IRANIAN JOURNAL OF CARDIAC SURGERY
Year:2011 | Volume:3 | Issue:1|Papers Count:28

Background: Cardiovascular operations are associated with an inherented bleeding tendency that some time leads to severe bleeding and transfusion requirement. Pharmacologic intervention to minimize post bypass bleeding and blood product transfusions has received increasing attention for both medical and economic attention.Methods: In this double-blind randomized placebo-controlled clinical trial, three groups of patients undergoing on-pump Coronary Artery Bypass Surgery (CABG),each group composed of 50 patients, were blindly randomized to receiving either low aprotinin, tranexamic acid or placebo, and then results were evaluated and compared in each group.Results: The following variables were similar in groups and there were no statistically significant differences in these variables: Age (P=0.308), Sex (P=0.973), ypelipidemia (P=0.720), Hypertention (P=0.786), Smoking(P=0.72), Diabetes(P=0.960). The amount of drainage from chest tubes were less in aprotinin and tranexamic acid groups compared to placebo, and this was statistically important (P<0.001). There were no statistically significant differences in need for reoperation for bleeding in three groups(P=0.998). Complications following surgery in three groups were statistically the same and not significantly different (table below). All complications had a good course and all patients were discharged from hospital uneventfully. There was no mortality in any group.Conclusions: low dose aprotinin and tranexamic acid can significantly reduce blood loss and transfusion requirement in CABG surgery without importantly increasing mortality and morbidity.

Background: The aim of this study was to investigate the feasibility of performing papillary muscle repositioning (PMR) for subvalvular-sparing mitral valve replacement procedures in patients with ischemic mitral regurgitation and to determine the early and late effects of this procedure on the clinical outcome and left ventricular mechanics.Methods: We prospectively randomly allocated 50 patients with severe ischemic mitral regurgitation and left ventricle dysfunction who were candidates for coronary artery bypass graft surgery and mitral valve replacement into a total chordal-sparing mitral valve replacement group or a PMR group. Echocardiography was performed preoperatively, at discharge, and after 3 years to determine the left ventricular dimensions, shape, and function.Results: The reduction in the left ventricle volumes and sphericity index in the PMR group was more significant than that in the other group. With regard to the left ventricular end-systolic and left ventricular end-diastolic volumes, sphericity index, and ejection fraction, the PMR group showed better results (p<0.05), but the difference in New York Heart Association functional class after 3 years was not statistically significant between the two groups (p>0.05).Conclusions: The PMR technique described herein can dramatically help ischemic patients by affecting the left ventricular shape and function more efficiently compared with the complete retention of the mitral subvalvular apparatus if the mitral valve is to be replaced.

After myocardial infarction, injured cardiomyocytes are replaced by fibrotic tissue promoting the development of heart failure. Stem cells are multipotent, undifferentiated cells capable of multiplication and differentiation. Preliminary experimental evidence suggests that stem cells derived from embryonic or adult tissues (especially bone marrow) may develop into myocardial cells. The overall clinical experience also suggests that stem cell therapy can be safely performed, if the right cell type is used in the right clinical setting. Preliminary efficacy data indicate that stem cells have the potential to enhance myocardial perfusion and/or contractile performance in patients with acute myocardial infarction, advanced coronary artery disease, and chronic heart failure. However, at the present time, the results have been mixed and inconclusive, and the mechanism of stem cell transplantation therapy remains unclear. This review discusses the controversies and problems that need to be addressed in future investigations.

Background: Long segment reconstruction of the diffusely diseased Left Anterior Descending Artery (LAD) with Left Internal Thoracic Artery (LITA) has been shown tobe beneficial for patients that have complicated, multiple and long segment lesions in LAD. In this prospective study we analyzed the results obtained with this technique.Methods: From Feb. 2007 to Feb. 2009, 56 patients were operated by this technique.LITA was used as a patch along the opened narrow segment of LAD from 2 to 8 centimeter. Data from all patients were collected and all patients worked up for postoperative complications, like post operative MI, ECG changes, NIHA class, enzymatic changes, post operative bleeding and CT-Angiography were done between 6 to 18 months after operation in some cases.Results: 56 cases,42 male (75%)and 14 female (25%), from 43 to78 years with mean age of 59.8+_9.3 years with multiple and long segment lesions in LAD were included in this study. Preoperative risk factors were Hypertension (66.1%), Diabetes (57.1%), Hyperlipidemia (50%), cigarette smoking (50%), renal failure (1.8%) and positive family history (7.1%). 23 patients (41.1%) have had remote MI and 9 patients (16.1%) have had recent MI.Significant left main lesion were found in7 patients (12.5%), peripheral vascular disease in 3 patients (5.3%) and preoperative arrhythmias in 2 patients (3.6%). Mean number of grafts that were used in operations was 2.85 +_1.5 and other concomitant operations were done in 5 patients. Post operative complications were arrhythmias in 10 (17.8%), postoperative MI in 1 (1.8%), surgical bleeding in 7 (12.5%), infections in 3 (5.3%), plural effusion in 3(5.3%), tamponade in 2(3.6%), pericardial effusion in 1 (1.8%) and hemiparesia in 1 patient (1.8%). there was no mortality in these patients.Conclusion: Long segment and multiple lesions in LAD are difficult challenges for cardiac surgeons and in these situations; results of long-segment LAD reconstruction are very encouraging.

Background: Narcotics are the most common drugs that have been used after cardiac surgery. Everyone knows that their side effects including respiratory depression, hemodynamic instability, and nausea, vomiting and itching are dose dependent. Magnesium is both N Methyl D Aspartate (NMDA) – receptor and calcium receptor antagonist and can modify important mechanisms of nociception. The purpose of this study was to investigate the effect of magnesium sulfate on pain score and reducing narcotic requirement in coronary artery bypass surgery patients.Methods: In a randomized, double blinded, placebo-controlled trial One hundred and eighty five patients (105 male and 80 female) undergoing elective coronary artery bypass graft surgery were studied. Mean age were 58±11 (from 24 to79 years). We enrolled them in two groups randomly. Group1 received magnesium sulfate as an IV infusion 80 mg/kg during one hour after induction and the second group received the same volume of normal saline as placebo. During the postoperative period, Morphine requirement and pain score (visual analogue scale: scaled as 0 to 10, 0=no pain and 10= worst possible pain) in 6, 12, 18, and 24 hours were recorded and documented.Results: There were no significant differences between two groups with respect to baseline data. In MG group, only 30 patients (32%) needed to receive Morphine Sulfate, but in placebo group, 75 patients (83%) needs some doses of Morphine Sulfate (p value < 0.001), The odds ratio showed that MG could strongly prevent the needs for receiving opioid analgesics for controlling of the pain.Conclusion: Intra operative use of magnesium sulfate can reduce receiving opioids after (CABG) operations.

Background: Patient-controlled analgesia (PCA) has been advocated as superior to conventional controlled analgesia with less risk to patients in cardiac surgery. In this double-blinded, randomized controlled trial, we tested whether the addition of Tramadol to morphine for patient-controlled analgesia (PCA) resulted in improved analgesia efficacy and smaller morphine requirements compared with morphine PCA alone after Coronary Artery Bypass Graft (CABG) surgery in adults.Methods: Seventy patients who were randomly allocated into two groups underwent anesthesia by Total IV anesthesia, midazolam, fentanyl and atracurim and, in end of surgery each group received morphine sulfat 0.2 mg/kg after arrived in ICU, morphin PCA was started with demand (bolus) dose 1mg, lockout interval 10 minutes. The Tramadol group after separated from cardiopulmonary bypass received an intra operative initial loading dose of Tramadol (1mg/kg) and a postoperative infusion of Tramadol at 0.2 mg• kg-1• h-1. The control group received an intra operative equivalent volume of normal saline and a postoperative saline infusion (placebo). The demographic data of both groups were the same. Post-operative data were recorded in the cardiac intensive care unit at 30 min, 1 h, 2 h, 4 h, 12 h and 24 h after extubation by the same anesthesiologist, who had no knowledge of the groups, and the side-effects were also evaluated.Results: Postoperatively, Tramadol was associated with improved subjective analgesic efficacy (P = 0.031) and there was significantly less PCA morphine use in the Tramadol group (P=0.023). No differences between the groups were found with regard to nausea dizziness, itching, antiemetic use, sedation, or quality of recovery (all P>0.05).Conclusions: We conclude that a Tramadol infusion combined with PCA morphine improves analgesia and reduces morphine requirements after cardiac surgery compared with morphine PCA alone.

Background: Pericardial effusion resulting in cardiac tamponade is uncommon after open heart surgery and is associated with significant morbidity and mortality.Methods: In a clinical randomized trial 80 patients that have undergone CABG, were divided in two groups, posterior pericardectomy group and control group. Both groups were evaluated after operation by TEE and clinical parameters for early and late postoperative pericardial effusion.Results: In this study 45% of control group and 5% in study group developed postoperative pericardial effusion, also the incidence of late pericardial effusion was 10% in study group and 57% in control group. Age, Gender, Smoking, Diabetes Mellitus and the Number of grafts didn’t have any effect on the incidence of pericardial effusion.Conclusion: Posterior pericardiotomy as a safe and simple procedure can significantly reduce the incidence of early and late pericardial effusion.

Objectives: This study was undertaken to examine clinicaland echocardiographic outcomes of aortic valve–sparing operations to treat aortic root aneurysms.Methods: From May 1988 to December 2007, a total of 228 patients underwent reimplantation of the aortic valve, and 61underwent remodeling of the aortic root. Patients were followed up prospectively and had echocardiographic evaluation of valve function. Mean follow-up was 7.28±4.33 years.Results: There were 5 operative and 26 late deaths. Survival at 12 years was 82.9±3.7% and similar between types of operations. Age and aortic dissection were independent predictorsof mortality. Seven patients have had reoperations on the aortic valve: 6 for aortic insufficiency and 1 for endocarditis. Five of these patients had undergone remodeling of the aortic root. Freedoms from reoperation at 12 years were 94.3% ±2.6% among all patients, 90.4%±4.7% after remodeling, and 97.4%±2.2% after reimplantation (P=.09). Postoperatively, moderate aortic insufficiency developed in 14 patients (8 remodeling and 6 reimplantation) and severe aortic insufficiency in 5 (3 remodeling and 2 reimplantation). The remaining patients had mild, trace, or no aortic insufficiency. Freedoms from moderate or severe aortic insufficiency at 12 years were 86.8%±3.8% among all patients, 82.6%±6.2% after remodeling, and 91.0% ± 3.8% after reimplantation (P=.035). Only age-by 5-year increments-was an independent predictor of postoperative aortic insufficiency.Conclusions: Aortic valve–sparing operations provide excellent patient survival and stable aortic valve function, particularly after reimplantation of the aortic valve

Background: The introduction of transcatheter aortic valves has focused attention on outcomes after open aortic valve replacement (AVR) in very high-risk patients. This study analyzes the short-term and midterm outcomes of AVR in this patient cohort in the current surgical era.Methods: A retrospective review was performed on 159 patients who underwent isolated, primary AVR with a STSPROM (Society of Thoracic Surgeons predicted risk of mortality) of 10% or greater from January 2002 to December 2007 at four US academic institutions. Patients with previous valve operations were excluded. A multivariable model was constructed to determine predictors of in hospital mortality. Estimates of the cumulative event rate mortality were calculated by the Kaplan-Meier method.Results: The mean age of all patients was 76.1±11.2 years, most were men (92 of 159, 57.9%), and mean STS PROM was 16.3%7.3%. Significant preoperative factors included the following: peripheral vascular disease, 33.3% (53 of 159); stroke, 23.3% (37 of 159); renal failure, 50.3% (80 of 159);New York Heart Association class III-IV heart failure, 78.0% (124 of 159); and previous coronary artery bypass grafting, 39.0% (62 of 159). Mean ejection fraction was 0.461 ± 0.153 and median implanted valve size was 23 mm. Postoperative complications included the following: stroke, 4.4% (7 of 159); heart block, 5.0% (8 of 159); multisystem organ failure, 6.9% (11 of 159); pneumonia, 7.5% (12 of 159); and dialysis, 8.2% (13 of 159). Postoperative length of stay was 12.6±11.0 days and in-hospital mortality was 16.4% (26 of 159). One-, three-, and 5-year survival was 70.9%, 56.8%, and 47.4%, respectively.Conclusions: In the current era, high-risk surgical patients undergoing open AVR have respectable short and mid-term survival. These results should serve as a benchmark for evaluating outcomes of transcatheter aortic valve implantation.

Objective: Robotic mitral valve repair is the least invasive approach to mitral valve repair, yet there are few data comparing its outcomes with those of conventional approaches. Therefore, we compared outcomes of robotic mitral valve repair with those of complete sternotomy, partial sternotomy, and right mini-anterolateral thoracotomy.Methods: From January 2006 to January 2009, 759 patients with degenerative mitral valve disease and posterior leaflet prolapse underwent primary isolated mitral valve surgery by complete sternotomy (n=114), partial sternotomy (n=270), right mini-anterolateral thoracotomy (n=114), or a robotic approach (n=261). Outcomes were compared on an intent-to-treat basis using propensity- score matching.Results: Mitral valve repair was achieved in all patients except 1 patient in the complete sternotomy group. In matched groups, median cardiopulmonary bypass time was 42 minutes longer for robotic than complete sternotomy, 39 minutes longer than partial sternotomy, and 11 minutes longer than right mini-anterolateral thoracotomy (P<.0001); median myocardial ischemic time was 26 minutes longer than complete sternotomy and partial sternotomy, and 16 minutes longer than right mini-anterolateral thoracotomy (P<.0001). Quality of mitral valve repair was similar among matched groups (P =.6, .2, and .1, respectively). There were no in-hospital deaths. Neurologic, pulmonary, and renal complications were similar among groups (P>.1). The robotic group had the lowest occurrences of atrial fibrillation and pleural effusion, contributing to the shortest hospital stay (median 4.2 days), 1.0, 1.6, and 0.9 days shorter than for complete sternotomy, partial sternotomy, and right mini-anterolateral thoracotomy (all P<.001), respectively.Conclusions: Robotic repair of posterior mitral valve leaflet prolapse is as safe and effective as conventional approaches. Technical complexity and longer operativetimes for robotic repair are compensated for by lesser invasiveness and shorter hospital stay

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in patients undergoing a surgery for endocarditis is a biological valve or mechanical valve superior for achieving long-term low rates of reinfection?' Altogether more than 41 papers were found using the reported search, of whichnine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomesand results of these papers are tabulated. Out of the studies that include statistical comparisons, in mechanical valve replacement the average endocarditis recurrence rate ranged from approximately 3 to 9% and in biological valves fromapproximately 7 to 29%. Out of the studies that specifically compared the outcomes of the two valves, 50% concludedthere to be no significant difference when separated from other risk factors and 50% recommended a mechanical valve for lower recurrence and higher survival rates. The Euro Heart Survey found that 63% of valve replacements were mechanical, due to young age (90%) and physician preference (75%) and only 21% bioprosthetic. Currentguidelines from American College of Cardiology/American Heart Association (ACC/AHA) recommend a mechanical valve in patients <65 years old and a bioprosthetic valve if >65, without risk factors for thromboembolism, but this is based on class II evidence (conflicting evidence or opinion). These guidelines are not specific to patients with infective endocarditis, so it is vital to review the literature related to this. Three of the studies in the search specify that for patients under 60–65 years old, a mechanical valve has greater benefit, but this was not found to be true for the over 65 years. It can be concluded that for patients under 65 years old, a mechanical valve may offer greater freedom from reoperation and increased long-term survival when compared to a bioprosthetic valve (assuming no other comorbidities), although this divide is narrowing with the use of newer generation bioprosthetic valves and has to be off-set against potential bleeding risks. For patients over 65 years, other important variants need to be considered including patient choice, correct protocols of antibiotics and radical debridement.

Background: The aim of this review was to analyze our results with extracorporeal membrane oxygenation (ECMO) support for primary graft failure (PGF) in heart transplantrecipients.Methods: A retrospective review of 239 consecutive patientswho underwent heart transplantation between January 2000 and August 2009 was performed. Orthotopic, heterotopic, and heart lung transplants were included in this analysis. Over that time period, 54 patients developed PGF, of whom 39 patients required ECMO support. These 39 patients form the basis of this review.Results: Thirty-four patients (87%) were successfully weaned from ECMO and 29 (74.3%) survived to hospital discharge. There were no significant differences in wean rates or complications between central and peripheral ECMO. Comparison of survival in the 39 ECMO patients to the non-PGF patients (n=185) showed a significantly worse survival in the ECMO group (p=0.007). When those patients who died in the first 30 days were excluded, there was no difference in overall survival between groups (p=0.73).Conclusions: Extracorporeal membrane oxygenation provides excellent circulatory support for patients with PGF after heart transplantation with good wean and survival to discharge rates. 6- Risk factors of stroke and delirium after off-pump coronary artery bypass surgery Interactive CardioVascular and Thoracic Surgery 2010, doi:10.1510/icvts.2010.248872 Off-pump coronary artery bypass surgery (CABG) has not abolished the risk of postoperative stroke and delirium seen for on-pump CABG. Advanced arteriosclerotic changes are common in both on-pump and off-pump CABG. Wesought to analyze if advanced arteriosclerotic changes arerisk factors of stroke or transient ischemic attack (TIA), and delirium after off-pump CABG. Patients undergoing off-pump CABG between 2001 and 2005 were reviewed using medical records (n=685). Potential risk factors of postoperative stroke and delirium were identified from previous studies. Further, variables retrieved from carotid artery duplex scanning as indices of advanced arteriosclerosis, were examined. The incidences of postoperative stroke/TIA and delirium after off-pump CABG were 2.6% (n=18) and 16.4% (n=112), respectively. Carotid artery stenosis >50% was a significant risk factor of stroke or TIA (P=0.02) as well as delirium (P=0.04) after off-pump CABG. A history of atrial fibrillation (AF) (P=0.037) or diabetes mellitus (P=0.041) was a risk factors of postoperative stroke or TIA. In contrast, age over 75 years (P=0.006), creatinine >1.3 mg/dl (P=0.011), a history of hypertension (P=0.001), past history of AF (P=0.024), and smoking (P=0.048) were significant risk factors of postoperative delirium. Keywords: Brain; Coronary artery bypass surgery; Stroke

The purpose of this study was to test, whether the late phase of remote ischaemic preconditioning (L-RIPC) improves myocardial protection in coronary artery bypass grafting (CABG) with cold-crystalloid cardioplegia and whether preoperative tramadol modifies myocardial ischaemia–reperfusion injury using the same group of patients in a singleblinded randomized controlled study. One hundred and one adult patients were randomly assigned to either the L-RIPC, control or tramadol group. L-RIPC consisted of three fiveminute cycles of upper limb ischaemia and three five-minute pauses using blood pressure cuff inflation 18 hours prior to the operation. Patients in the tramadol group received 200 mg tramadol retard at 19:00 hours, the day before theoperation and at 06:00 hours. Serum troponin I levels were measured at eight, 16 and 24 hours after surgery. Myocardial samples for inducible and endothelial nitric oxide synthases (iNOS, eNOS) estimation were drawn twice: before and after cannulation for cardiopulmonary bypass from the auricle of the right atrium. We found that L-RIPC canreduce injury beyond the myocardial protection provided by cold-crystalloid cardioplegia, and tramadol worsened myocardial injury after CABG. Expressions of iNOS were increased in the control (significantly) and L-RIPC groups and dampened in the tramadol group.

Background: Our aim was to evaluate early results of ganglionic plexus (GP) ablation with modified Cox maze lesion sets for concomitant atrial fibrillation (AF) during corrective valve surgery.Methods: Between December 2006 and April 2008, 20 patients (7 men; median age, 65 years; range, 52 to 82 years) with valvular heart disease and AF (intermittent in 12 [60%]) underwent corrective valve surgery with maze and GP ablation. Patients were then compared with a casematched control cohort who underwent radiofrequency ablation maze alone.Results: Procedures included mitral valve repair in 7 patients (35%), multivalve procedures in 5 (25%), mitral valve replacement in 4 (20%), aortic valve replacement in 3 (15%), and valve-sparing aortic root replacement in 1 (5%). All patients underwent concomitant AF ablation procedures (biatrial maze in 11 [55%], left-sided maze in9 [45%]). Ganglionic plexus stimulation was performed in all patients. Sites at which the R-R interval doubled were considered active and were ablated. There were no early deaths. Freedom from AF at 1 year was significantly higher (90% versus 50%; p=0.01) and mean New York Heart Association functional class was better (1 versus 1.7; p<0.001) in the group that underwent maze and GP ablation compared with maze alone.Conclusions: Active left atrial GP are frequently present in patients with AF and valvular heart disease, and GP ablation can be safely performed as an adjunct to AF ablation duringvalve surgery. Early results are promising and may yield higher freedom from AF compared with radiofrequency ablation nmaze alone.

Objectives: Temporary epicardial pacing wires are commonly placed during pediatric cardiac surgery. Data are sparse on postoperative pacing in this population. The objective of this study was to determine the frequency of use and identify predictors for the use of temporary epicardial pacing wires.Methods: Perioperative data were prospectively collected on all patients who underwent cardiac surgery at our institution (n = 162).Results: A total of 117 (72%) patients had temporary epicardial pacing wires placed. Postoperatively, 23 (20%) of 117 patients had hemodynamic improvement with the useof temporary epicardial pacing wires. Indications for pacing were slow junctional rhythm (11/23 [48%]), junctional ectopic tachycardia (7/23 [31%]), pace termination of supraventricular tachycardia (3/23 [13%]) and atrial flutter (1/23 [4%]), and complete heart block (1/23 [4%]). By using univariate analysis, single-ventricle anatomy, heterotaxy, the Fontan procedure, use of circulatory arrest, intraoperative arrhythmia, pacing in the operating room, and use of vasoactive medications were predictors for hemodynamic improvement with the use of temporary epicardial pacing wires (P<.05). On multivariate analysis, the Fontan procedure, circulatory arrest, and intraoperative arrhythmias were independent predictors (P<.01). When excluding all patients with any of these 3 risk factors, only 2% were paced. Patients with clinically significant pacing had longer chest tube drainage (P < .01) and intensive care unit length of stay (P<.01). There were no complications associated with temporary epicardial pacing wires.Conclusions: The Fontan procedure, use of circulatory arrest, and intraoperative arrhythmias were associated with hemodynamic improvement with postoperative pacing and might represent indications for empiric intraoperative placement of temporary epicardial pacing wires. Patients without these risk factors were less likely to require pacing. Temporary epicardial pacing wires were safe and useful in the management of arrhythmias after pediatric cardiac surgery.Abbreviations and Acronyms CICU=cardiac intensive care unit; OR=odds ratio.

Atrial fibrillation (AF) is a common arrhythmia that occurs postoperatively in cardiac surgery. There is evidence for the role of oxidative stress in the etiology of AF. In our study, we examined whether antioxidant ascorbic acid (vitamin C), could help in the reduction of the incidence of postoperative AF. Patients who were scheduled to undergo elective isolated on-pump coronary artery bypass grafting (CABG) were included in our study. One hundred and seventy patients were randomly divided in two groups: Group A (n=85) received vitamin C preoperatively and postoperatively whereas Group B (n=85) did not receive any (control group). The incidence of AF was 44.7% in the vitamin C group and 61.2% in the control group (P=0.041). The hospitalization time, the intensive care unit stay and the time interval for the conversion of AF into sinus rhythm was significantly shorter in the vitamin C group. Patients that developed AF also had longer hospital length of stay (9.5±2.8 days vs. 6.7±1.9, P=0.034). Supplementation of vitamin C reduces the incidence of post CABG AF, and decreases the time needed for rhythm restoration and length of hospital stay. Keywords: Post CABG atrial fibrillation; Oxidative stress; Ascorbic acid; Vitamin C class I or II, and 61.2% had some degree of persistent mitral regurgitation or stenosis, despite stable hemodynamics. Stenosis is a statistically significant risk factor for surgical intervention at less than 1 year of age and is related to higher overall mortality and incidence of late cardiac failure and mitral dysfunction; parachute mitral valve is related to higher mortality and morbidity.Conclusions: Mitral valve repair shows acceptable early mortality and reoperation rates. Mitral malformations in the complex group are related to a significantly higher risk of reoperation on the mitral valve. Parachute mitral valve is associated with a higher rate of early mortality.

Objective: Primary biventricular repair for left ventricular outflow tract obstruction and ventricular septal defect remains challenging. The intermediate-term outcomes and risk factors for mortality remain undefined.Methods: All patients undergoing primary biventricular repair of left ventricular outflow tract obstruction and ventricular septal defect from 1995 to 2008 at the C. S. Mott Children’s Hospital, University of Michigan Health Systems were analyzed.Results: Thirty-one patients (mean age, 18 days; 20 male) with a median follow-up of 6.7 years (range, 0.3–13.5years) were identified. The ventricular septal defect was enlarged in 15 patients, and a limited atrial septal defect was constructed in 16 patients. There were 6 hospital and 2 late deaths. Ten-year patient survival was 72.3%. Lower body weight (P=.040), complete atrial septal defect closure (P=.026), and longer cardiopulmonary bypass time (P=.026) were risk factors of hospital mortality. An atrial septal defect was patent in 16 patients at discharge, 2 of whom required later surgical closure. Relief of recurrent left ventricular outflow tract obstruction was performed in 1 patient. No patient required pacemaker implantation. Five-year freedom from right ventricle-to-pulmonary artery conduit replacement was 39.3%. Smaller-sized conduit (P=.020) and use of aortic allograft (P=.048) were risk factors for early failure.Conclusion: Primary biventricular repair for patients with left ventricular outflow tract obstruction and ventricularseptal defect provides good early and intermediate-term outcomes. Maintaining a small atrial septal defect may improve hospital mortality. Selective ventricular septal defect enlargement and careful construction of the intraventricular pathway result in a low incidence of recurrent left ventricular outflow tract obstruction, as well as avoidance of heart block. Maximizing valve diameter and avoiding aortic allografts may lengthen conduit longevity.

Background: Off-pump coronary artery bypass graft surgery (OPCAB) has proven to be beneficial in many high-risk subgroups. This study aims to determine whether OPCAB lowers the incidence of pulmonary complications among patients with chronic lung disease (CLD) when compared with on-pump coronary artery bypass graft surgery (ONCAB).Methods: From 2002 to 2007, 7,060 patients underwent isolated coronary artery bypass graft surgery in an academic center. Patients were classified according to surgery type (ONCAB or OPCAB) and presence or absence of CLD. A propensity score was produced to estimate each patient's likelihood of being assigned to OPCAB on the basis of 39 preoperative risk factors. Multiple logistic regression models and adjusted odds ratios with 95% confidence intervals were used to evaluate the effect of surgery type, CLD, and their interaction on pulmonary-related complications and mortality.Results: Among OPCAB patients, 15.3% (720 of 4,693) had CLD compared with 11.2% (264 of 2,367) for ONCAB. Off-pump coronary artery bypass graft surgery was performed in 73.2% of CLD patients compared with 66.5% in those without CLD (p < 0.0001). Chronic lung disease was associated with a greater incidence of prolonged ventilation, reintubation, pneumonia, intensive care unit hours, and non–home discharge. After propensity score adjustment, OPCAB was associated with a significantly reduced incidence of prolonged ventilation, pneumonia, intensive care unit stay, and mortality. No significant interactions existed between surgery type and CLD status, suggesting that OPCAB was equally beneficial to patients with and without CLD. Conclusions: In this series, patients with CLD were more likely to undergo OPCAB. Patients with CLD are at significantly greater risk of pulmonary-related complications thanpatients without CLD. Off-pump coronary artery bypass graft surgery reduced the incidence of pulmonary complications and mortality in all patients. Importantly, this benefit was seen similarly for patients with and without CLD.

Objective: Vasoconstrictors such as norepinephrine and vasopressin are commonly used to raise the blood pressure during myocardial revascularization. The internal thoracicartery is commonly used for coronary artery grafting because of its long-term patency. However, the internal thoracic artery is a living conduit that responds to vasoactive substances. The objective of this study was to measure change in internal thoracic arterial flow after infusion of norepinephrine or vasopressin.Methods: Forty-one patients undergoing elective off-pump coronary artery bypass grafting participated in this study. After the median sternotomy, the left internal thoracic artery was dissected with a pedicle and grafted to the left anterior descending artery. After all anastomoses were performed and hemodynamic parameters were stable, the grafted internal thoracic arterial blood flow was measured by transit time flowmeter on the distal portion of the graft asa baseline. Norepinephrine or vasopressin was then infused until mean arterial pressure was increased to 20% of baseline. Graft flow and hemodynamic variables were measured when mean arterial pressure reached the intended level.Results: Baseline grafted internal thoracic arterial flows were similar (norepinephrine 57.1±17.7 mL min–1, vasopressin 66.0±34.3 mL min–1). With norepinephrine, flow increased significantly relative to baseline (77.2±31.0 mL min–1); with vasopressin, it remained unchanged (68.3±37.0 mL min–1).Conclusions: For patients needing vasopressor support after coronary artery bypass grafting, norepinephrine appeared superior to vasopressin because of increased internal thoracic arterial flow

Objective: We sought to evaluate pulmonary artery banding in infants with complete atrioventricular septal defects.Methods: From 2000 to 2009, 20 infants with complete atrioventricular septal defects underwent pulmonary artery banding because of unsuitable anatomy (unbalanced ventricles, associated lesions, or both) or clinical condition (infection, chronic lung disease, or noncardiac malformation). Patients were divided into 2 groups: the conventional PAB group (n=13 [65%]; mean age, 74±56 days [range, 6–187 days]; mean weight, 3.3±1.1 kg [range, 2.1–5.8 kg]) and the FloWatch-PAB group (n = 7 [35%]; mean age, 111±40 days [range, 81–187 days]; mean weight, 4.3±1.2 kg [range, 3.2–6.1 kg]). There was no statistical difference in age or weight. Preoperative mechanical ventilation was required in 3 (23%) of 13 infants in the conventional PAB group and 5 (71%) of 7 infants in the FloWatch-PAB group (P<.05).Results: Ten (77%) of 13 infants in the conventional PAB group died versus 0 (0%) of 7 infants in the FloWatch-PAB group (P<.001). Sternal closure was delayed in 6 (46%) of 13 infants in the conventional PAB group and 0 (0%) of 7 infants in the FloWatch-PAB group (P<.05). The mean duration of mechanical ventilation, intensive care unit stay, and hospital stay was significantly longer (P<.05) in the conventional PAB group than in the FloWatch-PAB group (21±17 days [range, 4–61 days] vs 3±2 days [range, 1–8 days], 22±18 days [range, 5–61 days] vs 7±6 days [range, 2–21 days], and 54±12 days [range, 40–71 days] vs 29±25 days [range, 9–81 days], respectively). Left atrioventricular valve regurgitation increased (mild to moderate) in 2 infants in the conventional PAB group and decreased (severe to moderate) in 2 infants in the FloWatch-PAB group. Six of 10 survivors (1 in the conventional PAB group and 5in the FloWatch-PAB group) underwent pulmonary artery debanding and repair after a median interval of 125 days (range, 34–871 days); 4 of 10 are awaiting repair.Conclusions: In selected patients with complete atrioventricular septal defects, pulmonary artery banding followed by late repair is a viable alternative strategy. In our study the FloWatch-PAB device resulted in improved survival and made later repair possible in a better clinical state

Background: Ventricular function and arrhythmia in patients with Fontan circulation in long-term follow-up are still unknown.Methods: We retrospectively reviewed 48 patients who survived and were followed up for more than 15 years, among110 patients who underwent Fontan operation in our institute from 1979 to 1992. Atriopulmonary connection was performed in 26 patients and total cavopulmonary connection in 22. The patients were categorized into right ventricle, left ventricle, and biventricle groups. Follow-up cardiac catheterization and exercise test were performed routinely every 5 years post surgery. Median age at Fontan operation was 5 years.Results: Mean follow-up was 18.5 years. Cardiac index in the total cavopulmonary connection group was higher than in the atriopulmonary connection group at 10 and 15 years post surgery (p<0.05). Ejection fraction in the left-ventricle group was higher than in the right-ventricle group. End diastolic volume at 5, 10, and 15 years was significantly lower than at 1 year (p<0.05). End-diastolic pressure at 10 years was significantly higher than at 1 and 5 years (p<0.05). Beyond 15 years, 6 patients developed ventricular tachycardia. The only significant risk factors for the onset of ventricular tachycardia in a multivariate analysis were age at Fontan operation and absolute age (p<0.05).Conclusions: Long-term follow-up of patients demonstrated that postoperative ventricular systolic performance seemed to become steady. Ventricular tachycardia was detected 15 years post surgery, especially in older patients with older age at Fontan operation, possibly revealing a risk factor in the long-term postoperative period, thereby meriting further consideration

Background: Red blood cell transfusion is associated with morbidity and mortality among adults undergoing cardiac surgery. We aimed to evaluate the association of transfusion with morbidity among pediatric cardiac surgical patients.Methods: Patients discharged after cardiac surgery in 2003 were retrospectively reviewed. The red blood cell volume administered during the first 48 postoperative hours was used to classify patients into nonexposure, low exposure (³15 mL/kg), or high exposure (>15 mL/kg) groups. Cox proportional hazards modeling was used to evaluate the association of red blood cell exposure to length of hospital stay (LOS).Results: Of 802 discharges, 371 patients (46.2%) required blood transfusion. Demographic differences between the transfusion exposure groups included age, weight, prematurity, and noncardiac structural abnormalities (all p<0.001). Distribution of Risk Adjusted Classification for Congenital Heart Surgery, version 1 (RACHS-1) categories, intraoperative support times, and postoperative Pediatric Risk of Mortality Score, Version III (PRISM-III) scores varied among the exposure groups (p < 0.001). Median duration of mechanical ventilation (34 hours [0 to 493] versus 27 hours [0 to 621] versus 16 hours [0 to 375]), incidence of infection (21 [14%] versus 29 [13%] versus 17 [4%]), and acute kidney injury (25 [17%] versus 29 [13%] versus 34 [8%]) were highest in the high transfusion exposure group when compared with the low or no transfusion groups (all p<0.001). In a multivariable Cox proportional hazards model, both the low transfusion group (adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI]: 0.66 to 0.97, p=0.02) and high transfusion group (adjusted HR 0.66, 95% CI: 0.53 to 0.82, p<0.001) were associated with increased LOS. In subgroup analyses, both low transfusion (adjusted HR 0.81, 95% CI: 0.65 to 1.00, p = 0.05) and high transfusion (adjusted HR 0.65, 95% CI: 0.49 to 0.87, p = 0.004) in the biventricular group but not in the single ventricle group was associated with increased LOS.Conclusions: Blood transfusion is associated with prolonged hospitalization of children after cardiac surgery, with biventricular patients at highest risk for increased LOS. Future studies are necessary to explore this association and refine transfusion practices

Background: Whether an arterial switch operation benefits patients with transposition of the great arteries and severe pulmonary hypertension (PH) remains controversial. Therefore, we evaluated the relationship between preoperative PH and early and midterm clinical outcomes after an arterial switch procedure.Methods: In this retrospective study, 101 consecutive patients with transposition of the great arteries underwent anarterial switch operation between February 2004 and October2007. Seventy had a ventricular septal defect as well; patients with intact ventricular septum and complicated concomitant abnormities were excluded. Preoperative medical records were reviewed and mean follow-up was 22.4±15.2 months. After sternotomy, we directly measured pulmonaryartery pressure before and after instituting extracorporeal circulation. Patients were divided into three groups according to mean pulmonary artery pressure (mPAP): control group (mPAP<25 mm Hg, n=23), moderate PH group (mPAP 25 to 50 mm Hg, n=37), and severe PH group (mPAP 50 mm Hg, n=10). Early and midterm results were compared among groups.Results: Postoperatively, pulmonary artery pressure of both the moderate and severe PH groups decreased significantly. There were no significant differences in occurrence of postoperative complications or in-hospital mortality in the three groups (control group, 8.7%; moderate PH group, 8.1%; severe PH group, 10%; p=0.98). However, midterm mortality differed significantly (control group, 4.3%; moderate PH group, 2.7%; severe PH group, 40%; p<0.01).Conclusions: Patients with transposition of the great arteries and mPAP less than 50 mm Hg can achieve satisfying results after an arterial switch operation. However, even though the operation can decrease pulmonary artery pressure, patients with preoperative mPAP greater than 50 mm Hg still suffer from high midterm mortality.

Background: The purpose of this study was to assess deep hypothermic circulatory arrest (DHCA) as a modifier of neuro developmental (ND) outcomes in preschool children after cardiac surgery in infancy for repair of congenital heart defects (CHD).Methods: This is a planned analysis of infants enrolled in a prospective study of apolipoprotein E polymorphisms and ND outcome after cardiac surgery. The effect of DHCA was assessed in patients with single or biventricular CHD without aortic arch obstruction. Neuro developmental assessment at 4 years of age included cognition, language, attention, impulsivity, executive function, social competence, and visual-motor and fine-motor skills. Patient and procedural variables were evaluated in univariate and multivariate models.Results: Neuro developmental testing was completed in 238 of 307 eligible patients (78%). Deep hypothermic circulatory arrest was used at the discretion of the surgeon at least once in 92 infants (38.6%) with a median cumulative duration of 36 minutes (range, 1 to 132 minutes). By univariate analysis, DHCA patients were more likely to have single ventricle CHD (p=0.013), lower socioeconomic status (p<0.001), a higher incidence of preoperative ventilation (p< 0.001), and were younger and smaller at the first surgery (p<0.001). By multivariate analysis, use of DHCA was not predictive of worse performance for any ND outcome.Conclusions: In this cohort of children undergoing repair of CHD in infancy, patients who underwent DHCA had risk factors associated with worse ND outcomes. Despite these, use of DHCA for repair of single-ventricle and biventricular CHD without aortic arch obstruction was not predictive of worse performance for any ND domain tested at 4 years of age.

Objective: We sought to evaluate the results of surgical repair and determine predictors for the late outcome of congenital mitral valve dysplasia.Methods: Preoperative, operative and postoperative data were obtained from an institutional database; follow-up data came from regular clinical evaluation at our institution or elsewhere. Patients were divided into isolated and complex cases according to the complexity of associated lesions.Results: Between 1972 and 2008, 93 patients (43 male and 50 female patients) underwent mitral repair (median, 4.5 years; range, 0.16–19.8 years). Predominant mitral regurgitation was present in 52%. Associated cardiac anomalies were present in 72%. Sixty-one patients were in the complex group. All patients underwent successful mitral repair. Surgical repair was tailored to the patient’s valve anatomy. Early death was 7.5%. The postoperative course was uneventful in 86% of patients. At a mean follow-up of 10.3 years (median, 8.4 years; completeness, 94%), late mortality is 8% (7 patients). Twelve patients underwent mitral reintervention (11 replacements and 1 repair). Among the 80 survivors, 82.5% were in New York Heart Association.

Objective: To analyse the long-term patency of coronary arteries after neonatal arterial switch operation (ASO).Methods: A retrospective study of the operative reports, follow up and postoperative catheterisation data of 119 patients, who underwent the great arteries (TGA) repair since 1991, has been carried out. Patient population: Among the 133survivors of the 137 ASOs performed between 1991 and 2007, 119 patients have been studied by routine control cardiac catheterisation and form the study population. Median time between repair and the coronary angiography was 2.9±1.9 years. A comparison between the eight patients (6.7% out of the entire study population), known to have postoperative coronary obstructions (group I) and the rest of the cohort with angiographic normal coronary vessels (group II) was performed by univariate analysis of variance and logistic regression models. One patient had surgical plasty of the left coronary main stem with subsequent percutaneous angioplasty, three patients had primary coronary stent implantation and four patients had no further intervention at all. In group I, all but one patient denied symptoms of chestpain and echocardiography failed to show any difference between the two groups in terms of left ventricular systolic function (ejection fraction group I 61±2% vs 62±6% of group II, p=1.0). Results: The association of coronary obstruction with complex native coronary anatomy (Yacoub type B to E) was evident at both univariate (62% of group I vs 22% of group II, p=0.04) and logistic regression (p=0.007, odds ratio (OR) 8.1) models. The type of coronary reimplantation (i.e., coronary buttons on punch vs trap-door techniques) was similar between the two groups (punch reimplantation in 25% of patients of group I vs 31% of group II, p=0.1) as was the relative position of the great vessels (aorta anterior in 100% of patients of group I vs 96% of group II; univariate, p=0.1). Conclusions: The late outcome in terms of survival and functional status after ASOis excellent. Nevertheless, the risk of a clinically silent late coronary artery obstruction of the reimplanted coronary arteries warrants a prolonged follow-up protocol involving invasive angiographic assessment.

A case of thorombosis of the superior vena cava (SVC) was complicated by unilateralchylothorax . Removal of the SVC clot and repairing its stenosis with geor-tex patch led to the prompt resolution of the chylothorax .Chylothorax is an uncommon result of obstruction of the SVC. The most reported cause is the placement of the central venous catheters.(1-6)We describe a case of chylothorax after atrial septal defect( ASD) repair with single pericardial patch.

We present a one-year old male infant with heart murmurs discovered at birth. Transthoracic echocardiography revealed a perimembranous ventricular septal defect (VSD) as well as multiple cardiac masses. Pediatric cardiologists recommended closure of the VSD and biopsy of the uncertain cardiac masses. The VSD was repaired, and one of the masses was excised and sent for histopathological examination. Here, we discuss a case of multiple rhabdomyomas in an infant whose associated finding was congenital heart disease, rather than tuberous sclerosis. He was discharged in good clinical condition and his parents were given instructions to have routine followup visits for the evaluation of the possible regression of the remaining masses.