Stéphane Moniotte

Cardiac and neurological assessment of normothermia/warm blood cardioplegia vs hypothermia/cold crystalloid cardioplegia in pediatric cardiac surgery : insight from a prospective randomized trial.

OBJECTIVEnAlthough normothermia and warm blood cardioplegia are widely used in adults, cold crystalloids and hypothermia remain routinely used in pediatric cardiac surgery. The superiority of either technique in both brain and myocardial protection remains controversial. We designed a prospective randomized study to compare both approaches in terms of early myocardial protection and late neurodevelopmental status.nnnMETHODSnFrom 2004 to 2005, 47 patients were randomly assigned to either mild hypothermia associated to cold crystalloid cardioplegia (CCC, 22 patients) or normothermia with intermittent warm blood cardioplegia (IWBC, 25 patients). Intramyocyte adenosine triphosphate (ATP) was measured before, during and after cardioplegic arrest and results between groups were compared. In addition to their cardiac status, early and late neurologic assessment was performed by psychometric evaluation tests.nnnRESULTSnIntracellular ATP levels were not significantly different between the two groups. However, intragroup comparison revealed different profiles according to myocardial protection: in the normothermia/warm blood cardioplegia group, ATP concentration increased during cardioplegic arrest and returned to initial values afterward (11 nmol mg(-1) vs 21 nmol mg(-1) vs 10 nmol mg(-1), p < 0.001), such changes did not occur in the cold protocol (17 nmol mg(-1) vs 19 nmol mg(-1) vs 14 nmol mg(-1), p = NS). Early neurological outcome was similar in both groups. At late follow-up (mean = 4 years), no significant difference was observed between the two groups.nnnCONCLUSIONSnThis study demonstrates that normothermia/IWBC protocols are not deleterious when compared with more conventional approaches. A more physiologic ATP steady state, reflecting the absence of cellular ischemic insult was observed in the IWBC group. Importantly, no significant difference was found between IWBC and CCC groups in terms of early and late neurodevelopmental status.

Prenatal diagnosis of abnormal cardinal systemic venous return without other heart defects: a case series

To describe fetal spectrum and echocardiographic characteristics of anomalous systemic venous return (ASVR, cardinal veins) without other structural heart defects (isolated ASVR), evaluate associated extracardiac and genetic anomalies and review neonatal outcome.

Imaging of primary unilateral pulmonary hypoplasia: a case report

BackgroundPulmonary hypoplasia is a rare cause of neonatal dyspnea almost always secondary to other conditions. We report an exceedingly rare case of primary unilateral pulmonary hypoplasia.Results and discussionThis case illustrates the role of prenatal magnetic resonance imaging when this condition is suspected during the fetal life. Combined with ultrasounds, this imaging modality offers a three-dimensional evaluation of the lungs that can be critical for postnatal medical management.

Aortic valve repair in the paediatric population: insights from a 38-year single-centre experience.

OBJECTIVES To analyse our institutional results in the setting of paediatric aortic valve (AV) repair. Primary end-points were overall survival, freedom from AV reoperation and freedom from AV replacement. METHODS A retrospective analysis of all patients under 18 years of age operated on from 1977 to 2015 in a single tertiary care level institution. Patients were included if they benefited from any type of AV repair procedure, including commissurotomy, leaflet shaving or plication, or leaflet augmentation. All data were gathered from patients’ medical records, operative reports and referring paediatric cardiologists. The median follow-up was 50 months (IQR [13–140]). RESULTS Sixty-six patients were included. Indications for surgery were aortic stenosis, aortic regurgitation and mixed disease in 13 (19%), 36 (55%) and 17 (26%) patients, respectively. According to El Khourys functional classification, among the 55 patients with some degree of regurgitation there were 5 type Ib regurgitation, 23 type II and 27 type III. During AV repair, additional procedures were performed in 36 patients, VSD closure, subaortic membrane resection and mitral valve repair being the most frequent (18, 8 and 7 patients). RACHS score was predominantly 2 (98.5% of patients). The in-hospital mortality rate was 1.5% (1/66). Major morbidity included 10 pericardial effusions (1 pericardocentesis), 1 low cardiac output syndrome and 1 stroke. There were three late deaths (at 104, 140 and 179 months after repair). All were cardiac related. Overall 5- and 10-year survival rates were 100 and 95.7%. The rates of freedom from AV reoperation and AV replacement at 5 and 10 years were 90.6, 72.1 and 92.5, 82.7%, respectively. During follow-up, there was no occurrence of valve-related complication (endocarditis, thromboembolism and bleeding). CONCLUSIONS In our experience, AV repair in the paediatric population provides excellent results in terms of both overall survival and valve-related reoperation. It obviates the need for chronic anticoagulation and in most cases delays the time at which more complex surgery such as the Ross procedure should be undertaken.

Severe ostial stenosis of the left coronary artery in a 12-year-old girl as the first manifestation of Takayasu's arteritis

We report the case of a 12-year-old girl who presented with isolated chest pain on minimal exertion over the last 2 months. A coronary angiography revealed severe narrowing of the left coronary artery ostium and increased thickness of the ascending aortic wall was demonstrated by transoesophageal echocardiography, suggesting the diagnosis of Takayasu’s arteritis.The patient was successfully treated with corticosteroids and coronary artery bypass graft surgery.

Does Postoperative Cardiac Troponin-I Have Any Prognostic Value in Predicting Midterm Mortality After Congenital Cardiac Surgery?

OBJECTIVESnThis study evaluated the prognostic value of postoperative cardiac troponin-I (cTnI) in predicting all-cause mortality up to 3 months after normothermic congenital cardiac surgery.nnnDESIGNnProspective observational study.nnnSETTINGnUniversity hospital.nnnPARTICIPANTSnAll children ages 0 to 10 years.nnnINTERVENTIONSnNone.nnnMEASUREMENTS AND MAIN RESULTSncTnI was measured after the induction of anesthesia but before the surgery, at the pediatric intensive care unit arrival, and at 4, 12, and 24 hours postoperatively. Follow-up was extended up to 6 months. Overall, 169 children were analyzed, of whom 165 were survivors and 4 were nonsurvivors. cTnI levels were significantly higher in nonsurvivors only at 24 hours (p = 0.047). Children undergoing surgery with cardiopulmonary bypass (CPB) had significantly higher cTnI concentrations compared with those without CPB (p<0.001). Logistic regression analysis was performed on the 146 children in the CPB group with the following predictive variables: CPB time, postoperative cTnI concentrations, the presence of a cyanotic malformation, and intramyocardial incision. None of the variables predicted mortality. Postoperative cTnI concentrations did not predict 6 months׳ mortality. Only cTnI at 24 hours predicted the length of stay in the pediatric intensive care unit.nnnCONCLUSIONSnThis study did not find that postoperative cTnI concentration predicted midterm mortality after normothermic congenital heart surgery. (ClinicalTrials.gov identifier: NCT01616394).

Off-Pump Revascularization in a 2-Year-Old Girl After Neonatal Arterial Switch

One drawback of the arterial switch operation for treating transposition of the great arteries is the occurrence of coronary lesions, found during follow-up in about 5% of (a)symptomatic children. The established corrective procedures include coronary artery proximal patch arterioplasty or coronary artery bypass grafting (CABG). To avoid aortic manipulations and extracorporeal circulation, off-pump coronary artery bypass (OPCAB) has become increasingly used in the adult population. We report a case of OPCAB revascularization in a symptomatic 2-year-old child.

0331: Left ventricular systolic function assessment in a mouse model of cardiac hypertrophy using an 11.7T MRI scanner and comparison with ex-vivo measurements

Introduction In cardiovascular research, there has recently been an interest in ultra-high field MRI to characterize cardiac anatomy and function in rodents. However, reports on the accuracy of the method are scarce. The purpose of our work was to evaluate left ventricular (LV) systolic function in a mouse model of cardiac hypertrophy using an 11.7T MRI machine and to assess the validity of our results by comparing them with ex vivo measurements. Methods 24 C57Bl/6J mice were studied, including 11 animals having undergone a surgical transverse aortic constriction (TAC) and 13 sham animals. Imaging was performed on a 11.7 Tesla Bruker MR scanner. The LV systolic function was assessed from a stack of 1mm thick short-axis views obtained with a FLASH-cine sequence covering the entire ventricles. Using a dedicated software (SegmentTM, Medviso, Sweden), the following volumes (μl) were determined: end-diastolic, end-systolic and stroke volumes. LV ejection fraction (in %) and LV mass (mg) were subsequently deduced. One week after, mice were sacrificed and their LV mass and tibial length (TL) were measured. Results As expected, LV mass was significantly higher in the TAC group. When using the previously validated LV mass/tibial length ratio (LV/TL), sham mice showed a ratio of 4.65±0.09xa0mg/mm and 3.83±0.11xa0mg/mm for morphometric and MRI measurements respectively, and TAC mice showed a ratio of 6.50±0.40 and 5.39±0.28 respectively (p Conclusion High-field cardiac MRI is a promising tool to assess and follow LV systolic function and hypertrophy in mouse models of cardiovascular diseases. In this study, compared with ex vivo measurements, MRI showed similar differences between our experimental groups. Download : Download full-size image Abstract 0331 – Figure

Distal Aortic Arch Hypoplasia and Coarctation Repair: A Tailored Enlargement Technique

Background: Several techniques have been described to correct coarctation associated with distal arch hypoplasia. However, in neonates, residual gradients are frequently encountered and influence long-term outcome. We reviewed our experience with an alternative technique of repair combining carotid–subclavian angioplasty and extended end-to-end anastomosis. Methods: From 1998 through 2014, 109 neonates (median age, 9 days) with coarctation and distal arch hypoplasia (n = 106) or type A interrupted aortic arch (n = 3) underwent repair using this technique. Thirty patients had isolated lesions (group 1), 44 associated ventricular septal defect (group 2), and 35 associated complex cardiac lesions (group 3). Median follow-up was 98 months. Results: Repair was performed via left thoracotomy in 97%. There was one procedural-related death (0.9%) and overall five patients died during index admission (4.6%). Ten deaths were recorded at follow-up. Actuarial five-year survival was 86% (100% in group 1, 91% group 2, and 66% in group 3). Recurrent coarctation (clinical or invasive gradient >20 mm Hg) developed in 15 patients, all but 2 successfully treated by balloon dilatation. Freedom from any reintervention (dilatation or surgery) at five years was 86%. Only two patients were on antihypertensive drugs at last follow-up. Conclusions: This combined technique to correct distal arch hypoplasia and isthmic coarctation results in low mortality and acceptable recurrence rate. It preserves the left subclavian artery and allows enlargement of the distal arch diameter. Late outcome is excellent with very low prevalence of late arterial hypertension.