E.D. McKenzie

Repeat Sternotomy in Congenital Heart Surgery: No Longer a Risk Factor

BACKGROUND The risk of repeat sternotomy (RS) is often taken into account when making clinical management decisions. Current literature on RS suggests a risk of approximately 5% to 10% for major morbidity. We sought to establish the true risk of RS in a contemporary pediatric series. METHODS All RS between October 2002 and August 2006 were analyzed (602 RS in 558 patients). Median age was 3.6 years (range, 0.1 to 45.1); weight, 14.2 kg (2.0 to 112.2). Operations performed at RS were Glenn 22% (131), Fontan 21% (129), aortic valve repair/replacement 12% (72), right ventricle-pulmonary artery conduit 11% (67), Rastelli 7% (39), heart transplant 5% (31), and other 22% (133). Forty-seven percent of patients (280) had single-ventricle physiology. Incidence of second sternotomy was 67% (406), third 28% (166), fourth 4% (24), fifth 0.8% (5), and sixth 0.2% (1). A major injury upon RS was defined as one causing hemodynamic instability requiring vasopressor support or emergent transfusion; femoral cannulation or emergent cardiopulmonary bypass; and any morbidity. A minor injury is any other injury during RS. RESULTS The incidence of a major injury was not different between RS (0.3%; 2 of 602) and first-time sternotomy (0%; 0 of 1,274; p > 0.1). Incidence of a minor injury was 0.66% (4 of 602). No injury resulted in hemodynamic instability, neurologic injury, or death. Two patients (0.3%) required a nonemergent blood transfusion secondary to injury. (Nonemergent was defined as adminstration rate of less than 0.2 cc/kg/min and less than 10 cc/kg in total.) Femoral cannulation was performed in 4 of 602 RS cases (< 0.6%). Sternal wound infection was 0.5% (3 of 602); reoperation for postoperative bleeding was 1% (8 of 602). Median intensive care unit stay was 3 days (1 to 174); median hospital stay was 7 days (1 to 202). Hospital survival was 98%. CONCLUSIONS Repeat sternotomy can represent a negligible risk of injury and of subsequent morbidity or mortality. Therefore, the choice of management strategies for patients should not be affected by the need for RS.

Clostridium difficile colitis in children following lung transplantation

Rosen JB, Schecter MG, Heinle JS, McKenzie ED, Morales DL, Dishop MK, Danziger‐Isakov L, Mallory GB, Elidemir O. Clostridium difficile colitis in children following lung transplantation.
Pediatr Transplantation 2010: 14:651–656.

Bronchial artery revascularization and en bloc lung transplant in children

BACKGROUND Long-term success in pediatric lung transplantation is limited by infection and bronchiolitis obliterans syndrome (BOS). The bilateral sequential lung transplantation (BSLT) technique may result in airway ischemia leading to bronchial stenosis, dehiscence, or loss of small airways. En bloc lung transplant (EBLT) with bronchial artery revascularization (BAR) minimizes airway ischemia, thus promoting superior airway healing. BAR also allows for safe tracheal anastomosis, circumventing the need for bilateral bronchial anastomoses in small children. METHODS This was a retrospective review of bilateral transplantations from 2005 to 2014. Both techniques were used in parallel. Redo and multiorgan transplants were excluded. RESULTS There were 119 recipients comprising 88 BSLTs and 31 EBLTs. Follow-up time was 3 years (interquartile range, 1-5 years). Donor ischemic and cardiopulmonary bypass times were not different between techniques (p = 0.48 and p = 0.18, respectively). Degree of graft dysfunction and cellular rejection scores were not different (p = 0.83 and p = 0.93, respectively). There were 3 hospital deaths after BSLT and 2 after EBLT (p = 0.60). Overall survival was 61% for the BSLT group and 77% for the EBLT group (p = 0.54). Freedom from BOS was 71% in the BSLT group and 94% in the EBLT group (p = 0.08). On routine bronchoscopy, 57% BSLT and 16% EBLT patients had 1 or more airway ischemic findings (p < 0.0001). Multivariate analysis showed BSLT was associated with higher ischemic injury (relative risk, 2.86; 95 confidence interval, 1.3-6.5; p = 0.01) and non-airway complications (relative risk, 4.62; 95% confidence interval, 1.1-20.2; p = 0.04) but not airway reinterventions (p = 0.07). Airway dehiscence occurred in 3 BSLT patients. CONCLUSIONS Pediatric EBLT with BAR can be safely performed without increasing operative or graft ischemic times. Airway ischemia and non-airway complications were significantly reduced when BAR was combined with tracheal anastomosis, potentially diminishing morbidity caused by anastomotic healing complications.

Persistence of bilateral arterial ducts in pulmonary atresia despite confluent branch pulmonary arteries: Opportunity for two percutaneous therapeautic alternatives

We present a case of a newborn infant with double inlet left ventricle, pulmonary atresia, confluent pulmonary arteries, and bilateral arterial ducts (AD), to discuss the therapeutic alternatives offered by interventional catheterization techniques in this anatomic arrangement. The infant initially underwent stenting of the right AD to stabilize pulmonary blood flow off of prostaglandin infusion. Three weeks later, she developed left pulmonary artery isolation upon closure of the left arterial duct. An additional stent was placed in the pulmonary artery confluence, restoring blood flow to the left lung and significantly improving her oxygen saturations. At 6 months of age she underwent her first surgical procedure, a successful bidirectional cavopulmonary anastomosis with removal of the left pulmonary artery stent and patch enlargement of the pulmonary artery confluence. She continues to do well in clinical follow‐up at 16 months of age.

Lung transplantation in a patient with a thrombophilic disorder.

Abstract:  The prothrombin G20210A mutation has been associated with an increased risk of graft failure in renal transplant recipients. Little is known about the potential effect of this mutation on lung transplant recipients. We report the case of bilateral lung transplantation in a patient with cystic fibrosis who was heterozygous for the G20210A mutation of the prothrombin gene.

IS A PULSATILE GLENN AN ADEQUATE ALTERNATIVE FOR LONG-TERM PALLIATION IN PATIENTS WITH SINGLE VENTRICLE PHYSIOLOGY?

Background: There are limited studies analyzing pulsatile Glenns (PG) as a palliation strategy for complex single ventricle (SV) patients. This study sought to determine their outcomes at a single institution. Methods: All SV pts who underwent PG from 1995-2016 were included. Failure was defined as

Improved right ventricular outflow tract function in patients with Tetralogy of Fallot after infundibular sparing compared to transventricular repair

Background The right ventricular infundibular sparing approach (RVIS) to repair tetralogy of Fallot (TOF) avoids a ventricular incision used in the transventricular (TV) approach. Recent data has demonstrated better global right ventricular systolic function in patients who underwent RVIS compared to those who had a TV repair, however the impact of surgical strategy on RV infundibular size and function is not specifically known. We hypothesized that patients repaired with the RVIS approach have improved RV outflow tract ejection fraction (RVOTEF) and have lower RV outflow tract volumes as assessed by cardiac magnetic resonance (CMR) compared with those repaired with the TV approach.

Type B Interrupted Left Aortic Arch with Isolated Right Subclavian Artery

Interrupted aortic arch is a rare congenital heart malformation occurring in approximately three per 1 million births. Type B interrupted aortic arch (interruption between the second carotid artery and the ipsilateral subclavian artery) is the most common of three major types (A, B, and C). We report an extremely rare finding: a case of left-sided type B interrupted aortic arch with isolation of the right subclavian artery (origin from the right pulmonary artery).