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Tucker DL, Lee LJ, Ahmad M, Shaheen N, Gupta S, Najm HK, Hammoud MS, Tretter JT, Karamlou T. Surgical strategies to address re-operative complex left ventricular outflow tract and thoracic aortic pathology: Cleveland Clinic children's experience. Cardiol Young 2023; 33:2559-2566. [PMID: 37013896 DOI: 10.1017/s1047951122003936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Complex patients requiring operations on the left ventricular outflow tract, aortic valve, or thoracic aorta after previous repair of aortopathy constitute a challenging group, with limited information guiding decision-making. We aimed to use our institutional experience to highlight management challenges and describe surgical pearls to address them. METHODS Forty-one complex patients with surgery on the left ventricular outflow tract, aortic valve, or aorta at Cleveland Clinic Children's between 2016 and 2021 following previous repair of aortic pathology were retrospectively reviewed. Patients with known connective tissue disease or single ventricle circulation were excluded. RESULTS Median age at index procedure was 23 years (range 0.25-48) with median of 2 prior sternotomies. Previous aortic operations included subvalvular (n = 9), valvular (n = 6), supravalvular (n = 13), and multi-level surgeries (n = 13). Four deaths occurred in median follow-up of 2.5 years. Mean left ventricular outflow tract gradients improved significantly for patients with obstruction (34.9 ± 17.5 mmHg versus 12.6 ± 6.0 mmHg; p < 0.001). Technical pearls include the following: 1) liberal use of anterior aortoventriculoplasty with valve replacement; 2) primarily anterior aortoventriculoplasty following the subpulmonary conus in contrast to more vertical incision for post-arterial switch operation patients; 3) pre-operative imaging of mediastinum and peripheral vasculature for cannulation and sternal re-entry; and 4) proactive use of multi-site peripheral cannulation. CONCLUSIONS Operation to address the left ventricular outflow tract, aortic valve, or aorta following prior congenital aortic repair can be accomplished with excellent outcomes despite high complexity. These procedures commonly include multiple components, including concomitant valve interventions. Cannulation strategies and anterior aortoventriculoplasty in specific patients require modifications.
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Affiliation(s)
- Dominique L Tucker
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Leah J Lee
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Munir Ahmad
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Naseeb Shaheen
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sohini Gupta
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Miza Salim Hammoud
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's, and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Kumthekar RN, Opfermann JD, Mass P, Contento JM, Berul CI. Percutaneous epicardial pacing in infants using direct visualization: A feasibility animal study. J Cardiovasc Electrophysiol 2023; 34:1452-1458. [PMID: 37172303 DOI: 10.1111/jce.15926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/20/2023] [Accepted: 04/29/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND Pacemaker implantation in infants and small children is limited to epicardial lead placement via open chest surgery. We propose a minimally invasive solution using a novel percutaneous access kit. OBJECTIVE To evaluate the acute safety and feasibility of a novel percutaneous pericardial access tool kit to implant pacemaker leads on the epicardium under direct visualization. METHODS A custom sheath with optical fiber lining the inside wall was built to provide intrathoracic illumination. A Veress needle inside the illumination sheath was inserted through a skin nick just to the left of the xiphoid process and angled toward the thorax. A needle containing a fiberscope within the lumen was inserted through the sheath and used to access the pericardium under direct visualization. A custom dilator and peel-away sheath with pre-tunneled fiberscope was passed over a guidewire into the pericardial space via modified Seldinger technique. A side-biting multipolar pacemaker lead was inserted through the sheath and affixed against the epicardium. RESULTS Six piglets (weight 3.7-4.0 kg) had successful lead implantation. The pericardial space could be visualized and entered in all animals. Median time from skin nick to sheath access of the pericardium was 9.5 (interquartile range [IQR] 8-11) min. Median total procedure time was 16 (IQR 14-19) min. Median R wave sensing was 5.4 (IQR 4.0-7.3) mV. Median capture threshold was 2.1 (IQR 1.7-2.4) V at 0.4 ms and 1.3 (IQR 1.2-2.0) V at 1.0 ms. There were no complications. CONCLUSION Percutaneous epicardial lead implantation under direct visualization was successful in six piglets of neonatal size and weight with clinically acceptable acute pacing parameters.
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Affiliation(s)
- Rohan N Kumthekar
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Justin D Opfermann
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Paige Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia, USA
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Jacqueline M Contento
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia, USA
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Charles I Berul
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
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Harbeck B, Flitsch J, Kreitschmann-Andermahr I. Carney complex- why thorough medical history taking is so important - report of three cases and review of the literature. Endocrine 2023; 80:20-28. [PMID: 36255590 PMCID: PMC10060316 DOI: 10.1007/s12020-022-03209-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/22/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To present a new case series and to review the literature on Carney complex (CNC) with an emphasis on highlighting key clinical features of the disease and pointing out possibilities of shortening the diagnostic process. METHOD Searches of PubMed, identifying relevant reports up to April 2022. RESULTS CNC is a rare, autosomally dominant inherited neoplasia -endocrinopathy syndrome with high clinical variability, even among members of the same family. Data on length of diagnostic process are scarce with numerous case series reporting a diagnostic delay of decades. Suggestions to shorten the diagnostic process includes awareness of the multi-faceted clinical presentations of CNC, thorough history taking of index patients and family members and awareness of diagnostic pitfalls. Importantly, unusual symptom combinations should alert the clinician to suspect a rare endocrinopathy syndrome such as CNC. Already present and coming on the horizon are databases and novel phenotyping technologies that will aid endocrinologists in their quest for timely diagnosis. CONCLUSION In this review, we examine the current state of knowledge in CNC and suggest avenues for shortening the diagnostic journey for the afflicted patients.
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Affiliation(s)
- B Harbeck
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- MVZ Amedes Experts, Endocrinology, Hamburg, Germany.
| | - J Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Prabhu S, Joshi A, Mehra S, Shetty R, Murthy K, Ramachandra P, Maiya S. Branch Pulmonary Artery Jailing During Patent Ductus Arteriosus Stenting: Recruitment and Immediate Outcomes. World J Pediatr Congenit Heart Surg 2021; 12:320-330. [PMID: 33942686 DOI: 10.1177/2150135120980388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Branch pulmonary artery (PA) occlusion during patent ductus arteriosus (PDA) stenting procedure is the main reason why branch PA origin stenosis was considered as a contraindication for PDA stenting. This study was designed to assess the incidence of branch PA jailing during PDA stenting for cyanotics with duct-dependent pulmonary circulation and its immediate outcome. METHODS All the completed PDA stenting patients in our hospital between April 2017 and June 2019 were retrospectively analyzed for branch PA jailing and its outcome. RESULTS Of 63 completed PDA stenting, there was branch PA jailing in 13 (20.6%) patients, all successfully recruited either by strut dilatation or by surgery. The median duration of ventilation was 16 (interquartile range [IQR]: 8-22) hours for jailed patients and 17.5 (IQR: 5.25-34.25) hours for nonjailed patients (P = .978). Median intensive care unit [ICU] stay was 69 (IQR: 47.75-96) hours for jailed patients and 79.5 (IQR: 66.75-135.25) hours for nonjailed patients (P = .394). Procedural mortality was 1 (7.6%) for jailed patients and 3 (6%) for nonjailed patients. Since all the jailed pulmonary arteries were recruited, there was proportionate growth of branch PA till the most recent follow-up. CONCLUSION Jailing of branch PA does not increase the ventilation duration, ICU stay, or mortality risk if recruited immediately. Proportionate growth of branch PAs can be achieved in spite of jailing, if addressed aggressively. Branch PA stenosis should not be considered as a contraindication for PDA stenting.
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Affiliation(s)
- Sudesh Prabhu
- Pediatric Cardiac Services, 501944Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Abhijit Joshi
- Pediatric Cardiac Services, 501944Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Siddhant Mehra
- Pediatric Cardiac Services, 501944Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Riyan Shetty
- Pediatric Cardiac Services, 501944Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Keshava Murthy
- Pediatric Cardiac Services, 501944Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Prakash Ramachandra
- Pediatric Cardiac Services, 501944Narayana Institute of Cardiac Sciences, Bengaluru, India
| | - Shreesha Maiya
- Pediatric Cardiac Services, 501944Narayana Institute of Cardiac Sciences, Bengaluru, India
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Barbero C, Marchetto G, Pace Napoleone C, Calia C, Cura Stura E, Pocar M, Rinaldi M, Boffini M. Right mini-thoracotomy approach for grown-up congenital heart disease. J Card Surg 2021; 36:1917-1921. [PMID: 33634523 DOI: 10.1111/jocs.15449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/05/2021] [Accepted: 02/11/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Right mini-thoracotomy cardiac surgery has been recognized as a safe and effective procedure, with remarkable early and long-terms outcomes. However, most of the literature is focused on mitral valve surgery and few studies report on the minimally invasive approach applied to congenital disease. Aim of this study was to review our experience on patients with grown-up congenital heart (GUCH) undergoing right mini-thoracotomy cardiac surgery. METHODS Data of patients with GUCH undergoing right mini-thoracotomy cardiac surgery from 2006 to 2019 were retrospectively analyzed. Inclusion criteria were atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, and mitral or tricuspid valve dysfunction in congenital heart diseases. RESULTS During the study period 127 patients with GUCH underwent right mini-thoracotomy cardiac surgery. Mean age was 43.6 years and more than 60% were females; diagnosis was atrial septal defect in 57 cases (44.9%); 24 patients were redo (18.9%). No cases of stroke and major vascular complications were reported. Conversion to sternotomy was required in one case (0.8%). No residual shunts or valves dysfunction were recorded at the postoperative echocardiographic evaluation. Perioperative mortality was 1.6%. CONCLUSIONS Right mini-thoracotomy cardiac surgery in selected patients with GUCH allows to avoid the big scar of the sternotomy approach and to accelerate the recovery in a young population. Moreover, in redo cases, it allows the surgeon to reach the heart and the aorta avoiding the well-known risks of a re-sternotomy procedure.
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Affiliation(s)
- Cristina Barbero
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Torino, Italy
| | - Giovanni Marchetto
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Torino, Italy
| | - Carlo Pace Napoleone
- Pediatric Cardiac Surgery Division, Department of Pediatrics, Children's Regina Margherita Hospital, Torino, Italy
| | - Claudia Calia
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Torino, Italy
| | - Erik Cura Stura
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Torino, Italy
| | - Marco Pocar
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Torino, Italy
| | - Mauro Rinaldi
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Torino, Italy
| | - Massimo Boffini
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Torino, Italy
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Kwon Y, Park SJ, Kim HJ, Kim JB, Jung SH, Choo SJ, Lee JW. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2021; 34:354-360. [PMID: 35188960 PMCID: PMC8860419 DOI: 10.1093/icvts/ivab309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/14/2021] [Accepted: 10/06/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Right mini-thoracotomy approach may enhance the visualization of mitral valve (MV) visualization during redo MV surgery, thereby minimizing the risk of reoperative median sternotomy. We described the clinical outcomes of redo MV surgery by mini-thoracotomy and full-sternotomy approach. METHODS Of 730 consecutive adult patients who underwent redo MV surgery between 2002 and 2018 at our institution, we identified 380 patients (age: 56.0 [14.8] years) after excluding those who underwent concomitant aortic valve or coronary artery surgeries. RESULTS The clinical outcomes in patients who underwent mini-thoracotomy (MINI group; n = 168) and full-sternotomy (STERN group; n = 218) were described. The early and overall mortality in the MINI group was 4.3% (7/162) and 17.3% (28/162), with the rates of early major complications as follows: low cardiac output syndrome, 5.6% (9/162); early stroke, 6.8% (11/162); new-onset dialysis, 6.2% (10/162); prolonged ventilation, 15.4% (25/162); and postoperative bleeding requiring exploration, 7.4% (12/162). In the STERN group, the early mortality was 11.0% (24/218), whereas the risk of low cardiac output syndrome, early stroke, new-onset dialysis, prolonged ventilation, and postoperative bleeding was 12.4% (27/218), 14.2% (31/218), 17.0% (37/218), 33.0% (72/218), and 10.1% (22/218), respectively. The duration of intensive care unit and hospital stay was 2.0 [range 1.0, 3.0] and 8.0 [6.0, 13.0], respectively, in the MINI group and 3.0 [2.0, 7.0] and 14.0 [8.0, 29.0], respectively, in the STERN group. CONCLUSIONS Mini-thoracotomy may be a viable alternative to conventional sternotomy for redo MV surgery.
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Affiliation(s)
- Yelee Kwon
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Jun Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Corresponding author. Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea. Tel: +82-2-3010-3584; fax: +82-2-3010-6966; e-mail: (J.W. Lee)
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Comentale G, Palma G, Parisi V, Simeone S, Pucciarelli G, Manzo R, Pilato E, Giordano R. Preoperative Aspirin Management in Redo Tetralogy of Fallot Population: Single Centre Experience. Healthcare (Basel) 2020; 8:healthcare8040455. [PMID: 33153007 PMCID: PMC7712109 DOI: 10.3390/healthcare8040455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose: Redo operations and preoperative antiplatelet/anticoagulant therapy can significantly increase surgical risk in congenital heart surgery. This is a retrospective study on the impact of preoperative aspirin therapy on the outcome of Tetralogy of Redo Fallot patients undergoing right ventricle outflow tract (RVOT) conduit implantation. Methods: Ten-years retrospective analysis of medical records was carried out. A total of 72 patients were divided into two groups: “Daily-on-ASA” group on daily therapy with aspirin (ASA) until 5 days from surgery and “No-Home-ASA” without it. Propensity match analysis was done in order to standardize the populations. Intraoperative and postoperative lengths were compared as well as the need for inotropic support. In addition, differences in blood transfusions and need for Fresh frozen plasma (FFP)/platelets (PLT) were analysed. Findings: Intraoperative lengths were similar between the groups. Not statistically significative differences about postoperative time to extubation (p = 0.34), ICU Stay (p = 0.31) or in-hospital stay (p = 0.36) were found. Drain loss was higher in the “Daily-on-ASA” group (407.9 ± 96.7 mL vs. 349.5 ± 84.3 mL; p = 0.03) as well as blood transfusions (372.7 ± 255.1 mL vs. 220.1 ± 130.3 mL, p = 0.02) and PLT/FFP need (217.7 ± 132.1 mL vs. 118.7 ± 147.1 mL, p = 0.01). No differences were found in postoperative complications or re-explorations for bleeding. Implications: We found no advantages in surgical times and hospital stay comparing redo patients who stopped aspirin versus those that didn’t take it in the last 6 months. However, our results suggest that redo patients undergoing RVOT conduit implantation who take daily aspirin are at higher risk of bleeding even if it is stopped 5 days before surgery.
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Affiliation(s)
- Giuseppe Comentale
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
| | - Gaetano Palma
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
| | - Valentina Parisi
- Department of Translational Medical Sciences-University of Naples Federico II, 80131 Naples, Italy;
| | - Silvio Simeone
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (S.S.); (G.P.)
| | - Gianluca Pucciarelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (S.S.); (G.P.)
| | - Rachele Manzo
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
| | - Emanuele Pilato
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
| | - Raffaele Giordano
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
- Correspondence:
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Abou Zahr R, Gooty V, Tandon A, Greil G, Pirolli T, Davies R, Jaquiss R, Ramaciotti C, Hussain T. Feasibility of real-time cine cardiac magnetic resonance imaging to predict the presence of significant retrosternal adhesions prior to redo-sternotomy. J Cardiovasc Magn Reson 2019; 21:67. [PMID: 31672164 PMCID: PMC6824134 DOI: 10.1186/s12968-019-0576-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 09/21/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Injury to vital structures posterior to the sternum is a complication associated with redo sternotomy in congenital cardiac surgery. The goal of our study was a novel evaluation of real-time cine cardiovascular magnetic resonance (CMR) to predict the presence of significant retrosternal adhesions of cardiac and vascular structures prior to redo sternotomy in patients with congenital heart disease. METHODS Twenty-three patients who had prior congenital heart surgery via median sternotomy had comprehensive CMR studies prior to redo sternotomy. The real time cine (RTC) sequence that was used is an ungated balanced steady-state free precession (bSSFP) sequence using SENSitivity Encoding for acceleration with real-time reconstruction. Spontaneously breathing patients were instructed to take deep breaths during the acquisition whilst increased tidal volumes were delivered to mechanically ventilated patients. All patients underwent redo cardiac surgery subsequently and the presence and severity of retrosternal adhesions were noted at the time of the redo sternotomies. RESULTS Median age at the time of CMR and operation were 5.5 years (range, 0.2-18.4y) and 6.1 years (range, 0.3-18.8y) respectively. There were 15 males and 8 females in the study group. Preoperative retrosternal adhesions were identified on RTC in 13 patients and confirmed in 11 (85%) at the time of surgery. In only 2 patients, no adhesions were identified on CMR but were found to have significant retrosternal adhesions at surgery; false positive rate 15% (CI 0.4-29.6%), false negative rate 20% (CI 3.7-36.4%). The total classification error of the real time cine sequence was 17% (CI 1.7-32.4%) with an overall accuracy of 83% (CI 67.7-98.4%). Standard breath-hold cine images correlated poorly with surgical findings and did not increase the diagnostic yield. CONCLUSIONS RTC imaging can predict the presence of significant retrosternal adhesions and thus help in risk assessment prior to redo sternotomy. These findings complement the surgical planning and potentially reduce surgical complications .
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Affiliation(s)
- Riad Abou Zahr
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Vasu Gooty
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Animesh Tandon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Gerald Greil
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Timothy Pirolli
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Ryan Davies
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Robert Jaquiss
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, USA
| | - Claudio Ramaciotti
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Tarique Hussain
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, USA
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Pace Napoleone C. An investment for the future. Transl Pediatr 2018; 7:235-238. [PMID: 30159252 PMCID: PMC6087834 DOI: 10.21037/tp.2018.03.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Hasaniya N, Razzouk A, Newcombe J, Hassneiah D, Heimes J, Gysbers J, Martens T, Bailey L. An Absorbable Hydrogel Spray Reduces Postoperative Mediastinal Adhesions After Congenital Heart Surgery. Ann Thorac Surg 2017; 105:837-842. [PMID: 29145993 DOI: 10.1016/j.athoracsur.2017.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 07/02/2017] [Accepted: 07/10/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Adhesions encountered during reoperative cardiac surgery can prolong operative time and increase operative risk. The purpose of this clinical study was to investigate the antiadhesion property of a synthetic bioabsorbable polymer spray after cardiac reoperations in infants. METHODS A prospective randomized double-blinded study was designed. Forty infants requiring staged cardiac operations were randomly allocated to a study group (n = 20) or a control group (n = 20). The appropriate volume of the polymer was sprayed onto the mediastinal surfaces before chest closure after the first surgical procedure in the study group. At reoperation, adhesions were evaluated by a blinded investigator following a 5-grade scoring system. Five predetermined anatomic areas were scored. Incision to extracorporeal circulation time was also analyzed. RESULTS In all, 40 subjects were enrolled into the study. Four babies died before the second operation. Three others were missed for reevaluation. The control group (n = 16) had longer incision to extracorporeal circulation time (38 ± 10 minutes) than the study group (n = 17; 23 ± 6 minutes; p < 0.001). The control subjects had significantly more severe adhesions than the study group at all five mediastinal areas: (1) retrosternal (p < 0.001); (2) base of the heart (large vessels [p < 0.05]); (3) right side (p < 0.01); (4) left side (p < 0.02); and (5) diaphragmatic side of the mediastinum (p < 0.001). CONCLUSIONS The use of synthetic bioabsorbable polymer sealant spray at the end of primary pediatric cardiac surgery reduces the intensity of mediastinal adhesions and the reentry time in infants undergoing repeat median sternotomy.
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Affiliation(s)
- Nahidh Hasaniya
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California.
| | - Anees Razzouk
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California
| | - Jennifer Newcombe
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California
| | - Dana Hassneiah
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California
| | - Jessica Heimes
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California
| | - Joshua Gysbers
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California
| | - Timothy Martens
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California
| | - Leonard Bailey
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, California
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Jaroszewski DE, Gustin PJ, Haecker FM, Pilegaard H, Park HJ, Tang ST, Li S, Yang L, Uemura S, De Campos JRM, Obermeyer R, Frantz FW, Torre M, McMahon L, Hebra A, Chu CC, Phillips JD, Notrica DM, Messineo A, Kelly R, Yüksel M. Pectus excavatum repair after sternotomy: the Chest Wall International Group experience with substernal Nuss bars. Eur J Cardiothorac Surg 2017; 52:710-717. [DOI: 10.1093/ejcts/ezx221] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Sett SS, Lafaro RJ. Extracardiac Fontan Operation Through a Right Thoracotomy. Ann Thorac Surg 2017; 104:e147-e149. [PMID: 28734438 DOI: 10.1016/j.athoracsur.2017.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 10/19/2022]
Abstract
An extracardiac Fontan operation through a right thoracotomy incision is an alternative approach in children who have an ascending aorta that is in close proximity to the sternum, as in aortic atresia or transposed great vessels, and in those who have had prior mediastinitis.
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Affiliation(s)
- Suvro S Sett
- Department of Surgery, Section of Pediatric Cardiac Surgery, The Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, New York.
| | - Rocco J Lafaro
- Adult Cardiac Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York
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Villa-Hincapie CA, Carreno-Jaimes M, Obando-Lopez CE, Camacho-Mackenzie J, Umaña-Mallarino JP, Sandoval-Reyes NF. Risk Factors for Mortality in Reoperations for Pediatric and Congenital Heart Surgery in a Developing Country. World J Pediatr Congenit Heart Surg 2017; 8:435-439. [PMID: 28696882 DOI: 10.1177/2150135117704657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The survival of patients with congenital heart disease has increased in the recent years, because of enhanced diagnostic capabilities, better surgical techniques, and improved perioperative care. Many patients will require reoperation as part of staged procedures or to treat grafts deterioration and residual or recurrent lesions. Reoperations favor the formation of cardiac adhesions and consequently increase surgery time; however, the impact on morbidity and operative mortality is certain. The objective of the study was to describe the risk factors for mortality in pediatric patients undergoing a reoperation for congenital heart disease. METHODS Historic cohort of patients who underwent reoperation after pediatric cardiac surgery from January 2009 to December 2015. Operations with previous surgical approach different to sternotomy were excluded from the analysis. RESULTS In seven years, 3,086 surgeries were performed, 481 were reoperations, and 238 patients fulfilled the inclusion criteria. Mean number of prior surgeries was 1.4 ± 0.6. Median age at the time of reoperation was 6.4 years. The most common surgical procedures were staged palliation for functionally univentricular heart (17.6%). Median cross-clamp time was 66 minutes. Younger age at the moment of resternotomy, longer cross-clamp time, and Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery (STAT) Mortality Categories risk category greater than three were risk factors for mortality. The number of resternotomies was not associated with mortality. Mortality prior to hospital discharge was 4.6%, and mortality after discharge but prior to 30 days after surgery was 0.54%. Operative mortality was 5.1%. CONCLUSIONS Resternotomy in pediatric cardiac surgery is a safe procedure in our center.
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Affiliation(s)
- Carlos A Villa-Hincapie
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
| | - Marisol Carreno-Jaimes
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia
| | - Carlos E Obando-Lopez
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
| | - Jaime Camacho-Mackenzie
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
| | - Juan P Umaña-Mallarino
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
| | - Nestor F Sandoval-Reyes
- 1 Fundación Cardioinfantil (FCI), Instituto de Cardiología. Department of Congenital Heart Disease. Bogotá, Colombia.,2 Universidad del Rosario. Bogotá, Colombia
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Díliz-Nava H, Meléndez-Sagaón I, Tamaríz-Cruz O, García-Benítez L, Araujo-Martínez A, Palacios-Macedo A. [Safety of repeat median sternotomy in the palliative treatment of patients with a univentricular heart]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:302-306. [PMID: 28094119 DOI: 10.1016/j.acmx.2016.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/12/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To establish the morbidity and mortality of patients with univentricular hearts who underwent a repeat median sternotomy at the Instituto Nacional de Pediatría. METHOD A retrospective review was performed on the clinical charts of all patients who underwent a repeat median sternotomy from 2001 to 2016. RESULTS Sixty-five patients underwent 76 surgeries by repeat median sternotomy. Fifty-nine patients had a first repeat median sternotomy, with a mean age of 36 months (range: 4-176 months) and a mean weight of 12.2 kg (range: 3.2-21.5 kg). Forty patients had a Glenn procedure, and 19 patients had a Fontan procedure. There were 17 patients with a second repeat median sternotomy, with a mean age of 89 months (range 48-156 months), and a mean weight of 22.7 kg (14.4-41 kg). A Fontan procedure was performed on all these 17 patients. A section of the right coronary artery with electrocardiographic changes and a right atrium tear that caused hypotension occurred during first repeat sternotomy. An aortic tear occurred during a second repeat sternotomy with massive bleeding and subsequent death. This represents 3.9% of re-entry injuries. CONCLUSION It is concluded that repeat median sternotomy is a safe procedure.
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Affiliation(s)
- Héctor Díliz-Nava
- Cirugía Cardiovascular, Instituto Nacional de Pediatría, Ciudad de México, México
| | - Isis Meléndez-Sagaón
- Cirugía Cardiovascular, Instituto Nacional de Pediatría, Ciudad de México, México
| | - Orlando Tamaríz-Cruz
- Anestesiología Cardiovascular, Instituto Nacional de Pediatría, Ciudad de México, México
| | - Luis García-Benítez
- Cirugía Cardiovascular, Instituto Nacional de Pediatría, Ciudad de México, México
| | - Aric Araujo-Martínez
- Terapia Cardiovascular, Instituto Nacional de Pediatría, Ciudad de México, México
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Salehi M, Bakhshandeh AR, Saberi K, Alemohammad M, Sobhanian K, Karamnezhad M, Rigi FS. Resternotomy, a single-center experience. Asian Cardiovasc Thorac Ann 2016; 25:13-17. [PMID: 27784819 DOI: 10.1177/0218492316678119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Reoperations are technically more difficult because of the risks associated with reentry in a heart with more advanced pathology, little reserve, and more frequent comorbidities. Routine peripheral cannulation before resternotomy is inadvisable, time-consuming, and has no noticeable role in decreasing the risks of reentry. We present our experience of resternotomy without routine peripheral cannulation. Methods This was a retrospective study on 237 consecutive patients who underwent resternotomy between June 2011 and July 2013. Their mean age was 47.7 ± 18.2 years. We chose the best approach individually, according to lateral radiograph findings, patient risk factors, and previous surgery. Our goal was to observe events intraoperatively and their outcomes postoperatively. Results Mean intensive care unit stay was 3.1 ± 0.9 days. Twenty-one (8.8%) patients died during their hospital stay. The most common cause of death was renal failure in 15 (71.4%) patients, coagulopathy in 4 (19%), and cardiac failure in 2 (9.5%). We had 3 right ventricular, one right atrial, one pulmonary artery, and 2 inferior vena caval tears during resternotomy and dissection; bleeding was controlled easily without peripheral cannulation. Femoral cannulation before resternotomy was performed in one patient who needed an emergency pulmonary embolectomy. Conclusions Based on our experience, resternotomy with central cannulation is a safe strategy, and peripheral cannulation before resternotomy should be reserved for highly selected patients.
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Affiliation(s)
- Mehrdad Salehi
- 1 Department of Cardiovascular Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Reza Bakhshandeh
- 1 Department of Cardiovascular Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Kianoush Saberi
- 2 Department of Anesthesia, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmood Alemohammad
- 2 Department of Anesthesia, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Keivan Sobhanian
- 1 Department of Cardiovascular Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Maziar Karamnezhad
- 1 Department of Cardiovascular Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Farangis Sarouneh Rigi
- 1 Department of Cardiovascular Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Bandettini WP, Karageorgiadis AS, Sinaii N, Rosing DR, Sachdev V, Schernthaner-Reiter MH, Gourgari E, Papadakis GZ, Keil MF, Lyssikatos C, Carney JA, Arai AE, Lodish M, Stratakis CA. Growth hormone and risk for cardiac tumors in Carney complex. Endocr Relat Cancer 2016; 23:739-46. [PMID: 27535175 PMCID: PMC4991637 DOI: 10.1530/erc-16-0246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/15/2016] [Indexed: 11/08/2022]
Abstract
Carney complex (CNC) is a multiple neoplasia syndrome that is caused mostly by PRKAR1A mutations. Cardiac myxomas are the leading cause of mortality in CNC patients who, in addition, often develop growth hormone (GH) excess. We studied patients with CNC, who were observed for over a period of 20 years (1995-2015) for the development of both GH excess and cardiac myxomas. GH secretion was evaluated by standard testing; dedicated cardiovascular imaging was used to detect cardiac abnormalities. Four excised cardiac myxomas were tested for the expression of insulin-like growth factor-1 (IGF-1). A total of 99 CNC patients (97 with a PRKAR1A mutation) were included in the study with a mean age of 25.8 ± 16.6 years at presentation. Over an observed mean follow-up of 25.8 years, 60% of patients with GH excess (n = 46) developed a cardiac myxoma compared with only 36% of those without GH excess (n = 54) (P = 0.016). Overall, patients with GH excess were also more likely to have a tumor vs those with normal GH secretion (OR: 2.78, 95% CI: 1.23-6.29; P = 0.014). IGF-1 mRNA and protein were higher in CNC myxomas than in normal heart tissue. We conclude that the development of cardiac myxomas in CNC may be associated with increased GH secretion, in a manner analogous to the association between fibrous dysplasia and GH excess in McCune-Albright syndrome, a condition similar to CNC. We speculate that treatment of GH excess in patients with CNC may reduce the likelihood of cardiac myxoma formation and/or recurrence of this tumor.
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Affiliation(s)
- W Patricia Bandettini
- National HeartLung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Alexander S Karageorgiadis
- National Institute of Child Health and Human Development (NICHD)NIH, Bethesda, Maryland, USA Department of PediatricsGeorgetown University Hospital, Washington, District of Columbia, USA
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology ServiceClinical Center, NIH, Bethesda, Maryland, USA
| | - Douglas R Rosing
- National HeartLung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Vandana Sachdev
- National HeartLung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | | | - Evgenia Gourgari
- National Institute of Child Health and Human Development (NICHD)NIH, Bethesda, Maryland, USA Department of PediatricsGeorgetown University Hospital, Washington, District of Columbia, USA
| | - Georgios Z Papadakis
- Department of Radiology and Imaging SciencesClinical Center, NIH, Bethesda, Maryland, USA
| | - Meg F Keil
- National Institute of Child Health and Human Development (NICHD)NIH, Bethesda, Maryland, USA
| | - Charalampos Lyssikatos
- National Institute of Child Health and Human Development (NICHD)NIH, Bethesda, Maryland, USA
| | - J Aidan Carney
- Department of Laboratory Medicine and PathologyMayo Clinic, Rochester, Minnesota, USA
| | - Andrew E Arai
- National HeartLung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Maya Lodish
- National Institute of Child Health and Human Development (NICHD)NIH, Bethesda, Maryland, USA
| | - Constantine A Stratakis
- National Institute of Child Health and Human Development (NICHD)NIH, Bethesda, Maryland, USA
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Lee C, Lee CH, Kwak JG. Outcomes of redo pulmonary valve replacement for bioprosthetic pulmonary valve failure in 61 patients with congenital heart disease. Eur J Cardiothorac Surg 2016; 50:470-5. [DOI: 10.1093/ejcts/ezw037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 01/25/2016] [Indexed: 11/12/2022] Open
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Yin CH, Yan J, Li SJ, Li DY, Wang Q, Wang ES. Effect analysis of repeat sternotomy in pediatric cardiac operations. J Cardiothorac Surg 2015; 10:179. [PMID: 26621353 PMCID: PMC4666069 DOI: 10.1186/s13019-015-0381-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 11/18/2015] [Indexed: 11/10/2022] Open
Abstract
Background Reoperation for congenital heart disease may be associated with cardiac or vascular injuries during repeat sternotomy, resulting in increased mortality and/or morbidity rates. The aim of this study was to determine the frequency of these cardiac injuries and the associated outcome. Methods Between January 2012 and December 2013, 4256 sternotomy procedures were performed at the Pediatric Cardiac Center in Fuwai Hospital, including 195 repeat sternotomy procedures (RS). We retrospectively studied the clinical data of 195 RS patients and 250 randomly selected primary sternotomy (PS) patients. Demographic and operative details, major injures (MI), and clinical outcomes were compared between the two groups. We also assessed the risk factors for major injury and in-hospital mortality and morbidity. Results Significant differences were observed between the RS and PS groups in terms of skin incision to cardiopulmonary bypass(CPB) time, overall CPB time, cross-clamp time and blood requirement, and ventilation time (p < 0.001). MI during RS occurred in 7 of the 195 patients (3.6 %), while operative mortality was 1.0 % (2/195). However, in the RS patients, mortality and morbidity rates were not significantly different between the MI subgroup and the non-MI subgroup (p = 1.000 and 0.556, respectively). Additionally, no significant difference was found between the RS and PS groups in terms of mortality (p = 1.000) and morbidity (p = 0.125). Conclusions Both RS and MI are not associated with increased risk of operative mortality and morbidity. Outcomes for reoperative pediatric operations in contemporary practice are similar with those for primary operations.
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Affiliation(s)
- Chao-hua Yin
- Department of Pediatric Cardiac Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, China.
| | - Jun Yan
- Department of Pediatric Cardiac Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, China.
| | - Shou-jun Li
- Department of Pediatric Cardiac Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, China.
| | - Dian-yuan Li
- Department of Pediatric Cardiac Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, China.
| | - Qiang Wang
- Department of Pediatric Cardiac Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, China.
| | - En-shi Wang
- Department of Pediatric Cardiac Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, China.
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Computed Tomography Imaging in Patients with Congenital Heart Disease Part I: Rationale and Utility. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT). J Cardiovasc Comput Tomogr 2015; 9:475-92. [DOI: 10.1016/j.jcct.2015.07.004] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/17/2015] [Indexed: 12/16/2022]
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Mangukia CV, Agarwal S, Satyarthy S, Aggarwal SK, Datt V, Satsangi DK. Management of iatrogenic RV injury - RV packing and CPB through PTFE graft attached to femoral artery. Ann Pediatr Cardiol 2015; 8:53-5. [PMID: 25684889 PMCID: PMC4322403 DOI: 10.4103/0974-2069.149520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Cardiac injuries during repeat sternotomy are rare. While undergoing debridement for chronic osteomyelitis (post arterial septal defect closure), a 4-year-old girl sustained significant right ventricular (RV) injury. Bleeding from the RV was controlled by packing the injury site, which helped in maintaining stable hemodynamics till arrangements were made for instituting cardiopulmonary bypass (CPB). Since the femoral artery was very small and unsuitable for direct cannulation, a polytetrafluoroethylene (PTFE) graft sutured end-to-side to the femoral artery was used for establishing CPB. The injury was successfully repaired.
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Affiliation(s)
- Chirantan V Mangukia
- Department of Cardiothoracic and Vascular Surgery, Govind Ballabh Pant Hospital, New Delhi, India
| | - Saket Agarwal
- Department of Cardiothoracic and Vascular Surgery, Govind Ballabh Pant Hospital, New Delhi, India
| | - Subodh Satyarthy
- Department of Cardiothoracic and Vascular Surgery, Govind Ballabh Pant Hospital, New Delhi, India
| | | | - Vishnu Datt
- Department of Anaesthesia, Govind Ballabh Pant Hospital, New Delhi, India
| | - Deepak Kumar Satsangi
- Department of Cardiothoracic and Vascular Surgery, Govind Ballabh Pant Hospital, New Delhi, India
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Chest wall, thymus, and heart vascularized composite allograft proof of concept cadaveric model for heart transplantation. Ann Plast Surg 2014; 73:102-4. [PMID: 24918739 DOI: 10.1097/sap.0000000000000181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of vascularized composite allografts allows for the reconstruction of complex scenarios that previously have required multistaged operations. Heart transplantation often follows a series of previous operations leading to chest wall deformities and significant mediastinal adhesions that can limit the use of larger hearts, making it difficult to find a suitable donor. Further, research has shown that the use of vascularized bone marrow and vascularized thymus in transplantation potentially prolongs graft survival with decreased immunosuppression requirements. The authors propose using a vascularized composite allograft of the chest wall consisting of sternum and thymus in conjunction with the heart for cardiac transplantation to allow for more flexibility from the donor pool, maintain chest wall integrity and physiology, and potentially immunoregulate the concomitant solid organ transplant.
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Kogon BE, Daniel W, Fay K, Book W. Is the liberal use of preoperative 3-dimensional imaging and presternotomy femoral cutdown beneficial in reoperative adult congenital heart surgery? J Thorac Cardiovasc Surg 2014; 147:1799-804. [DOI: 10.1016/j.jtcvs.2013.07.074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Revised: 07/04/2013] [Accepted: 07/26/2013] [Indexed: 11/28/2022]
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Adachi K, Ejima Y, Adachi O, Yamauchi M. Anesthetic management of pulmonary valve replacement for pulmonary regurgitation in six patients with surgically repaired tetralogy of Fallot. J Anesth 2014; 28:928-31. [PMID: 24854519 DOI: 10.1007/s00540-014-1846-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/02/2014] [Indexed: 11/29/2022]
Abstract
Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) encountered in CHD patients surviving into adulthood. A number of patients with surgically repaired TOF have significant pulmonary regurgitation (PR) that can lead to right ventricular (RV) dilatation, RV failure, and arrhythmia. We describe the anesthetic management for pulmonary valve replacement (PVR) in six PR patients with surgically repaired TOF. Although all patients had dilated RVs and depression of RV ejection fraction preoperatively, and arrhythmia and unexpected bleeding perioperatively, they could tolerate a well-managed PVR operation. Anesthesiologists should be aware of the multiplicity of comorbidities, sequelae, and residua in patients with surgically repaired TOF. RV function should be monitored using transesophageal echocardiography, and inotropic vasodilators and alpha-adrenergic agents should be administered, as appropriate. Arrhythmias, vascular injury during removal of adhesions during re-sternotomy, and bleeding from collateral vessels are also frequent complications.
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Affiliation(s)
- Koko Adachi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, 980-0872, Japan,
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Potential interest of a new absorbable collagen membrane in the prevention of adhesions in paediatric cardiac surgery: A feasibility study. Arch Cardiovasc Dis 2013; 106:433-9. [DOI: 10.1016/j.acvd.2013.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 04/27/2013] [Accepted: 05/06/2013] [Indexed: 11/22/2022]
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Gandolfo F, Filippelli S, Cetrano E, Carotti A. Managing major vessel injuries with a Fogarty catheter during chest re-opening in children. Interact Cardiovasc Thorac Surg 2013; 17:216-7. [PMID: 23543404 DOI: 10.1093/icvts/ivt084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Injury of structures, leading to a major bleeding during chest opening, is a severe and potentially life-threatening complication, especially in redo cardiac surgery, both in adults and children. In three paediatric redo operations performed via midline sternotomy, we managed this complication successfully and uneventfully by using an inflated Fogarty catheter to plug the blood leak from the injured vessel before repairing the lesion under direct vision in a bloodless surgical field. Herein we report in detail the technique used and a comment on our experience.
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Affiliation(s)
- Fabrizio Gandolfo
- Department of Paediatric Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Shin HJ, Kim YH, Ko JK, Park IS, Seo DM. Outcomes of mechanical valves in the pulmonic position in patients with congenital heart disease over a 20-year period. Ann Thorac Surg 2012; 95:1367-71. [PMID: 22884602 DOI: 10.1016/j.athoracsur.2012.07.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 07/03/2012] [Accepted: 07/10/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Homografts or bioprosthetic valves have been preferred in the pulmonic position in patients with congenital heart disease. However, unsatisfactory long-term results have aroused interest in the use of mechanical valves. In this study, we investigated the long-term outcomes of mechanical valves implanted in the pulmonic position. METHODS The medical records of 37 patients (27 male, 73%) who underwent 38 mechanical pulmonary valve replacements between October 1988 and February 2011 were reviewed, retrospectively. The median age of patients was 13.5 years (range, 7 months to 23 years), and the median number of prior operations per patient was 2 (range, 0 to 5). Tetralogy of Fallot was the most common diagnosis (n=23). The median valve size was 23 mm (range, 17 to 27 mm), and the median follow-up duration after pulmonary valve replacement was 24.6 months (range, 1.3 months to 22.5 years). Events were defined as the following: valve failure, thrombosis, embolism, bleeding, reoperation, and death. RESULTS There was no in-hospital mortality, but there were 2 late deaths (1 heart failure and 1 traffic accident at 10.8 months and 8.7 years postoperatively, respectively). Excluding the traffic accident death, survival rates were 97%, 97%, and 97%, at 1, 5, and 10 years, respectively. Freedom from thromboembolism or bleeding events was 92%, 92%, and 78.8%, at 1, 5 and 10 years, respectively. Two reoperations were performed at 6.8 and 10.2 years postoperatively. Freedom from reoperation was 100%, 100%, and 85.7%, at 1, 5, and 10 years, respectively. CONCLUSIONS Durability of mechanical valve in pulmonic position was excellent. Thromboembolism or bleeding events due to anticoagulation therapy were rare. In growing patients who have undergone prior sternotomies requiring a pulmonary valve replacement, a mechanical valve could be an attractive option.
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Affiliation(s)
- Hong Ju Shin
- Department of Cardiovascular Surgery, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Korea
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Risk Factors and Early Outcomes of Multiple Reoperations in Adults With Congenital Heart Disease. Ann Thorac Surg 2011; 92:122-8; discussion 129-30. [DOI: 10.1016/j.athoracsur.2011.03.102] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Revised: 03/21/2011] [Accepted: 03/22/2011] [Indexed: 11/23/2022]
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Ovcina I, Knez I, Curcic P, Ozkan S, Nagel B, Sorantin E, Puchinger M, Tscheliessnigg K. Pulmonary valve replacement with mechanical prostheses in re-do Fallot patients. Interact Cardiovasc Thorac Surg 2011; 12:987-91; discussion 991-2. [DOI: 10.1510/icvts.2010.252254] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Salminen JT, Mattila IP, Puntila JT, Sairanen HI. Prevention of postoperative pericardial adhesions in children with hypoplastic left heart syndrome. Interact Cardiovasc Thorac Surg 2010; 12:270-2. [PMID: 21081553 DOI: 10.1510/icvts.2010.241448] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Reoperations for congenital cardiac defects are associated with an increased surgical risk due to adhesions. We compared the capability of a polytetrafluoroethylene (PTFE) membrane, synthetic polyethyleneglycol hydrogel (PEG), and a combination of them to prevent postoperative pericardial adhesions in patients with hypoplastic left heart syndrome (HLHS). Eighteen consecutive patients with HLHS were included. At the end of the Norwood I operation the cranial and the caudal half of the heart of each patient was randomized to receive a PTFE membrane, a synthetic PEG, a combination of them, or no treatment (control). Tenacity and density of adhesions, epicardial visibility, and adhesions between the heart and the sternum were analyzed semiquantitatively at a subsequent bidirectional Glenn operation. The PTFE membrane significantly decreased adhesion formation between the heart and the sternum (P<0.001). However, the PTFE membrane, with or without synthetic PEG, impaired epicardial visibility (P<0.05) when compared to synthetic PEG or controls. Synthetic PEG alone did not significantly reduce the formation of pericardial adhesions. Tenacity and density of adhesions were not affected by any of the treatment modalities. The PTFE membrane significantly decreases postoperative adhesions between the heart and the sternum, but impairs epicardial visibility. Synthetic PEG does not prevent formation of pericardial adhesions.
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Affiliation(s)
- Jukka T Salminen
- Department of Paediatric Cardiac Surgery, Hospital for Children and Adolescents, University of Helsinki, P.O.B. 281, 00029 Helsinki, Finland.
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Morales D, Williams E, John R. Is resternotomy in cardiac surgery still a problem? Interact Cardiovasc Thorac Surg 2010; 11:277-86. [PMID: 20525761 DOI: 10.1510/icvts.2009.232090] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Multiple factors contribute to the growing number of reoperations for congenital and acquired cardiovascular diseases in the United States. Although the hazards are well-recognized, the health economic burden of resternotomy (RS) remains unclear and may be difficult to quantify. Contrary to published studies citing low frequencies of catastrophic hemorrhage and mortality, survey responses from practicing surgeons disclose higher rates of complications. Safety strategies in cardiac reoperation have generally involved efforts to maximize visualization during dissection, specialized surgical maneuvers and instrumentation, customized methods for establishing extracorporeal circulation, and techniques to prevent or avoid retrosternal adhesions. Yet, the relative cost-effectiveness of these strategies is largely unexplored. With the ongoing constraints in healthcare budgets, differentiating the value of existing and future approaches in terms of relative clinical benefits, costs, and impact on resource utilization will become increasingly important. We reviewed the relevant published literature in order to survey the morbidity and resource utilization associated with RS in cardiac reoperation and to identify key issues relevant for future studies.
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Affiliation(s)
- David Morales
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, MC-WT 19345H, Houston, TX 77030, USA.
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Sternal erosion detected by computed tomographic angiography before repeat sternotomy in an adolescent with congenital heart disease. J Cardiovasc Comput Tomogr 2010; 4:66-9. [DOI: 10.1016/j.jcct.2009.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Revised: 10/29/2009] [Accepted: 11/11/2009] [Indexed: 11/21/2022]
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Napoleone CP, Valori A, Crupi G, Ocello S, Santoro F, Vouhé P, Weerasena N, Gargiulo G. An observational study of CoSeal® for the prevention of adhesions in pediatric cardiac surgery☆☆☆. Interact Cardiovasc Thorac Surg 2009; 9:978-82. [DOI: 10.1510/icvts.2009.212175] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Morbidity and mortality risk factors in adults with congenital heart disease undergoing cardiac reoperations. Ann Thorac Surg 2009; 88:1284-9. [PMID: 19766822 DOI: 10.1016/j.athoracsur.2009.05.060] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 05/19/2009] [Accepted: 05/20/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Reoperations represent relatively frequent events in adults with congenital heart disease (ACHD). Cardiac operations in these patients present major difficulties in management and technique. Although reoperations in ACHD are becoming increasingly frequent, limited knowledge exists regarding perioperative risk factors. METHODS The study included 164 ACHD patients who underwent cardiac reoperations between January 2002 and December 2007 at our institution. Preoperative and intraoperative data were analyzed to identify morbidity and mortality risk factors. RESULTS Reoperations included pulmonary valve implantation or conduit replacement in 60, aortic valve/root procedures in 36, residual atrial or ventricular septal defect closure in 19, and Fontan operation/conversion in 19. Hospital mortality was 3.6%. The mean mechanical ventilation time was 26 hours. Mean intensive care unit stay was 3.1 days. Severe postoperative complications occurred in 24 (15.1%). Cardiopulmonary bypass time (p = 0.001), Fontan operation/conversion (p = 0.001), preoperative hematocrit (p = 0.004), previous number of operations (p = 0.001), and preoperative congestive heart failure (p = 0.021) were associated with severe morbidity. No factor was associated with death. CONCLUSIONS Reoperations in ACHD are mostly due to right ventricular outflow tract lesions and were associated with a low mortality rate if performed in a center with a considerable activity and a dedicated program. Severe morbidity is relatively frequent and is generally associated with the preoperative (high hematocrit due to cyanosis, congestive heart failure, and the number of previous operations) and operative (Fontan operation/conversion and cardiopulmonary bypass duration) conditions of the patient.
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One thousand repeat sternotomies for congenital cardiac surgery: risk factors for reentry injury. Ann Thorac Surg 2009; 88:158-61. [PMID: 19559217 DOI: 10.1016/j.athoracsur.2009.03.082] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 03/27/2009] [Accepted: 03/31/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reentry injury is a risk associated with repeat sternotomy for cardiac surgery. This risk has been well defined for adults, but there is less information available for patients with congenital heart disease. The goal of this review was to identify the incidence, risk factors, and outcomes for reentry injury in patients with congenital heart disease. METHODS Eight hundred two patients with congenital heart disease had 1,000 consecutive repeat sternotomies between August 2000 and November 2007. Records were reviewed for demographics, history, operative techniques, and outcomes. Univariate risk factors for reentry injury and operative mortality were assessed. RESULTS Median age and weight were 2.1 years (range, 0.1 to 34.6 years) and 11 kg (range, 2.5 to 123 kg). There were 639 second, 287 third, and 74 fourth or higher sternotomies. There were 13 reentry injuries (1.3%) involving right ventricle-pulmonary artery conduits (n = 4), aorta or aortic conduits (n = 3), right ventricular outflow tract patches or pseudoaneurysms (n = 3), and others (n = 3). Risk factors for injury were presence of a right ventricle-pulmonary artery conduit (6 of 115 with conduit [5.2%] versus 7 of 885 without [0.8%]; p < 0.001) and sternotomy number (relative risk, 2.28; p < 0.001). Reentry injury was associated with longer procedure times (median, 420 minutes with injury versus 248 without; p < 0.001). Operative mortality occurred in 18 patients and was associated with sternotomy number and procedure time (p < 0.001), but not reentry injury (p = 0.2). CONCLUSIONS Risk of reentry injury during repeat sternotomy for congenital heart disease is low. Increasing sternotomy number and the presence of a right ventricle-pulmonary artery conduit are risk factors for reentry injury. However, reentry injury is not associated with increased risk of operative mortality.
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Repeat sternotomy in congenital heart surgery: no longer a risk factor. Ann Thorac Surg 2008; 86:897-902; discussion 897-902. [PMID: 18721579 DOI: 10.1016/j.athoracsur.2008.04.044] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 04/04/2008] [Accepted: 04/07/2008] [Indexed: 11/22/2022]
Abstract
BACKGROUND The risk of repeat sternotomy (RS) is often taken into account when making clinical management decisions. Current literature on RS suggests a risk of approximately 5% to 10% for major morbidity. We sought to establish the true risk of RS in a contemporary pediatric series. METHODS All RS between October 2002 and August 2006 were analyzed (602 RS in 558 patients). Median age was 3.6 years (range, 0.1 to 45.1); weight, 14.2 kg (2.0 to 112.2). Operations performed at RS were Glenn 22% (131), Fontan 21% (129), aortic valve repair/replacement 12% (72), right ventricle-pulmonary artery conduit 11% (67), Rastelli 7% (39), heart transplant 5% (31), and other 22% (133). Forty-seven percent of patients (280) had single-ventricle physiology. Incidence of second sternotomy was 67% (406), third 28% (166), fourth 4% (24), fifth 0.8% (5), and sixth 0.2% (1). A major injury upon RS was defined as one causing hemodynamic instability requiring vasopressor support or emergent transfusion; femoral cannulation or emergent cardiopulmonary bypass; and any morbidity. A minor injury is any other injury during RS. RESULTS The incidence of a major injury was not different between RS (0.3%; 2 of 602) and first-time sternotomy (0%; 0 of 1,274; p > 0.1). Incidence of a minor injury was 0.66% (4 of 602). No injury resulted in hemodynamic instability, neurologic injury, or death. Two patients (0.3%) required a nonemergent blood transfusion secondary to injury. (Nonemergent was defined as adminstration rate of less than 0.2 cc/kg/min and less than 10 cc/kg in total.) Femoral cannulation was performed in 4 of 602 RS cases (< 0.6%). Sternal wound infection was 0.5% (3 of 602); reoperation for postoperative bleeding was 1% (8 of 602). Median intensive care unit stay was 3 days (1 to 174); median hospital stay was 7 days (1 to 202). Hospital survival was 98%. CONCLUSIONS Repeat sternotomy can represent a negligible risk of injury and of subsequent morbidity or mortality. Therefore, the choice of management strategies for patients should not be affected by the need for RS.
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Abstract
OBJECTIVE The purpose of this study was to report the anesthetic care of patients during performance of a Fontan procedure without cardiopulmonary bypass (CPB). DESIGN Retrospective chart review. SETTING Operating room of a university hospital. PARTICIPANTS Seven pediatric-patients undergoing inferior vena cava (IVC)-to-pulmonary artery (PA) anastomosis for completion of the Fontan procedure. INTERVENTIONS Charts were reviewed for anesthetic technique, hemodynamic and ventilatory changes occurring during the procedure, and anesthetic interventions that were provided. MEASUREMENTS AND MAIN RESULTS The off-bypass Fontan procedure was attempted in 7 patients (age: 26 months-7 years, weight: 13 to 28 kg). Exposure of the PA was not feasible in 1 patient because of a markedly enlarged right atrium. In the remaining 6 patients, before cross-clamping of the PA to allow for the proximal anastomosis between the PA and the conduit, alkalosis (pH > or =7.5) was maintained by the administration of sodium bicarbonate. After PA cross-clamping, fluid administration was necessary in 5 patients and dopamine (3-7 microg/kg/min) was necessary in 4 patients. The minute ventilation was increased by 18 +/- 7% to maintain baseline PaCO2 values. Before the placement of the PA cross-clamp, the end-tidal PaCO2 difference was 7 +/- 4 mmHg and the transcutaneous (TC)-PaCO2 difference was 3 +/- 2 mmHg. The end-tidal PaCO2 difference increased to 14 +/- 6 mmHg during cross-clamping of the PA, whereas no change was noted in the TC-PaCO2 difference. Once the proximal anastomosis was completed, a bridge was placed to redirect blood from the IVC to the right atrium while the IVC was clamped and attached to the distal end of the conduit. After placement of the distal end of the bridge into the IVC, fluid administration to maintain the blood pressure was necessary in 3 patients. In 1 patient, 20 minutes after placement of the bridge, the authors noted a progressive increase in the central venous pressure reading measured from the left femoral vein and the need for the administration of volume to maintain the mean arterial pressure. Examination of the bridge revealed occlusion with thrombus despite an activated coagulation time value of 250 to 300 seconds. The tracheas of 3 of the 6 patients were extubated in the operating room, whereas the other 3 were extubated in the pediatric intensive care unit within 4 hours of completion of the procedure. The 1 patient who required the use of CPB required reintubation and had a protracted intensive care unit course. The other 6 patients were discharged home on postoperative days 7 to 12. CONCLUSIONS With alteration of the anesthetic technique, the Fontan procedure can be performed in selected patients without the need for CPB.
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Affiliation(s)
- Joseph D Tobias
- Department of Pediatrics, University of Missouri, Health Sciences Center, Columbia, MO 65212, USA.
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Elahi M, Dhannapuneni R, Firmin R, Hickey M. Direct complications of repeat median sternotomy in adults. Asian Cardiovasc Thorac Ann 2005; 13:135-8. [PMID: 15905341 DOI: 10.1177/021849230501300208] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Whilst the potential risk to underlying vital structures from redo-sternotomy is well recognized, the actual risk is poorly quantified. Our aim was to determine the incidence of complications directly attributable to redo-sternotomy and to ascertain whether the use of femoro-femoral CPB (FF) prior to redo-sternotomy alters operative morbidity and mortality. Case notes of 185 patients undergoing cardiac surgery necessitating redo-sternotomy between May 1998 and November 2002 were reviewed. Of 121 males and 64 females, the median age was 65.5 years (range 60.1-75 years). Elective FF was performed in 71 (38.3%) of cases and 114 (60%) were performed without the aid of prior femoro-femoral CPB (WFF). Three (1.6%) patients initially planned for WFF were converted to emergency FF due to serious complications. Complications directly attributable to redo-sternotomy occurred in 21 (11.3%) cases; 12 (16.9%) in the FF group and 9 (5.3%) in the WFF group. Overall mortality was 1.6%. In summary, our results suggest that morbidity risk for the operation increases significantly with redo-sternotomy alone. Three deaths in our series from direct complications attributable to redo-sternotomy signify an added risk. Hence the necessity for careful surgical technique and judicious use of elective FF-CPB is emphasized.
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Affiliation(s)
- Maqsood Elahi
- Department of Cardiothoracic Surgery, Glenfield Hospital, Leicester, United Kingdom.
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Haas F, Schreiber C, Hörer J, Kostolny M, Holper K, Lange R. Is There a Role for Mechanical Valved Conduits in the Pulmonary Position? Ann Thorac Surg 2005; 79:1662-7; discussion 1667-8. [PMID: 15854949 DOI: 10.1016/j.athoracsur.2004.10.054] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2004] [Indexed: 11/17/2022]
Abstract
BACKGROUND The use of allografts or xenografts is the treatment of choice for pulmonary valve replacement. However, the limited durability is responsible for multiple reoperations associated with increased morbidity. In search of a definitive solution, the implantation of a mechanical valved conduit might be an option in highly selected patients. This study evaluated short-term results after pulmonary valve replacement with a mechanical valved conduit. METHODS Fourteen patients underwent pulmonary valve replacement with a mechanical valved conduit. All patients had a mean of 3.0 +/- 1.2 previous operations. Seven patients were previously operated on for tetralogy of Fallot, 3 patients for pulmonary atresia, 3 patients for common arterial trunk, and 1 patient for subaortic stenosis. RESULTS All patients survived the operation and are currently well. At follow-up (11 to 63 months), all but 2 patients showed normal right ventricular function, with a mean gradient of 14 +/- 9 mm Hg (range, 4 to 30 mm Hg) across the pulmonary valve. At follow-up, there was no evidence of valve failure or tissue growth within the valve annulus. All patients are receiving anticoagulants to maintain an international normalized ratio of 3.0 to 4.5. CONCLUSIONS In highly selected patients, the use of a mechanical valved conduit in the pulmonary position leads to satisfactory results. To avoid a predictable reoperation after multiple right ventricular outflow tract reconstruction, and therefore reoperation-related morbidity, the implantation of a mechanical prosthesis as a lifelong solution requires consideration. Selection criteria for this permanent solution should include older age, multiple previous operations, and patient compliance with anticoagulant therapy.
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Affiliation(s)
- Felix Haas
- Department of Pediatric Cardiothoracic Surgery, Wilhelmina Children's Hospital, Utrecht, The Netherlands.
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Abstract
We report a patient who underwent a total cavopulmonary connection with an extracardiac conduit through a right thoracotomy. The thoracotomy approach was useful in circumventing possible hazardous complications at the sternal reentry for the completion of a staged Fontan due to previous mediastinitis in this patient.
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Affiliation(s)
- Miwa Nanaumi
- Department of Thoracic and Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
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Affiliation(s)
- I Takanami
- Department of Surgery, Teikyo School of Medicine, Tokyo, Japan.
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