Surgical Repair of Anomalous Origin of the Left Subclavian Artery From the Pulmonary Artery Using a Supraclavicular Approach.

Anomalous origin of the left subclavian artery from the pulmonary artery is a rare congenital cardiac malformation. We describe a case of anomalous origin of the left subclavian artery from the pulmonary artery in a patient who presented with symptoms of vertebrobasilar insufficiency and underwent reimplantation of the left subclavian artery into the left common carotid artery from the supraclavicular approach.

Single-stage off-pump repair of coarctation of the aorta and ventricular septal defects in children.

OBJECTIVES: The appropriate approach for surgical repair of coarctation of the aorta with a ventricular septal defect (VSD) remains controversial. This study evaluated the outcomes of primary repair of VSDs with periventricular device closure without cardiopulmonary bypass through a left thoracotomy in patients without arch hypoplasia. METHODS: We selected 21 patients aged <1 year, including 7 neonates, who underwent repair of coarctation of the aorta with periventricular device closure of a VSD. RESULTS: The median occluder size was 6 (range, 5-8) mm. The median mechanical ventilation time was 14 (range, 2-68) h, and the median duration of hospital stay was 11 (range, 7-16) days. No reoperations were required to correct VSD shunting, and the median residual shunt size was 1 (range, 1-2) mm. The median follow-up period was 13 (range, 4-31) months. No late deaths were reported, and no haemodynamically significant pressure gradient at the anastomotic site was observed. The median distal aortic arch z-score was 0.39 (range, -0.1-to 0.9). Only 1 patient had a permanent pacemaker implanted towards the end of the follow-up period. CONCLUSIONS: Periventricular device closure can be used safely for closure of VSD in children with coarctation of the aorta without a hypoplastic aortic arch, even in neonates, to reduce the risk of prolonged cardiopulmonary bypass. This hybrid approach can be performed with a low incidence of rhythm disturbances and residual shunting. However, a meticulous assessment of the VSD anatomy is essential to avoid any unfavourable events.

Residual Lesion Diagnostics in Pediatric Postcardiotomy Extracorporeal Membrane Oxygenation and Its Outcomes.

BACKGROUND: To assess the impact of diagnostic procedures in identifying residual lesions during extracorporeal membrane oxygenation (ECMO) on survival after pediatric cardiac surgery. METHODS: Between January 2012 and December 2017, 74 patients required postcardiotomy ECMO. Patients were retrospectively divided into 2 groups: Group I underwent only echocardiography ([echo only] 46 patients, 62.2%) and group II (echo+) underwent additional diagnostic tests (ie, computed tomography [CT] or cardiac catheterization; 28 patients, 37.8%). Propensity score matching was used to balance the 2 groups by baseline characteristics. RESULTS: Two equal groups (28 patients in each group) were formed by propensity score matching. Fourteen (50%) patients in the echo-only group and 20 (71%) patients in the echo+ group were successfully weaned from ECMO (P = .17). Four (14.3%) patients survived in the echo-only group and 15 (53.5%) patients survived in the echo+ group (P = .004). Patients in the echo+ group had a lower chance of dying compared to the echo-only group (odds ratio, 0.14.6; 95% CI, 0.039-0.52; P = .003). The residual lesions, which may have served as a mortality factor, were found by autopsy in 8 (40%) patients in the echo-only group, while none were found in the echo+ group (P = .014). CONCLUSIONS: The autopsies of patients who died despite postcardiotomy ECMO support showed that in 40% of cases that had been investigated by echo only, residual lesions that had not been detected by echocardiography were present. The cardiac catheterization and CT during ECMO are effective and safe for identifying residual lesions. Early detection and repair of residual lesions may increase the survival rate of pediatric cardiac patients on ECMO.

Diepoxy- Versus Glutaraldehyde-Treated Xenografts: Outcomes of Right Ventricular Outflow Tract Reconstruction in Children.

BACKGROUND: Xenografts used for right ventricular outflow tract (RVOT) reconstruction are typically treated with glutaraldehyde. However, potential benefit of epoxy treatment was demonstrated in experimental studies. We aimed to compare diepoxy-treated bovine pericardial valved conduits (DE-PVCs) and glutaraldehyde-treated bovine pericardial valved conduits (GA-PVCs) for RVOT reconstruction in pediatric patients. METHODS: Between 2002 and 2017, 117 patients underwent RVOT reconstruction with PVC in single center: DE-PVC group, n = 39; and GA-PVC group, n = 78. After performing propensity score analysis (1:1) for the entire sample, 29 patients from the DE-PVC group were matched with 29 patients from the GA-PVC group. RESULTS: There were no conduit-related deaths. In the DE-PVC group, the freedom from conduit failure was 90.9% at four years and 54.3% at eight years postoperatively. In the GA-PVC group, it was 46.3% and 33.1%, respectively. The difference was significant (P = .037). Conduit failure was typically caused by stenosis in both groups. In the DE-PVC group, the main cause of stenosis was xenograft calcification (27.6%); while in the GA-PVC group, it was mostly due to neointimal proliferation (25.0%) and, less often, calcification (14.3%). Conduit thrombosis was the cause of replacement in 6.9% of patients from the GA-PVC group. CONCLUSIONS: Diepoxy-treated bovine pericardial valved conduit is a suitable alternative to GA-PVC for RVOT reconstruction in pediatric patients. Diepoxy-treated bovine pericardial valved conduits may be less prone to conduit failure and more resistant to neointimal proliferation and conduit thrombosis than GA-PVCs.

Selective Antegrade Cerebral Perfusion With or Without Additional Lower Body Perfusion During Aortic Arch Reconstruction in Infants.

BACKGROUND: Aortic arch reconstruction is often challenging, especially in infants, owing to its high postoperative complication risks. This study aimed to compare the effectiveness between selective antegrade cerebral perfusion (SACP) alone and SACP in combination with continuous lower body perfusion with descending aortic cannulation (DAC) in preserving renal function, and to determine the influence of perfusion strategy on the postoperative course of infants who underwent aortic arch reconstruction. MATERIAL AND METHODS: A total of 121 infants who underwent aortic arch reconstruction between January 2008 and December 2018 were included in the analysis. Patients (median age: 29 days, range: 3-270 days) were divided into the following groups: those who underwent repair with SACP (SACP group, 79 patients) and those who underwent additional lower body perfusion (DAC group, 42 patients). RESULTS: Three (7.1%) and nine (11.4%) patients died in the DAC and SACP groups, respectively (P = .54). The SACP group had more patients requiring renal replacement therapy (P = .002) and higher incidence of second stage acute kidney injury (AKI) development (Kidney disease improving global outcomes (KDIGO) criteria; P = .032). The SACP group had higher frequency of open chest postoperatively than the DAC group (P = .011). The DAC group had lower vasoactive inotropic score (VIS) at the first postoperative day (P < .001) and shorter intensive care unit length of stay (P = .050). There was no difference in neurological complications between the groups (P = .061). High VIS was associated with early mortality (odds ratio [OR]: 1.79 [1.33-2.41], P < .001) and AKI (OR: 1.60 [1.35-1.91], P < .001). The DAC perfusion strategy with minimal hypothermia was associated with lower risk of AKI (OR: 0.91 [0.84-0.98], P = .016). CONCLUSION: Antegrade cerebral perfusion with continuous lower body perfusion via DAC could effectively be used for improving early postoperative results among infants undergoing procedures that include aortic arch reconstruction.

Double Arterial Cannulation in the Critical Management of Neonatal Aortic Arch Obstruction With Closed Ductus Arteriosus.

The neonatal management of critical aortic arch obstruction in association with an arterial duct that remains closed or significantly constricted requires urgent surgical repair, with a postoperative focus on resolving the impaired function of compromised organs. Here, we present two neonatal cases illustrating the use of the dual arterial cannulation perfusion method in the complete repair of interrupted aortic arch and critical coarctation of the aorta with nonfunctional ductus arteriosus. We suggest that dual arterial cannulation, which provides total body perfusion (with the exception of cardiac perfusion during cardioplegic arrest of the heart), may be a good alternative to other perfusion strategies in cases of absent ductal blood flow, as this method allowed us to avoid the further development of severe multiple organ failure.

In search of the best xenogeneic material for a paediatric conduit: an analysis of clinical data.

OBJECTIVES: In this study, we aimed to determine the incidence of reintervention and calcification of xenografts in paediatric patients who underwent placement of the right ventricle-to-pulmonary artery valved conduits. METHODS: We retrospectively analysed clinical data of paediatric patients (1 day-18 years) who underwent right ventricular outflow tract reconstruction using xenograft from 2000 to 2016 at a single centre. RESULTS: A total of 301 patients underwent the placement of 337 xenografts, including glutaraldehyde-treated bovine jugular vein (n = 171, 50.7%), glutaraldehyde-treated bovine pericardial valved conduit (n = 75, 22.3%), diepoxy-treated porcine aortic conduit (n = 58, 17.2%) and diepoxy-treated bovine pericardial valved conduit (DE-PVC) (n = 33, 9.8%). There were 284 (84.3%) primary implantations and 53 (15.7%) reimplantations. The median follow-up was 4.2 years (range 1.5 months-14.5 years). The multivariate regression analysis did not reveal statistically significant associations of the first reintervention with the type of xenograft (P = 0.78). At reintervention, calcification of the wall and/or cusps was the main cause of conduit dysfunction in 66.4% of cases. On the basis of the multivariate Cox regression analysis, xenograft types were significant predictors of reintervention caused by conduit calcification (P = 0.012). The diepoxy-treated porcine aortic conduit group had the risk of calcification 3 times higher than the glutaraldehyde-treated bovine jugular vein group (P < 0.001).The glutaraldehyde-treated bovine pericardial valved conduit and diepoxy-treated bovine pericardial valved conduit groups had the risk of calcification comparable with the glutaraldehyde-treated bovine jugular vein group in multivariate proportional hazards model (P = 0.36 and P = 0.59, respectively). CONCLUSIONS: We have not revealed significant difference in the freedom from first reintervention among types of conduit. Calcification leading to the conduit dysfunction was present in all groups; however, diepoxy-treated porcine aortic conduits demonstrated suboptimal results in terms of calcification at follow-up.

In search of the best xenogeneic material for a paediatric conduit: an experimental study.

OBJECTIVES: The development of calcification-resistant bioprosthetic materials is a very important challenge for paediatric surgery. The subcutaneous implantation in rats is the well-known first-stage model for this kind of research. Using this model, we aimed to compare calcification of the porcine aortic wall and bovine pericardium and jugular vein wall cross-linked with glutaraldehyde (GA) and ethylene glycol diglycidyl ether (DE). We also determined the efficacy of DE-preserved tissue modification with 2-(2-carboxyethylamino)ethylidene-1,1-bisphosphonic acid (CEABA). METHODS: Three groups of each biomaterial were evaluated: GA-treated, DE-treated and DE + CEABA-treated. The microstructure of non-implanted biomaterials was assessed by light microscopy after Picro Mallory staining; the phosphorus content of the DE and DE + CEABA samples was assessed by atomic emission spectrometry. Samples were implanted subcutaneously into young rats for 10 and 60 days. The explant end-point included quantitative calcification assessment by atomic absorption spectrophotometry and light microscopy examination after von Kossa staining. RESULTS: All GA-treated biomaterials had a high calcium-binding capacity (>100 µg/mg dry tissue). DE preservation decreased the vein wall and pericardium calcium content by 4- and 40-fold, respectively, but was ineffective for the aortic wall. The calculated CEABA content was almost equal in the vein wall and pericardium (17.7 and 18.5 µM/g) and slightly less in the aortic wall (15 µM/g) (P = 0.011). CEABA effectively reduced mineralization in the DE aortic wall and DE pericardium to 10.1 (7.8-21.1) and 0.95 (0.57-1.38) µg/mg but had no effect in the DE vein wall. Mineralization in the GA- and DE-treated aortic and vein walls was predominantly associated with elastin. CEABA modification decreased elastin calcification but did not block it completely. CONCLUSIONS: Each xenogeneic material requires individual anticalcification strategy. DE + CEABA pretreatment demonstrates a high mineralization-blocking efficacy for the bovine pericardium and should be employed to further develop the paediatric pericardial conduit. Aortic wall calcification cannot be blocked completely using this strategy.

Does mitral valve repair matter in infants with ventricular septal defect combined with mitral regurgitation?

OBJECTIVES: This study aimed to assess mitral valve function after repair of ventricular septal defect (VSD) combined with mitral regurgitation (MR) in the mid-term follow-up period, to evaluate the clinical utility of simultaneous mitral valve repair (MVR). METHODS: From June 2005 to March 2014, 60 patients with VSD and MR underwent surgical treatment. After performing propensity score analysis (1:1) for the entire sample, 46 patients were selected and divided into 2 groups: those with VSD closure and MVR (VSD + MVR, 23 patients) and those with VSD closure without mitral valve intervention (VSD only, 23 patients). The follow-up period ranged from 12 to 48 months (median 32 months; interquartile range 28-40 months). RESULTS: There was no postoperative mortality in either group. There was no significant difference in the duration of the postoperative period between groups (ventilation time, P = 0.49; inotropic support, P = 0.50). Mean cardiopulmonary bypass time and aortic cross-clamping time were significantly longer in the 'VSD + MVR' group (cardiopulmonary bypass, P = 0.023; aortic cross-clamp, P < 0.001). There was no significant difference in regurgitation area (P = 0.30) and MR grade (P = 0.76) between groups postoperatively. There was no significant difference in freedom from MR ≥ 2+ between groups (log-rank test, P = 0.28). In the 'VSD + MVR' group, 12-, 36- and 42-month freedom from MR ≥ 2+ values were 100%, 59 ± 10.4% [95% confidence interval (CI) 36.1-76.2%] and 44 ± 15% (95% CI 15.8-69.7%), respectively, while in the 'VSD only' group, these values were 100%, 54.5 ± 10.6% (95% CI 32-72.3%) and 54.5 ± 10.6% (95% CI 30-72.3%), respectively. The only significant risk factor for recurrent MR ≥ 2+ during the follow-up period was mild residual MR in the early postoperative period (P = 0.037). CONCLUSIONS: In infants with VSD combined with MR, simultaneous MVR has no benefits simultaneous MVR provided no advantage over that of isolated VSD closure. We found that the presence of mild residual MR in the early postoperative period predisposes the development of MR ≥ 2+ in follow-up period.

Risk Factors For Unfavorable Outcomes After Bidirectional Cavopulmonary Anastomosis.

BACKGROUND: Bidirectional cavopulmonary anastomosis (BCPA) is an important preliminary step toward the Fontan procedure; thus, understanding of risk factors for morbidity and mortality after BCPA may ultimately promote improved rates of success with Fontan completion and general survival. This study evaluated survival and predictors of unfavorable outcomes in patients after BCPA. METHODS: Clinical data of 157 patients who underwent BCPA from 2003 to 2015 at a single center were retrospectively analyzed. RESULTS: Three-year and nine-year survival after BCPA were 87.1% ± 2.8% and 85.8% ± 2.9%, respectively. Freedom from unfavorable outcomes (mortality, BCPA takedown, nonsuitability for Fontan procedure) was 83.8% ± 3.1% at three years and 73.5% ± 4.8% at nine years. Multivariate proportional hazards regression analysis revealed that total anomalous pulmonary venous connection (TAPVC; hazard ratio [HR]: 3.74, 95% confidence interval [CI]: 1.35-10.36; P = .01) and increased mean pressure in BCPA circuit (HR: 1.17, 95% CI: 1.02-1.34; P = .03) were independent risk factors for unfavorable outcomes. Postoperative mean pressure in BCPA circuit in patients with poor outcomes was median 16 mm Hg (interquartile range [IQR]: 14-18 mm Hg) versus median 14 mm Hg (IQR: 12-15.5 mm Hg) in patients with favorable outcomes ( P < .01). Preoperative (HR: 1.87, 95% CI: 1.20-2.91; P < .01) and postoperative atrioventricular valve regurgitation (AVVR; HR: 2.22, 95% CI: 1.24-3.94; P < .01) were also associated with unfavorable outcome in univariate Cox regression. CONCLUSIONS: Elevated mean pressure in the BCPA circuit is the main predictor of unfavorable outcome; therefore, thorough preoperative examination and careful patient selection are critical points for successful intermediate-stage and later Fontan completion. Total anomalous pulmonary venous connection and insufficient correction of AVVR worsen the prognosis in this patient group.