Rotation of the outflow tracts

The optimal treatment for transposition of the great arteries with stenosis along the pulmonary tract has always been a challenge. En bloc rotation of the truncus arteriosus has been proposed as an alternative method in this group of patients. We report a truncus turnover in a 3-month-old, 3.4 kg infant.

Photo-oxidized bovine pericardium in congenital cardiac surgery: single-centre experience

Objectives

Dye-mediated photo-oxidation of pericardium is an alternative method to chemical treatment with glutaraldehyde for cross-linking collagen, providing biostability of the patch material while avoiding late calcification and cytotoxicity. There are few data available, on using photo-oxidation-treated pericardium, in congenital cardiac surgery. This study reports the outcomes using Photofix™ bovine pericardium in neonates, infants, children and young adults undergoing paediatric cardiac surgery.

Methods

A total of 490 patches in 383 consecutive operations (364 patients) were used in the surgical repair of congenital heart defects at our institution from October 2008 to October 2011. Recorded variables included demographic data, age at operation, primary cardiac diagnosis, associated complications and number, type and location of patches placed and patch-related reintervention.

Results

Median age at operation was 5.3 years, ranging from <1 month to 56 years. The overall survival rate at late follow-up was 92%, and no deaths were related to failure of the tissue substitute. Two patients (0.5%) underwent reintervention late due to patch material failure: one for residual shunt after Rastelli repair and one for aneurysmal dilatation of a right ventricular outflow tract patch. The patch material was explanted in 8 patients at a mean of 20 months (range, 1-72 months) following implantation. Histological examination revealed mild to moderate inflammation with variable calcification.

Conclusions

Photo-oxidized bovine pericardium demonstrated excellent performance when used as a patch material in cardiovascular repair in children. Its handling characteristics and biocompatibility are consistent with a wide range of applications.

Left-Sided Reoperations After Arterial Switch Operation: A European Multicenter Study

BACKGROUND

We sought to report the frequency, types, and outcomes of left-sided reoperations (LSRs) after an arterial switch operation (ASO) for patients with D-transposition of the great arteries (D-TGA) and double-outlet right ventricle (DORV) TGA-type.

METHODS

Seventeen centers belonging to the European Congenital Heart Surgeons Association (ECHSA) contributed to data collection. We included 111 patients who underwent LSRs after 7,951 ASOs (1.4%) between January 1975 and December 2010. Original diagnoses included D-TGA (n = 99) and DORV TGA-type (n = 12). Main indications for LSR were neoaortic valve insufficiency (n = 52 [47%]) and coronary artery problems (CAPs) (n = 21 [19%]).

RESULTS

Median age at reoperation was 8.2 years (interquartile range [IQR], 2.9-14 years). Seven patients died early after LSRs (6.3%); 4 patients with D-TGA (5.9%) and 3 patients with DORV TGA-type (25%) (p = 0.02). Median age at last follow-up was 16.1 years (IQR, 9.9-21.8 years). Seventeen patients (16%) required another reoperation, which was more frequent in patients with DORV- TGA type (4 of 9 [45%]) than in patients with D-TGA (13 of 95 [14%]). Late death occurred in 4 patients (4 of 104 [3.8%]). The majority of survivors were asymptomatic at last clinical examination (84 of 100 [84%]).

CONCLUSIONS

Reoperations for residual LSRs are infrequent but may become necessary late after an ASO, predominantly for neoaortic valve insufficiency and CAPs. Risk at reoperation is not negligible, and DORV TGA-type anatomy, as well as procedures on the coronary arteries, were significantly associated with a higher morbidity and a lower overall survival. Recurrent reoperations after LSRs may be required.

Ring-reinforced Sano right ventricular to pulmonary artery conduit at Norwood stage I

Reinterventions for proximal conduit obstruction or on the pulmonary arteries are frequent after Sano-modified stage I Norwood palliation of hypoplastic left heart syndrome. We report our experience with a modified Sano stage I, in which the right ventricle-to-pulmonary artery (PA) conduit used is reinforced by external rings to avoid collapse, and the conduit is inserted into the right ventricle through a limited ventriculotomy and 'dunked' into the ventricular cavity. In our experience, this modification was associated with fewer reinterventions or complications with the proximal anastomosis (P = 0.046 and 0.004), improved PA pulse pressure (9.1 ± 4.1 vs 4.8 ± 3.8 mmHg in controls, P < 0.001) and Nakata index (213 ± 76 vs 134 ± 68 mm(2)/m(2) in controls, P < 0.0001), although overall survival to a median of 20 months was not significantly different from controls. Right ventricular function at stage II-bidirectional Glen was marginally better in patients with the modified Sano conduit, however not to a significant level. Further evaluation of late ventricular function is currently ongoing.

Neonatal Mitral Valve Repair in Biventricular Repair, Single Ventricle Palliation, and Secondary Left Ventricular Recruitment: Indications, Techniques, and Mid-Term Outcomes

Objectives

Although mitral valve repair is rarely required in neonates, this population is considered to be at high risk for adverse outcomes. The aim of this study was to review the indications for surgery, mechanisms, repair techniques, and mid-term outcomes of neonatal mitral valve repair.

Methods

The demographic, procedural, and outcome data were obtained for all neonates who underwent mitral valve repair from 2005 to 2012. The primary endpoints included mortality, transplantation, and mitral valve reoperation.

Results

Twenty patients were included during the study period. Median age at operation was 11 days (range: 3–25). Eleven patients (55%) presented with mitral stenosis, three had regurgitation (15%), and six had mixed mitral disease (30%). Nineteen of 20 patients had mild or less regurgitation on immediate postoperative imaging. During a median follow-up of 5 months (1 month–4.8 years), six patients died at a median of 33 months (7–41 months) from repair and one patient required orthotopic heart transplantation. Six patients required mitral valve reoperation, five for mitral valve re-repair, and one for mitral valve replacement. Freedom from death, transplantation, or mitral valve replacement was 84.2 ± 8.4% at 1 month, 71.3 ± 11% at 6 months, 64.1 ± 12% at 1 year, and 51.3 ± 15% at 2 years and was worse for patients presenting with mitral regurgitation compared to stenosis or mixed mitral valve disease.

Conclusion

Although mitral valve repair can be performed with acceptable immediate postoperative result, this procedure carries a high burden of late death and mitral valve reoperations.

Asymptomatic right circumflex aortic arch associated with ventricular septal defect and biscuspid aortic valve

INTRODUCTION

Anomalies of the aortic arch are frequent congenital malformations, which rarely form partial or complete vascular rings. A rare form of vascular ring is the encircling, or circumflex, aortic arch.

CASE REPORT

A 19-month-old boy, with no respiratory symptoms, was referred for ventricular septal defect (VSD) repair. Cardiac magnetic resonance imaging and echocardiography confirmed the perimembranous VSD, a bicuspid aortic valve with normal function, and showed a right-sided ascending aorta, bifurcating to the left behind the esophagus and trachea above the tracheal bifurcation, with a left-sided descending aorta, a left ligamentum arteriosum and aberrant left subclavian artery, realizing a circumflex aortic arch. The child underwent successful VSD repair and ligamentum arteriosum division, with an uneventful postoperative course.

CONCLUSIONS

Previous reports have described the association of circumflex aortic arch with VSD, but there is no previous report of its association with VSD and bicuspid aortic valve. Patients are usually symptomatic either preoperatively, or after VSD repair. For this reason, division of the ligamentum arteriosum, to open the vascular ring and free the trachea and esophagus from compression, should be performed in patients undergoing cardiac surgery for associated malformations.

Biventricular repair for common atrioventricular canal defect with parachute left atrioventricular valve

OBJECTIVES

Parachute left atrioventricular (AV) valve can complicate repair of common atrioventricular canal (CAVC), and single-ventricle palliation is sometimes preferred. The goal of this study is to review our single institutional experience in biventricular repair in this patient group.

METHODS

The demographic, procedural and outcome data were obtained for all children who underwent biventricular repair for complete CAVC with parachute [single left ventricular (LV) papillary muscle] or forme fruste parachute left AV valve (closely spaced LV papillary muscles) from 2001 to 2012. Primary outcomes were survival, freedom from left AV valve stenosis (defined as an inflow gradient ≥7 mmHg and post-capillary pulmonary hypertension) and freedom from left AV valve replacement.

RESULTS

A total of 24 patients were included (21 parachutes, 3 forme frustes). There was 1 early death (4.2%). At discharge, no patient had more-than-mild regurgitation and 1 had stenosis. During a median follow-up of 3.7 years (IQR 4 months to 5 years), there were 2 late deaths (8.3%), 6 patients (25%) presented significant left AV valve stenosis and 2 patients (8.3%) required valve replacement. Freedom from stenosis was 95 ± 4.9% at 1 year, 83.1 ± 8.9% at 3 years, 64.7 ± 13.5% at 5 years and 51.7 ± 15.8% at 10 years. Complete cleft closure was not associated with a significantly different freedom from left AV valve reoperation (log-rank test, P = 0.89) or significant stenosis (P = 0.47).

CONCLUSION

Biventricular repair in parachute left AV valve and CAVC is feasible with acceptable mortality and freedom from stenosis. The burden of reoperation remains significant in this patient group.

Ring-reinforced Sano conduit at Norwood stage I reduces proximal conduit obstruction

BACKGROUND

Reinterventions for proximal conduit obstruction or on the pulmonary arteries are frequent after the Sano-modified stage I Norwood palliation of hypoplastic left heart syndrome. We report our initial experience with a modified Sano technique using a ring-reinforced graft inserted transmurally through the right ventricle with a limited ventriculotomy.

METHODS

All patients who underwent the Sano-modified stage I Norwood procedure using a modified "dunked" technique from September 2010 to September 2012 at our institution were reviewed. An historical control group consisted of patients undergoing the traditional Sano right ventricle-to-pulmonary artery conduit anastomosed to the epicardium. The primary outcome measures included death, reintervention on the Sano and pulmonary arteries, and ventricular function.

RESULTS

The study included 29 patients. No patients required intervention on the Sano conduit, pulmonary arteries, or aortic arch before discharge after the stage I procedure. During a median follow-up of 20 months (range, 26 days to 3.3 years), survival was estimated at 96.6% ± 3.4% at 1 month and 86.2% ± 6.4% at the latest follow-up. One patient underwent heart transplantation. No interstage intervention was required on the proximal or distal Sano conduit. Intervention was required on the midportion of the conduit in 1 patient and on the pulmonary arteries in 3 patients. At the time of the bidirectional Glenn anastomosis, freedom from conduit and pulmonary artery intervention was estimated at 92.3% ± 7.4% and 90.1% ± 8.7%, respectively, and global right ventricular dysfunction was mild or less in 84% (16 of 19) of patients.

CONCLUSIONS

The ring-reinforced right ventricle-to-pulmonary artery Sano conduit transmurally inserted into the right ventricle provides acceptable results, with a low incidence of interstage reinterventions in patients undergoing stage I palliation.

Biodegradable materials for surgical management of infective endocarditis: new solution or a dead end street?

Background

One third of patients with infective endocarditis will require operative intervention. Given the superiority of valve repair over valve replacement in many indications other than endocarditis, there has been increasing interest and an increasing number of reports of excellent results of valve repair in acute infective endocarditis. The theoretically ideal material for valve repair in this setting is non-permanent, “vanishing” material, not at risk of seeding or colonization. The goal of this contribution is to review currently available data on biodegradable materials for valve repair in infective endocarditis.

Discussion

Rigorous electronic and manual literature searches were conducted to identify reports of biodegradable materials for valve repair in infective endocarditis. Articles were identified in electronic database searches of Medline, Embase and the Cochrane Library, using a predetermined search strategy. 49 manuscripts were included in the review. Prosthetic materials needed for valve repair can be summarized into annuloplasty rings to remodel the mitral or tricuspid annulus, and patch materials to replace resected valvar tissue. The commercially available biodegradable annuloplasty ring has shown interesting clinical results in a single-center experience; however further data is required for validation and longer follow-up. Unmodified extra-cellular matrix patches, such as small intestinal submucosa, have had promising initial experimental and clinical results in non-infected valve repair, although in valve repair for endocarditis has been reported in only one patient, and concerns have been raised regarding their mechanical stability in an infected field.

Summary

These evolving biodegradable devices offer the potential for valve repair with degradable materials replaced with autologous tissue, which could further improve the results of valve repair for infective endocarditis. This is an evolving field with promising experimental or initial clinical results, however long-term outcomes are lacking and further data is necessary to validate this theoretically interesting approach to infective endocarditis.