped for 60 min and the systolic aortic root pressure was maintained at the pressure determined in study 1. Study 1. The diastolic coronary flow was stabilized at values comparable to that before initiation of CPB (6.6±1.4 ml/beat) when the systolic aortic root pressure was above 80 mmHg. Intracardiac pressure and the myocardial oxygen consumption (MvO2) seemed to be acceptable when the systolic aortic root pressure was below 100 mmHg. Therefore, 90 mmHg was selected for study 2. Study 2. Perioperative cardiac function did not differ between the groups. We concluded that 90 mmHg was the systolic aortic root pressure appropriate for this method.

Effect of inhibition of glycogen synthase kinase-3 on cardiac hypertrophy during acute pressure overload.

OBJECTIVE: A large number of diverse signaling molecules in cell and animal models participate in the stimulus-response pathway through which the hypertrophic growth of the myocardium is controlled. However, the mechanisms of signaling pathway including the influence of lithium, which is known as an inhibitor of glycogen synthase kinase-3beta, in pressure overload hypertrophy remain unclear. The aim of our study was to determine whether glycogen synthase kinase-3beta inhibition by lithium has acute effects on the myocyte growth mechanism in a pressure overload rat model. METHODS: First, we created a rat model of acute pressure overload cardiac hypertrophy by abdominal aortic banding. Protein expression time courses for beta-catenin, glycogen synthase kinase-3beta, and phosphoserine9-glycogen synthase kinase-3beta were then examined. The rats were divided into four groups: normal rats with or without lithium administration and pressure-overloaded rats with or without lithium administration. Two days after surgery, Western blot analysis of beta-catenin, echo-cardiographic evaluation, left ventricular (LV) weight, and LV atrial natriuretic peptide mRNA levels were evaluated. RESULTS: We observed an increase in the level of glycogen synthase kinase-3beta phosphorylation on Ser 9. A significant enhancement of LV heart weight (P < 0.05) and interventricular septum and posterior wall thickness (P < 0.05) with pressure-overloaded hypertrophy in animals treated with lithium were also observed. Atrial natriuretic peptide mRNA levels were significantly increased with pressure overload hypertrophy in animals treated with lithium. CONCLUSIONS: We have shown in an animal model that inhibition of glycogen synthase kinase-3beta by lithium has an additive effect on pressure overload cardiac hypertrophy.

Post-mortem tissue-type plasminogen activator preserves graft function of hearts harvested from non-pre-treated non-heart-beating donors.

BACKGROUND: Intracoronary microthrombi may cause primary graft failure of hearts harvested from non-pre-treated non-heart-beating donors (NHBDs). We examined the extent of functional recovery to compare the protective effects of post-mortem tissue-type plasminogen activator (t-PA) and heparin pre-treatment. METHODS: Heparin pre-treatment was systemically administered before hypoxic cardiac arrest in 6 mongrel dogs (Group A). No pre-treatments, including heparin, were administered in 8 dogs (Group B). After 60 minutes of ischemia, intracoronary microthrombi were flushed by retrograde blood cardioplegia with t-PA. After 120 minutes of controlled reperfusion, pre-load was increased for ejection against an after-load of 80 mm Hg. Pressure-volume loops were recorded to obtain the end-systolic pressure-volume relationship (ESPVR) and end-diastolic pressure-volume relationship (EDPVR). Stroke volume at a given pre-load was calculated from averaged ESPVR, EDPVR, and after-load identical to the averaged baseline value. The Frank-Starling relationship was obtained, and cardiac status was classified using the Forrester hemodynamic sub-set. RESULTS: There were no significant differences between Group A and Group B in post-resuscitated end-systolic elastance (3.1 +/- 0.7 vs 3.0 +/- 0.8 mm Hg/ml), time constant of isovolumic relaxation (40 +/- 7 vs 40 +/- 6 msec), LV max +dP/dt (1133 +/- 131 vs 1090 +/- 105 mm Hg/s), and LV max -dP/dt (732 +/- 131 vs 752 +/- 122 mm Hg/s). The post-resuscitated cardiac index was decreased to about 50%, and cardiac status was classified as Forrester III or IV sub-set. CONCLUSIONS: Post-mortem t-PA preserves graft function of hearts harvested from non-pre-treated NHBDs. This pharmaceutical intervention may be an alternative to heparin pre-treatment, which could increase the number of cardiac allografts harvested from potential non-pre-treated NHBDs.

Tolerance of the developing cyanotic heart to ischemia-reperfusion injury in the rat.

OBJECTIVE: Whether chronic hypoxia attenuates myocardial ischemia-reperfusion injury remains controversial because conflicting data have been reported probably due to the existence of many factors influencing the functional recovery of hearts. These factors include the differences of species, the time at which hypoxia begins, the degree of hypoxia, and so on. Regarding chronic hypoxia from birth, so far the only available data are based on findings in rabbit hearts. The purpose of this study was to describe the effect of chronic hypoxia from birth on myocardial reperfusion injury in the rat heart. METHODS: Normoxic hearts were obtained from rats housed in ambient air for 6 weeks (normoxic group); hypoxic hearts were obtained from rats housed in a hypoxic chamber (13%-14% oxygen) from birth for 6 weeks (hypoxic group). Isolated, crystalloid perfused working hearts were subjected to 30 min of global normothermic ischemia followed by 15 min of reperfusion; functional recovery was then measured in the two groups. The excretion of cyclic guanosine monophosphate (cGMP) in the coronary drainage was measured at the end of the preischemia and reperfusion periods. RESULTS: The percent recovery of the left ventricular developed pressure and the first derivative of left ventricular pressure were significantly better in the hypoxic group than in the normoxic group. cGMP excretion in the coronary drainage was significantly increased during both the preischemia and reperfusion periods. CONCLUSION: Chronic hypoxia from birth increased myocardial tolerance to ischemia-reperfusion injury with increased cGMP synthesis in the isolated heart model in rats.

Age-dependent vulnerability to ischemia-reperfusion injury of cyanotic myocardium in a chronic hypoxic rat model.

This study evaluated the effects of chronic hypoxia from birth on the resistance of rat hearts to global ischemia, with special emphasis on the duration of hypoxia. Male Wistar rats were housed from birth for 4 weeks or 8 weeks either in a hypoxic environment (FiO2 = 0.12) or in ambient air (8 animals for each group). Isolated rat hearts were perfused for 40 min with oxygenated Krebs-Henseleit buffer, subjected to 20 min global no-flow ischemia at 37, and then underwent 40 min of reperfusion. A non-elastic balloon was inserted into the left ventricle and inflated until the pre-ischemic LVEDP rose to 8 mmHg. Cardiac function was measured before and after ischemia. The post-ischemic percent recovery of LVDP in hypoxic hearts was worse than in normoxic hearts (4 weeks:55+/-7 vs. 96+/-3%, p0.01;8 weeks:40+/-5 vs. 92+/-4%, p0.01), and was worst in the 8-week-hypoxic hearts. Similarly, the percent recovery of dP/dt in the hypoxic hearts was lower than in the normoxic hearts (4 weeks:51+/-5 vs. 96+/-7%, p0.01;8 weeks:31+/-6 vs. 92+/-7%, p0.01), and was lowest in the 8-week-hypoxic hearts. In conclusion, cyanotic myocardium revealed an age-dependent vulnerability to ischemia-reperfusion injury in a chronic hypoxic rat model.

The potential of disproportionate growth of tricuspid valve after decompression of the right ventricle in patients with pulmonary atresia and intact ventricular septa.

OBJECTIVE: Tricuspid valve size is the major determinant of outcomes for patients with pulmonary atresia with intact ventricular septum. Lack of right ventricle-pulmonary artery continuity is associated with poor tricuspid valve growth (decrement in Z-value). However, most reports did not show evidence for disproportionate growth of the tricuspid valve after establishment of right ventricle-pulmonary artery continuity. METHODS: We studied 40 patients with pulmonary atresia with intact ventricular septum who underwent initial right ventricular decompression for planned staged repair. The initial Z-value of the tricuspid valve diameter (Zt1) was obtained from the echocardiography-derived normal value. The late Z-value (Zt2) was measured before definitive repair or the last available Z-value, if definitive repair was not yet reached. The factors associated with the changes of Z-values (Zt2 - Zt1) were analyzed. RESULTS: The mean initial tricuspid Z-value (Zt1) was -6.2 +/- 3.5. After treatment (Zt2), the mean Z-value was -6.0 +/- 3.4 (n = 34). Overall, the tricuspid Z-values did not change. Individually, the change in Z-value (Zt2 - Zt1) was larger than +2 in 11 (32%) patients and smaller than -2 in 6 (18%) patients. Increases in Z-value (Zt2 - Zt1) were significantly associated with right ventricular pressure/left ventricular pressure ratio measured after initial palliation (r = -0.54; P = .001) and the initial tricuspid valve Z-value (Zt1) (r = -0.40; P = .02). CONCLUSIONS: Disproportional growth of the tricuspid valve can occur, especially in patients with small tricuspid valves and lower right ventricular pressures after decompression. The findings support the possibility of neonates with small tricuspid valves undergoing biventricular repair after right ventricular decompression surgery.

Effect of a miniaturized cardiopulmonary bypass system on the inflammatory response and cardiac function in neonatal piglets.

The cognitive impairment and hemodynamic instability after neonatal cardiac surgery with cardiopulmonary bypass (CPB) might be exacerbated by hemodilution. Therefore, this study investigated the impact of different bloodless prime volumes on the hemodynamics and the inflammatory response by a miniaturized CPB system in neonatal piglets. The bypass circuit consisted of a Capiox RX05 (Capiox Baby RX, Terumo Corp., Tokyo, Japan) oxygenator and 3/16 internal diameter arterial and venous polyvinyl chloride tubing lines, with a minimum 75 mL prime volume. Twelve 1-week-old piglets were placed on a mild hypothermic CPB (32 degrees C) at 120 mL/kg/min for 2 h. The animals were divided into two groups, based on the volume of the prime solution. The priming volume was 75 mL in Group I and 175 mL in Group II. No blood transfusions were performed, and no inotropic or vasoactive drugs were used. The interleukin-6 (IL-6) and thrombin-antithrombin (TAT) complex levels, as well as right ventricular and pulmonary functions, were measured before and after CPB. Group I had low levels of IL-6 and TAT immediately after CPB (4370 +/- 2346 vs. 9058 +/- 2307 pg/mL, P < 0.01 and 9.9 +/- 7.7 vs. 25.1 +/- 8.8 ng/mL, P < 0.01, respectively). Group I had significantly improved cardiopulmonary function, cardiac index (0.22 +/- 0.03 vs. 0.11 +/- 0.05 L/kg/min, P < 0.001), and pulmonary vascular resistance index (7366 +/- 2860 vs. 28 620 +/- 15 552 dynes/cm(5)/kg, P < 0.01) compared with Group II. The miniaturized bloodless prime circuit for neonatal CPB demonstrated that the influence of hemodilution can reduce the subsequent inflammatory response. In addition, a low prime volume could therefore be particularly effective for attenuating pulmonary vascular resistance and right ventricular dysfunction in neonates.

Coarctation of right aortic arch with left descending aorta in an adult.

We report an adult case of right aortic arch coarctation with a left descending aorta. Associated anomalies included dextrocardia, situs inversus, polysplenia, bilateral superior vena cava, and absent inferior vena cava with azygos connection. Extensive mobilization of the azygos vein was needed to obtain a good surgical field, including the left descending aorta via a right thoracotomy, and the lesion was anatomically repaired by resection and end-to-end anastomosis.