Ghassan M. Baslaim

Late Presenters with Dextro-transposition of Great Arteries and Intact Ventricular Septum: To Train or Not to Train the Left Ventricle for Arterial Switch Operation?

OBJECTIVE We report our experience in managing late presenters (older than 4 weeks) with dextro-transposition of great arteries and intact ventricular septum (d-TGA/IVS) in an effort to achieve successful arterial switch operation (ASO) in a third world setting. DESIGN We retrospectively reviewed the charts of all late presenters with d-TGA/IVS. Patients were divided into two groups: left ventricular training (LVT) group and non-left ventricular training (non-LVT) group. LVT group underwent pulmonary artery banding and Blalock-Taussig Shunt prior to ASO. RESULTS Twenty-one late presenters were included in the study. In LVT group, 11 patients with median age of 6 months (range, 1-72 months) underwent LVT. Later, 8 patients with median age of 9.25 months (range, 1.33-84 months) underwent ASO. Prior to ASO, left ventricle (LV) collapse resolved in all and left ventricle to systemic pressure (LV/SP) ratio was 0.81 (range, 0.76-0.95) in 4 patients. Two patients who had LVT for < or =14 days required postoperative extracorporeal membrane oxygenation (ECMO) support due to LV dysfunction. Seven patients survived to discharge. In non-LVT group, 10 patients with median age of 2.5 months (range, 1-98 months) underwent ASO. Five patients had LV collapse, and median LV/SP ratio was 0.67 (range, 0.56-1.19) in 5 patients. Seven patients needed ECMO support. Seven patients survived to discharge. CONCLUSION Late presenters with d-TGA/IVS, who have LV collapse on echocardiography and/or a LV/SP ratio <0.67 on cardiac catheterization, should be subjected to LVT preferably for duration of longer than 14 days in order to avoid potential ECMO use.

Venovenous malformation: a common finding after Kawashima operation

OBJECTIVES It has been reported that systemic venovenous malformation (VVM) can develop in patients with interrupted inferior vena cava (IVC) and univentricular type of congenital heart disease who undergo superior vena cava to pulmonary artery connection (Kawashima operation). These malformations can lead to profound systemic desaturation postoperatively. However, there have been few reports that characterise the prevalence, anatomic details and clinical correlations of these systemic VVM arising after Kawashima operation. In this study, we describe our experience with VVM after Kawashima operation, and discuss issues regarding their evaluation and postoperative management. METHODS Eight patients with median age 19 months (range: 5-238) who underwent Kawashima operation were subjected to postoperative angiography, prospectively. Sites of VVM origin and entry, as well as their course, were documented. The presence of pulmonary arteriovenous malformations (AVMs) was also documented. RESULTS At median follow-up of 31 months (range: 16-72 months), a total of 14 VVM were found in different supra- and infra-diaphragmatic sites in six patients (75%); four of them had concomitant pulmonary AVM while the remaining two patients had only pulmonary AVM. CONCLUSIONS Our findings suggest that systemic VVM can occur frequently after Kawashima operation and can produce significant desaturation postoperatively, and hence we support hepatic incorporation. Performing detailed angiographic studies of the supra- and infra-diaphragmatic systemic veins in routine assessment of patients before Kawashima operation is, probably, warranted.

Anesthesia for deep hypothermic circulatory arrest in adults: Experience with the first 50 patients

OBJECTIVE To evaluate the efficacy of a simple method of central nervous system (CNS) protection in patients undergoing deep hypothermic circulatory arrest (DHCA) lasting less than 30 minutes, for a variety of complex cardiovascular procedures. DESIGN A retrospective case review. SETTING A university teaching hospital. PARTICIPANTS Fifty consecutive patients (25 women, 25 men) undergoing elective or emergency cardiovascular operations requiring DHCA between August 1991 and December 1996. INTERVENTIONS Patients underwent DHCA for a variety of surgical procedures. Neurologic protection was with thiopental, ice packs to the head, and systemic core hypothermia to a nasopharyngeal temperature (NPT) of 18 degrees to 20 degrees C. MEASUREMENTS AND MAIN RESULTS The mean duration of circulatory arrest was 18 +/- 10 minutes (range, 5 to 42 minutes). The mean NPT at time of arrest was 18.7 degrees +/- 1.7 degrees C. Three patients (6%) had gross CNS morbidity, one of whom died. The circulatory arrest times for these three patients were 8, 39, and 40 minutes. Perioperative mortality was 8% (n = 4). The circulatory arrest times for the patients who died were 12, 13, 23, and 39 minutes. CONCLUSION The anesthetic management of DHCA described is simple, effective, and safe, and can be performed in any institution that performs cardiac surgery.

Assessment of Right Ventricular Function Postretrograde Cardioplegia by Transesophageal Echocardiography

Abstract The impact of continuous retrograde cardioplegia (RCP) on right ventricular (RV) function was evaluated prospectively with intraoperative transesophageal echocardiography (TEE) in 36 patients (23 males, 13 females) with a mean age of 60.4 years (ages 24–82). Operative procedures included 12 aortic valve replacements, 16 mitral valve repair/replacements, both with or without an associated cardiac operation, and 8 Ross procedures. Mean cardiopulmonary bypass (CPB) time was 123.3 minutes (66–280 minutes) with an average cross‐clamp time of 88.9 minutes (43–199 minutes). The amount of cold blood RCP ranged from 3160–18.500 mL (mean = 7382.51, and the average pulmonary artery pressure was 35/18 mmHg. The coronary sinus was distally snared in 11 patients. TEE documented biventricular global dysfunction in two patients and post‐CPB with preservation of the left ventricular function in all other patients. Localized akinesis of the RV apex and outflow tract were noted in three patients, and isolated worsening tricuspid insufficiency of moderate to severe intensity in six patients. Two of the six patients with worsening tricuspid insufficiency belonged to the snared coronary sinus group (11 patients). All of the documented RV dysfunctions were new and showed no correlation with the perfusion data. In conclusion: (1) RV apex, RV outflow tract and tricuspid valve were particularly subject to important dysfunction post‐RCP; (2) RCP did not protect RV adequately in 11 patients (31%); and (3) TEE is a convenient intraoperative technique in evaluating RV dysfunction. (J Card Surg 1998;13:32–36)

Repair of complete atrioventricular septal defects: results with maintenance of the coronary sinus on the right atrial side.

Abstract  Background: This study was undertaken to determine that maintaining coronary sinus on the right atrial side during the surgical repair of complete atrioventricular septal defect (AVSD) does not increase the risk of postoperative complete heart block. Methods: This is a retrospective study of 51 consecutive patients who underwent biventricular repair of complete AVSD from September 2000 to January 2005. Electrocardiograms and operative data were analyzed. Results: The mean age was 13.3 months (4 to 60). In all the 51 patients, except 13 cases, repair was performed using the two‐patch technique. All atrial septal defects were closed using the patch technique with the coronary sinus maintained on the right atrial side in 48 (94%) cases. The cleft in the neomitral valve was closed in all patients. Associated lesions were repaired in four patients (7.8%); coarctation of aorta in two patients; multiple ventricular septal defects (VSD) with coronary sinus type‐total anomalous pulmonary venous drainage and right‐sided diaphragmatic eventration in one patient; and tetralogy of Fallot in one patient. There were five deaths (9.8%) in a series. The mean hospital stay was 11.8 days. During the same hospitalization, reintervention was required in two cases: one for residual VSD and the other for a severely dysplastic regurgitant mitral valve. Mean follow‐up was 11.3 months. One patient required reoperation for residual VSD, residual atrial septal defect, and moderate mitral regurgitation 5 months after the initial repair. Except for first‐degree heart block documented in nine cases and right bundle branch block in two cases, all patients remained in sinus rhythm on follow‐up electrocardiography as preoperatively documented. No patient required prolonged cardiac pacing in the postoperative period. Conclusion: We believe that maintenance of the coronary sinus on the right side can be safely accomplished in the majority of complete AVSD repair as long as careful attention is paid to the anatomy of the conduction system. This technique did not increase the risk of postoperative heart block and permanent pacemaker insertion was not required.

Extracorporeal Membrane Oxygenation Support Post-arterial Switch Procedure for a Child with Cystic Fibrosis: Case Report

Abstract  This is a case report of an unusual presentation of transposition of the great arteries with a unique coronary artery pattern associated with cystic fibrosis in an infant whose management required the use of the extracorporeal life support after his arterial switch operation to ameliorate his postoperative pulmonary dysfunction.

Resternotomy for a Retrosternal Cardiac Pseudoaneurysm in a 1.5-Year- Old Child: A Case Report

Abstract  Cardiac pseudoaneurysm is a contained rupture of the myocardium that can occur after cardiac surgery, chest trauma, and endocarditis. The wall of the pseudoaneurysm consists of fibrous tissue and lacks the structural elements found in a normal cardiac wall, and it is contained by the pericardial adhesions or the epicardial wall. Early surgery is recommended even for asymptomatic patients due to the propensity for rupture and fatal outcome. We report our experience with the surgical approach of a child with a cardiac pseudoaneurysm who had undergone a biventricular repair of a double outlet right ventricle with non‐committed ventricular septal defect in the form of intraventricular tunneling.

REMOVED: Newly developed right ventricular outflow tract obstruction after arterial switch operation in a late presenter.

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