Submitral aneurysm in children.

BACKGROUND: We report a surgical series of submitral aneurysm in children. METHODS: Between March 2011 and December 2015, eight consecutive patients less than 18 years old with submitral aneurysm underwent surgical correction. RESULTS: Six patients were female, the mean age was 7 ± 3.8 years old, and mean weight was 21.4 kg. Six patients were in NYHA functional class III or IV. Six patients underwent repair via a transatrial approach, another with a transatrial combined with transaneurysmal approach, and another with a transventricular approach. There were no in-hospital deaths but one 30-day mortality. One patient required reoperation. Two patients required mitral valve replacement. At discharge, one patient had severe and another had moderate mitral regurgitation. The mean follow-up time was 26.4 months and five patients were alive. No reintervention was required. CONCLUSIONS: Submitral aneurysm is not restricted to adults. Heart failure is the commonest clinical presentation in the pediatric age. The transatrial approach is feasible, safe, and associated with good short-term results. The mitral valve can be preserved in the majority of cases.

Early graft patency after off-pump and on-pump coronary bypass surgery: a prospective randomized study.

AIMS: Uncertainty persists regarding the impact of the off-pump technique on coronary bypass graft patency. The primary objective of this study was to assess coronary artery bypass graft patency in patients randomized to off-pump and on-pump multivessel coronary artery bypass grafting (CABG). Secondary objectives were clinical outcomes and neuropsychological functioning. METHODS AND RESULTS: One hundred and fifty patients were randomized to off-pump (n = 75) or on-pump CABG (n = 75). Graft patency was assessed by multidetector computed tomography 5 weeks after surgery. The two groups were similar regarding patients' characteristics and logistic Euroscore (3.6 vs. 3.7%). Mean number of grafts performed was 3.5 ± 0.6 and 3.5 ± 0.6 in off-pump and on-pump, respectively (P = 0.7). Raw graft patency rate was 89.9% in off-pump and 95.0% in on-pump (OR 2.2, 95% CI 1.07-4.44; P = 0.03). Nineteen (27%) off-pump and 9 (13%) on-pump patients had at least one occluded graft (P = 0.04) and the proportion of patent grafts per patient was 0.91 ± 0.2 in off-pump vs. 0.96 ± 0.1 in on-pump (P = 0.06). However, after adjusting by heparin dose, graft patency was not statistically different between groups (OR 0.87, 95% CI 0.25-2.98, P = 0.83). At 30 days, there was no statistically significant difference in major adverse events and neuropsychological functioning between off-pump and on-pump groups. One-year follow-up showed similar functional class and positive treadmill exercise tests. CONCLUSIONS: Under the conditions this trial was conducted, CABG performed off-pump had lower overall graft patency rate than on-pump, which was not statistically different after controlling for total heparin dose. Thirty-day complications, neuropsychological functioning, and one-year clinical and functional outcomes were not statistically different between the two techniques.

Off-pump coronary artery bypass surgery in women.

OBJECTIVE: Gender is a well-known risk factor for mortality and morbidity after coronary artery bypass grafting and various reasons have been proposed to explain the poorer results observed in women. The study objective was to determine whether female gender was still an operative risk factor with the adoption of off-pump coronary artery bypass surgery. METHODS: Of 2123 consecutive patients who underwent isolated CABG between November 2002 and December 2007, 1966 (92.6%) (481 women and 1485 men) were operated without cardiopulmonary bypass and form the study population. Women were older (69.0 vs. 64.7 years; p = 0.001) and had more severe angina (CCS class 3.1 vs. 2.7; p = 0.001), smaller body surface area (1.6 vs. 1.8 m2; p = 0.001), higher body mass index and greater incidence of diabetes (48.3% vs. 34.2%; p = 0.005) than men. There were no statistically significant differences in the incidence of three-vessel disease (69.5% vs. 71.9%) or left main disease (22.2% vs. 27.0%) but ejection fraction was higher in women (61.3% vs. 59.0%; p = 0.01). Risk factors for in-hospital mortality were identified by univariate analysis and logistic regression. RESULTS: The number of distal anastomoses was lower in women than in men (2.8 vs. 3.0; p = 0.001). In-hospital mortality was 2.0% in women and 0.8% in men (p = 0.01) and female gender was one of the eight risk factors for in-hospital mortality identified by univariate analysis. Using a logistic regression model, only age (OR: 1.7; 95% CI 1.01-1.14; p = 0.02) and logistic EuroSCORE (OR: 1.07; 95% CI 1.03-1.10; p < 0.001) were independently associated with in-hospital mortality. Logistic EuroSCORE was the only independent risk factor for major morbidity (OR: 1.07 95% CI 1.04-1.10; p < 0.001). CONCLUSION: Women who undergo coronary artery bypass grafting have an unfavorable clinical profile compared to men, resulting in higher unadjusted in-hospital mortality. However, in an unselected patient population undergoing off-pump CABG, female gender was not found to be an independent risk factor for mortality or major morbidity.

Single Ventricle Palliation in a Developing Sub-Saharan African Country: What Should be Improved?

INTRODUCTION: Single ventricle physiology management is challenging, especially in low-income countries. OBJECTIVE: To report the palliation outcomes of single ventricle patients in a developing African country. METHODS: We retrospectively studied 83 consecutive patients subjected to single ventricle palliation in a single center between March 2011 and December 2017. Preoperative data, surgical factors, postoperative results, and survival outcomes were analyzed. The patients were divided by palliation stage: I (pulmonary artery banding [PAB] or Blalock-Taussig shunt [BTS]), II (Glenn procedure), or III (Fontan procedure). RESULTS: Of the 83 patients who underwent palliation (stages I-III), 38 deaths were observed (31 after stage I, six after stage II, and one after stage III) for an overall mortality of 45.7%. The main causes of operative mortality were multiple organ dysfunction due to sepsis, shunt occlusion, and cardiogenic shock. Twenty-eight survivors were lost to follow-up (22 after stage I, six after stage II). Thirteen stage II survivors are still waiting for stage III. The mean follow-up was 366 ± 369 days. Five-year survival was 28.4 % for PAB and 30.1% for BTS, while that for stage II and III was 49.8% and 57.1%, respectively. Age (hazard ratio, 0.61; 95% confidence interval: 0.47-0.7; P = .000) and weight at surgery (hazard ratio, 0.45; 95% confidence interval: 0.31-0.64; P = .002) impacted survival. CONCLUSION: A high-mortality rate was observed in this initial experience, mainly in stage I patients. A large number of patients were lost to follow-up. A task force to improve outcomes is urgently required.

Ebstein's anomaly: a case with an unexpected evolution.

Ebstein's anomaly of the tricuspid valve is a rare and complex congenital heart defect. Its etiology is unknown and in the majority of cases it is multifactorial. Mortality in the neonatal period is high. The authors present a case of severe Ebstein's anomaly diagnosed antenatally. In the perinatal period a Blalock-Taussig shunt was performed and at the age of five months the infant underwent successful percutaneous pulmonary valvuloplasty. The clinical outcome has been favorable and we decided to postpone a Glenn procedure. At 18 months the child is asymptomatic.

Interrupted aortic arch: an eight-year experience.

INTRODUCTION: Interrupted aortic arch (IAA) is a rare congenital heart defect with a high mortality rate in the neonatal period. Surgical correction of associated intracardiac anomalies can be performed in a one-stage (primary) or two-stage approach. OBJECTIVES: Case review of children with IAA operated in our center and to evaluate the surgical outcomes and the occurrence of complications. METHODS: A retrospective chart review of children operated from June 1998 to October 2006. RESULTS: Twelve children (nine girls and three boys) were operated. Nine patients had ventricular septal defect with septal malalignment, two had univentricular hearts and two had transposition of the great arteries. Primary correction was performed in eleven patients (aged between two and 38 days), including two Norwood procedures. There was no early mortality. The follow-up time ranged from 30 days to six years (median 2.6 years), with late mortality of 33%. Two children required reintervention for aortic arch restenosis, which was successfully treated by catheterization. DISCUSSION: Our experience is that early primary repair of IAA has low early and late mortality and is the method of choice most situations. Late mortality depends the severity of associated anomalies.

A Right Upper Lobe Mass in the Thorax After Modified Blalock-Taussig Shunt.

We report an incidental finding of pseudoaneurysm in a 10-month-old boy with tetralogy of Fallot and Down syndrome who had undergone placement of a modified Blalock-Taussig shunt at age four months. Computed tomography was a determinant exam for better assessment. The lesion was successfully resected with concomitant complete repair of tetralogy of Fallot in a single-stage. The child was asymptomatic at fourth month follow-up.

Less invasive coronary artery bypass surgery: early results in 1083 patients operated off-pump.

OBJECTIVE: To analyze the early results of coronary surgery without cardiopulmonary bypass using the EuroSCORE risk model. METHODS: Out of a series of 1104 consecutive patients undergoing CABG during a 20-month period and whose data were prospectively collected, 1083 patients (98.1%) were operated without cardiopulmonary bypass (CPB) and represent the patient population. Mean age was 65.6 +/- 9.9 years (31-90), 23.1% were female, 77.9% hypertensive, 38.0% diabetic, 22.8% had peripheral vascular disease, 73.0% triple-vessel disease, 54.7% previous myocardial infarction and 67.0% were in CCS class III or IV. Three hundred and forty-one patients (31.5%) were operated on urgently. Surgery was performed with the aid of cardiac stabilizers and intracoronary shunts. RESULTS: The mean number of distal anastomoses was 2.9; the left internal mammary artery was used in 99% of patients. In 10 patients (0.9%), conversion to CPB was required, without mortality or morbidity. Sixteen patients (1.5%) had myocardial infarction; mean troponin T and CK-MB at 24 h were 0.20 +/- 0.43 ng/ml and 28.2 +/- 49.9 U/l respectively. Twenty patients (1.8%) had neurologic deficit, 10 (0.9%) required hemofiltration or dialysis, 229 (21%) received blood transfusions and 135 (14.2%) had atrial fibrillation. Median intubation time was 9 h, and median ICU stay was one day. Median hospital stay was 5 days. Twelve patients died in hospital (1.1%). Thirty-day observed mortality and EuroSCORE-predicted mortality were 1.3% and 4.0% respectively (p < 0.01). CONCLUSION: Off-pump CAB surgery has become our preferred method in almost all patients undergoing coronary surgery, without compromising completeness of revascularization. Observed mortality was significantly lower than that predicted by EuroSCORE and the incidence of complications was reasonably low considering the population's risk factors.

Ebstein's anomaly in children: a single-center study in Angola.

INTRODUCTION AND OBJECTIVE: Ebstein's anomaly is a rare complex congenital heart defect of the tricuspid valve. We aimed to describe the frequency, clinical profile, and early and short-term post-operative results in patients under the age of 18 years operated for this anomaly in a tertiary center in Angola. METHODS: A retrospective cross-sectional study was conducted over a period of 37 months. We analyzed all patients diagnosed with congenital heart defects. RESULTS: Of the 1362 patients studied, eight (0.6%) had Ebstein's anomaly; six patients (75%) were female. Mean age was 69±59 months. Five patients were in NYHA functional class III or IV. Mean cardiothoracic index was 0.72. Seven patients (87.5%) had severe tricuspid regurgitation and five (62.5%) had another associated congenital heart defect. All patients were operated: two had complications and one (12.5%) died in the early post-operative period. The mean follow-up time was 1.22±0.6 years, and mortality during follow-up was 12.5% (n=1). At the end of the study, of the five patients in whom cone reconstruction was performed, four (80%) were in functional class I. Mean cardiothoracic index decreased to 0.64. Three patients had mild and two had moderate tricuspid regurgitation. The patient who underwent cone reconstruction and a Glenn procedure was in functional class I. CONCLUSION: The frequency of Ebstein's anomaly was similar to that in other centers. Cone reconstruction was viable in the majority of patients, with good early and short-term results.

Coronary surgery in patients with porcelain aorta.

Four patients with unstable angina due to left main or three-vessel disease scheduled for coronary artery bypass grafting were found intra-operatively to have porcelain ascending aorta, defined as massive calcification of the ascending aorta from the aortic valve to the transverse arch, precluding ascending aorta cannulation or clamping. A no-touch operative technique was applied using the two internal mammary arteries in three cases, with complementary Y-grafting when necessary. Three cases underwent off-pump myocardial revascularization. The fourth case was revascularized with pump-assisted beating heart and proximal saphenous graft anastomosis with an automatic connector. There was no mortality or neurologic morbidity and all patients were discharged home before post-operative day 8.

Coronary surgery: which method to use?

OBJECTIVE: To compare 4 methods of myocardial protection in GABG in terms of markers of myocardial ischemia, mortality, morbidity and mid-term results. MATERIAL & METHODS: Retrospective study of 241 consecutive patients undergoing isolated > 1 CABG using one of 4 methods: off-pump (OFF, n = 108), cardiopulmonary bypass (CPB) and cardioplegia (CARD, n = 66), CPB and beating heart (BEAT, n = 47), or CPB and ventricular fibrillation (FIBR, n = 20). Mean age was 65.7 +/- 9.3 years and mean EuroSCORE was 3.2 +/- 2.3. The groups were similar in terms of age, gender distribution, body mass index, incidence of smoking, hypertension, renal insufficiency, CCS class, ventricular function and mean EuroSCORE. Serial blood samples were collected for CK-MB and troponin T, preoperatively and 1, 6, 12 and 24 hours after the procedure. RESULTS: Mean number of distal anastomoses was 3.27 BEAT, 2.98 CARD, 2.90 FIBR and 2.55 OFF (p < 0.05 OFF vs. the other 3 groups). Six patients died in hospital (2.5%), 2/47 BEAT (4.2%), 1/66 CARD (1.5%), 1/20 FIBR (5.0%), 2/108 (1.9% OFF) (p = 0.1). The incidence of atrial fibrillation, stroke/TIA and blood transfusion and length of stay were similar between groups (p = 0.1) but there was a tendency for increased incidence of Q-wave MI (p = 0.08) in OFF and combined adverse events in FIBR (p = 0.07). At 12 hours postoperatively, CK-MB and troponin T were significantly higher in FIBR than in CARD or OFF (p < 0.05) and at 24 hours, troponin T remained higher in FIBR than in all other groups (p < 0.05). After a mean follow-up of 19 months, no significant difference was observed between groups in mortality or relief of angina. CONCLUSION: We were unable to demonstrate the superiority of any one revascularization method over another in terms of mortality, morbidity or length of stay. As shown by lower levels of myocardial markers of ischemia, better myocardial protection was obtained with OFF, BEAT and CARD compared to FIBR. Mid-term survival and relief of angina were similar between groups.

Congenital medium sternal cleft with partial ectopia cordis repair.

Congenital sternal malformation is a rare anomaly often diagnosed as an asymptomatic condition at birth. The authors report a clinical case of a full-term female neonate with congenital sternal cleft and partial ectopia cordis. Successful surgical repair was accomplished at 6 days of age. When surgery is performed shortly after birth, the procedure is easier and better results are achieved.

Rationale, design and methodology for a Prospective Randomized Study of graft patency in Off-pump and On-pump MultI-vessel coronary artery bypasS Surgery (PROMISS) using multidetector computed tomography.

BACKGROUND: Off-pump coronary artery bypass grafting has been accused of possibly compromising graft patency. Sixteen slice computed tomography has shown good diagnostic accuracy in the assessment of coronary bypass graft patency when compared with conventional coronary artery angiography and is less invasive. The study hypothesis is that coronary artery bypass grafting (CABG) performed without cardiopulmonary bypass (Off-Pump) has equivalent early graft patency as if performed with cardiopulmonary bypass (On-Pump) and may have reduced complication rate. METHODS/DESIGN: The Prospective Randomized Comparison of Off-Pump and On-Pump MultI-vessel Coronary Artery BypasS Surgery (PROMISS) is a controlled, single blinded, single centre clinical trial, comparing early graft patency using 16-slice computed tomography in patients with multi-vessel coronary artery disease operated either without or with extracorporeal circulation. Inclusion criteria are multivessel disease with an indication for first time, isolated, non emergent coronary artery bypass grafting with a minimum of three distal anastomoses. Secondary end points are peri-operative mortality, combined morbidity, length of stay, neuro-cognitive testing at 6 weeks and adverse events, stress test and quality of life at 6 months and one year. The sample size of one hundred and fifty patients was calculated in order to enable the detection of a 5% difference in graft patency, with 80% power, considering a minimum of 3 distal anastomoses per patient. Enrollment started in April 2005 and ended July 2007 with study closure in July 2008. CONCLUSION: The PROMISS trial aims to shed new light on the effect of Off-Pump as compared to On-Pump coronary artery bypass surgery on graft patency, assessed by multidetector computed tomography, in unselected patients with multivessel coronary artery disease. TRIAL REGISTRATION: Current Controlled Trials ISRCTN58800729.

Sixteen-slice multidetector computed tomography for graft patency evaluation after coronary artery bypass surgery.

OBJECTIVE: To investigate the ability of 16-slice multidetector computed tomography (MDCT) to assess coronary artery bypass graft patency and to detect bypass stenosis by comparison with coronary angiography. METHODS: Thirty patients underwent both conventional coronary bypass angiography and retrospective ECG gated 16-slice multidetector computed tomography after surgery using 0.4 seconds rotation time and 1.25 mm slice thickness. RESULTS: Among a total of 107 bypass grafts, 101 grafts (94.4%) were evaluable by MDCT. Thirteen patients were taking oral beta blockers. Mean heart rate was 73.6 (52-105). Of the 40 internal mammary arteries and two radial arteries examined, only one was occluded by coronary bypass angiography and MDCT, resulting in a sensitivity of 100% and a specificity of 100%. MDCT correctly diagnosed all patent venous grafts and missed two of the 14 venous grafts shown occluded by conventional angiography resulting in a sensitivity of 85.7% and specificity of 100%. When occluded grafts were excluded, MDCT did not detect two out of two anastomotic arterial graft stenosis >50% and resulted in one false positive result for a sensitivity and specificity of 0% and 97.4%, respectively. MDCT correctly diagnosed one out of three venous stenosis >50% and falsely diagnosed one venous graft stenosis >50% yielding a 33.3% and 97.6% sensitivity and specificity, respectively. CONCLUSION: Sixteen-slice MDCT allows for noninvasive evaluation of coronary bypass grafts patency with high diagnostic accuracy. Assessment of distal anastomotic stenosis was deficient, particularly for arterial grafts, still limited by low resolution or artifacts. Improved accuracy may be obtained by more aggressive heart rate reduction.