Experience with surgical correction of double outlet both ventricles

Double outlet both ventricles is a rare abnormal ventriculo-arterial malformation in which both great arterial trunks are committed to both the ventricles, albeit now being recognized with increasing frequency. Patients with the lesion present with a spectrum of clinical manifestations. The size and location of the interventricular communication dictate the feasibility of biventricular repair. Literature on the malformation, however, is sparse. We report our experience with five patients, all of whom underwent successful surgical biventricular repair.

Clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects: A retrospective study from two centres in Southern India

BACKGROUND

Recent advances in fetal ultrasound imaging, especially four-dimensional (4D) spatio-temporal image correlation techniques permit detailed evaluation of the fetal venous system and its abnormalities. In this report, we present the clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy, and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects from two centres in southern India.

OBJECTIVES

To report the clinical presentation, conventional/4D spatio-temporal image correlation imaging findings, pregnancy, and early postnatal outcomes in fetuses having anomalies of systemic venous return in the absence of significant intracardiac defects from two centres in Southern India.

METHODS

Retrospective study (October 2017 to March 2022). All fetuses referred with abnormal cardiac imaging findings who were diagnosed to have anomalies of systemic venous return in the absence of significant intracardiac defects were included. Imaging techniques like 2D with color and 4D spatio-temporal image correlation fetal imaging were used to evaluate systemic venous anomalies. Systemic venous anomalies were grouped into cardinal venous anomalies and umbilico-portosystemic venous anomalies.

RESULTS

Thirty-nine fetuses were included; this represented 4.4% of all cardiac anomalies diagnosed during the study period. Cardinal venous anomalies were seen in 29 fetuses (74%); the mean gestation age at diagnosis was 25.5 ± 3.4 weeks. Absent dilated coronary sinus was associated with anomalous drainage of superior caval vein through completely unroofed coronary sinus into the left atrium (n = 3) which resulted in cyanosis after birth in all infants. Among the three cases, one underwent surgery at 6 months of age due to a progressive increase in cyanosis (Spo2 78%) and others are awaiting surgery. A prenatal genetic evaluation was performed in 17 (58.6%). Cardinal venous anomalies were not associated with genetic abnormalities. Live births occurred in all fetuses with cardinal venous anomalies. Umbilico-portosystemic venous anomalies were seen in 10 (26%). The mean gestation age at diagnosis was 26.5 ± 4.5 weeks. Except in a fetus with the extrahepatic portosystemic shunt (umbilical vein to iliac vein), the genetic evaluation was normal in our cohort. Extracardiac anomalies (n = 3/10; 30%) were seen in both intra (n = 1) and extrahepatic portosystemic shunts (n = 2).

CONCLUSION

Anomalies of systemic venous return in the absence of significant intracardiac, extracardiac, and genetic abnormalities carried an overall favorable prognosis in our cohort. Precise characterization of anatomic details using advanced imaging techniques helps in the understanding of this complex three-dimensional anatomy and in the prognostication of these anomalies.

Role of intrapulmonary artery septation in univentricular hearts

The optimal management of functionally univentricular hearts with a significant unbalanced pulmonary blood flow is unclear. The role of cavopulmonary shunt in the rehabilitation of hypoplastic pulmonary arteries is limited. Intrapulmonary artery septation is a technique, wherein a systemic-to-pulmonary artery shunt provides an additional source of blood flow to rehabilitate the hypoplastic pulmonary artery. We report a case of functionally univentricular heart with hypoplastic left pulmonary artery following a cavopulmonary shunt in whom intrapulmonary artery septation resulted in adequate growth of the left pulmonary artery.

Prenatal diagnosis of transposition of great arteries with left anterior aorta (SDL-TGA)

We report a case with prenatal diagnosis of transposition of great arteries (TGA) with L-posed aorta (SDL-TGA) which was confirmed by postnatal echocardiography. The anatomic findings were confirmed during the successful arterial switch operation (ASO). The technical challenges of ASO in the L-posed aorta are also described.

Total Anomalous Pulmonary Venous Connection Repair: Single-Center Outcomes in a Lower-Middle Income Region

BACKGROUND

The management of total anomalous pulmonary venous connection (TAPVC) in neonates and infants is resource-intensive. We describe early and follow-up outcomes after surgical repair of isolated TAPVC at a single institution in a resource-limited setting.

METHODS

The data of 316 consecutive patients with isolated TAPVC undergoing repair (January 2010-September 2020) were reviewed. The study setting was a tertiary hospital in southern India that provides subsidized or charitable care. Standard surgical technique was used for repair, circulatory arrest was avoided, and suture-less anastomosis was reserved for small or stenotic pulmonary veins. Surgical and postoperative strategies were directed toward minimizing intensive care unit (ICU) stay.

RESULTS

302 (95.6%) patients were infants and 128 patients (40.5%) were neonates; median weight was 3.3 kg (IQR 2.8-4.0 kg). Obstruction of the TAPVC was seen in 176 patients (56%) and pulmonary hypertension in 278 patients (88%). Seventeen (5.4%) underwent delayed sternal closure. The median postoperative ICU stay was 120 h (IQR 96-192 h), mechanical ventilation was 45 h (IQR 24-82 h), and hospital stay was 13 days (IQR 9-17 days). There were three in-hospital deaths (0.9%). Over a median follow-up period of 53.3 months (IQR 22.9-90.4), pulmonary vein restenosis was seen in 32 patients (10.1%) after a mean of 2.2 months (1-6 months). No perioperative risk factors for restenosis were identified.

CONCLUSIONS

Using specific perioperative strategies, it is possible to correct TAPVC with excellent surgical outcomes in low-resource environments. Late pulmonary vein restenosis remains an important complication.

Intrapulmonary artery septation for pulmonary artery growth in functionally univentricular hearts

The pulmonary artery anatomy is one of the important determinants of Fontan completion and its outcomes in patients with functionally univentricular hearts. Despite several modifications to Fontan operation, unbalanced pulmonary arteries pose a significant challenge in this subset of patients. Intrapulmonary artery septation is a technique, developed to rehabilitate the unilateral hypoplastic pulmonary artery following various initial palliative procedures in functionally univentricular hearts. Literature is sparse on this technique. This article reviews the basic concepts and literature on intrapulmonary artery septation. We also describe our experience with modified intrapulmonary artery septation.

Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 1-anatomy, pathophysiology, and diagnosis)

Right ventricle (RV) dysfunction and failure are now increasingly recognized as an important cause of perioperative morbidity and mortality after cardiac surgery. Although RV dysfunction is common, RV failure is very rare (0.1%) after routine cardiac surgery. However, it occurs in 3% of patients after heart transplantation and in up to 30% of patients after left ventricular assist device implantation. Significant RV failure after cardiac surgery has high mortality. Knowledge of RV anatomy and physiology are important for understanding RV dysfunction and failure. Echocardiography and haemodynamic monitoring are the mainstays in the diagnosis of RV dysfunction and failure. While detailed echocardiography assessment of right heart function has been extensively studied and validated in the elective setting, gross estimation of RV chamber size, function, and some easily obtained quantitative parameters on transesophageal echocardiography are useful in the perioperative setting. However, detailed knowledge of echocardiography parameters is still useful in understanding the differences in contractile pattern, ventriculo-arterial coupling, and interventricular dependence that ensue after open cardiac surgery.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12055-021-01240-y.

Aortic uncrossing with concomitant arch augmentation in a rare case of left circumflex aorta with arch hypoplasia

Retro-esophageal circumflex aortic arch is a rare form of vascular ring. Majority of cases occur in isolation without any intracardiac lesions. Only a few cases of left circumflex aorta have been reported in the literature. We present a case of left circumflex aorta with associated arch hypoplasia and coarctation, ventricular septal defect, who underwent single-stage repair.

Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 2-management of right ventricular failure)

The single most important factor in improving outcomes in right ventricular (RV) failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation, occurs, leading to cardiogenic shock, multi-organ failure, and death. RV dysfunction and failure theoretically can occur in three settings-increase in the pre-load; increase in after load; and decrease in contractility. For patients deemed low risk for the development of RV failure, when it occurs, the correction of underlying cause is the most important and effective treatment strategy. Therapy of RV failure must focus on improving the RV coronary perfusion, lowering pulmonary vascular resistance, and optimizing the pre-load. Pre-load and after-load optimization, ventilator adjustments, and improving the contractility of RV by inotropes are the first line of therapy and should be initiated early to prevent multi-organ damage. Mechanical assist device implantation or circulatory support with extracorporeal membrane oxygenation (ECMO) may be needed in refractory cases.

Berry syndrome-a rare congenital cardiac anomaly

Berry syndrome is a rare congenital cardiac anomaly, characterized by distal aortopulmonary window, hypoplasia or interruption of the aortic arch, intact ventricular septum, and aortic origin of the right pulmonary artery and patent ductus arteriosus. Anatomic depiction of each component is important for the diagnosis. Single-stage surgical repair is challenging but feasible with good survival outcomes. The available literature on this anomaly is limited. Hence, this paper aims at reviewing the literature on Berry syndrome.

Circumflex aorta: An uncharted territory

BACKGROUND

Vascular rings are aortic arch anomalies with a spectrum of manifestations ranging from asymptomatic lesions detected incidentally to an acute presentation secondary to tracheo-esophageal compression. Circumflex retro-esophageal aortic arch is an extreme form of true vascular ring. It remains an uncharted territory to many surgeons.

METHODS

A comprehensive search of peer reviewed journals was completed based on the key words, "Circumflex aorta," "Circumflex retro-esophageal aorta" and "circumflex arch" using Google scholar, Scholars Portal Journals and PubMed. The reference section for each article found was searched to obtain additional articles. Literature on the circumflex aorta was reviewed starting from the embryogenesis to the latest management strategies.

RESULTS

Right circumflex aorta is more prevalent compared to left circumflex aorta. It can occur in isolation or in association with other intracardiac lesions. Mainly presents in children, however reported in adults too. The presentation may vary from asymptomatic lesion to acute respiratory distress secondary to airway compression. Computerized tomography (CT) and magnetic resonance imaging (MRI) are important tools in delineating the vascular anatomy. Aortic uncrossing is the definitive procedure. However, the role of concomitant tracheobronchopexy is emerging. Native tissue-to-tissue anastomosis is commonly preferred, but cases of extra-anatomic grafts are reported.

CONCLUSION

Circumflex aorta is amenable to complete repair. Preoperative delineation of anatomy is important for successful surgical outcome. Division of the retro-esophageal segment is crucial in relieving the compressive symptoms. In addition, tracheobronchopexy is helpful in addressing residual tracheomalacia but this accounts for a high-risk surgery.

Transaxillary Approach for Surgical Repair of Simple Congenital Cardiac Lesions: Pitfalls, and Complications

BACKGROUND

In the treatment of simple congenital cardiac lesions, percutaneous and cosmetic surgical approaches have steadily gained prominence. Surgically, right vertical axillary approach is sparsely used despite superior cosmesis and less pain and blood product usage. Knowledge of potential pitfalls could lead to its more widespread acceptance.

METHODS

We retrospectively analyzed perioperative outcomes of 104 consecutive patients who underwent surgery by this technique between mid-2016 and December 2019, including ostium secundum (67), sinus venosus (34), coronary sinus (1), and ostium primum (1) atrial septal defects and hemianomalous pulmonary venous connection (1). Perioperative variables, surgical times, complications, and follow-up data were analyzed.

RESULTS

Patient weight ranged from 6.8 to 41 kg. Incision length ranged from 4 to 6 cm. There was no mortality. All cannulation was central. Difficulty in cannulation (inferior vena cava) was seen in two patients. Morbidity included pneumothorax in 2 (1.9%) patients and subcutaneous emphysema necessitating prolonged intercostal drain retention in 20 (19.2%) patients. Surgical time increased linearly (r = 0.567; P < .001) with increasing patient weight but cardiopulmonary bypass (CPB) time remained unaffected. No chest deformities or paresthesia were noted on follow-up. Scar size decreased in some patients.

CONCLUSIONS

Right vertical axillary approach can be safely employed to treat simple congenital cardiac lesions with adequate awareness of potential pitfalls. Increasing patient weight increases the surgical time but does not affect CPB times. Incidence of pneumothorax and subcutaneous emphysema is similar to other thoracotomy approaches. It is cosmetically superior.

3D/4D spatiotemporal image correlation (STIC) fetal echocardiography provides incremental benefit over 2D fetal echocardiography in predicting postnatal surgical approach in double-outlet right ventricle

OBJECTIVE

To analyze the incremental benefit of 3D/4D spatiotemporal image correlation (STIC) fetal echocardiography over 2D fetal echocardiography with respect to the accuracy of identification of anatomic details crucial for surgical decision-making and in predicting surgical approach in fetuses with double-outlet right ventricle (DORV).

METHODS

This was a retrospective study of fetuses with DORV which had undergone both 2D echocardiography and 3D/4D STIC echocardiography and which underwent surgery postnatally in a tertiary pediatric cardiac center in Kerala between October 2015 and March 2019. All such cases with normal atrial arrangement, concordant atrioventricular connections and balanced ventricles were included. 2D and 3D/4D STIC fetal echocardiographic data were analyzed by two experienced observers blinded to the other dataset. Anatomic variables crucial for surgical decision-making, i.e. location and routability of the ventricular septal defect, relationship of the great arteries and presence of outflow obstruction, were compared between the two modalities with respect to agreement with postnatal echocardiography. The accuracy of prenatal prediction of the surgical pathway was compared between 2D and 3D/4D modalities with respect to the procedure undertaken.

RESULTS

Included in the study were 22 fetuses with DORV which had undergone both 2D and 3D/4D imaging as well as postnatal surgery. Accuracy of prenatal interpretation of all four anatomic variables was significantly higher using 3D/4D STIC than using 2D fetal echocardiography (19/22 (86.4%) vs 8/22 (36.4%), P < 0.001). Surgical procedures included single-stage repair in 14 (63.5%) patients and a multistage approach in eight (36.4%). Prenatal prediction of the surgical pathway was significantly more accurate on 3D/4D STIC than on 2D echocardiography (20/22 (90.9%) vs 12/22 (54.5%), P = 0.021). Prenatal predictive accuracy of single-stage biventricular repair was significantly better for 3D/4D STIC than for 2D echocardiography (14/14 (100%) vs 8/14 (57.1%), P = 0.04).

CONCLUSION

Addition of 3D/4D STIC to conventional 2D fetal echocardiography confers incremental benefit on the accuracy of identification of anatomic details crucial for surgical decision-making and the prediction of postnatal surgical approach in fetuses with DORV, thereby potentially aiding prenatal counseling. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal diagnosis of partial absence of the tricuspid valve with perimembranous ventricular septal defect-The utility of prenatal 4-dimensional spatiotemporal image correlation rendering

First described in 1965 by Johnson and Wilcox, partial absence of the tricuspid valve (TV) associated with a ventricular septal defect (VSD) is a very rare malformation (Ann Surg. 1966;164:334-336). Heart failure secondary to severe TV regurgitation results in utero fetal compromise (J Am Coll Cardiol. 1991;17:167). We present here a fetus with partial absence of the tricuspid valve with perimembranous VSD.

Repair of Taussig-Bing anomaly with unusual coronary pattern using autologous pericardial tube extension

The incidence of unusual coronary patterns including single coronary artery is high in Taussig-Bing anomaly (TBA). The relocation of a single coronary artery from a nonfacing sinus can be technically challenging with implications on early and late outcomes. Many innovative techniques for coronary transfer have been described and no coronary pattern precludes arterial switch operation in the current era. We describe a technique of coronary transfer using autologous pericardial tube extension with good early outcome.

Atrioventricular, ventriculoarterial discordance and Ebstein malformation of the tricuspid valve with severe regurgitation resulting in aortic atresia in a neonate

Aortic atresia is uncommonly associated with atrioventricular and ventriculoarterial discordance. Presence of severe regurgitation of Ebstein malformation of the tricuspid valve in this subset results in reduced aortic blood flow in-utero. We report here a term neonate with this anomaly detected antenatally.

Comparison of Fontan Surgical Options for Patients with Apicocaval Juxtaposition

Apicocaval juxtaposition (ACJ) is a rare form of viscerocardiac malpositions in association with single-ventricle congenital heart defects. The Fontan surgery is the common palliation, and possible surgical options include ipsilateral, contralateral, and intra-atrial conduits. Concerns include lower hemodynamic performances or risks of conduit compression by the cardiac mass. This study investigates the hemodynamics and clinical outcomes of ACJ patients and potential surgical improvements. Ten consecutive ACJ patients were included, along with a reference cohort of ten non-ACJ patients. Magnetic resonance images were acquired at 6 ± 0.6 year follow-up for anatomical analysis and hemodynamic assessments using computational fluid dynamics. Metrics of interest are deformation index (DI), indexed power loss (iPL), and hepatic flow distribution (HFDoff). A "virtual" surgery was performed to explore potential hemodynamic improvements using a straightened conduit. DI for ACJ patients fell within the DI range of non-ACJ patients. Contralateral conduits had insignificantly higher iPL (0.070 [0.032,0.137]) than ipsilateral conduits (0.041 [0.013,0.095]) and non-ACJ conduits (0.034 [0.011,0.061]). HFDoff was similar for the ipsilateral (21 [12,35]), contralateral (26 [7,41]), and non-ACJ Fontan conduits (17 [0,48]). Virtual surgery demonstrated that a straightened conduit reduced HFDoff and iPL for the contralateral and ipsilateral conduits, potentially leading to improved clinical outcomes. In this limited sample, the hemodynamic performance of ACJ patients was not significantly different from their non-ACJ counterparts. The use of a straightened conduit option could potentially improve patient outcomes. Additionally, the fear of significant compression of conduits for ACJ patients was unsupported.

Unrecognized double aortic arch in a preterm infant: Diagnostic challenges and perioperative management

Vascular rings are relatively rare, and are frequently overlooked as a potential cause of neonatal respiratory distress in non specialized centres. This might lead to delay in diagnosis during which the child is subjected to repeated respiratory insults. Procrastination in prompt diagnosis and management can lead to significant comorbidities or even death. We highlight the case report of a preterm infant with an unrecognized double aortic arch who presented with severe respiratory morbidity and the subsequent management.

In-stent restenosis: surgical and histopathological perspective

Background In-stent restenosis has been recognized as a distinct clinical entity that warrants a repeat procedure either in the form of percutaneous reintervention or coronary artery bypass grafting. Multivessel grafting with endarterectomy and explantation of the stent is rarely performed, with few cases reported in the literature. We aim to study the pathomorphology of the stent-vascular interface in coronary vessels undergoing in-stent restenosis. Methods Over a period of 3 years, 3 patients who had undergone angioplasty for diffuse coronary artery disease developed in-stent restenosis and were advised coronary artery bypass. The mean age was 53 years, the average time from the previous intervention was 77 months. Coronary endarterectomy with stent removal and concomitant multivessel coronary artery bypass was performed. Results Histology showed significant proliferation of the well-endothelialized intima as the reason for in-stent restenosis. There were no signs of local thrombus formation or increased inflammatory activity in any of the specimens. After coronary artery bypass, all patients were asymptomatic at a mean follow-up of 32 months. Conclusion Coronary endarterectomy with stent explantation and multivessel coronary artery bypass is a procedure that requires attention because the need is increasing due to the rise in the number of angioplasties. The complexity of this procedure increases to the extent that the adventitia is involved during stent explantation.

Use of Indigenous Decellularized Valved Xenograft Conduit for Double-Barrel Right Ventricular Outflow Tract Reconstruction: Nine-Year Follow-Up

Over the last two decades, numerous conduit options and implantation techniques have been described for right ventricular outflow tract (RVOT) reconstruction in the management of tetralogy of Fallot (TOF) with hypoplastic pulmonary annulus. The limited availability of homografts and the cost factor have led us to explore the use of decellularized xenografts as an alternative. Here we present a nine-year follow-up of an adult patient with TOF with hypoplastic pulmonary annulus, who underwent reconstruction of the RVOT by the double-barrel technique, using a decellularized porcine pulmonary artery xenograft valved conduit.