David Mishaly

Right ventricular outflow tract reconstruction: valved conduit of choice and clinical outcomes.

Background The valved conduit of choice in right ventricular outflow tract (RVOT) reconstruction provides a challenge for cardiac surgeons. The present study collected data regarding the clinical outcome of valved conduits for RVOT reconstruction, so as to explore various options of ideal conduits in clinical practice. Methods English language articles on valved conduits for RVOT reconstruction were retrieved from the MEDLINE database with respect to the commonly used homograft, stented xenograft and stentless xenograft, and the occasionally used autologous tissue valved conduit as well. Clinical outcomes of each conduit were outlined with respect to their early and late mortalities, conduit failure, conduit reoperation, reoperation-free interval, actuarial freedom from reoperation, and survival rates. Conduit-related complications, risk factors and pathological findings of the valved conduits were summarized. Results Conduit failure was defined as the need for reoperation for conduit stenosis or extrinsic compression, conduit regurgitation, or anastomotic dehiscence. The conduit failure rates at 2 years were 9–55%, 35% and 25% for homograft, stented xenograft and stentless xenograft conduits, respectively. The 5-year actuarial freedoms from reoperation were 87–98.2% for homograft, 37% for Hancock, 81–92% for Carpentier–Edwards, 78% for Contegra, and 82.95% for LabCor, respectively. The result for Hancock at 5 years appeared to be disappointing, although it did prove promising, and was 79.5% at 10 years and 65.8% at 15 years. Autologous pericardial valved conduits for RVOT reconstruction showed superb properties, and the autologous monocusp pulmonary artery conduit functioned well early postoperatively, but data for long-term follow-up are lacking. Conclusion Conduit failure and explant is inevitable. This phenomenon is worse with a longer follow-up. Mechanisms involved in conduit failure are unknown, even though they were accounted for by calcification and extensive intimal proliferation, and somatic outgrowth. Homografts are commonly used and have experienced a long history. The pulmonary homograft is the most commonly used RVOT conduit, especially in small children, due to its excellent characteristics. The newly-developed Contegra conduit has become popular due to its availability in full sizes and the acceptable results obtained at intermediate follow-up. The Hancock conduit can function sufficiently well for as long as 5–10 years, and early valve failure is relatively rare. It is admissible to use the Hancock conduit as an interim measure for future conduit reoperation due to its adequate function until subsequent operation. The application of an autologeous tissue valved conduit should be considered when other alternatives are not available.

Minimally Invasive Congenital Cardiac Surgery Through Right Anterior Minithoracotomy Approach

BACKGROUND Median sternotomy has been the conventional approach for correction of congenital cardiac defects despite poor cosmetic results at times. Right anterior minithoracotomy was, therefore, assessed as an alternative procedure with a better cosmetic outcome. METHODS From October 2002 through February 2007, 75 patients underwent correction of congenital cardiac malformations with the use of cardiopulmonary bypass through right anterior minithoracotomy involving a short incision through the fifth intercostal space and the minimally invasive cannulation. Of them, 18 patients were infants, 42 were children, and 15 were adult. The average age was 9.26 +/- 14.1 years (range, 1.2 to 56). The average weight was 19.59 +/- 24.3 kg (range, 8.5 to 118 kg). The corrected defects included atrial septal defect type II, sinus venosus atrial septal defect with partial anomalous pulmonary venous drainage, atrial component of atrioventricular septal defect, perimembranous ventricular septal defects with patent foramen ovale, mitral valve repair (complex), repair of cleft mitral valve, cor triatum atrial septal defect, repair of double-chambered right ventricle and extraction of atrial septal defect closure device. Skin incisions were as long as 5 cm. RESULTS There was no operative or late mortality or major morbidity. The mean cardiopulmonary bypass time was 58.67 +/- 35.11 minutes (range, 32 to 263). Sixty-five patients were extubated in the operating room; the remaining 10 patients were extubated within 4 hours. Cosmetic result was very satisfactory in all patients. Two adult patients complained of some right chest musculoskeletal discomfort. CONCLUSIONS The right anterior minithoracotomy incision is a safe and effective alternative to a median sternotomy for correction of congenital heart defects. Cosmetic results are highly satisfactory.

A randomized trial of outcomes of anesthetic management directed to very early extubation after cardiac surgery in children.

OBJECTIVES Intraoperative management directed to early extubation of children undergoing cardiac surgery has been suggested as a viable alternative to prolonged postoperative mechanical ventilation. The authors evaluated the safety and efficacy of this approach in a randomized prospective trial. DESIGN A prospective randomized observational study. SETTING A single university-affiliated hospital. PARTICIPANTS One hundred consecutive pediatric patients (age 1 month-15 years, weight 3.0-51 kg) requiring cardiac surgery. Patients younger than 1 month of age and those requiring mechanical ventilation before the operation were considered ineligible for the study. INTERVENTIONS Patients were randomly allocated to a group with anesthetic management and extubation in the operating room (early group [EG]) and a group with elective prolonged mechanical ventilation (control group [CG]). MEASUREMENTS AND MAIN RESULTS A difference in outcome as reflected by the pediatric intensive care unit (PICU) and hospital lengths of stay and postoperative morbidity and mortality was analyzed. A separate analysis was performed in children younger than 3 years old. The extubation time in the CG was 25.0 +/- 26.9 hours. No differences in mortality, the need for re-exploration for bleeding, the need for reintubation, the incidence of abnormal chest radiographic findings, or cardiac and septic complications between groups were found. PICU and postoperative hospital lengths of stay were significantly shorter in patients in the EG (3.3 +/- 1.9 days in the EG v 5.8 +/- 4.1 in the CG, p < 0.001, and 7.4 +/- 2.9 days in the EG v 11.2 +/- 6.8 days in the CG, p = 0.009). CONCLUSIONS In children undergoing cardiac surgery, anesthetic management with early cessation of mechanical ventilation appears to be safe and decreases hospital and PICU length of stay. However, because the size of the study did not allow for the detection of possible differences in perioperative mortality, only a large multicenter study may provide a definite answer to this question. The present study may be treated as a pilot for such a trial.

Left superior vena cava to the left atrium: do we have to change the traditional approach?

Left superior vena cava (LSVC) to the left atrium is a rare congenital cardiac complex, which may appear as an isolated anomaly, or as part of more complex cardiac anomalies. Traditionally, an intraatrial baffle was the preferred surgical technique. Although this technique has proved reliable and successful, acute ligation and extracardiac repair are simpler and easier solutions, requiring less myocardial ischemic time. We present 3 patients who underwent simple ligation and discuss the literature for other extracardiac options of surgical repair. Our patients had short transient congestion in the left upper part of their body that resolved completely after a few weeks, without further complications. We believe that either acute ligation or extracardiac repair is a much simpler yet effective solution to divert the left caval flow to the lesser circulation.

Spinal anesthesia for diagnostic cardiac catheterization in high-risk infants

Background : The main goals of diagnostic cardiac catheterization (DCC) in infants are to evaluate the anatomy and physiology of congenital and acquired cardiac defects while maintaining normal respiratory and hemodynamic variables. The aims of anesthesia for infants undergoing DCC are to prevent pain and movement during the procedure. General anesthesia (GA) or deep sedation could have undesirable respiratory and hemodynamic effects for conducting such studies. Furthermore, GA is associated with increased risks, especially in high‐risk infants. Spinal anesthesia (SA) is a successful alternative to GA in surgery on infants with a history of prematurity and respiratory problems, with minimal respiratory and hemodynamic changes.

Accessory Mitral Valve Tissue: A Case Report and an Updated Review of Literature

Abstract  Accessory mitral valve tissue is an unusual congenital cardiac anomaly and a rare cause responsible for left ventricular outflow tract obstruction. An 18‐year‐old patient was referred to this hospital due to an occasionally noted heart murmur in a medical examination. Echocardiography facilitated the diagnosis of accessory mitral valve tissue. To relieve the left ventricular outflow tract obstruction, an operation including resection of the accessory mitral valve tissue, implantation of artificial chordae tendineae, and mitral valve annuloplasty was performed successfully. Postoperative echocardiography showed a complete relief of the mitral valve leaflets and a wide patent left ventricular outflow tract. However, transient ischemic attack and Horners syndrome complicated the patient early postoperatively. He was administered with a high dose of aspirin, and he recovered shortly. Surgical removal is mandatory insomuch as a definite diagnosis of accessory mitral valve tissue with left ventricular outflow tract obstruction is established. A prophylactic treatment should be applied to the patients with accessory mitral valve tissue in virtue of their susceptibility to neurological events.

Combining low inspired oxygen and carbon dioxide during mechanical ventilation for the Norwood procedure

Background: Staged reconstruction has become the preferred approach for treating neonates with hypoplastic left heart syndrome (HLHS). The haemodynamic instability of a single ventricle providing blood flow in parallel to the systemic and the pulmonary circulation, combined with the effects of cardiopulmonary bypass (CPB), results in precarious perioperative conditions. The two ventilatory manoeuvres commonly used for increasing pulmonary vascular resistance are (i) decreasing the fraction of inspired oxygen to < 0.21 and (ii) adding carbon dioxide (CO2) to the ventilatory circuit. Whether molecular nitrogen (N2) or CO2 is used in these situations is a matter of physician and institutional preference. The effect of the two modalities in combination has not been studied in depth.

The role of flexible fibreoptic bronchoscopy in evaluation of pulmonary diseases in children with congenital cardiac disease.

BACKGROUND Diseases of the lungs and airways can be life-threatening in patients with congenital cardiac disease. External compression, and tracheobronchomalacia, as well as pathology of the large airways, can cause respiratory symptoms such as wheezing, stridor, fever, and dyspnoea, along with producing difficulty to wean the patient from mechanical ventilation. A definite diagnosis may be achieved by fibreoptic flexible bronchoscopy. AIMS To characterize the patients who underwent bronchoscopy for respiratory diseases associated with congenital cardiac disease, and to evaluate the safety, total diagnostic rate, and diagnostic rate, which yielded alteration of treatment in this group of patients. METHODS We reviewed retrospectively the records of 39 patients with congenital cardiac disease associated with abnormalities of the airways who underwent 49 fibreoptic bronchoscopies between 1999 and 2004. The patients were evaluated with regard to rate of diagnosis, the rate of procedures that resulted in alteration of management, and the rate of complications. RESULTS Fibreoptic flexible bronchoscopy was safe, and contributed to a specific diagnosis in almost nine-tenths of the procedures. A specific diagnosis that resulted in treatment alteration was achieved in one-fifth of the procedures. CONCLUSIONS Fibreoptic flexible bronchoscopy has an important role in the evaluation of pulmonary abnormalities in patients with congenital cardiac diseases, and should be considered as an initial diagnostic tool that may guide the clinician with regard to the proper therapy.

Mitral valve destruction by Hodgkin's lymphoma-associated Loefler endocarditis.

We present a case of nearly total posterior mitral leaflet destruction due to Loeffler endocarditis associated with Hodgkin’s lymphoma in a 15-year-old adolescent. The patient was treated medically with subsequent surgical mitral valve replacement. Cardiac aspects of hypereosinophilic syndrome are also discussed.

Prolonged prostaglandin E1 therapy in a neonate with pulmonary atresia and ventricular septal defect and the development of antral foveolar hyperplasia and hypertrophic pyloric stenosis

Abstract Prostaglandin E1 (alprostadil) is widely used for maintaining the patency of ductus arteriosus in ductus-dependent congenital heart defects in neonates to improve oxygenation. Among more common side effects are fever, rash, apnoea, diarrhoea, jitteriness, and flushing. More severe side effects are brown fat necrosis, cortical hyperostosis, and gastric outlet obstruction, most commonly the result of antral foveolar hyperplasia or hypertrophic pyloric stenosis. We report on an infant with a ductus-dependent congenital heart defect who developed symptoms and sonographic evidence of focal foveolar hyperplasia and hypertrophic pyloric stenosis after prolonged treatment with prostaglandin E1. Gastrointestinal symptoms persisted after corrective cardiac surgery, and pyloromyotomy was required. Study of the case and of available literature showed an association between the total dose of prostaglandin E1 administered and duration of treatment and the development of gastric outlet obstruction. We conclude that if patients are treated with a prostaglandin E1 infusion, careful monitoring for symptoms and signs of gastric outlet obstruction is required.