Cardiac Laterality: Surgical Results of Right Atrial Isomerism

Right atrial isomerism (RAI) is a complex entity with varying diagnostic and treatment outcomes due to its rarity. Treatment options range from palliative to corrective surgeries, resulting in heterogeneous outcomes. The aim of this study was to analyze the results obtained after cardiac surgery in patients with RAI. A retrospective study was conducted, including patients diagnosed with RAI who underwent cardiac surgery. Their follow-up was from 1 January 2010 to 31 March 2020. Demographic characteristics and perioperative conditions were described. Thirty-eight patients were included, the median age was 4 years (IQR 2-9.2) and 57.9% were men. The main diagnoses were atrioventricular canal (63.2%) and pulmonary stenosis (55.3%). The most common surgical procedures were modified Blalock-Taussig shunt (65.8%) and total cavopulmonary connection with an extracardiac conduit fenestrated without cardiopulmonary bypass (15.9%). We did not find any factors associated with negative outcomes in these patients. The overall survival was 86.8%, with a better outcome in those who did not require reintubation (log rank, p < 0.01). The survival of RAI was similar to other centers. Individuals with RAI should be evaluated rigorously to determine an adequate repair strategy, considering high morbidity and mortality.

Hypertrophic cardiomyopathy in the systemic right ventricle in a patient with congenitally corrected transposition of the great arteries: A case report

Congenitally corrected transposition of the great arteries is a rare clinical entity, which usually presents during adulthood with associated defects; atrioventricular block, heart failure, systemic valve failure, and arrhythmias usually complicate the clinical course. Even rarer is associated hypertrophic cardiomyopathy, which complicates the disease course and clinical decision-making. Herein, we present a patient with this condition who underwent heart transplantation, with adequate clinical resolution.

[Congenital heart disease in Down's syndrome]

Background

Down syndrome is the most common chromosomal abnormality, it is associated with a wide variety of congenital heart defects, being considered as clinical elements of high infant morbidity and mortality. Objective.

Objective

To describe the clinical outcomes of patients with Down syndrome undergoing surgery and interventionism as treatment for congenital heart disease at this Institution.

Material and methods

368 patients with Down syndrome and associated congenital heart disease were diagnosed. The variables studied were weight, stature, sex, age, type of heart disease, corrective procedure, length of stay in the hospital and intensive care unit, morbidity and mortality.

Results

368 pediatric patients underwent surgical or interventional correction. Of which 197 (54%) were female, the median age was 24 months (interquartile range [IQR]: 14-48) in the surgical group and 36 months (IQR: 17-85) in the interventional group. The most frequent congenital heart diseases were: PCA (31%), IVC (28%), CAV (20%), ASD (16%) and tetralogy of Fallot with 4% respectively. Hospital stay was 9 days (IQR: 7-15) in the surgical group and 3 days (IQR: 2-5) in the hemodynamic group. Morbidities were postoperative infection in 30 patients (14%) and complete atrioventricular block in 19 patients (9%). Overall mortality including both surgical and interventional was 2%.

Conclusions

The therapeutic, surgical and interventional results in children with Down syndrome and congenital heart disease have improved very satisfactorily. The lower prevalence of the atrioventricular canal in the Mexican population is noteworthy. It is essential to carry out a cardiological evaluation of children with Down syndrome and those with congenital heart disease to correct them in a timely manner to promote survival and quality of life.

Pulmonary arterial hypertension in children with congenital heart disease: a deeper look into the role of endothelial progenitor cells and circulating endothelial cells to assess disease severity

Endothelial progenitor cells and circulating endothelial cells have been proposed as useful markers of severity and disease progression in certain vascular diseases, including pulmonary arterial hypertension. Our study focused on evaluating the levels of circulating endothelial progenitor cells and circulating endothelial cells in patients with congenital left-to-right shunts and pulmonary hypertension undergoing definitive repair. Endothelial progenitor cells (identified by simultaneous co-expression of CD45dim, CD34 + and KDR2 + surface antibodies) and circulating endothelial cells (identified by simultaneous co-expression of inherent antibodies CD45-, CD31+, CD146 + and CD105+) were prospectively measured in seventy-four children (including children with Down syndrome), median age six years (2.75-10), with clinically significant left-to-right shunts undergoing transcatheter or surgical repair and compared to thirty healthy controls. Endothelial progenitor cells and, particularly, circulating endothelial cells were significantly higher in children with heart disease and pulmonary arterial hypertension when compared to controls. Endothelial progenitor cells showed significant correlation with pulmonary vascular resistance index when measured both systemically (r = 0.259; p = 0.026) and in the superior vena cava (r = 0.302; p = 0.009). Children with Down syndrome showed a stronger correlation between systemic cellularity and pulmonary vascular resistance index (r = 0.829; p = 0.002). Endothelial progenitor cells were reduced along their transit through the lung, whereas circulating endothelial cells did not suffer any modification across the pulmonary circulation. In children with yet to be repaired left-to-right shunts, endothelial progenitor cells and circulating endothelial cell counts are increased compared to healthy subjects.

Replacement of Obstructed Right Ventricle to Pulmonary Artery Conduits: The Modified Peel Operation

Reconstruction of the right outflow tract with extracardiac conduits has made complete repair of complex cardiac malformations possible. However, reoperation is usually required for a right ventricle-to-pulmonary artery conduit obstruction. We describe a modified peel operation, where the sides and posterior half of the previously placed conduit are preserved, and a prosthetic roof is placed over the conduit remnant. This has been our current technique to manage conduit obstructions. It is a safe operation and to teach residents. This review aims to convey the technical details of each step of this technique.

Prenatal Diagnosis and Outcome of Intrapericardial Teratoma: Report of Two Clinical Scenarios

Intrapericardial teratoma is a rare tumor composed of tissue from the three germ cell layers with a rapid growth that may cause severe hemodynamic complications due to compressive effects. We present two clinical cases: the first case had severe fetal heart failure with fatal outcome, and the second underwent surgical treatment during the immediate postnatal period with a favorable evolution. Although teratomas are histologically benign tumors, rapid growth can cause serious hemodynamic complications. The importance of prenatal diagnosis is to allow appropriate monitoring of tumor growth and establish a prompt therapeutic plan. Opportune surgical treatment can prevent death and improve the prognosis of these patients.

Surgical outcomes among children with bicuspid aortic valve: 17 years of experience in a single center. First report in Mexico

PURPOSE

To evaluate the clinical and surgical outcomes among children with bicuspid aortic valve who underwent cardiac surgery.

METHODS

This observational and retrospective study included patients with a diagnosis of bicuspid aortic valve who underwent cardiac surgery between January 1, 2003, and March 31, 2020. Demographic characteristics and perioperative conditions were described.

RESULTS

One hundred and sixteen patients were included, with a mean age of 12.4 ± 4.2 years; 63.2% were male. The most frequent diagnosis was congenital aortic stenosis (23.5%), followed by connective tissue disorders (16%). Mechanical aortic prostheses were used in 87.7% of cases, with a mean size of 21 ± 2.6 mm. The main factors associated with mortality were valve prosthesis dysfunction (odds ratio [OR]: 12.44; 95% confidence interval [CI]: 1.05-147.48; p = .04) and reoperation (OR: 24.29; 95% CI: 1.03-570.08; p = .04). The overall survival was 87.9%, with better outcomes among those who did not undergo reoperation (Log Rank, p = .01).

CONCLUSIONS

Outcomes after aortic valve replacement in children with bicuspid aortic valve are excellent in the short and long term, regardless of using mechanical or biological prostheses.

Coronary Revascularization in Patients With Cardiac Sequelae of Kawasaki Disease at a Single Center

Background: Kawasaki disease (KD) is a self-limited vasculitis that mainly affects infants and preschool-age children, characterized by coronary aneurysms and/or stenoses that may lead to the occurrence of ischemia, heart attack, and sudden death. This study aimed to evaluate the clinical and surgical results of pediatric patients with KD and cardiac sequelae who underwent coronary artery bypass grafting. Methods: A retrospective study was carried out. Patients with a diagnosis of KD and cardiac sequelae who underwent coronary artery bypass grafting from January 1, 2004, through March 31, 2021, were included: preoperative characteristics and conditions. Results: Ten patients were included, with a mean age of 6.4 ± 3.7 years; 80% males. Seven (70%) had the compromise of 2 coronary arteries, the most affected being the left anterior descendent artery (36.9%) with aneurysm and the right coronary artery (36.8%) with stenosis. 40% had preoperative moderate-to-severe ventricular dysfunction. The graft most frequently used was the right internal thoracic artery (47.6%), and the most frequent coronary bypass target vessel was the left anterior descending artery (38.1%). There was no early mortality or deaths during follow-up; 90% remained in functional class I. Among the cohort as a group, there was an overall improvement in postoperative ventricular function ( P = .03). This persisted, being unchanged at subsequent follow-up ( P = .95). Conclusions: Coronary artery bypass grafting is an appropriate treatment option for children with cardiac sequelae of KD, with excellent surgical results. Furthermore, this surgical procedure avoids the deterioration of left ventricular function in pediatric age.

Total anomalous pulmonary venous connection: 16 years of surgical results in a single center

PURPOSE

The aim of the study was to analyze the surgical outcome of patients with total anomalous pulmonary venous connection (TAPVC) who underwent cardiac surgery.

METHODS

A retrospective study was carried out. Patients with diagnosis of TAPVC undergoing cardiac surgery at the National Institute of Cardiology Ignacio Chávez, from January 1, 2003 and June 30, 2019 were included. Descriptive statistics were calculated, as well as a bivariate analysis of the variables associated with mortality. A logistic regression model was included to determine risk factors associated with the main outcome and survival was analyzed using the Kaplan-Meier method.

RESULTS

A total of 5314 patients diagnosed with congenital heart disease (CHD) underwent surgery, 414 (7.8%) were patients with TAPVC, with an average age of 17.1 ± 34.6 months, 58.2% were male. It was frequent in infants (61.6%) and preschool (19.6%). Predominant type was supracardiac TAPVC (47.4%). Pulmonary venous obstruction (PVO) occurred in 32.1%. Risk factors associated with mortality were infracardiac TAPVC (odds ratio [OR]: 3.26; 95% confidence interval [CI]: 1.17-9.03; p = .02), PVO (OR: 2.56; 95% CI: 1.05-6.22; p = .03) and postoperative mechanical ventilation (OR: 1.005; 95% CI: 1.002-1.008; p = .01). Overall survival was 87.2%, with better outcomes in adolescents (100%), children (94.1%), mixed TAPVC (96%), and cardiac TAPVC (91.9%; p < .001).

CONCLUSIONS

The survival of our institution after surgical correction of TAPVC is similar to that of other referral centers, where patients with infracardiac TAPVC and newborns worse outcomes. All patients must undergo a rigorous evaluation to determine an adequate repair strategy.

Cardiac surgery in patients with atrial isomerism: Long-term results and outcomes

PURPOSE

The aim of the study was to identify, determine, and analyze the clinical and surgical outcomes of patients with atrial isomerism (AI) undergoing cardiac surgery.

METHODS

A retrospective study was carried out. Patients with diagnosis of AI undergoing cardiac surgery at the National Institute of Cardiology Ignacio Chávez, from January 1, 2010 and March 31, 2020 were included; demographic characteristics and perioperative conditions of the patients were considered.

RESULTS

Sixty-five patients were included, with an average age of 6.4 ± 4.9 years, 50.8% males. Thirty-eight (58.5%) had right atrial isomerism (RAI) and 27 (41.5%) had left atrial isomerism (LAI); univentricular physiology (78.5%) predominated. Atrioventricular septal defect (AVSD) in RAI and septal defects in LAI were identified as the main associated defects. The most common surgical procedures performed were modified Blalock-Taussig shunt (MBTS) (27.6%), MBTS with total anomalous pulmonary venous connection (TAPVC) repair (15.3%) and total cavopulmonary connection (TCPC) with an extracardiac conduit fenestrated (10.8%); 100% RAI required a univentricular approach, while in LAI it was 48.1%. Overall survival was 92.3%, with 100% survival in LAI with biventricular physiology and 86.8% in RAI with univentricular physiology.

CONCLUSIONS

The survival of our institution is similar to that of other referral centers, where patients with LAI had a better evolution than RAI; in addition, the univentricular approach was required in all with RAI. Patients with AI must undergo a rigorous evaluation to determine an adequate repair strategy, considering univentricular RAI with a high possibility of morbidity and mortality.

Impact of the COVID-19 Pandemic on Congenital Cardiac Surgeries at a National Referral Center in Mexico

Severe acute respiratory syndrome coronavirus 2, the etiologic agent of coronavirus disease 2019, has caused more than 160 million infections globally. The experience of our department showed that the execution of a strict surgery protocol, universal severe acute respiratory syndrome coronavirus 2 screening, surgical prioritization, and an orderly reactivation of the cardiac surgery program is a feasible way to keep congenital heart diseases surgery program.

Rehabilitation of pulmonary arteries: Hybrid treatment in the unilateral absence of the pulmonary artery

BACKGROUND

Unilateral abscence of pulmonary artery is a rare congenital heart disease. If these anomaly is unrecognized and treated the risk of pulmonary hypertension in the contralateral lung can be lethal for the patients.

AIMS

To report the successful sequential hybrid-surgical approach of two cases of rescue of pulmonary branches only fed by ductus arteriosus.

MATERIALS & METHODS

Description of two rare cases of absence of a unilateral pulmonary branch successfully treated in our institution.

RESULTS, DISCUSSSIION AND CONCLUSION

The timely identification of these cases and the strategic planning of interventional and surgical hybrid sequential treatment of these rare cases is effective.

Association between congenital heart disease and NKX2.5 gene polymorphisms: systematic review and meta-analysis

Aim: To analyze the association of NKX2.5 gene with congenital heart disease (CHD), and to determine if the variants rs703752, rs3729753 and rs2277923 increase the risk for developing CHD. Materials & methods: PubMed, EBSCO and Web of Science databases were screened to identify eligible studies. Through a comprehensive meta-analysis software, the association between NKX2.5 gene variants and susceptibility of CHD was calculated by pooled odd ratio (ORs) and 95% CI. Results: We observed that the allelic model of rs703752 and rs2277923 increased the risk in the overall population: OR = 1.24; 95% CI: 1.00-1.55; Z p-value = 0.049; OR = 1.18; 95% CI: 0.01-1.37; Z p-value = 0.036; respectively. Conclusion: Our results suggested that the rs703752 and rs2277923 polymorphisms of the NKX2.5 gene are associated with CHD.

[Coronary Revascularization in Kawasaki's disease]

Kawasaki´s disease (KD) has surpassed rheumatic fever in many countries as the first cause of acquired heart disease in pediatric age, being the coronary aneurism its worst complication. We present a case of successful revascularization in a 5-year-old patient, with three-vessel coronary disease secondary to KD, who underwent a coronary bypass with anastomosis from the left internal mammary artery to the anterior descending artery, the right mammary artery to the marginal obtuse artery and the radial artery to the posterior descending artery. Close follow-up and choosing the right time to undergo surgery will prevent adverse events like permanent disability of the patient, ventricular dysfunction, arrhythmias, global infarction and sudden death.

Regionalization of congenital heart disease care: A pending goal

Congenital heart diseases (CHDs) are considered the most frequent malformations. In Mexico, every year between 12 and 16 thousand children are born with some type of CHD and it is the second cause of mortality in children under 1 year of age and in children aged between 1 and 4 years. The problem of the care of CHDs is analyzed from a perspective of health policies in the country with an emphasis on regionalizing their care to rationalize the use of available resources and with the aim of serving the largest number of patients and achieve the best clinical results. It emphasizes the need to promote cooperation among the different civil society organizations and institutions to exchange ideas to create consensus and joint projects for a better use of available resources to achieve universal and quality care of children with CHD in all the country.

La regionalización de la atención de cardiopatías congénitas: una meta pendiente

Congenital heart diseases are considered the most frequent malformations. In Mexico every year between 12 and 16 thousand children are born with some type of congenital heart disease and it is the second cause of mortality in children under 1 year of age and in children aged between 1 and 4 years. The problem of the care of congenital heart diseases is analyzed from a perspective of health policies in the country with an emphasis on regionalizing their care in order to rationalize the use of available resources and with the aim of serving the largest number of patients and achieve the best clinical results. It emphasizes the need to promote cooperation among the different civil society organizations and institutions to exchange ideas to create consensus and joint projects for a better use of available resources to achieve universal and quality care of children with congenital heart disease in all the country.

Coronary Revascularization in Children at a Mexican Cardiac Center: Thirteen-Year Outcomes

BACKGROUND

The indications for pediatric coronary revascularization are diverse. There are a large proportion of patients with sequelae of severe inflammatory diseases such as Kawasaki disease, and other less common causes.

METHODS

Retrospective review of ten pediatric patients undergoing coronary artery bypass surgery from January 2004 to December 2016.

RESULTS

Ten children and adolescents ranging in age from 2 to 17 (median, 6) years at operation were followed up for as long as 13 years with a median follow-up of 2 years. The surgical indications include ischemia symptoms and/or coronary stenosis angiographically documented. Diagnoses include Kawasaki disease, anomalous origin of the left coronary artery from the pulmonary artery, and iatrogenic lesion of the right coronary artery. All the surgical procedures were performed with cardiopulmonary bypass with crystalloid cardioplegic arrest. The number of distal anastomoses was 1.6 per patient, and the left internal thoracic artery was used in one patient, the right internal thoracic artery in four patients, bilateral internal thoracic artery in four patients, and bilateral internal thoracic artery plus left radial artery in one patient, most frequently for right coronary artery revascularization. The patients underwent noninvasive diagnostic study during follow-up to evaluate their coronary status. The ten patients had no symptoms, and there was no mortality.

CONCLUSIONS

Although survival was excellent after pediatric coronary bypass in our center, we need to continue the follow-up. Coronary revascularization by means of arterial grafting is a safe and reliable surgical modality for coronary disease in children.

Common Arterial Trunk Repair by Means of a Handmade Bovine Pericardial-Valved Woven Dacron Conduit

BACKGROUND

Surgical repair of common arterial trunk (CAT) by means of a homograft conduit has become a standard practice. We report our experience in the correction of this heart disease with a handmade bovine pericardial-valved woven Dacron conduit as an alternative procedure to homografts, with a focus on early, mid-term, and long-term results.

METHODS

We designed a retrospective study that included 15 patients with a mean age of 1.5 years (range: three months to eight years), who underwent primary repair of simple CAT. Right ventricular outflow tract was reconstructed in all the cases with this handmade graft that was explanted at the time of its biological stenotic degeneration. A peeling procedure was performed at this time, in order to reconstruct the right ventricle-to-pulmonary artery continuity.

RESULTS

Overall mortality was 13.3% (one death at the early postoperative primary repair and the other at the mid-term postoperative peeling reoperation). Actuarial survival rate was 93.3%, 86.7%, and 86.7% at 5, 10, and 15 years, respectively. All of the 14 survivors developed stenosis of the handmade conduit at the mid-term period (8 ± 3 years), but after the peeling procedure, 13 survivors remain asymptomatic to date.

CONCLUSIONS

Primary repair of common arterial trunk using a handmade conduit can be performed with very low perioperative mortality and satisfactory mid-term and long-term results, which can be favorably compared with those reported with the use of homografts. When graft obstruction develops, peeling procedure is a good option because it does not affect the overall survival, although long-term outcomes warrant further follow-up.

[Comparison between patients undergoing Fontan operation with or without cardiopulmonary bypass]

Fontan operation is the final palliative stage of patients with univentricular hearts. Cardiopulmonary bypass (CPB) decreases ventricular performance and increases pulmonary artery pressures in the post operative recovery period. It seems that Fontan operation performed without CPB decreases short term morbidity and intra hospitalary length of stay.

OBJETIVE

Compare outcome in Fontan patients who have undergone surgery with or without CPB.

METHOD

This is a retrospective review of patients undergoing Fontan operation from january 2009 to december 2012. Patients were grouped according to CPB use and comparative analyses were done.

RESULTS

Ten patients were operated without CPB use. There was a discrepancy between age in both groups, being younger in the no CPB group. Around 80% of patients in both groups had a staged procedure. A 18mm graft was used in half of the cases; a fenestration was created in all cases. Length of stay was equal in both groups, there was less need of pharmacologic support and nitric oxide use in patients without CPB use. No deaths were reported also in this group. At folllow up, most patients had a class i functional status.

CONCLUSIONS

In our experience, Fontan operation without CPB has similar outcomes compared with CPB use.

Identification of Copy Number Variations in Isolated Tetralogy of Fallot

Tetralogy of Fallot (ToF) is one of the most common and severe congenital heart defects (CHD). Recently, unbalanced structural genomic variants or copy number variations (CNVs) were proposed to be involved in the etiology of many complex diseases, including CHDs. The aim of this study was to investigate the frequency of CNVs in a region with a high density of CNVs, 22q11.2, and other regions with CHD-related genes in a sample of 52 Mexican mestizo patients with isolated ToF and negative fluorescence in situ hybridization staining for 22q11. CNVs were studied using two multiplex ligation-dependent probe amplification (MLPA) kits, SALSA P250-B1® (DiGeorge gene region) and SALSA MLPA P311-A1® CHD-related gene regions (GATA4, NKX2-5, TBX5, BMP4, and CRELD1). The MLPA assay detected a de novo CNV deletion of the probes located in exons 2 and 7 of the TBX1 gene in one of the 52 patients studied; this result was confirmed by real-time quantitative polymerase chain reaction. This deletion was not present in the patient's parents and 104 chromosomes from healthy control subjects. Our results clearly suggest a possible etiologic association between the TBX1 deletion and the ToF in our patient.

[Percutaneous closure of atrial septal defects with the Amplatzer® device: 15 years of experience]

INTRODUCTION

Percutaneous closure of atrial septal defects is an alternative to surgical treatment.

OBJECTIVES

We report the results of percutaneous closure of atrial septal defects with the Amplatzer(®) device.

METHOD

We include patients taken to the catheterization laboratory from September 1997 to December 2011.

RESULTS

We proceeded with defect closure in 721 patients and in 85 the defect was considered not suitable for closure. The stretched diameter of the defect was 23±6.7mm (limits, 5-42). All devices were positioned successfully. In 15 cases (2.1%) the device was changed due to instability and in 6 (0.8%) the device embolized within the first 24h, 4 were retrieved and repositioned (final success with intention to treat 719/806-89.2%). Immediate control showed complete closure in 247 patients (34.3%), leak through the device in 395 (54.9%), mild residual leak in 75 (10.4%) and moderate in 2 (0.3%). We have follow-up in 626 patients (87.1%) for 33±27.5 months, with headache in 54 (8.6%), new supraventricular arrhythmia in 10 (1.6%), puncture site complications in 4 (0.6%), and stroke in one (0.1%).

CONCLUSION

The design of the Amplatzer(®) device allows effective closure of atrial septal defects with a simple technique and patient safety.

Mexican registry of pediatric cardiac surgery. First report

BACKGROUND

Currently, there is a spreading worldwide tendency to characterize health issues and to propose alternative solutions via the creation of computerized databases. The aim of this study was to present the results in a computerized database of pediatric cardiac surgeries developed under the auspices of the Mexican Association of Specialists in Congenital Heart Diseases (Asociación Mexicana de Especialistas en Cardiopatías Congénitas A.C) and coordinated by the collegiate group of Pediatric Cardiology and Surgery as petitioned by the National Institutes of Health and High Specialty Hospitals Coordinating Commission.

METHODS

We analyzed all cases registered in the database during a 1-year observation period (August 1, 2011 to July 31, 2012) by all major Health Ministry-dependent institutes and hospitals offering surgical services related to pediatric cardiopathies to the non-insured population.

RESULTS

Seven institutions participated voluntarily in completing the database. During the analyzed period, 943 surgeries in 880 patients with 7% reoperations (n=63) were registered. Thirty-eight percent of the surgeries were performed in children <1 year of age. The five most common cardiopathies were patent ductus arteriosus (n=96), ventricular septal defect (n=86), tetralogy of Fallot (n=72), atrial septal defect (n=68), and aortic coarctation (n=54). Ninety percent of surgeries were elective and extracorporeal circulation was used in 62% of surgeries. Global mortality rate was 7.5% with the following distribution in the RACHS-1 score categories: 1 (n=4, 2%), 2 (n=19, 6%), 3 (n=22, 8%), 4 (n=12, 19%), 5 (n=1, 25%), 6 (n=6, 44%), and non-classifiable (n=2, 9%).

CONCLUSIONS

This analysis provides a representative view of the surgical practices in cardiovascular diseases in the pediatric population at the national non-insured population level. However, incorporating other health institutions to the national registry database will render a more accurate panorama of the national reality in surgical practices in the population <18 years of age.

[Pediatric cardiovascular surgical data base registry in México. First report]

INTRODUCTION

Current world tendency is the detection of health problems in order to offer solution alternatives by means of the development of computarized data bases.

OBJECTIVE

To present the results of a computerized data base developed for the registry of pediatric cardiac surgery with the support of Asociación Mexicana de Especialistas en Cardiopatías Congénitas (AMECC, A.C.).

MATERIAL AND METHODS

A one-year analysis (from August 1, 2011 to July 31, 2012) of a computerized data base was performed with the support of AMECC and the participation of the most important Mexican institutions for pediatric surgical heart disease health care, particularly for the uninsured population.

RESULTS

There were 7 health institutions voluntarily incorporated to the national data base registry, and in the first year of observation, 943 surgical procedures in 880 patients and 7% re-operations (n = 63), were reported. Patients up to one-year old accounted for 38%. The most frequent types of operated congenital heart diseases were: patent ductus arteriosus (n = 96), ventricular septal defect (n = 86), tetralogy of Fallot (n = 72), atrial septal defect (n = 68), and aortic coarctation (n = 54). Elective procedures were 90%, and 62% of them were performed with the use of cardiopulmonary bypass. Overall mortality was 7.5% with the following RACHS-1 score risk distribution: 1 (n = 4.2%), 2 (n = 19.6%), 3 (n = 22.8%), 4 (n = 12.19%), 5 (n = 1.25%), 6 (n = 6.44%) and not classifiable (n = 2.9%).

CONCLUSIONS

Although this analysis gives a representative vision of the cardiovascular surgical health care for the uninsured national pediatric population, the incorporation of other health institutions to this data base may lead us to have a most realistic overview in relation to the surgical cardiovascular health care for the up to 18 year-old population.

Congenital Heart Disease in Mexico

Consistent with the mission of the World Society for Pediatric and Congenital Heart Surgery to promote health care for children with congenital heart disease all around the world, a Mexican Association of Specialists in Congenital Heart Disease (abbreviated in Spanish as AMECC) was created in Mexico in 2008. Our efforts were coordinated with those of the National Health Secretary with the objective being implementation of a national plan for regionalization of care for patients with congenital heart disease. To improve our knowledge related to technologic and human resources for management of congenital heart disease, we developed a national survey. Finally, a national database was created for collecting all Mexican centers’ information related to congenital heart disease care in order to quantify the advances related to the proposed plans. The database utilized international consensus nomenclature. The aim of this article is to show the sequence of our actions in relation to direct accomplishments and the current status of congenital heart disease care in Mexico. This article emphasizes the main aspects of these actions: regionalization project implementation, national survey results, and cardiovascular pediatric surgical database creation. Knowledge of outcomes related to successful actions would be useful for those countries that face similar challenges and may lead them to consider adoption of similar measures with the respective adjustments to their own reality.

[Changing the paradigm of congenital heart disease: from the anatomy to the molecular etiology]

Heart development consists in a group of complex and specific morfogenetic interactions, that requires the proper activity of each factor implicated in this process. Congenital heart defects (CHD) are a group of multifactorial complex diseases with environmental and genetic factors playing important roles. There is not an exact relation between molecular mechanisms and morphological defects in CHD, because in most of the cases the proper development of an anatomical structure implies the adequate function of several pathways that may depend of the action of different genes. This review summarizes the genetic factors implied in the normal heart development and the most common gene mutations associated with CHD.

Fontan Procedure at 2,240 m Above Sea Level

The modified Fontan procedure represents the final stage of reconstructive surgery for most patients with functionally univentricular hearts. Although outcomes following Fontan procedures performed at sea level are widely reported, less has been documented and reported concerning outcomes in regions at high altitude. To clarify the main features involved, we present our institutional experience with Fontan operations performed in Mexico city (2,240 m above the sea level), with an emphasis on historical evolution of treatment. A retrospective and observational study was undertaken, which included 98 patients over a period of 18 years, and clinical outcomes in terms of morbidity and mortality were analyzed. A change in operative technique from intra-cardiac nonfenestrated Fontan procedure to extra-cardiac fenestrated technique occurred in 2001. Early mortality rates before and after this change in surgical approach were 26% and 4.7%, respectively. The most common morbidity was the occurrence of pleural effusions (98% of patients), which also appears to be a risk factor for operative mortality. Much remains unknown about the pathophysiology of the Fontan circulation at high altitude, and we need to develop morphological study protocols that include pulmonary biopsy to increase our knowledge and inform our therapeutic actions.

[Operative results in cardiovascular surgery of the neonate]

OBJECTIVE

To present our institutional postoperative results in cardiovascular surgery of the neonate, and to give an idea of its contribution to the national problematic knowledge in this area.

MATERIAL AND METHODS

A retrospective, descriptive, and observational study was carried out, including all neonates with congenital heart disease who were operated at the Ignacio Chávez National Cardiology Institute in a 7 year period. We made special emphasis in postoperative morbidity and mortality, as well as in the risk factors for early mortality.

RESULTS

We operated on 484 neonates with congenital heart disease due to total anomalous pulmonary venous conection, classic transposition of great arteries, pulmonary atresia, and aortic coarctation. Causes for early mortality were cardiac failure, pulmonary hypertension, pulmonary sepsis, and arrhythmias. Operative mortality was 12.2% and was due mainly to congenital heart disease with 5 and 6 RACHS-1 risk score. Risk factors for operative mortality were: age < 15 days, body surface area < 0.20 m2, weight < 4 kg, and univentricular heart physiology.

CONCLUSIONS

There is still a high operative mortality for complex neonatal heart disease in this series. Our institutional outcomes can not be extrapolated to the rest of the country, but highlights several challenges that national pediatric health care institutions and associations must assume in order to improve the attention that neonatal patients demand.

[Scimitar syndrome in infancy]

OBJECTIVE

To expose our 26 year experience in clinical management, interventional catheterization and surgical treatment of patients younger than 18 years with scimitar syndrome at the National Cardiology Institute.

MATERIAL AND METHODS

We reviewed retrospectively all patients with scimitar syndrome in infancy between 1984 and 2010. Patients were divided in two groups: younger an older than one year at the time of the diagnosis. Medical records were analized, as well as chest radiography, electrocardiogram, echocardiogram and helicoidal tomography. All therapeutic procedures performed and their outcomes were analized.

RESULTS

We studied 22 patients with scimitar syndrome, 20 of them with associated congenital heart disease. Congestive heart failure (p > or = 0.0001) and severe pulmonary hypertension (p > or = 0.002) were more frequent in patients younger than one year. We documented dextroposition and right lung hypoplasia in 14 patients, and aorto-pulmonary collateral arteries in 15 of them. Pulmonary hypertension was an important mortality risk factor (p > or = 0.007).

CONCLUSIONS

Congestive heart failure and pulmonary hypertension are more frequent in patients younger than one year, and the former is a mortality risk factor. It is important to suspect this congenital heart disease in infants with dextroposition and congestive heart failure in order to provide an opportune treatment.

[Medical and surgical health care for congenital heart disease: a panoramic vision of the reality in Mexico. Inquiry 2009]

INTRODUCTION

The only way to characterize the Mexican problem related to congenital heart disease care is promoting the creation of a national database for registering the organization, resources, and related activities.

MATERIAL AND METHODS

The Health Secretary of Mexico adopted a Spanish registration model to design a survey for obtaining a national Mexican reference in congenital heart disease. This survey was distributed to all directors of medical and/or surgical health care centers for congenital heart disease in Mexico. This communication presents the results obtained in relation to organization, resources and activities performed during the last year 2009.

RESULTS

From the 22 health care centers which answered the survey 10 were reference centers (45%) and 12 were assistant centers (55%). All of them are provided with cardiologic auxiliary diagnostic methods. Except one, all centers have at least one bidimentional echocardiography apparatus. There is a general deficit between material and human resources detected in our study. Therapeutic actions for congenital heart disease (70% surgical and 30% therapeutical interventionism) show a clear centralization tendency for this kind of health care in Mexico City, Monterrey and finally Guadalajara.

CONCLUSIONS

Due to the participation of almost all cardiac health centers in Mexico, our study provides an important information related to organization, resources, and medical and/or surgical activities for congenital heart disease. The data presented not only show Mexican reality, but allows us to identify better the national problematic for establishing priorities and propose solution alternatives.

[Importance of the heart-brain binomial in the management of congenital heart disease]

A case of a two month infant with complex congenital heart disease (aortic coarctation with ventricular septal defect) associated to a cellular brain migration failure is presented. The management strategy consisted on the correction of congenital heart disease by means of a two-stage surgery without a further preoperative evaluation of the neurological status. The patient developed several perioperative complications such as two episodes of cardiac arrest, reconnection to cardiopulmonary bypass, cardiac tamponade, chilothorax and septic shock. A neurological protocol consisting in electroencephalography, brain magnetic resonance and Single Photon Emission Computed Tomography (SPECT) was practiced during the postoperative period, which detected microgyria with paquigyria and a cellular brain migration failure was suspected. The final outcome was death due to multisystemic failure and the autopsy confirmed the neurological disease, as well as poor life function prognosis. Should the heart-brain binomial had been considered in an integral preoperative evaluation, the therapeutical approach could have been modified.

Percutaneous closure of hypertensive ductus arteriosus

BACKGROUND

The Amplatzer duct occluder (ADO) has been used with success to close large patent ductus arteriosus (PDA), but some problems exist especially with hypertensive PDAs, such as incomplete closure, haemolysis, left pulmonary artery stenosis, obstruction of the descending aorta and progressive pulmonary vascular disease.

METHODS AND RESULTS

We analysed a group of 168 patients with isolated PDA and pulmonary artery systolic pressure (PSAP) > or =50 mm Hg. Mean age was 10.3 +/- 14.3 years (median 3.9), PDA diameter was 6.4 +/- 2.9 mm (median 5.9), PASP was 63.5 +/- 16.2 mm Hg (median 60), Qp/Qs was 2.7 +/- 1.2 (median 2.5), total pulmonary resistance index (PRI) was 3.69 +/- 2.15 (median 3.35) and vascular PRI was 2.73 +/- 1.72 (median 2.37). We used ADOs in 145 (86.3%) cases, Amplatzer muscular ventricular septal defect occluders (AMVSDO) in 18 (10.7%), Amplatzer septal occluders (ASO) in three (1.8%) and the Gianturco-Grifka device in two (1.2%) cases. Device diameter was 106.3% +/- 51% higher than PDA diameter. PASP decreased after occlusion to 42.5 +/- 13.3 mm Hg (p<0.00001). Immediately after closure, no or trivial shunt was present in 123 (74.5%) cases. Immediate complications were device embolisation in five (3%) cases and descending aortic obstruction in one case. The overall success rate was 98.2%. Follow-up in 145 (86.3%) cases for 37.1 +/- 24 months (median 34.1) showed further decrease of the PASP to 30.1 +/- 7.7 mm Hg (p<0.0001).

CONCLUSIONS

Percutaneous treatment of hypertensive PDA is safe and effective. ADO works well for most cases, but sometimes other devices (MVSDO or ASO) have to be used. When cases are selected adequately, pulmonary pressures decrease immediately and continue to fall with time.

Surgical repair of congenital mitral valve malformations

Surgical development of mitral valve repair techniques in pediatric patients has been slow because of the great variety in the presentation of congenital mitral valve malformations and the still unknown growing effect over the complex mitral valve apparatus. The aim of this study is to review our early an mid-term institutional outcomes in surgical repair of congenital mitral valve malformations. We studied retrospectively 14 patients with surgical repair of congenital mitral valve malformations in a 5 year period. Clinical and echocardiographic follow-up at a mean of 25 months was performed in all cases. Operative morbidity was 77% and operative mortality 7%. There were no late deaths. Clinical functional class stratification at the mid-term improved in 73% of survivors and did not change in the remaining 27%. Freedom from reoperation for mitral valve prosthetic replacement due to mitral valve repair failure was 84% at 30 days and 77% at 3.5 years. Surgical repair is probably the best technique option in the treatment of congenital malformations of the mitral valve, and transesophageal intraoperatory echocardiography must be highly recommended for evaluation of results.

Anatomic diagnosis of congenital heart disease. A practical approach based on the sequentiality principle

Based on the sequentiality principle, this review proposes a practical method that allows the systematization of the anatomic diagnosis of congenital heart disease. We emphasize the need to use sequential connection between the different cardiac segments: atria, ventricles and great arteries. Five ordered steps are defined, which include determination of atrial situs and of the connection features between the ventricles and the great arteries. Related lesions and some additional special features are a second stage in the sequential analysis of congenital heart disease, which is also important for the integral diagnosis.

[Congenital heart disease in Mexico. Regionalization proposal]

Congenital cardiopathies are the most frequent congenital malformations. Reports of its prevalence around the world range from 2.1 to 12.3 for every 1000 newborns. Prevalence in our country remains unknown, but it probably occupies sixth place for mortality in infants less than a year old, and third place for mortality in those aged between 1 and 4 years. Based on birthrate, it is calculated that 10 to 12 000 infants in our country have some cardiac malformation. To understand the magnitude of the problem, it is important to identify the global number of newborns with some congenital cardiopathy each year and the type of malformation that they have, in order to determine the necessary resources and to plan their distribution. The main objective of regionalization is the justification of the resources with an emphasis in the specialized medical services to provide the best results for the patients. Hence, reason, based on the resources of each state, as well as their natality and infant mortality rates related to congenital cardiovascular pathology, we should proceed to regionalize the attention, and to simultaneously create a trustworthy database of the congenital cardiopathies. This should have many benefits, such as increase the number of total attended cases, improve the quality of attention, use appropriately the existent resources, and -surely- decrease the infant mortality.