Nicola Viola

Primary sutureless repair for infants with mixed total anomalous pulmonary venous drainage.

BACKGROUND Mixed type total anomalous pulmonary venous drainage (TAPVD) poses technical challenges and high mortality owing to diminutive size and remote location of the pulmonary vein (PV) confluences. We hypothesized that primary application of sutureless repair may better incorporate small and remote confluences, thereby minimizing PV stenosis and improving outcomes. METHODS Twenty-two consecutive infants (1985 to 2009; median age 27 days; body weight 3.7 kg) with mixed type TAPVD were retrospectively reviewed. Survival and reintervention were compared between the sutureless group (n = 8) and the conventional group (n = 14). Predictors for death and reintervention were identified by an univariate analysis using a chi(2) test. RESULTS No differences were noted on preoperative and intraoperative variables between the groups. There were 5 early deaths in the conventional group and no deaths in the sutureless group (p = 0.05). There were trends toward improved survival (100% versus 57% at 1 year, p = 0.07) and freedom from reintervention (100% versus 67% at 1 year, p = 0.09) in the sutureless group. The univariate analysis showed that preoperative PV obstruction (p = 0.05), conventional repair (p = 0.05), palliative surgery (p = 0.001), and residual PV obstruction (p = 0.002) were the risk factors for death. Preoperative PV obstruction, palliative surgery, and residual PV obstruction were the predictors for reintervention (p < 0.05 for all). CONCLUSIONS The primary sutureless repair for the patients with mixed type TAPVD appeared to be safe and effective, resulting in no mortality and reintervention. There were nonsignificant trends toward improving survival and reintervention in the sutureless group. The patients who had sutureless repair and partially unrepaired PV revealed reasonable early and medium-term physiologic tolerance without need for reinterventions.

Use of extra corporeal membrane oxygenation in the management of sepsis secondary to an infected right ventricle-to-pulmonary artery Contegra conduit in an adult patient.

This is the first report in the cardiac surgical literature in a grown-up congenital heart male patient with endocarditis of the Contegra conduit who developed septic shock with cardio-respiratory failure and required treatment with extra corporeal membrane oxygenation (ECMO) in order to stabilize his clinical condition preoperatively.

Repair of Bland-White-Garland Syndrome via a Modified Technique

Surgically repairing Bland-White-Garland syndrome (anomalous origin of the left coronary artery from the pulmonary artery) is a challenge if there are variations in the origin of the anomalous artery. We report the successful repair of this congenital abnormality in a 19-year-old woman who presented with an acute anterior myocardial infarction. The anomalous artery originated from the anterior-facing sinus of the pulmonary artery, which precluded typical repair by direct reimplantation or fashioning an intrapulmonary tunnel. We created an extrapulmonary tunnel, using a strip of pulmonary artery anteriorly and an aortic flap posteriorly. Three years postoperatively, the anastomosis was patent and the patient was asymptomatic. Our modified technique might serve as an alternative method during similar surgical circumstances.

Intrapericardial teratoma in neonates: a surgical emergency

Primary cardiac tumors are very rare, with a reported incidence of 0.15% to 0.2% in autopsy series. They can be life threatening because of myocardial compression and ventricular dysfunction. Once diagnosed during pregnancy, the clinical condition of the baby is monitored because of the risk of rupture of the tumor capsule. The authors report a rare case of a neonate who presented with respiratory and cardiac compromise due to cardiac tamponade necessitating emergency exploration of the pericardium and excision of tumor. A well-encapsulated tumor measuring around 5 cm and bigger than the heart was completely excised. This was diagnosed to be an immature teratoma. Follow-up echocardiogram was normal, and on serial monitoring, alpha-fetoprotein was within normal limits. The baby was discharged home with no complications. Intrapericardial teratoma in neonates is a surgical emergency if presented with significant pericardial effusion. It can be a challenge if diagnosed in utero with rupture before the viability of pregnancy. A multidisciplinary team approach is necessary to manage such situations. Complete excision is necessary because of its association with tissues of malignant potential.

Surgical intervention for retrograde type A aortic dissection caused by endovascular stent insertion for type B aortic dissection

Retrograde type A aortic dissection after endovascular stent grafting (ESG) for type B aortic dissection is not commonly reported. We report such a complication in a patient 4 weeks after ESG for type B aortic dissection. With the expanding indications for aortic ESGs, knowledge of such a complication and its management is vital because surgeons will face this surgical dilemma more than before.

Postinfarction Inferior Ventricular Septal Rupture: Surgical Repair Through the Right Atrium

Abstract  Operative mortality of inferior postinfarct ventricular septal rupture (VSR) remains high. Previous reports have described a transatrial approach to access the VSR avoiding a ventriculotomy, thereby reducing the potential risks of myocardial damage, hemorrhage, and ventricular arrhythmias. The transatrial right ventricular patch or direct suture repair, however, is exposed to the left‐to‐right pressure gradient and is at risk of residual shunting. In this report, a transatrial approach is used, with direct suture of the VSR, patch exclusion of the right ventricle, and biological glue instillation to protect the patch from left ventricular pressures.

Primary surgical repair of tetralogy of Fallot at under three months of age

Background Classical management of small infants with tetralogy of Fallot has involved placement of a Blalock-Taussig shunt followed later by complete repair, rather than primary complete repair which is the strategy adopted in larger infants. Some advantages of early complete repair compared to a staged strategy have been shown. We sought to review our institutional outcomes. Methods Patients under 3-months old undergoing complete surgical repair of tetralogy of Fallot in our institution between 2005 and 2015 were retrospectively reviewed and compared with an older control group matched by anatomical diagnosis and outflow tract intervention. Results Fourteen index cases (group A) and 14 controls (group B) were identified. At surgery, the median age was 43 days and weight 4.2 kg in group A, and 130 days and 6.1 kg in group B. Nine of 14 in group A were admitted for surgery as emergencies compared to none in group B. Peak inotrope score (22.3 vs. 12.8, p = 0.02) and intensive care unit stay (4.4 vs. 2.6 days, p = 0.02) were higher in group A. Bypass and crossclamp times, duration of intubation, and total length of stay did not differ. Conclusions We conclude that although babies undergoing early repair of tetralogy of Fallot have an increased need for intensive care support in the early postoperative period, the total length of stay is not prolonged despite more emergency admissions. As it is known that early repair may reduce long-term morbidity, we propose consideration of earlier complete repair of tetralogy of Fallot.