Si Chan Sung

Pulmonary artery banding before the Damus-Kaye-Stansel procedure.

Subaortic stenosis (SAS) in a single ventricle leads to myocardial hypertrophy and compromises Fontan results. Moreover, controversy exists concerning the optimal surgical strategy for relieving SAS. We have applied pulmonary artery banding (PAB) before the Damus–Kaye–Stansel procedure (DKS), and here we analyze factors that influence systemic ventricular compliance. Thirteen patients underwent PAB before DKS. Median PAB duration was 5.5 months (range, 20 days to 17.7 months). Procedures administered concomitantly with DKS were Blalock–Taussig shunt (n = 6), bidirectional cavopulmonary shunt (n = 5), and Fontan operation (n = 2). All survived and were doing well after a median follow-up 2.7 years. Cardiac catheterization before DKS showed that the mean pressure gradient across the systemic ventricular outflow tract and PAB were 20.6 ± 10.1 and 67.4 ± 10.2 mmHg, respectively. After DKS, systemic ventricular end diastolic pressure (SVEDP) was significantly correlated with PAB duration (r = 0.65, p = 0.022), but not with PAB or systemic ventricle outflow tract pressure gradients. After DKS, SVEDP decreased or fell to within the range in patients with PAB duration less than 7 months (p < 0.05). Seven patients had a successful Fontan operation, and 6 without risk factors are waiting operation. SVEDP was found to be correlated with PAB duration, and our findings indicate that short-term PAB can be considered a safe option in patients with a single ventricle and SAS.

A Novel Technique of Supra-Annular Mitral Valve Replacement

We describe a new technique of mitral valve replacement in an 11.5-month-old, 5.5 kg baby whose native mitral annulus was only 14 mm. We successfully implanted a 16-mm mechanical valve in the supra-annular position by sewing it into a short polytetrafluoroethylene graft that was then sutured to the native annulus.

Anterior Translocation of the Right Pulmonary Artery to Avoid Airway Compression in Aortic Arch Repair

BACKGROUNDnAirway compression caused by an enlarged right pulmonary artery (RPA) in patients with a large shunt can usually be managed with intracardiac repair and concomitant anterior aortopexy. However, anterior aortopexy can be less effective or even dangerous in patients with coexisting arch anomaly due to excessive tension at the arch repair site. We have adopted anterior translocation of RPA without aortic transection in the group of patients with a high risk of postoperative airway compression. We reviewed the early and midterm results of this technique.nnnMETHODSnFrom February 2006 to January 2013, 8 patients underwent RPA anterior translocation as a concomitant procedure in one-stage repair of ventricular septal defect (VSD) and aortic arch anomaly to avoid postoperative airway problems. The enlarged RPA was disconnected from the main pulmonary artery (MPA) at its origin and was relocated anterior to the ascending aorta, and subsequently reimplanted to the U-shaped trapdoor incision at the anterolateral MPA wall. The mean age atxa0operation was 34 days (median, 14 days, 6 to 77 days), and the mean body weight was 3.6 kg (2.15 to 5.5xa0kg). Allxa0patients had coarctation of the aorta and VSD except 1 who had aortic arch interruption. Five patients were dependent on a ventilator preoperatively. Six patients had evidence of preoperative bronchial compression (left; 4, right and left; 2), and 2 had a high probability of postoperative bronchial compression due to unusual anterior location of the descending aorta.nnnRESULTSnThere was no early or late death. There were no postoperative airway problems such as reintubation or left lung atelectasis. Widely patent RPA was confirmed on postoperative computed tomographic angiography in all patients. The mean follow-up duration was 54.0 ± 17.1 months. One patient required balloon angioplasty for mild stenosis at the clamping site 3 years after the operation. All patients had no RPA stenosis at the latest follow-up evaluation.nnnCONCLUSIONSnAnterior translocation of the RPA as a concomitant procedure in one-stage repair of VSD and arch anomaly is a safe and effective procedure to avoid postoperative airway problems in high-risk patients.

Right Ventricle-to-Pulmonary Artery Shunt in Pulmonary Atresia with a Ventricular Septal Defect: A Word of Caution

The management of pulmonary atresia with a ventricular septal defect (PA/VSD) depends on the anatomy of the pulmonary artery or on the surgical strategy used at individual institutions. In our institution, we adopted a right ventricle-to-pulmonary artery (RV-PA) shunt in 2011 as a palliative procedure for PA/VSD to overcome the disadvantages of a Blalock-Taussig shunt. We evaluated the results of the RV-PA shunt as initial palliative surgery for PA/VSD. Thirteen patients with ductus-dependent PA/VSD from August 2011 to August 2015 were enrolled. The mean age at surgery was 17.9u2009±u200915.3 (range 5–60) days, and the mean body weight was 2.9u2009±u20090.6 (range 2.2–4.0) kg. A Gore-Tex tube graft was used in all patients. We retrospectively observed intra- and postoperative complications, early and late mortality, and palliation duration to definitive repair. Left pulmonary artery angioplasty was performed as a concomitant procedure in three patients. There were no early hospital mortalities, although two inter-stage deaths occurred 34 and 47xa0days postoperatively: one patient died of aspiration and the other of right ventricular outflow tract (RVOT) pseudoaneurysm rupture. Two patients (15.4%) required the extracorporeal membrane oxygenation support postoperatively: one because of failure to wean from a bypass caused by persistent hypoxemia and the other because of sudden massive bleeding from the RVOT suture line in the intensive care unit 2 days postoperatively. These two patients underwent second-stage definitive repair successfully. Five patients (41.7%) required catheter intervention, for juxtaductal left pulmonary artery stenosis in three patients, right pulmonary artery stenosis in one, and shunt inflow stenosis in one. Two patients (15.4%) required re-operation because of shunt inflow stenosis and RVOT pseudoaneurysm, respectively. All patients who survived the RV-PA shunt underwent total correction at a mean interval of 13.1 months. A RV-PA shunt is an option for the initial palliation of ductus-dependent PA/VSD. Major complications can occur, including RVOT pseudoaneurysm, shunt inflow stenosis, persistent hypoxemia during the immediate postoperative period, and dehiscence of the shunt anastomosis site. Caution should be taken when performing the RV-PA shunt for palliation of PA/VSD.

Long-term results of pulmonary valve annular enlargement with valve repair in tetralogy of Fallot

OBJECTIVESnWe adopted an operative technique of pulmonary valve (PV) annular enlargement with valve repair in tetralogy of Fallot (TOF) correction to reduce postoperative pulmonary regurgitation (PR) 16u2009years ago. Here, we have evaluated the long-term results.nnnMETHODSnBetween April 2000 and August 2005, 43 patients (26 men) with tetralogy of Fallot with pulmonary stenosis underwent PV annular enlargement with valve repair. The median age and body weight at the time of surgery were 14u2009months and 10.2u2009kg, respectively.nnnRESULTSnThere was no operative mortality. Mean postoperative PR grade at discharge was 0.93u2009±u20090.40 (none or trivial in 10 patients, mild in 27 patients, mild to moderate in 5 patients and moderate in 1 patient), and the mean postoperative pressure gradient across PV was 13.0u2009±u200910.9u2009mmHg. The mean follow-up duration was 131.9u2009±u200942.9u2009months. During follow-up, 1 reoperation was performed for residual ventricular septal defect. The mean PR grade at the last follow-up echocardiography was 1.59u2009±u20090.60 (mild in 17 patients, mild to moderate in 8 patients, moderate in 14 patients, moderate to severe in 1 patient and severe in 3 patients), and the mean pressure gradient was 22.7u2009±u20099.9u2009mmHg. We have compared the incidence of moderate or more PR with the incidence of patients who underwent simple transannular patch enlargement through propensity score matching. The PV repair group had a lower incidence of moderate or more PR compared with the simple transannular patch group (40% vs 68%, Pu2009=u20090.04).nnnCONCLUSIONSnPV annular enlargement with valve repair has reasonable long-term results and yields a lower long-term incidence of significant PR compared with the simple transannular patch enlargement technique.

Transposition Complex with Aortic Arch Obstruction: Outcomes of One-Stage Repair Over 10 Years

The surgical management of transposition complex with aortic arch obstruction remains technically demanding due to anatomic complexity. Even in the recent surgical era, there are centers that address this anomaly with a staged strategy. This report presents our experiences with a one-stage repair of transposition complexes with aortic arch obstructions more than the last 10xa0years. Since 2003, 19 patients with a transposition of the great arteries (TGA, 2 patients) or a double outlet of the right ventricle (DORV, 17 patients) and aortic arch obstruction have undergone one-stage repair of their anomalies. The mean age was 6.7xa0±xa02.3xa0days, and the mean body weight was 3.4xa0±xa00.3xa0kg. The 2 patients with TGA exhibited coarctation of the aorta. The 17 patients with DORV all exhibited the Taussig–Bing type. The great artery relationships were anteroposterior in 4 patients (21.1xa0%). The coronary artery anatomies were usual (1LCx; 2R) in 8 patients (42.1xa0%). There were 2 early deaths (10.5xa0%). Seven patients (36.8xa0%) required percutaneous interventions. One patient required re-operation for pulmonary valvar stenosis and left pulmonary artery patch angioplasty. The overall survival was 84.2xa0%. The freedom from mortality was 83.5xa0% at 5xa0years, and the freedom from intervention was 54.4xa0% at 5xa0years. The one-stage repair of transposition complexes with aortic arch obstructions resulted in an acceptable survival rate and a relatively high incidence of postoperative catheter interventions. Postoperative catheter interventions are highly effective. Transposition complexes combined with aortic arch obstructions can be managed by one-stage repair with good early and midterm results.

Staged Repair of Truncus Arteriosus Associated with Complete Atrioventricular Septal Defect

We report a case of successful repair of truncus arteriosus (TA) associated with complete atrioventricular septal defect (c-AVSD) using a staged approach. TA associated with c-AVSD is a very rare congenital cardiac anomaly. No report of successful staged repair in South Korea has yet been published. We performed bilateral pulmonary artery banding when the patient was 33 days old, and total correction using an extracardiac conduit was performed at the age of 18 months. The patient recovered uneventfully and is doing well.

Primary Sutureless Repair of Total Anomalous Pulmonary Venous Connection: Suture-and-Open Technique

We used a suture-and-open technique with a biatrial incision for primary sutureless repair of total anomalous pulmonary venous connection (TAPVC). With this technique, the common pulmonary venous sinus and its branching pulmonary veins are opened after completion of suturing of the left atrial incision to the pericardium around the common pulmonary venous sinusxa0and its branching veins. The technique allows thexa0primary sutureless repair of TAPVC to be done in axa0lessxa0bloody field under full-flow cardiopulmonary bypass. We have performed this technique in our recentxa05 consecutive TAPVC patients without significant complications.

Ruptured intracranial aneurysm in an adolescent with infective endocarditis

Infectious intracranial aneurysms are rare in children, but the reported frequency may be underestimated because some such aneurysms are clinically asymptomatic. Infectious intracranial aneurysms usually have thin friable walls susceptible to rupture. Given the high mortality rate associated with rupture, early detection and treatment of infectious aneurysms is important. Many aneurysms of this type, however, are not suspected until they rupture. If a patient with infective endocarditis has any neurological symptoms, a clinician should suspect infectious intracranial aneurysm and perform further serial diagnostic evaluations.

Late results of right ventricular outflow tract reconstruction with a bicuspid expanded polytetrafluoroethylene valved conduit

We report the results of a bicuspid expanded polytetrafluoroethylene (ePTFE) valved conduit used for right ventricular outflow tract reconstruction (RVOTR).