Long-term evaluation of the impact of bicuspid pulmonary valve on neoaortic valve regurgitation and aortic root dilatation (ARD) after arterial switch operation (ASO) for transposition of the great arteries (TGA).

Between January 1987 and March 2010, 980 neonates underwent ASO for TGA. A total of 40 patients (4.0%) had a pulmonary bicuspid valve with no significant left ventricular outflow tract obstruction. In this group, 11 patients (28%) had associated ventricular septal defect, three hypoplastic aortic arch, and three had a right ventricular hypoplasia. No pulmonary valvuloplasty was attempted. Mean follow-up was 7.7 ± 5.5 years. Echocardiography evaluations of neoaortic valve function and morphology and aortic root dimensions were performed.

There were two hospital deaths (5%) related to hypoplastic right ventricle and left ventricular dysfunction, and no late death yielding an actuarial survival to 95% SD at 1, 5, and 10 years. At last follow-up, five patients (12%) had mild-to-moderate aortic regurgitation (AR). None had aortic valve stenosis. ARD was noted in 28% of the patients (Z-score up to +3). One patient needed a Bentall procedure for significant AR and severe dilatation of the ascending aorta at 11 years of age. As many as four patients underwent reoperation (10%) for stenosis of the left coronary artery. Freedom from reoperation was 95% SD, 88% SD, and 75% SD at 1,5, and 10 years, respectively.

ASO is a safe option for TGA associated with a well-functioning bicuspid pulmonary valve with low morbidity and mortality. Prevalence of AR was not particularly high. Even though ARD was frequent, neoaortic bicuspid valve did not represent a high risk for aortic reoperation. Long-term individual follow-up is mandatory to observe the potential risk of root dilatation and AR.

In some centers, passive peritoneal drainage (PD) is implemented following surgery for congenital heart disease. The utility of this practice has yet to be studied. We hypothesized that passive PD can promote negative fluid balance without compromising intravascular volume.

A retrospective review of infants who underwent repair of complete atrioventricular septal defect (AVSD) between 6/2006 and 8/2010 was completed. Data are represented as mean ± standard deviation.

Thirty-six infants underwent AVSD repair, 18 of whom had PD catheters placed without complication. Infants with passive PD had longer duration of cardiopulmonary bypass (211 ± 59 vs 137 ± 41 min, P < 0.001) and aortic cross-clamp (148 ± 29 vs 102 ± 21 min, P < 0.001); had higher Aristotle complexity score (12.6 ± 3 vs 10.7 ± 2, P = 0.03) and ventilatory support immediately after surgery (ventilation index score 19.5 ± 6.5 vs 14.3 ± 2.5, P = 0.004); and received greater fluid administration (225 ± 6 3 vs 168 ± 45 ml kg^–1, P = 0.002) in the first 48 postoperative hours. Despite these differences, infants with passive PD achieved negative fluid balance more rapidly (12 ± 10 vs 27.3 ± 13 h, P < 0.0001) and to a greater extent (-73 + 55 vs +2.6 + 39 mL kg^-1 at 48 h, P = 0.002). Moreover, postoperative hemodynamics, urine output, creatinine clearance, blood urea nitrogen, peak lactate, and duration of mechanical ventilation were similar between groups.

Passive PD is safe and promotes negative fluid balance after repair of complete AVSD without adversely affecting intravascular volume.

Partial anomalous pulmonary venous connection (PAPVC) draining into the superior vena cava (SVC) has been repaired with various techniques. We investigated the outcome of the Warden procedure for repair of this anomaly.

From December 1994 to January 2011, 30 patients underwent a Warden procedure for repair of PAPVC to the SVC in our center. Their median age at the time of the operation was 4.9 years (range, 1 month to 55 years). Follow-up data were obtained through a review of medical records, correspondence with the patients' cardiologists, and direct telephone contact. The mean follow-up duration was 5.3 ± 5.1 years (range, 1 month to 16 years).

One patient died of an underlying cardiac condition and cerebral complication unrelated to the Warden procedure. One patient had transient postoperative sinus node dysfunction. During follow-up, pulmonary venous pathway obstruction occurred in one patient, and systemic venous pathway obstruction occurred in three patients. Re-operation or re-intervention for systemic venous pathway obstruction was required in younger (<2 years) and smaller (<7 kg) patients within 1 year after the Warden procedure. All patients were in regular sinus rhythm in the latest electrocardiogram.

The Warden procedure is a safe and effective surgical option for repair of PAPVC to the SVC in terms of preserving the sinus node function and non-obstructive pulmonary venous pathway. However, more attention must be paid to the reconstruction of non-obstructive systemic venous pathway, especially in younger and smaller children. Patch augmentation could be considered and effectively performed, if there is any doubt regarding tension-free anastomosis.

We introduced a new atrial septum remodeling technique and further investigated the feasibility of this method in facilitating the intra-operative device closure (IODC) of multiple atrial septal defects (ASDs).

Adult patients with multiple nearby ASDs, which were not eligible for transcatheter closure, were enrolled in this study. Transesophageal echocardiogram (TEE) was applied for intra-operative evaluation. The multiple ASDs were divided into three different types according to its morphology. Based on the concept of breaking the rim between multiple ASDs and making it feasible for single device closure, atrial septum remodeling procedure was carried out via pre-atrial approach using special clamp under the guidance of TEE. IODC was then attempted for reshaped ASD. Successful rate and perioperative complications were then noted.

Eleven patients were enrolled in this study, with mean age being 23.4 ± 5.3 years and mean weight 51.6 ± 8.0 kg. Among them, seven patients have double ASDs and four have triple ASDs. Mean diameter of isolated ASD was 10.4 ± 3.8 mm with a mean distance of 3.2 ± 1.2 mm between each other. Atrial septum remodeling procedure was successfully done in all patients. One device was then used for each patient. Mean ASD diameter after remodeling procedure was 20.6 ± 3.9 mm with mean device size 23.5 ± 4.0 mm. Complete closure of multiple ASDs was achieved in nine patients immediately after the procedure; two patients had trivial grade shunt after device deployment that resolved within the 3-month follow-up. No severe complications were noticed during the perioperative period and the 3-month follow-up.

Atrial septum remodeling technique seems to be a safe and effective method that could largely facilitate the successful IODC of multiple ASDs.

We examined whether the socio-economic circumstances of a developing country justify pulmonary artery banding (PAB) for the deferral of perceived high-risk patients requiring biventricular repair.

A retrospective cohort analysis was done on 143 consecutive patients with ventricular anatomy suitable for a biventricular repair, who had a pulmonary artery band applied between 1 January 2002 and 31 December 2007 as they were considered too high a risk to undergo corrective surgery. The goal in all patients was to lower their risk of definitive surgery by improving their clinical condition. The minimum follow-up period was 2 years with the closing date for data collection being 31 January 2010. The mean weight and age at PAB was 5.34 ± 2.94 kg and 9.9 ± 17.3 months. The endpointsof the study were mortality, interval hospital readmission, growth pattern post-banding, whether or not definitive correction was achieved, and the current follow-up status of uncorrected patients.

The hospital mortality was 8% (n = 12), the inter-stage mortality 21% (n = 30), and the total mortality 29% (n = 42). Positive growth was not shown in 50% following the banding procedure. The mean number of inter-current hospital admissions was 1.5 ± 2 times per patient. At the termination of data collection, after a mean interval of 24.5 ± 14.3 months, debanding and full correction was achieved in 43% (n = 62). In addition to the 29% (n = 42) that were confirmed to be dead, an additional 28% (n = 39) were not corrected and of these almost half were regarded as lost to follow-up. Thus, of the entire cohort of patients, 57% (n = 81) have not achieved definitive correction at the termination of data collection.

A strategy of deferring biventricular repair by the application of a pulmonary artery band is ineffective under Third World conditions largely due to lack of patient compliance. This study shows that the overall mortality in the inter-stage period following PAB is high prior to definitive correction. Less than half of patients will eventually be repaired in a reasonable time frame and patient follow-up is unreliable. We conclude that consideration should be given to early definitive repair even in perceived high-risk cases.

The present study tested the hypothesis that there is an intrinsic abnormality of aortic elasticity in infants/children with tetralogy of Fallot (TOF) before corrective surgery. The study also determined the independent and quantitative effects of aortic volume load on aortic dilation in this group of TOF patients.

Aortic stiffness (pulse wave velocity; PWV) and aortic volume load (aortic volume flow) were measured during catheterization in 37 infants and children with TOF before corrective surgery and in 55 control subjects.

PWV was significantly higher in TOF patients than in controls, irrespective of age, sex, hemodynamic burden on the aortic wall, and existence of aorto-pulmonary shunt. Aortic diameter was also significantly greater in TOF patients than in controls. Multivariate regression analysis identified aortic volume load as an independent determinant of aortic dilation (aortic diameter = 0.72 aortic flow + 26.1 body surface area + 2.79, r² = 0.58, p < 0.001). Increased aortic-wall stiffness correlated with the increase in aortic diameter in patients with dominant left-to-right shunt (without aortic volume load); aortic diameter = 0.007 PWV + 13.5 body surface area (BSA) + 6.3 (r² = 0.73, p < 0.05).

The present study highlighted the intrinsic abnormality of the mechanical property of the aortic wall as a feature of aortopathy in TOF. The study also indicated that aortic volume overload and, to a lesser extent, intrinsically high aortic stiffness correlated significantly with aortic dilation in TOF.

Despite the introduction of smaller cardiopulmonary bypass (CPB) circuits for paediatrics, it is frequently necessary to add irradiated red blood cell concentrate (IRBC) to maintain adequate haemoglobin levels and the oxygen carrying capacity. Irradiation of blood weakens the cell membranes and results in an increase of lactate and potassium concentration. In addition, prolonged shelf time of IRBC may enhance its lactate level. To avoid the adverse effects of increased lactate and potassium concentration during paediatric bypass, prewashing of homologous blood in a cell-saving device was implemented at our institution. A retrospective audit of clinical data was performed to assess the relevance of this method.

Preceding the introduction of the blood pre-washing, we investigated 14 units of IRBC for lactate, potassium levels and shelf time. Afterwards, we evaluated the CPB and laboratory data from 69 patients with body weight <10 kg and the lactate levels in the priming of the bypass circuit.

The shelf time of blood units was 7.6 ± 2.7 days (minimum 5, maximum 14 days) with lactate concentration of 12.6 ± 2 mmol/land potassium concentration of 16.2 ± 4.7 mmol/l. In the priming after pre-washing, the lactate concentration was significantly lower than the standard priming (2.5 ± 0.9 vs 4.5 ± 20 mmol/l, p = 0.002). At the start of bypass, the lactate concentration after pre-washing was still lower (1.5 ± 0.4 vs 1.9 ± 0.9 mmol/l; p = 0.04), but at the end of bypass we detected a significant increase of lactate in the pre-washed group (1.5 ± 0.4 vs 2.2 ± 1.1 mmol/l, p = 0.01). There was no significant difference between the groups at the end of bypass (1.8 ± 0.9 vs 2.2. ± 1.1 mmol/l, p = 0.17). Other clinical and patient data were not significantly different.

Our retrospective audit shows that pre-washing of IRBCs is not associated with decreased lactate levels at the end of CPB compared with standard use of IRBCs, suggesting that the added value of pre-washing of IRBCs on minimisation of lactate levels during CPB remains doubtful.