15 años de cirugía cardiaca infantil miniinvasiva; evolución y tendencias / 15 years of minimally invasive paediatric cardiac surgery; development and trends

INTRODUCCIÓN: Los abordajes miniinvasivos en cirugía cardiaca infantil no son habituales. Pocos grupos presentan programas y experiencia, quedando limitados a cardiopatías simples. Presentamos una casuística recopilada a lo largo de 15 años y más de 200 pacientes. MATERIAL Y MÉTODOS: En el año 2000 comenzamos un programa de acceso submamario, ampliándolo progresivamente a casos complejos y edades menores. En 2009 incorporamos el abordaje axilar, con idénticas pautas. En 2013 iniciamos la cirugía por miniesternotomía inferior, ampliando la cartera de servicios. Entre julio del 2000 y diciembre del 2014 se intervino a 203 pacientes: 102 por vía submamaria, 50 por axilar, 44 por miniesternotomía inferior, 4 por toracotomía lateral-posterior y 3 por miniesternotomía superior. RESULTADOS: Por patologías, la más frecuente fue la comunicación interauricular ostium secundum (128), seguida del seno venoso (20), comunicación interventricular (20), ostium primum (16) y otras (19). Un caso fue reconvertido a esternotomía. No hubo eventos neurológicos. Las medias de edad fueron 7,8/3,7 y 1,8 años, con medias de peso de 28,1/16,1 y 9,4 kg en los accesos submamario, axilar y miniesternotomía, respectivamente. Los resultados estéticos han sido excelentes. CONCLUSIONES: Tras 15 años de experiencia acumulada, la cirugía miniinvasiva es segura y eficaz, con resultados estéticos excelentes. La introducción gradual de diferentes accesos alternativos permite establecer pautas de aprendizaje. La versatilidad de accesos (submamario, axilar, miniesternotomía) facilita la selección de abordajes en función de cardiopatía y edad/peso

INTRODUCTION: The minimally invasive approach is seldom reported in paediatric cardiac surgery. Teams gathering experience are scarce, with programs focused on simple cases. The experience is presented on a series of over 200 cases operated on in the past 15 years. MATERIAL AND METHODS: A sub-mammary approach program was started in 2000, which was gradually extended to include more complex and younger patients. The axillary incision was adopted in 2009, following the same steps. In 2013, the mini-sternotomy incision was introduced, increasing our armamentarium. From July 2000 until December 2014, 203 patients were operated on. The sub-mammary approach was used in 102 cases, axillary in 50 patients, mini-sternotomy in 44, postero-lateral thoracotomy in 4 cases, and upper mini-sternotomy in 3. RESULTS: By diagnosis, ostium secundum atrial septal defect was the most common (128), followed by sinus venosus (20), ventricular septal defect (20), ostium primum (16), and others (19). One patient was converted to sternotomy. No neurological events were detected. The mean age was 7.8/3.7 and 1.8 years, and the mean weight was 28.1/16.1 and 9.4 Kg. in the sub-mammary, axillary and mini-sternotomy approaches, respectively. The aesthetic results were excellent. CONCLUSIONS: Based on our 15 years of experience, minimally invasive surgery is safe and yields excellent cosmetic results. The gradual introduction of alternative approaches (sub-mammary, axillary, mini-sternotomy) allowed us to set-up guidelines and learning curves. The wide range of incisions enables the most appropriate one to be selected depending on age/weight and cardiac condition

[15 years of minimally invasive paediatric cardiac surgery; development and trends]. / 15 años de cirugía cardiaca infantil miniinvasiva; evolución y tendencias.

INTRODUCTION: The minimally invasive approach is seldom reported in paediatric cardiac surgery. Teams gathering experience are scarce, with programs focused on simple cases. The experience is presented on a series of over 200 cases operated on in the past 15 years. MATERIAL AND METHODS: A sub-mammary approach program was started in 2000, which was gradually extended to include more complex and younger patients. The axillary incision was adopted in 2009, following the same steps. In 2013, the mini-sternotomy incision was introduced, increasing our armamentarium. From July 2000 until December 2014, 203 patients were operated on. The sub-mammary approach was used in 102 cases, axillary in 50 patients, mini-sternotomy in 44, postero-lateral thoracotomy in 4 cases, and upper mini-sternotomy in 3. RESULTS: By diagnosis, ostium secundum atrial septal defect was the most common (128), followed by sinus venosus (20), ventricular septal defect (20), ostium primum (16), and others (19). One patient was converted to sternotomy. No neurological events were detected. The mean age was 7.8/3.7 and 1.8 years, and the mean weight was 28.1/16.1 and 9.4 Kg. in the sub-mammary, axillary and mini-sternotomy approaches, respectively. The aesthetic results were excellent. CONCLUSIONS: Based on our 15 years of experience, minimally invasive surgery is safe and yields excellent cosmetic results. The gradual introduction of alternative approaches (sub-mammary, axillary, mini-sternotomy) allowed us to set-up guidelines and learning curves. The wide range of incisions enables the most appropriate one to be selected depending on age/weight and cardiac condition.

Switch arterial paliativo como primer tiempo hacia Fontan en pacientes con fisiología univentricular y estenosis subaórtica / Palliative arterial switch as first-line treatment before the fontan procedure in patients with single-ventricle physiology and subaortic stenosis

Introducción y objetivos. Para la paliación inicial de pacientes con fisiología univentricular, discordancia ventriculoarterial y estenosis subaórtica, se utilizan diversas técnicas. La cirugía tipo Fontan depende de una correcta paliación inicial que evite la aparición de estenosis subaórtica (además de hipertrofia ventricular y disfunción diastólica). Métodos. Presentamos a 7 pacientes con fisiología univentricular, transposición y estenosis subaórtica, con bajo gasto sistémico e hiperaflujo pulmonar, de 21–383 (mediana, 75) días de edad y 3,4–9,6 (mediana, 4,2) kg de peso. Todos fueron tratados mediante switch arterial paliativo, «cambiando» su estenosis subaórtica por una estenosis subpulmonar. En 6 casos se asoció cirugía de arco aórtico; en 4, septectomía auricular y en 1, resección de membrana subaórtica. Resultados. Un paciente falleció en el postoperatorio; otro sufrió recoartación, tratada mediante angioplastia; 3 pacientes han alcanzado el estadio de Glenn y 2, el de Fontan. La función ventricular es correcta en todos ellos. Conclusiones. La fisiología de ventrículo único con transposición y estenosis subaórtica se puede tratar inicialmente mediante un switch paliativo. Esta compleja técnica inicial presenta buenos resultados y permite la progresión futura hacia Glenn y Fontan (AU)

Introduction and objectives. There are several techniques for the palliative treatment of patients with single-ventricle physiology, ventriculoarterial discordance and subaortic stenosis. The Fontan procedure relies on optimal initial palliation to avoid the development of subaortic stenosis (as well as ventricular hypertrophy and diastolic dysfunction). Methods. We present seven patients with single-ventricle physiology, transposition of the great arteries and subaortic stenosis, with low systemic output and high pulmonary flow, aged 21 to 383 days (median, 75) and weighing between 3.4 and 9.6 kg (median, 4.2). All were treated with a palliative arterial switch, thus “switching” their subaortic stenosis to subpulmonary stenosis. Six patients also underwent aortic arch surgery, 4 an atrial septectomy, and 1 a subaortic membrane resection. Results. One patient died after surgery, another developed recoarctation, which was treated with an angioplasty, 3 patients reached the Glenn stage and 2 the Fontan stage. All had good ventricular function. Conclusions. A palliative switch is an effective initial treatment for single-ventricle physiology with transposition of the great arteries and subaortic stenosis. This complex initial technique produces good results and allows the patient to progress to the Glenn or Fontan stage (AU)

Palliative arterial switch as first-line treatment before the fontan procedure in patients with single-ventricle physiology and subaortic stenosis.

INTRODUCTION AND OBJECTIVES: There are several techniques for the palliative treatment of patients with single-ventricle physiology, ventriculoarterial discordance and subaortic stenosis. The Fontan procedure relies on optimal initial palliation to avoid the development of subaortic stenosis (as well as ventricular hypertrophy and diastolic dysfunction). METHODS: We present seven patients with single-ventricle physiology, transposition of the great arteries and subaortic stenosis, with low systemic output and high pulmonary flow, aged 21 to 383 days (median, 75) and weighing between 3.4 and 9.6kg (median, 4.2). All were treated with a palliative arterial switch, thus "switching" their subaortic stenosis to subpulmonary stenosis. Six patients also underwent aortic arch surgery, 4 an atrial septectomy, and 1 a subaortic membrane resection. RESULTS: One patient died after surgery, another developed recoarctation, which was treated with an angioplasty, 3 patients reached the Glenn stage and 2 the Fontan stage. All had good ventricular function. CONCLUSIONS: A palliative switch is an effective initial treatment for single-ventricle physiology with transposition of the great arteries and subaortic stenosis. This complex initial technique produces good results and allows the patient to progress to the Glenn or Fontan stage.

[Comparative study of thoracic approaches in atrial septal defect closure]. / Estudio comparativo de la vía de abordaje en el cierre de la comunicación interauricular.

Our early experience in approaching ASD by right thoracotomy as opposed to midline sternotomy is presented. Between July 2000 and December 2001, 15 patients (group A) were operated by right thoracotomy. Mean age of patients was 8.6 years and mean weight was 31.6 kg. In the same period, midline sternotomy was used in 16 patients (group B). Mean age was 4.7 years and weight was 16.5 kg. The duration of the procedure, by-pass, and aortic cross-clamping were similar. Bleeding was 265 ml (8.4 ml/kg) in group A, and 152 ml (9.2 ml/kg) in group B. The duration of the ICU stay and time of discharge were 2.4 days and 6 days in group A, and 2.23 days and 6.87 days in group B, respectively. No significant differences were found in ASD closure by thoracotomy and sternotomy. The cosmetic appearance acceptance of right thoracotomy was excellent.

Estudio comparativo de la vía de abordaje en el cierre de la comunicación interauricular / Comparative study of thoracic approaches in atrial septal defect closure

Presentamos nuestra experiencia inicial en cierre de la comunicación interauricular (CIA) por vía derecha, comparándola con esternotomía media. Entre julio de 2000 y diciembre de 2001, 15 pacientes (grupo A) fueron intervenidos por toracotomía derecha. La media de edad fue de 8,6 años y el peso medio, de 31,6 kg. En el mismo período, 16 pacientes (grupo B) fueron intervenidos por esternotomía media. La edad media fue de 4,7 años y el peso, de 16,5 kg. Las duraciones de la intervención, de la circulación extracorpórea y de la isquemia cardíaca fueron similares. El drenaje total fue de 265 ml (8,4 ml/kg) en el grupo A, y de 152 (9,2 ml/kg) en el grupo B. La estancia media en la UCI y postoperatoria fue de 2,4 y 6 días, respectivamente, en el grupo A, y de 2,23 y 6,87 días, respectivamente, en el grupo B. No encontramos diferencias significativas en el cierre de CIA por toracotomía o esternotomía. Por toracotomía derecha el resultado estético fue excelente (AU)

Aortic coarctation, vascular ring, and right aortic arch with aberrant subclavian artery.

Right aortic arch, in all situations, is relatively rare. In association with coarctation and vascular compression, it is extremely rare. We present a patient with a right aortic arch and an aberrant left subclavian artery, in addition to coarctation. This was dealt with through a left thoracotomy by dividing the ligamentum arteriosum and placing a Dacron graft from the ascending aorta to the descending aorta.

Retorno venoso pulmonar total anómalo en pediatría: importancia del diagnóstico ecocardiográfico y de la cirugía precoz / Total anomalous pulmonary venous connection in the pediatric age:iImportance of echocardiographic diagnosis and early repair

Introducción y objetivos. Estudiamos los pacientes afectados de retorno venoso pulmonar total anómalo intervenidos en nuestro centro. Presentamos la importancia del diagnóstico ecocardiográfico exclusivo previo a la cirugía. Métodos. Desde 1990 hasta 1999, 14 pacientes fueron intervenidos de dicha cardiopatía en nuestro centro. El sitio de drenaje fue en 6 pacientes supracardíaco, 4 infracardíaco, 1 cardíaco (seno coronario) y en 3 pacientes mixto. En 11 casos el diagnóstico se realizó por estudio ecocardiográfico, siendo los hallazgos corroborados durante la cirugía. Resultados. Sólo hubo una muerte durante la intervención quirúrgica, relacionada con un ventrículo izquierdo pequeño, y a los 35 días de la intervención se produjo otro fallecimiento por sepsis. Durante el postoperatorio inmediato, el control y tratamiento de la hipertensión pulmonar fueron los objetivos primordiales. Tras un seguimiento medio de 50 meses, sólo un paciente precisó reintervención; el resto de pacientes se encuentra asintomático. Conclusiones. El diagnóstico ecocardiográfico de esta cardiopatía puede ser suficiente para indicar la cirugía. Así mismo la corrección quirúrgica precoz del retorno venoso pulmonar anómalo total puede ser realizada con bajo riesgo y buenos resultados a medio plazo (AU)