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.

Switch arterial tardío, sin preparación previa ni oxigenador de membrana extracorpórea de soporte / Late arterial switch, without previous preparation or extracorporeal membrane oxygenation back-up

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Cirugía mínimamente invasiva en niños. Corrección de la comunicación interauricular por vía axilar y submamaria / Minimally invasive pediatric cardiac surgery. Atrial septal defect closure through axillary and submammary approaches

Introducción y objetivos. Los accesos mínimamente invasivos en cardiopatías no complejas ofrecen alternativas que disminuyen las secuelas estéticas. Asimismo, la cirugía se indica en edades más tempranas. En trabajos previos, comparamos la incisión submamaria con la esternotomía media. Presentamos nuestra experiencia inicial en el acceso axilar para el cierre de las comunicaciones interauriculares con circulación extracorpórea en comparación con el acceso submamario. Métodos. Se recoge en total a 20 pacientes: 10 casos por vía submamaria derecha (7 ostium secundum, 2 seno venoso, 1 ostium primum) y 10 casos operados a través de la axila derecha (7 ostium secundum, 3 seno venoso). Las medias de edad y de peso eran 6,4±3,62 (3-13) años y 23,5±8,74 (12-38) kg en el grupo submamaria y 5,5±2,04 (3-9) años y 19,7±5,88 (14-29) kg en el grupo axilar. En todos ellos, el procedimiento (canulación y corrección) se realiza completamente a través de la propia incisión respetando grupos musculares, sin puertos complementarios. Resultados. No se registran defectos residuales en la ecografía de control al alta. Ningún caso precisó reconversión a esternotomía media. Las maniobras de abordaje y canulación axilares son algo más complejas que las submamarias. Los tiempos de circulación extracorpórea y pinzamiento son superponibles en ambos grupos, comparados por enfermedades (p>0,05). Conclusiones. En pacientes seleccionados y con defectos abordables a través de la aurícula, la vía axilar derecha es tan segura como la submamaria. El resultado estético es excelente(AU)

Introduction and objectives: Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy.We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal circulation. Methods: 20 patients are included: 10 in the submammary group (7 ostium secundum, 2 sinus venosus, 1 ostium primum) and 10 in the axillary group (7 ostium secundum, 3 sinus venosus). Mean age and weight are 6.4 +/- 3.62 years (range 3-13) and 23.5 +/- 8.74 Kg (range 12-38) in the submammary group, and 5.5 +/- 2.04 years (range 3-9) and 19.7 +/- 5.88 Kg (range 14-29) in the axillary one, respectively. Muscles are spared (pectoralis in submammary and latissimus in axillary). The whole procedure (cannulation and correction) is performed through a single incision, with no side ports. Results: No residual defects were found at discharge. Surgical approach maneuvers are more cumbersome through the axillary than the submammary approach. In a peer comparison, extracorporeal circulation and cross-clamp time were similar in both groups (P > .05). Conclusions: 1. Axillary approach is as safe as submammary access in selected patients and for defects approached through the atrium. 2. Cosmetic result is excellent(AU)

Minimally invasive pediatric cardiac surgery. Atrial septal defect closure through axillary and submammary approaches.

INTRODUCTION AND OBJECTIVES: Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy. We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal circulation. METHODS: 20 patients are included: 10 in the submammary group (7 ostium secundum, 2 sinus venosus, 1 ostium primum) and 10 in the axillary group (7 ostium secundum, 3 sinus venosus). Mean age and weight are 6.4±3.62 years (range 3-13) and 23.5±8.74 Kg (range 12-38) in the submammary group, and 5.5±2.04 years (range 3-9) and 19.7±5.88 Kg (range 14-29) in the axillary one, respectively. Muscles are spared (pectoralis in submammary and latissimus in axillary). The whole procedure (cannulation and correction) is performed through a single incision, with no side ports. RESULTS: No residual defects were found at discharge. Surgical approach maneuvers are more cumbersome through the axillary than the submammary approach. In a peer comparison, extracorporeal circulation and cross-clamp time were similar in both groups (P>.05). CONCLUSIONS: 1. Axillary approach is as safe as submammary access in selected patients and for defects approached through the atrium. 2. Cosmetic result is excellent.

Use of a pulmonary neovalve with a transannular patch for repair of tetralogy of fallot.

INTRODUCTION AND OBJECTIVES: To report on our initial experience with the implantation of a pulmonary valve using Nunn's technique in association with a transannular patch for the complete repair of the tetralogy of Fallot. METHODS: In total, 21 patients were treated between September 2008 and February 2010. Their ages ranged from 7 months to 15 years (median 12 months) and weights from 6.8 kg to 44 kg (median 10 kg). Four patients had previously undergone palliative shunt placement; in two, it was associated with the diagnosis of a complete atrioventricular septal defect. Use of the transannular patch (treated autologous pericardium) was preceded by implantation of a 0.1-mm polytetrafluoroethylene (PTFE) monocusp valve using posterior fixation. Intraoperative transesophageal echocardiography and pressure gradient measurement were carried out, and echocardiography was repeated before discharge. RESULTS: No deaths were recorded. One patient had a residual ventricular septal defect that required reintervention. Echocardiography showed that the maximum gradient across the PTFE valve was 25 mmHg. Regurgitation was mild in 19 cases and moderate in 2 (the first and second in the series). CONCLUSIONS: Initial results using a transannular patch with a modified monocusp valve to repair the outflow tract in the tetralogy of Fallot were promising: there was only a slight pressure gradient and mild regurgitation. A medium-or long-term follow-up study is required to confirm these findings and to compare them with results obtained using other techniques.

Neoválvula pulmonar en la corrección del Fallot con parche transanular / Use of a pulmonary neovalve with a transannular patch for repair of tetralogy of Fallot

Introducción y objetivos. Presentamos nuestra experiencia inicial en la implantación de válvula pulmonar según técnica de Nunn, asociada al parche transanular, en la corrección completa de la tetralogía de Fallot. Métodos. Se intervino a 21 pacientes entre septiembre de 2008 y febrero de 2010. Intervalo de edad, 7 meses- 15 años (mediana, 12 meses). Peso de 6,8-44 kg (mediana, 10 kg). Cuatro pacientes presentaban fístula paliativa; en dos se asociaba el diagnóstico de canal completo. El parche transanular (pericardio autólogo curtido) se acompañó de implantación previa de válvula monocúspide de PTFE de 0,1 mm de grosor, mediante fijación posterior. Se realizó ecografia transesofágica, presiones intraoperatorias y ecografía antes del alta. Resultados. No hubo mortalidad. Un paciente presentó CIV residual que precisó reintervención. Por ecografía, el gradiente máximo atribuible a la válvula de PTFE es de 25 mmHg, y la insuficiencia es ligera en 19 casos y moderada en 2 (primero y segundo de la serie). Conclusiones. Los resultados iniciales del parche transanular con válvula monocúspide modificada en reconstrucción del tracto de salida de Fallot son prometedores (regurgitación ligera, gradiente escaso). Es preciso un seguimiento a medio-largo plazo para confirmar estos resultados y compararlos con otras técnicas (AU)

Introduction and objectives. To report on our initial experience with the implantation of a pulmonary valve using Nunn’s technique in association with a transannular patch for the complete repair of the tetralogy of Fallot. Methods. In total, 21 patients were treated between September 2008 and February 2010. Their ages ranged from 7 months to 15 years (median 12 months) and weights from 6.8 kg to 44 kg (median 10 kg). Four patients had previously undergone palliative shunt placement; in two, it was associated with the diagnosis of a complete atrioventricular septal defect. Use of the transannular patch (treated autologous pericardium) was preceded by implantation of a 0.1-mm polytetrafluoroethylene (PTFE) monocusp valve using posterior fixation. Intraoperative transesophageal echocardiography and pressure gradient measurement were carried out, and echocardiography was repeated before discharge. Results. No deaths were recorded. One patient had a residual ventricular septal defect that required reintervention. Echocardiography showed that the maximum gradient across the PTFE valve was 25 mmHg. Regurgitation was mild in 19 cases and moderate in 2 (the first and second in the series). Conclusions. Initial results using a transannular patch with a modified monocusp valve to repair the outflow tract in the tetralogy of Fallot were promising: there was only a slight pressure gradient and mild regurgitation. A mediumor long-term follow-up study is required to confirm these findings and to compare them with results obtained using other techniques (AU)