Postoperative Troponin Levels in Children Undergoing Open Heart Surgery With and Without Coronary Intervention.

We aimed to characterize the ranges, temporal trends, influencing factors, and prognostic significance of postoperative troponin levels after congenital heart surgery. This single-center retrospective study included patients from 2006 to 2021 who had ≥ 1 postoperative troponin-T measurement collected within 96 h of congenital heart surgery (CHS). Patients were grouped as Anomalous Aortic Origin of the Coronary Artery-"AAOCA repair," or congenital heart surgery with "Other Coronary Interventions" other than AAOCA repair, or "No Coronary Intervention." In each group, information on concomitant surgery requiring one or more of the following-atriotomy, ventriculotomy, right ventricular muscle bundle resection, and/or septal myectomy-was collected. Clinical correlates of troponin values were analyzed in three postoperative windows: < 8, 8-24, and 24-48 h. The highest median [range] troponin levels (ng/mL) for the samples were 0.34 [0.06, 1.32] at < 8 h for "AAOCA repair," 1.35 [0.14, 12.0] at < 8 h for those undergoing CHS with "Other Coronary Interventions," and 0.87 [0.06, 25.1] at 8-24 h for those undergoing CHS with "No Coronary Interventions." Atriotomy was associated with higher median troponin levels in the AAOCA group at < 8 h (0.40 [0.31, 0.77] vs. 0.29 [0.17, 0.54], P = 0.043) and in the Other Coronary Intervention group at 8-24 h (1.67 [1.04, 2.63] vs. 0.40 [0.19, 1.32], P = 0.002). Patients experiencing major postoperative complications (vs. those who did not) had higher troponin levels in the AAOCA group as early as 8-24 h (0.36 [0.24, 0.57] vs. 0.21 [0.14, 0.33], P = 0.03). Similar findings were noted in the Coronary Intervention (2.20 [1.34, 3.90] vs. 1.11 [0.51, 2.90], P = 0.028) and No Coronary Intervention (2.2 [1.49, 15.1] vs. 0.74 [0.40, 2.34], P = 0.027) groups but earlier at < 8 h. In the AAOCA group, 2/18 (11%) troponin outliers experienced cardiac arrest in comparison to 0/80 (0%) non-outliers (P = 0.032). In the Other Coronary Intervention group, troponin outliers had longer median times to ICU discharge (10 vs. 4 days) and hospital discharge (21 vs. 10 days) (both P < 0.001). Postoperative troponin levels depend on a multitude of factors and may have prognostic value in patients undergoing congenital heart surgery with coronary interventions.

Magnetic resonance three-dimensional steady-state free precession imaging of the thoracic duct in patients with Fontan circulation and its relationship to outcomes.

BACKGROUND: Lymphatic complications are common in patients with Fontan circulation. Three-dimensional balanced steady-state free precession (3D bSSFP) angiography by cardiovascular magnetic resonance (CMR) is widely used for cardiovascular anatomical assessment. We sought to determine the frequency of thoracic duct (TD) visualization using 3D bSSFP images and assess whether TD characteristics are associated with clinical outcomes. METHODS: This was a retrospective, single-center study of patients with Fontan circulation who underwent CMR. Frequency matching of age at CMR was used to construct a comparison group of patients with repaired tetralogy of Fallot (rTOF). TD characteristics included maximum diameter and a qualitative assessment of tortuosity. Clinical outcomes included protein-losing enteropathy (PLE), plastic bronchitis, listing for heart transplantation, and death. A composite outcome was defined as presence of any of these events. RESULTS: The study included 189 Fontan patients (median age 16.1 years, IQR 11.0-23.2 years) and 36 rTOF patients (median age 15.7 years, IQR 11.1-23.7 years). The TD diameter was larger (median 2.50 vs. 1.95 mm, p = 0.002) and more often well visualized (65% vs. 22%, p < 0.001) in Fontan patients vs. rTOF patients. TD dimension increased mildly with age in Fontan patients, R = 0.19, p = 0.01. In Fontan patients, the TD diameter was larger in those with PLE vs. without PLE (age-adjusted mean 4.11 vs. 2.72, p = 0.005), and was more tortuous in those with NYHA class ≥ II vs. class I (moderate or greater tortuosity 75% vs. 28.5%, p = 0.02). Larger TD diameter was associated with a lower ventricular ejection fraction that was independent of age (partial correlation = - 0.22, p = 0.02). More tortuous TDs had a higher end-systolic volume (mean 70.0 mL/m2 vs. 57.3 mL/m2, p = 0.03), lower creatinine (mean 0.61 mg/dL vs. 0.70 mg/dL, p = 0.04), and a higher absolute lymphocyte count (mean 1.80 K cells/µL vs. 0.76 K cells/µL, p = 0.003). The composite outcome was present in 6% of Fontan patients and was not associated with TD diameter (p = 0.50) or tortuosity (p = 0.09). CONCLUSIONS: The TD is well visualized in two-thirds of patients with Fontan circulation on 3D-bSSFP images. Larger TD diameter is associated with PLE and increased TD tortuosity is associated with an NYHA class ≥ II.

The Use of Regional Catheters in Children Undergoing Repair of Aortic Coarctation.

OBJECTIVE: The objective was to assess the effectiveness and safety of peripheral regional anesthesia in congenital cardiac surgical patients undergoing thoracotomy for aortic coarctation. DESIGN: A retrospective chart review of pediatric patients (<18 years) who underwent surgical repair of congenital heart diseases via thoracotomy between September 2013 and July 2018 was done. Among patients who underwent coarctation repair, a propensity score was used to match patients who received a regional catheter (C) versus traditional medical treatment only (M). SETTING: A single center children's hospital. PARTICIPANTS: The median age was 172 days (IQR 64-1315) in group C and 176 days (IQR 71-1146) in group M (SMD = 0.07). The median weight was 6.8 kg (IQR 4.8-13.6) in group C and 7.7 kg (4.6-17.4) in group M (SMD = 0.003). MEASUREMENTS AND MAIN RESULT: Outcomes assessed were postoperative hospital length of stay, median pain scores in the first 24 and 48 hours, and total morphine equivalent use in the first 24 and 48 hours. Complications related to the catheters were reviewed. The median oral morphine equivalent dose administered in the first 24 hours was lower in group C than group M (0.8 mg/kg, IQR 0.5-1.1 vs. 1.4 mg/kg, IQR 0.9-1.7, p = 0.019). There were no major complications related to the catheters, including hematoma. CONCLUSIONS: Peripheral regional catheters may be used to reduce opioid requirements in patients after CoA repair. Due to the low risk of these catheters, they should be considered as part of a pain management strategy for pediatric patients undergoing thoracotomy and should be incorporated into strategies to improve outcomes.

Hybrid Left Heart Bypass Circuit for Repair of the Descending Aorta in an 8-kg Williams Syndrome Patient.

A 1-year old male patient with Williams syndrome and multiple prior interventions presented for surgical repair of his descending aorta (DA) through a left thoracotomy. Concerns for significant bleeding and spinal cord protection led the care team to consider a left heart bypass (LHB) circuit with options for pump sucker use, heat exchange capacity, and the possibility of converting to traditional cardiopulmonary bypass (CPB). A traditional CPB circuit with a roller-head arterial pump was assembled with a bypass line around the cardiotomy venous reservoir (CVR). Excluding the CVR with this line allowed for a closed LHB circuit. A second pump head was integrated to both recirculate the CVR volume and to serve as a means for controlled volume administration to the closed LHB circuit. Pump sucker return directed to the CVR could easily be transfused back to the patient. The patient was placed on the hybrid LHB circuit and cooled to 32°C. DA clamps were placed. Upper body dynamic blood pressure was managed for a target mean of 50 mmHg, the left atrial pressure (LAP) was maintained in the 5-7 mmHg range, and the nonpulsatile lower body blood pressure was targeted at 40-50 mmHg. Cerebral near-infrared spectroscopy (NIRS) helped guide volume and pressure management. The surgeons placed two long-segment patches on the DA, moving clamps as needed. The patient was rewarmed and separated from the hybrid LHB circuit after 82 minutes. Closed circuit LHB can be provided with a roller-head hybrid circuit incorporating an oxygenator for gas exchange, central cooling and warming, and arterial line filtration along with a CVR for pump sucker use and controlled transfusion to the patient.

Complications of Transthoracic Intracardiac and Central Venous Lines in Neonates Undergoing Cardiac Surgery.

Neonates undergoing congenital heart surgery require central venous access for diagnostic information and medication administration. There are multiple options for central access including peripherally inserted central catheters, umbilical, central venous, and transthoracic intracardiac lines. We retrospectively identified all patients younger than 30 days who underwent cardiac surgery in a 1-year period. Data were collected on demographic and medical characteristics, adverse events, pre-emptive transfusion of blood products prior to line removal, and transfusion of blood products following removal of transthoracic intracardiac lines and central venous lines. In our cohort of 124 neonates, 176 transthoracic intracardiac lines were placed in 113 patients. Eighty-two patients had pre-existing central venous access including 35 umbilical venous lines, 21 PICC lines, and 18 CVLs. Ninety-eight patients received a CVL in the operating room by anesthesia. Five patients were transfused to correct laboratory derangement prior to transthoracic intracardiac line removal. Transfusion of packed red blood cells (pRBC) occurred after transthoracic intracardiac line removal in 25 patients. Thrombus formation was present in one patient with a transthoracic intracardiac line and three patients with CVLs. One patient underwent surgical intervention for repositioning of a transthoracic intracardiac line. There were no cases of cardiac arrest, extracorporeal life support, or deaths attributable to lines. In this cohort, transthoracic intracardiac lines were generally safe. There were very few complications of thrombus, infection, or requirement for surgical intervention; however, transfusion of pRBCs following transthoracic intracardiac line removal occurred in 20% of patients.

Twenty Years of Anesthetic and Perioperative Management of Patients With Tetralogy of Fallot With Absent Pulmonary Valve.

OBJECTIVE: Review the authors' institutional experience of the induction and perioperative airway management of children with tetralogy of Fallot with an absent pulmonary valve. DESIGN: Retrospective chart review. SETTING: Large academic children's hospital. PARTICIPANTS: Patients with the diagnosis of tetralogy of Fallot with absent pulmonary valve undergoing primary cardiac repair over a 20-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-four patients were identified with tetralogy of Fallot with an absent pulmonary valve from January 1995 through August 2014. Forty-two patients (95%) required surgery in their first year of life. Sixteen patients (36%) required mechanical ventilation preoperatively, including 11 neonates. Of the 28 patients not intubated preoperatively, only 1 (3.8%) exhibited minor airway obstruction following induction that was managed uneventfully. All intubations in the operating room were performed in the supine position. Five patients who were mechanically ventilated preoperatively in a lateral or prone position were supinated in the operating room without significant cardiopulmonary compromise. There were no patients who suffered cardiopulmonary arrest or required mechanical circulatory support. The median time to extubation was 2 days (range 1-13 days) in those patients who were not mechanically ventilated prior to their surgery. Ultimately, 5 patients required tracheostomy and 1 patient underwent lobectomy. Although, there was no mortality at 30 days, 4 children died within 1 year of their surgery. All the children who died had a genetic syndrome and required mechanical ventilation preoperatively. CONCLUSIONS: While there are theoretical concerns specific to the induction and airway management of tetralogy of Fallot with an absent pulmonary valve, there were no episodes of cardiorespiratory arrest or extracorporeal membrane oxygenation in the authors' series. Neonatal age at the time of surgery, preoperative need for mechanical ventilation, and concomitant genetic syndromes are risk factors for respiratory morbidity. Mortality in this study was low compared to historic reports, likely reflecting improvement in surgical technique and intensive care management.

Transposition of the great arteries and sinus venosus defect with partially anomalous pulmonary venous return: physiological and anatomic considerations.

Transposition of the great arteries is a common congenital heart defect causing cyanosis in neonates, occurring in 0.2 per 1000 live births. It has been reported to occur with other associated congenital heart lesions. However, its association with a superior sinus venosus defect and partially anomalous pulmonary venous return has not been reported. We present a neonate with transposition of the great arteries, superior sinus venosus defect with partially anomalous pulmonary venous return that underwent successful complete neonatal repair, and discuss important physiological and anatomic considerations.

Repeat Repair After Translocation of an Anomalous Left Coronary Artery.

We repaired a left anomalous aortic origin of coronary artery using coronary ostium translocation/reimplantation. Repeat repair was required due to suboptimal flow pattern in postoperative transesophageal echocardiography, which was confirmed with coronary angiography. We emphasize the importance of early recognition, diagnosis, and intervention to deal with a problem with the coronary repair.

Safety of Berlin Heart EXCOR pump changes in the PICU.

OBJECTIVE: To describe whether Berlin Heart EXCOR Pediatric pump changes in the ICU are associated with infection, hemodynamic and ventilatory instability, and neurologic injury. DESIGN: Retrospective, descriptive chart review. SETTING: PICU in a quaternary care children's hospital. PATIENTS: Eight patients were supported on Berlin Heart EXCOR Pediatric pumps due to cardiomyopathy or cardiogenic shock. Two patients were supported with left ventricular assist devices, five had biventricular assist devices, and one required a univentricular assist device. INTERVENTIONS: A team of cardiac surgeons, pediatric intensivists, and operating room nurses conducted sixteen pump changes in the pediatric intensive care unit. Patients were monitored for deleterious effects for 5 days following the change. MEASUREMENT AND MAIN RESULTS: For the first 48 hrs following the EXCOR pump change, no patients exhibited acute neurologic deficits or escalation of hemodynamic or ventilatory support. Over the first 5 days, no blood cultures were positive for microbes. CONCLUSIONS: Berlin Heart EXCOR Pediatric pump changes in the pediatric intensive care unit appear to be a safe procedure when conducted by a highly specialized team.

Predictors of anesthesia ready time: Analysis and benchmark data.

Objective: Patients undergoing congenital cardiac surgery require induction of anesthesia. Our objective was to identify the median anesthesia ready time and the predictors of this time. Methods: By using the Society of Thoracic Surgeons Congenital Heart Surgery Database, we identified patients who underwent cardiopulmonary bypass procedures from 2017 to 2021. Univariate and multivariable regression modeling to predict the anesthesia ready time was performed using mixed-effects linear regression. Results: After exclusion of outliers, 44,418 cases were analyzed. The median anesthesia ready time was 51 minutes (interquartile range, 38-66). On multivariable analysis, independent predictors of a longer anesthesia ready time included decreasing weight (0.3 min/10 kg, 95% CI, 0.1-0.6; P = .011), prematurity (1.5 minutes, 95% CI, 0.8-2.2; P < .001), and presence of chromosomal abnormality (3.4 minutes, 95% CI, 1.5-5.2; P < .001). An increase in the duration in anesthesia ready time was seen with increasing Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery mortality category with an additional 7.8 minutes (95% CI, 5.2-10.4; P < .001) for a Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery 5 procedure compared with Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery 1. Emergency versus elective case designation was associated with an anesthesia ready time reduction of 3.6 minutes (95% CI, 1.1-6.1; P = .005), and an afternoon case start was associated with an anesthesia ready time reduction of 4.2 minutes (95% CI, 2.8-5.6; P < .001). The presence of an anesthesia trainee increased the anesthesia ready time by 3.8 minutes (95% CI, 2.6-5.0; P < .001). The presence of an airway in situ decreased the anesthesia ready time by 3.6 minutes (95% CI, 1.6-5.5; P < .001), whereas an in situ arterial line decreased the anesthesia ready time by 7.4 minutes (95% CI, 4.6-10.2; P < .001). Placement of a central venous line increased the anesthesia ready time by 8.5 minutes (95% CI, 5.9-11.1; P < .001). Conclusions: The median anesthesia ready time was 51 minutes. For patients with characteristics associated with prolonged anesthesia ready time, consideration should be given to allocation of additional anesthesia staffing to improve efficiency.

Trends in surgical management of anomalous aortic origin of the coronary artery over 2 decades.

Objective: To evaluate outcomes of patients undergoing surgery for anomalous aortic origin of the coronary artery (AAOCA) at a tertiary care center and determine the influences of a coronary artery program on management strategies and outcomes. Methods: This retrospective review of consecutive surgical patients who had isolated AAOCA at a tertiary care center between August 1, 1999, and October 31, 2022, compared patient characteristics, interventional timing, and surgical strategies before and after program inception in 2018. Comparisons between time periods and anatomical subgroups were performed using Fisher exact and Wilcoxon rank-sum tests. Results: Of 149 surgical AAOCA patients, 102 (69%) had AAO of the right coronary artery. Compared with AAO of the left coronary artery (AAOLCA), AAO of the right coronary artery (AAORCA) was associated with greater athletic participation (intramural, varsity, and college-level) (74% vs 43%; P < .001) and preoperative functional imaging (72% vs 49%; P = .01), but were less likely to have ischemic changes on functional imaging (5% vs 23%; P = .03) or any postoperative complications (7% vs 19%; P = .04). Moderate or greater aortic insufficiency occurred postoperatively in 1 (1%) of AAORCA and 1 (3%) of AAOLCA patients. After the coronary artery program inception, there was an increase among patients with AAOCA undergoing preoperative computed tomography angiography (pre-2018: 39 out of 98 [40%] vs post-2018: 48 out of 51 [94%]; P < .001) and a decrease in isolated AAOCA unroofing procedures performed (30 [31%] vs 5 [10%]; P = .004). Conclusions: Surgical management of AAOCA evolved over time, and can be achieved with low instance of postoperative aortic insufficiency. Establishment of a coronary artery program has streamlined care.

Computed tomography angiography (CTA) of anomalous aortic origin of a coronary artery (AAOCA): Which measurements are accurate and reliable?

BACKGROUND: The variation and accuracy of computed tomography angiography (CTA) features of anomalous aortic origin of a coronary artery (AAOCA) have not been completely characterized. We evaluated anomalous right (AAORCA) and left (AAOLCA) coronary arteries by CTA, with an emphasis on reproducibility, comparison with surgical measurements, and effect of nitroglycerin. METHODS: CTAs were interpreted for location of coronary origin & exit from the aorta, course, and dominance; minor & major diameters of the proximal & distal coronaries; shape of orifice; and intramural length. Relationships between vessel measurements, body surface area (BSA), and nitroglycerin use were evaluated. Comparisons between CTA and surgical measurements included intramural length, surgical probe size pre-intervention vs. CTA proximal AAOCA diameter, and surgical probe size post-intervention vs. CTA distal AAOCA diameter. RESULTS: Of 104 patients [81 (78%) AAORCA], all but 1 were intramural. Compared to AAOLCA, AAORCA patients were more likely to have a high origin (91% vs. 31%, p â€‹< â€‹0.01), and slit-like orifice (58% vs. 26%, p â€‹< â€‹0.01). When CTAs with nitroglycerin were compared to those without, no difference in proximal AAOCA dimensions was identified; however distal AAOCA and normal-origin coronary dimensions were larger in scans with nitroglycerin. Aside from slit-like orifice, reliability of coronary CTA measurements, including proximal AAOCA minor diameter and intramural length, was moderate to good between readers. In a subgroup of 54 patients, proximal AAOCA minor diameter and intramural length had good agreement and correlation with surgery. CONCLUSION: Proximal AAOCA dimensions and intramural length are reproducible variables. The lack of difference in proximal AAOCA dimensions with nitroglycerin may reflect abnormal vessel mechanics. Multicenter studies are an important next step in understanding the generalizability of our findings.

Histopathology of resected tissue from repair of anomalous aortic origin of a coronary artery: Potential mechanism of coronary artery compression.

Objective: This study aimed to describe the histomorphologic characteristics of resected (unroofed) common wall tissue from repair of anomalous aortic origin of a coronary artery and to determine whether the histologic features correlate with clinical and imaging findings. Methods: The histology of resected tissue was analyzed and reviewed for the presence of fibrointimal hyperplasia, smooth muscle disarray, mucoid extracellular matrix accumulation, mural fibrosis, and elastic fiber disorganization and fragmentation using hematoxylin and eosin and special stains. Clinical, computed tomography imaging, and surgical data were correlated with the histopathologic findings. Results: Twenty specimens from 20 patients (age range, 7-18 years; 14 males) were analyzed. Anomalous aortic origin of a coronary artery involved the right coronary in 16 (80%), and a slit-like ostium was noted in 18 (90%). By computed tomography imaging, the median proximal coronary artery eccentricity index was 0.4 (range, 0.20-0.90). The median length of intramural course was 8.2 mm (range, 2.6-15.2 mm). The anomalous vessel was determined to be interarterial in 14 patients (93%, 15 had evaluable images). The median distance from a commissure was 2.5 mm above the sinotubular junction (STJ) (range: 2 mm below the STJ-14 mm above the STJ). Prominent histopathologic findings included elastic fiber alterations, mural fibrosis, and smooth muscle disarray. The shared wall of the aorta and intramural coronary artery is more similar to the aorta histologically. Mural fibrosis and elastic fiber abnormalities tended to be more severe in patients >10 years of age at the time of surgery, but this did not reach statistical significance. The extent of vascular changes did not appear to have a clear relationship with the imaging features. Conclusions: The findings confirm the aortic wall-like quality of the intramural segment of the coronary artery and the presence of pathologic alterations in the wall microstructure.

The Yasui operation: A single institutional experience over 30 years.

Objective: The Yasui operation was introduced in 1987 for patients with 2 adequate ventricles, a ventricular septal defect, and aortic atresia or interrupted aortic arch. Despite promising early outcomes, left ventricular outflow tract obstruction (LVOTO) remains a long-term concern. The purpose of this study is to report our institutional experience with the Yasui operation. Methods: We retrospectively reviewed all patients undergoing the Yasui operation between 1989 and 2021. Results are reported as median with interquartile range (IQR). Results: Twenty-five patients underwent a Yasui operation (19 primary), at 11 days (IQR, 7-218 days) of life and weight of 3 kg (IQR, 2.8-4.1 days). Fundamental diagnosis was ventricular septal defect/interrupted aortic arch in 11 patients and ventricular septal defect/aortic atresia in 14. Follow-up was 96% (24 out of 25) at 5 years (IQR, 1.4-14.7) with 92% survival. Freedom from LVOTO reoperation was 91% at late follow-up with 2 patients requiring baffle revision at 6 and 9 years. Latest echocardiogram showed 100% of patients had normal biventricular function and 87% (20 out of 23) less than mild LVOTO at 5 years (IQR, 2.3-14.9). Diagnosis, aortic valve morphology, and material used were not predictors of LVOTO. Freedom from right ventricle-to-pulmonary artery conduit reoperation was 48% at a median of 5 years (IQR, 1.4-14.7). Conduit type was not a predictor of reintervention. Conclusions: The Yasui operation can be performed with low morbidity and mortality in patients with 2 acceptable-size ventricles and aortic atresia or interrupted aortic arch with severe LVOTO. Despite some burden of reoperation, midterm reoperation for LVOTO is not common and ventricular function is preserved.

Patch augmentation of small ascending aorta during stage I procedure reduces the risk of morbidity and mortality.

OBJECTIVES: Hypoplastic left heart syndrome (HLHS) with aortic atresia (AA) patients are prone to coronary insufficiency due to a small ascending aorta. Prophylactic patch augmentation of the small ascending aorta during the stage I procedure (S1P) may reduce the risk of coronary insufficiency as marked by ventricular dysfunction, need for extracorporeal membrane oxygenator (ECMO) support or mortality. METHODS: Retrospective analysis of patients with HLHS with AA who underwent an S1P was completed. Baseline ascending aorta size, right ventricular (RV) function and outcome variables of transplant-free survival, ECMO support after the stage 1 operation and RV function at the time of the bidirectional Glenn and latest follow-up were collected. RESULTS: Between January 2010 and April 2020, 11 patients underwent prophylactic ascending aorta augmentation at the time of the S1P as a planned portion of the procedure. A total of 125 patients underwent S1P during this period as a comparison. Overall survival was 100% for the augmented group and 74% for the control group (P = 0.66). A composite end point of transplant-free survival, no post-S1P ECMO and less than moderate RV dysfunction was created. At the time of BDG, this composite end point was 100% for the augmented group and 61.8% for the control group (P = 0.008) and at most recent follow-up was 100% for the augmented group and 59.3% for control (P = 0.007). Eight patients required a rescue procedure for the clinical evidence of coronary insufficiency following S1P that included ascending aorta patch augmentation or stent placement. When comparing these rescue versus prophylactic ascending aortic augmentations, there were also differences in the composite outcome 100% for augmented and 60% for rescue (P = 0.009) and at the time of most recent follow-up 100% for augmented and 50% for rescue (P = 0.029). CONCLUSIONS: Prophylactic patch augmentation of the ascending aorta in HLHS patients with AA may reduce the risk of mortality, ECMO and reduced RV function. Patients not initially undergoing augmentation but then requiring a rescue procedure have particularly poor outcomes. Patch augmentation for smaller ascending aortic diameters should be considered and further clinical experience may help delineate aorta diameter threshold for augmentation.

Can the impact of change of surgical teams in cardiovascular surgery be measured by operative mortality or morbidity? A propensity adjusted cohort comparison.

OBJECTIVE: Our objective was to examine the impact of team changeover and unfamiliar teams in cardiovascular surgery on traditional clinical outcome measures. BACKGROUND: The importance of teamwork in the operating room is increasingly being appreciated, but the impact on more traditional outcome measures is unclear. METHODS: Elective or urgent cardiovascular procedures were divided into categories: team D (patients who had an operation with a day team); team E (patients who had an operation with an evening team); team C (patients who had an operation which included changeover between a day and evening team). Comparison groups were adjusted using propensity scores. RESULTS: We identified 6698 patients who met inclusion criteria (team D, n =3781; team E, n = 518; team C, n = 2399). After propensity score adjustment,there was an increased skin­skin time of 28 minutes in team C when compared with team D (P < 0.001) and of 21 minutes when compared with team E (P <0.001). There were also more episodes of septicemia among team C patients(OR 1.85, P = 0.013) when compared with team D. Patients operated by a day team had a statistically significantly lower number of ventilated hours and shorter hospital length of stay when compared with team E and team C (P < 0.001 and P < 0.001, respectively). There was no difference between teams in operative death, reoperation for bleeding, blood transfusion, renal failure/dialysis, neurologic events, or deep/superficial wound infections. CONCLUSIONS: The change in operating room personnel from the day team to the evening team added significant length to the total operating department time in cardiovascular surgery; however, its impact on most traditional outcome measures was difficult to demonstrate. More sensitive outcome measures may be required to assess the impact of teamwork interventions.

Repair of Anomalous Left Anterior Descending Coronary Artery Arising From the Pulmonary Artery Using a Dacron Interposition Bypass Graft.

An anomalous left anterior descending artery arising from the pulmonary artery (ALADAPA) is exceedingly rare. We present an adult case of ALADAPA that was repaired using a Dacron interposition graft.

Surgical Repair of Congenital Atresia of the Left Coronary Ostium.

Congenital left main coronary artery atresia is an exceedingly rare condition with potentially fatal consequences if not diagnosed in a timely fashion. We present a case series in children and adolescents, including surgical repair and outcomes. We describe the presenting symptoms and subsequent management of each patient, including surgical repair and outcomes. (Level of Difficulty: Advanced.).

Relationship of Preoperative Thyroid Dysfunction to Clinical Outcomes in Pediatric Cardiac Surgery.

CONTEXT: Thyroid function may be assessed in children before cardiac surgery because of concerns that hypothyroidism or thyrotoxicosis might adversely affect cardiac function perioperatively. However, the relationship between preoperative thyroid dysfunction and surgical outcomes is unknown. OBJECTIVE: Determine the relationship between preoperative thyroid dysfunction and outcomes of pediatric cardiac surgery. METHODS: Retrospective cohort study (January 2005 to July 2019). SETTING: Academic pediatric hospital. PATIENTS: All patients <19 years old who underwent cardiac surgery with cardiopulmonary bypass and had thyrotropin (TSH) measured within 14 days preoperatively. Exclusion criteria included neonates (≤30 days), preoperative extracorporeal life support, salvage operations, or transplantation procedures. MAIN OUTCOME MEASURES: Subjects were stratified by preoperative TSH concentration (mIU/L): low (<0.5), normal (0.5-5), mildly high (5.01-10), or moderately high (>10). Outcomes were compared among subjects with normal TSH (control) and each group with abnormal TSH concentrations. The primary outcome was 30-day mortality. Secondary outcomes included time to extubation, intensive care unit and hospital length of stay, and operative complications. RESULTS: Among 592 patients analyzed, preoperative TSH was low in 15 (2.5%), normal in 347 (58.6%), mildly high in 177 (29.9%), and moderately high in 53 (9.0%). Free thyroxine was measured in 77.4% of patients and was low in 0 to 4.4% of subjects, with no differences among TSH groups. Thirty-day mortality was similar among TSH groups. There were no differences in any secondary outcome between patients with abnormal TSH and patients with normal TSH. CONCLUSION: Preoperative mild to moderate subclinical hypothyroidism was not associated with adverse postoperative outcomes in children undergoing cardiopulmonary bypass procedures.