Peter Murín

Stentless full root bioprosthesis in surgery for complex aortic valve-ascending aortic disease: a single center experience of over 300 patients

OBJECTIVE The technically demanding full root aortic valve replacement necessitating coronary ostia reimplantation apparently leads to hesitation by some surgeons despite the superior hemodynamics and excellent long-term clinical performances of the stentless xenografts. Clinical data of stentless full root replacements was retrospectively analyzed in this perspective for validation. METHODS From November 1999 to March 2007, 317 adult patients (male: 196, female, 121) underwent modified Bio-Bentall procedure using the Medtronic Freestyle xenograft as a full root replacement. Two hundred and three patients received an isolated root replacement or a root and ascending aortic replacement (ARR). In 114 patients a variety of concomitant procedures including coronary artery bypass grafting (n=32), mitral valve repair (n=11) and aortic arch replacement (n=36) were performed. (ARR+). RESULTS Mean patient age was 70.3+/-10.2 years (range 17-94 years), 97 patients were 75 and older at time of procedure. Mean operative time for the ARR was 190+/-57 min with a clamp time of 88+/-27 min. Mean operative time for ARR+ group was 282+/-93 min with an average clamp time of 110+/-32 min. Overall operative mortality was 7.9% (25/317), for ARR it was 5.4% (11/203). Mean ICU stay was 4.9+/-8.1 days, mean hospital stay being 9.8+/-8.1 days. Necessity for bailout bypass surgery among patients with ARR was low at 1.5% (3/203) comparable to stented xenograft implantations. Echocardiography demonstrated excellent clinical results with low transvalvular gradients especially when a single suture inflow anastomosis technique was used. CONCLUSIONS Full root stentless valve implantation preserving porcine root integrity is a valuable option in aortic valve/ascending aorta surgery. Though technically a more challenging operation, it does not lead to increased perioperative morbidity and mortality and can be beneficial mainly for elderly patients with small aortic roots with or without aortic root pathology.

Functional outcome of anatomic correction of corrected transposition of the great arteries

OBJECTIVE Anatomic correction of corrected transposition of the great arteries, utilizing the morphologic left ventricle as a systemic pumping chamber, is considered the preferred method. The purpose of the study was to analyze the intermediate functional outcome following anatomical correction. METHODS Between 1997 and 6/2010, 23 patients with corrected transposition of the great arteries and associated lesions underwent anatomical correction. Seventeen (74%) and six patients (26%) had situs solitus {S,L,L} and situs invs {I,D,D}, respectively. Fifteen patients (65%) had undergone 18 palliations before the corrective operation. The median age at palliation was 0.23 years, with a range of 0.016-8.4 years. A corrective, modified Senning-arterial switch procedure was performed in nine patients, 13 patients underwent a modified Senning-Rastelli procedure, and in one patient a combination of modified Senning and aortic translocation (Bex/Nikaidoh) was used. The median age at the corrective operation was 2 years (from 0.3 to 15.7 years). RESULTS There was no mortality or heart transplant within the mean follow-up of 3.4 years. Freedom from reintervention was 77% at 5 years. There were no signs of obstruction of the systemic and pulmonary venous tunnels. The function of both ventricles was normal in all patients, even in the four patients who required retraining of the left ventricle. Mild aortic regurgitation was noticed in three patients. Preoperatively detected significant tricuspid regurgitation either disappeared or became trivial after the operation in all the six patients. All patients except two are in sinus rhythm; one patient is pacemaker-dependent preoperatively and one is pacemaker-dependent postoperatively. There were no clinically apparent neurological problems. All patients, but one, are in the New York Heart Association (NYHA) class I. CONCLUSIONS Anatomic correction of corrected transposition of the great arteries can be performed in selected patients without mortality and with acceptable morbidity. The mid-term functional outcome is excellent, resulting in normal ventricular function, even in retrained left ventricles, and minimal incidence of complete heart block. The long-term function of the aortic valve, intraventricular tunnels, conduits, and ventricles requires close surveillance.

Poor outcome for patients with totally anomalous pulmonary venous connection and functionally single ventricle

Totally anomalous pulmonary venous connection, when also associated with a functionally univentricular connection, is known to have a poor outcome. We retrospectively analysed results for 19 patients undergoing surgery for this combination of lesions between 1995 and February 2009.Of the patients, 12 were neonates, with 11 presenting with signs of pulmonary venous obstruction. In 3 patients, a modified Blalock-Taussig shunt had been constructed. The dominant ventricle was of right ventricular morphology in 17 of the 19 patients, and double inlet was present in all bar 1. Pulmonary atresia or stenosis was found in 14 patients, a common atrioventricular junction in 14 patients, and isomerism of the right atrial appendages in 12 patients, respectively. Comprehensive Aristotle scores ranged from 14 to 23.50. The mean was 16.55, with a standard deviation of 2.19. Pulmonary venous rerouting was combined in 6 patients with construction of a modified Blalock-Taussig, in 4 with banding of the pulmonary trunk, in another 4 with a bidirectional Glenn anastomosis, in 3 with creation of a total cavo-pulmonary connection, and in 1 each with enlargement of the right ventricular outflow tract and the Norwood procedure. Of the cohort, 8 patients died early due to pulmonary hypertension, with all patients having Aristotle scores of at least 18 points dying. Among the 11 early survivors, 5 needed mechanical ventilation for over a week, but 5 patients died later, 3 due to pulmonary hypertension and 2 due to infection. Actuarial survival stabilized at 31.6%, with standard error of 10.7%, from one year onwards. Conversion to the Fontan circulation was successful in 5 patients.Our experience confirms that totally anomalous pulmonary venous connection, when associated with the functionally univentricular arrangement, carries one of the worst outcomes in current surgical practice. Use of the Aristotle comprehensive complexity scores effectively discriminates those patients with this condition at particularly high risk.

Pulmonary artery sling with tracheal stenosis

Pulmonary artery sling (PAS) is a rare congenital heart disease in which the left pulmonary artery (LPA) originates from the right pulmonary artery (RPA) and encircles the distal trachea and right mainstem bronchus as it courses between the trachea and esophagus. Typically, patients with PAS have some respiratory symptoms, either due to external tracheal compression that can be corrected by relief of the sling mechanism, or due to severe diffuse tracheal stenosis with complete rings (ring-sling complex). The diagnosis of PAS is optimally made by echocardiography, while bronchoscopy is the key to the assessment of tracheal stenosis. Diagnosis is indication for surgery. Repair using a strategy of median sternotomy, cardiopulmonary bypass, division of the LPA and reimplantation into the main pulmonary artery (MPA), and simultaneous tracheal repair takes preference. Tracheal repair should be considered only in clinically symptomatic patients. The techniques of free tracheal autograft plasty or slide tracheoplasty offer promising results, and the choice of tracheal reconstruction should be guided by the clinical experience of the surgeon. Coexisting intracardiac pathologies are repaired at the same time. Postoperative care requires close multidisciplinary effort to achieve the best long-term result.

Cone Reconstruction of Ebstein's Anomaly in a Neonate

Neonatal repair of Ebsteins anomaly is challenging and should be considered only if medical measures to stabilize the circulation and provide antegrade pulmonary blood flow fail. Anatomic repair, based on the cone reconstruction technique, has demonstrated promising survival benefits in older patients; however, there are no data regarding neonatal repair. This is a report on a successful salvage operation using cone reconstruction of Ebsteins anomaly in a neonate who had required extracorporeal membrane oxygenation support before surgery and who had failed to wean.

Aortopulmonary window associated with interrupted aortic arch: report of surgical repair of eight cases and review of literature.

BACKGROUND Patients with combined aortopulmonary window (APW) and interrupted aortic arch (IAA) malformations are rarely seen. We reviewed cases with such association with emphasis on surgical management and long-term outcome. METHODS 109 patients with IAA and 25 patients with APW were operated upon between 1981 and 2011. The clinical records, operation and follow-up data were analyzed. Long-term outcome was completed with the help of either outpatient data or inquiring. Related literature was investigated. RESULTS Combined APW/IAA was found in 8 cases: 7.3% (8/109) of those with IAA diagnosis and 32% (8/25) with APW. All APWs were proximal. 7 patients had interruption type A. A ventricular septal defect (VSD) was associated in one case only. Median age at surgery was 10 days. The two first patients were operated upon without cardio-pulmonary bypass (CPB) and one died during operation. The other six underwent single stage approach under CPB with no death: overall early mortality of 12.5% (⅛). APW was closed with one or two patches; aortic arch was reconstructed either directly (extended end-to-side anastomosis) or by patch augmentation. There was no late death and no reoperation during mean follow-up of 118 months (range 1-360 months). Six patients were in functional NYHA class I, the remainder in class II. The cumulative APW/IAA incidence from literature varies between 4.9% (56/1105) and 22.2% (42/189). Early mortality reaches 15.1% (8/53) (95% CI: 6.8% - 27.6%). CONCLUSION Neonatal repair with thorough mobilization of the aortic arch and extended end-to-side anastomosis or use of patch augmentation carries potential for the best early and late outcome for combined APW/IAA malformation.

The modified Senning procedure as an integral part of an anatomical correction of congenitally corrected transposition of the great arteries.

In the current era of anatomical correction of complete transposition of the great arteries, the Senning operation is reserved only for the atrial switch part of anatomical corrections of congenitally corrected transposition of the great arteries. These rare operations are performed in only a few centers all over the world; the majority of practicing cardiac surgeons therefore have limited experience with the Senning operation. The proposed modified Senning procedure might simplify the original concept. Once the technical aspect of the procedure is accomplished, the risk of systemic and pulmonary baffle obstructions is minimal, even in situs solitus with dextrocardia or situs inversus with levocardia. Furthermore, this technique has the potential to provide adequate capacity of the pulmonary venous atrium, to preserve optimal geometry of the mitral valve, to minimize damage of sinus node and to make the coronary sinus accessible for electrophysiological studies or intervention by keeping the coronary sinus in the systemic venous baffle. The modified technique is simple, highly reproducible and applicable, regardless of the situs and position of the apex of the heart.

Ross-Konno operation in children

The Ross-Konno procedure is an excellent technique for the treatment of complex multilevel left ventricular outflow tract obstruction with severe annular hypoplasia and a dysplastic aortic valve. The operation can be performed earlier in life, thus avoiding repeated surgical reinterventions, which may provide only short-term palliation and potentially exacerbate ventricular function. The Ross-Konno procedure increases our therapeutic choices for neonates or infants with critical aortic stenosis, who show unacceptable results following open valvotomy or balloon valvotomy. The pulmonary autograft demonstrates durability without the likelihood of developing aortic stenosis or progressive dilatation and a low incidence of developing aortic insufficiency. Despite the technically demanding nature of the operation, the Ross-Konno procedure is the method of choice for the multilevel type of left ventricle outflow tract obstruction, especially in newborns and infants.

Surgery for tetralogy of Fallot – absent pulmonary valve syndrome. Technique of anterior translocation of the pulmonary artery

Patients with absent pulmonary valve syndrome (APVS) and tetralogy of Fallot represent a particular managements challenge. The distinctive feature of APVS is the airway obstruction caused by tracheobronchial compression that results from massive dilatation of the main pulmonary artery (PA) and its first- and second-order branches. Consequential tracheomalacia and bronchomalacia determine the timing and severity of respiratory compromise, as well as the morbidity and mortality of these patients. Although several techniques have been proposed for decompression of the airways, the method of choice is still controversial. Translocation of the PA anterior to the aorta and away from the airways has the potential to reduce or eliminate bronchial compression. Overall, the intermediate-term functional outcomes using this technique have been encouraging, with zero mortality even in the youngest age group of patients and the disappearance of respiratory symptoms in the majority of them. Nevertheless, failure of the treatment could be expected in symptomatic patients in whom the pathology of the airways extends beyond the proximal PAs.

Anatomic Correction of Corrected Transposition of the Great Arteries with Ventricular Septal Defect and Obstruction of the Left Ventricular Outflow Tract

The long-term outcome of patients with corrected transposition of the great arteries and associated lesions after physiologic repair is uncertain. Anatomic correction, utilizing the morphologic left ventricle as a systemic pumping chamber and the mitral valve as the systemic atrio-ventricular valve, is considered the preferred method, especially for patients with either tricuspid valve regurgitation, with Ebstein’s malformation of the tricuspid valve, or with right ventricle dysfunction. Anatomic correction of corrected transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction represents a group of procedures in which the atrio-ventricular discordance is ‘corrected’ by an atrial switch, and ventriculo-arterial discordance is ‘corrected’ by the Rastelli procedure, by translocation of the aortic root, or by an arterial switch operation, depending on the underlying morphology and mechanism of the left ventricular outflow tract obstruction and/or morphology and position of the ventricular septal defect. These operations can be performed with minimal mortality and acceptable morbidity. In the mid-term, an excellent functional outcome can be achieved, which leads to normal ventricular function, with low incidence of complete heart block. However, the long-term functioning of the conduction system, the aortic valve, the intraventricular tunnel, the conduit, and the ventricles is variable and requires close surveillance. Prophylactic anatomic correction in patients without symptoms and a well-functioning tricuspid valve and right ventricle is not recommended.