Antegrade Blood Flow Research Articles

Cerebral and Renal Oxygen Saturation Are Not Compromised in the Presence of Retrograde Blood Flow in either the Ascending or Descending Aorta in Term or Near-Term Infants with Left-Sided Obstructive Lesions

Background: In infants with left-sided obstructive lesions (LSOL), the presence of retrograde blood flow in either the ascending or descending aorta may lead to diminished cerebral and renal blood flow, respectively. Objectives: Our aim was to compare cerebral and renal tissue oxygen saturation (rSO₂) between infants with LSOL with antegrade and retrograde blood flow in the ascending aorta and with and without diastolic backflow in the descending aorta. Methods: Based on 2 echocardiograms, the study group was categorized according to the direction of blood flow in the ascending and descending aorta. We measured cerebral and renal rSO₂ using near-infrared spectroscopy and calculated fractional tissue oxygen extraction (FTOE). Results: Nineteen infants with LSOL, admitted to the NICU between 0 and 28 days after birth, were included. Infants with antegrade blood flow (n = 12) and infants with retrograde blood flow in the ascending aorta (n = 7) had similar cerebral rSO₂ and FTOE during both echocardiograms. Only during the first echocardiogram, infants with retrograde blood flow in the ascending aorta had lower renal FTOE (0.14 vs. 0.32, p = 0.04) and tended to have higher renal rSO₂ (80 vs. 65%, p = 0.09). The presence of diastolic backflow in the descending aorta was not associated with cerebral or renal rSO₂ and FTOE during the first (n = 8) as well as the second echocardiogram (n = 10). Conclusions: Retrograde blood flow in the ascending aorta was not associated with cerebral oxygenation, while diastolic backflow in the descending aorta was not associated with renal oxygenation in infants with LSOL.

Blood flow patterns during incremental and steady-state aerobic exercise.

Endothelial shear stress (ESS) is a physiological stimulus for vascular homeostasis, highly dependent on blood flow patterns. Exercise-induced ESS might be beneficial on vascular health. However, it is unclear what type of ESS aerobic exercise (AX) produces. The aims of this study are to characterize exercise-induced blood flow patterns during incremental and steady-state AX. We expect blood flow pattern during exercise will be intensity-dependent and bidirectional. Six college-aged students (2 males and 4 females) were recruited to perform 2 exercise tests on cycle-ergometer. First, an 8-12-min incremental test (test 1) where oxygen uptake (VO2), heart rate (HR), blood pressure (BP), and blood lactate (La) were measured at rest and after each 2-min step. Then, at least 48-hr. after the first test, a 3-step steady state exercise test (test 2) was performed measuring VO2, HR, BP, and La. The three steps were performed at the following exercise intensities according to La: 0-2 mmol/L, 2-4 mmol/L, and 4-6 mmol/L. During both tests, blood flow patterns were determined by high-definition ultrasound and Doppler on the brachial artery. These measurements allowed to determine blood flow velocities and directions during exercise. On test 1 VO2, HR, BP, La, and antegrade blood flow velocity significantly increased in an intensity-dependent manner (repeated measures ANOVA, P<0.05). Retrograde blood flow velocity did not significantly change during test 1. On test 2 all the previous variables significantly increased in an intensity-dependent manner (repeated measures ANOVA, P<0.05). These results support the hypothesis that exercise-induced ESS might be increased in an intensity-dependent way and blood flow patterns during incremental and steady-state exercises include both antegrade and retrograde blood flows.

Initial Experience With the 6-F and 8-F Indigo Thrombectomy System for Acute Renovisceral Occlusive Events

Purpose: To examine the safety and effectiveness of the new large-bore Indigo thrombectomy catheters to treat patients with acute renovisceral occlusion without the need of thrombolytic agents. Methods: Between November 2015 and 2016, 7 consecutive patients (mean age 65±5 years; 5 men) with acute renovisceral artery occlusion were treated with the new large-bore (6-F and 8-F) vacuum-assisted thrombectomy catheters. The occluded vessels were 6 renal arteries and 3 superior mesenteric arteries (SMAs); 5 of the 9 thromboses were in bridging stent-grafts associated with branched endografts. Mean lesion length was 63±36 mm. For the SMA and all bridging stent-grafts, 8-F catheters are routinely used through a brachial access, whereas 6-F aspiration catheters were used in native renal arteries. Technical success was defined as restoration of antegrade blood flow without the need of lysis or alternative thrombectomy/revascularization strategies. Safety endpoints were any in-hospital major adverse events. Pre- and postoperative hemoglobin and hematocrit levels were compared. Results: Technical success was 100% with no major adverse events or fatal bleeding. The mean amount of aspirated blood was 219±97 mL. The mean hemoglobin and hematocrit values were 13.1±2.1 g/dL and 39%±6% prior to and 11.6±2.2 g/dL (p=0.001) and 34%±6% (p<0.0001) directly after the intervention, respectively. Conclusion: The first assessment of the new large-bore Indigo thrombectomy catheters showed them to be an effective and safe lysis-free frontline therapy for acute renovisceral artery occlusion in a small cohort of patients. New users should be fully aware of the potential blood loss during aspiration.

Relationship of Common Vascular Anatomy to Cannulated Catheters.

Superficial veins of the upper extremity are the primary location for placement of peripheral IV catheters (PIVC). It is believed that a significant portion of PIVCs placed may cross or abut valves and branching veins or occlude a significant portion of the vein, limiting the ability to aspirate blood from the PIVC. Two separate clinical investigations using ultrasound were performed to understand the potential interaction between PIVCs and the vein lumen and the venous valves and branches of the superficial veins of the upper extremity. One study with 35 adult volunteers interrogated 210 vein segments where a PIV would likely be placed. A second pediatric study evaluated 35 vein segments central to indwelling PIVCs. The combined data from the two studies showed that over 80% of adult veins and 85% of pediatric veins can properly accommodate 20-gauge and 22-gauge PIVC, respectively. Venous valves are frequent findings, either immediately peripheral to branching veins or at periodic 5 to 7 cm points. Antegrade blood flow can be restricted by a placed PIVC, while retrograde flow is very likely to be restricted by venous valves. Together, these findings may explain the difficulty in reliable aspiration of blood from PIVC.

СЛУЧАЙ УСПЕШНОГО ПРИМЕНЕНИЯ ЧРЕСКОЖНОЙ ВРЕМЕННОЙ ОККЛЮЗИИ ВЕНОЗНОГО СИНУСА СЕРДЦА У БОЛЬНОГО С ОСТРЫМ КОРОНАРНЫМ СИНДРОМОМ С ЭЛЕВАЦИЕЙ СЕГМЕНТА ST ПРИ ОТСУТСТВИИ ГЕМОДИНАМИЧЕСКИ ЗНАЧИМОГО АТЕРОСКЛЕРОТИЧЕСКОГО ПОРАЖЕНИЯ КОРОНАРНЫХ АРТЕРИЙ

The search for new methods of adequate antegrade blood flow restoration in the coronary arteries of patients with acute coronary syndrome with ST-segment elevation (ACSesST) without hemodynamically significant atherosclerotic lesions of the coronary arteries is a poorly studied item. The author gives the clinical example of a patient with ACSesST without hemodynamically significant atherosclerotic lesions of the coronary arteries and deceleration of antegrade blood flow in the area of the anterior descending artery (ADA). Percutaneous temporary occlusion of the coronary sinus was done to the patient during 10 minutes in the balloon catheter «inflation-deflation». The procedure resulted in a positive impact on coronary hemodynamics such as distal coronary spasm cupping, myocardial perfusion improvement and restoration of adequate antegrade blood flow in the pool ADA.

COMPARATIVE RESULTS OF RECOMBINANT NON-IMMUNOGENIC STAPHYLOKINASE AND TENECTEPLASE USE IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION IN REAL CLINICAL PRACTICE

Aim . To compare the efficacy and safety of thrombolytic therapy with recombinant non-immunogenic staphylokinase and tenecteplase in ST elevation myocardial infarction (STEMI) in real clinical practice. Material and methods . 84 patients with onset of STEMI symptoms up to 12 hours ago were included into the non-experimental study with mixed design. Recombinant non-immunogenic staphylokinase and tenecteplase were used in 38 and 46 patients, respectively. The dynamics of the ST segment on the ECG, angiographic reperfusion criteria were evaluated as well as clinical outcomes – mortality, reinfarction, stroke, bleeding and allergic reactions. Results . The ST-segment resolution by 70% after 180 min was achieved in 66% and 66% of patients in recombinant non-immunogenic staphylokinase group and in tenecteplase group, respectively (p=0.66) as well as antegrade coronary blood flow through the infarct-related artery TIMI II-III in 61% and 67% of patients, respectively (p=0.63). Mortality and the rate of reinfarction, intracranial bleeding, stroke, cardiogenic shock, left ventricle aneurism and thrombosis were similar in both groups. Large bleeding (otherwise intracranial one) and allergic reactions were not registered. Conclusion . In real clinical practice the efficacy and safety of recombinant non-immunogenic staphylokinase and tenecteplase in STEMI are similar.

RESULTS OF HOSPITAL USE OF RECOMBINANT NON-IMMUNOGENIC STAPHYLOKINASE IN PATIENTS WITH ST-ELEVATED MYOCARDIAL INFARCTION

Aim. To assess effectiveness and safety of the hospital use of recombinant non-immunogenic staphylokinase in patients with acute ST-elevated myocardial infarction (STEMI). Material and methods . Recombinant non-immunogenic staphylokinase was administered during in-hospital stage of treatment of 93 patients with acute STEMI, followed by clinical and electrocardiographic assessment and angiographic verification of the degree of blood flow in the infarct-related coronary artery. Hemorrhagic complications, allergic reactions, and hospital mortality were also considered. Results. When monitoring electrocardiogram after 90 minutes from the first bolus of recombinant non-immunogenic staphylokinase, the decrease of ST segment by 50% to the isoline was found in 93.5% of patients. Intracranial and extra brain major and small bleedings were not observed, as well as allergic reactions. In the group of patients who underwent coronary angiography (n=15), antegrade blood flow TIMI 3 was visualized in 100% of cases. Hospital mortality was 6%. Conclusion. Modern thrombolytic drug of recombinant non-immunogenic staphylokinase demonstrated high effectiveness in recovery of blood flow in the infarct-related coronary artery, hemorrhagic safety, and easy to use in the bolus administration.

THE RESULTS OF DELAYED ENDOVASCULAR INTERVENTION IN ST ELEVATION ACUTE MYOCARDIAL INFARCTION DUE TO THROMBOTIC OCCLUSION OF CORONARY ARTERY

Aim . To study clinical results and safety of delayed vs urgent stenting with application of modern antithrombotic drugs in massive coronary thrombosis in patients with ST-elevation acute myocardial infarction (STEMI). Material and methods . Totally, 28 STEMI patients included, age 52 (25-77) y.o., of those males 80% (n=23), who, during January 2014 to February 2016, in first 6-12 hours from the onset of the disease, received endovascular treatment with purpose to recover adequate blood flow without urgent stent implanting into infarct-related artery. Minimal invasive strategy with the aim to recover antegrade blood flow up to TIMI 2-3 was done for 14 (50%) patients. In all patients, after restoring of the antegrade flow, there was thrombus, visualized in artery lumen, with TIMI thrombus grade score (TTG) ≥3. Another criteria of efficacy was resolving of ST elevation by ≥50%. As antiplatelet support during the intervention all patients received the combination of IIb/IIIa blockers (eptifibatide) and 600 mg clopidogrel or 180 mg ticagrelor. Second coronary arteriography (CAG) was done in up to 5 days. Results. By 4,0±1,0 day, blood flow TIMI 2-3 in infarction-related artery was secure in 100% patients; there was marked decrease of the grade of target stenosis in infarction-related artery from 77,8±10,2% to 50,5±19,5%; decrease by its length from 21,5±8,5 to 15,5±5,5 mm; increase of the reference diameter of artery from 3,1±0,8 to 3,5±0,75 mm, and thrombosis bride by TTG — from 3,9 to 0,9. By the data from CAG, stenting of the target segment was done in 8 (29%) patients, and in 3 (10%) stenting done based on the data from intravascular ultrasound. In 17 (61%) patients the infarction-related stenosis was non-significant. In the group of delayed stenting there was no cases of no/slow-reflow development. At hospital stage of management, there were no cardiovascular events in the observation group. Conclusion. In patients with massive thrombosis of infarction-related artery (TTG ≥3) and restored antegrade coronary flow TIMI 2-3, the delayed stenting is a safe and effective strategy of treatment at hospital stage.

Percutaneous transhepatic obliteration and percutaneous transhepatic sclerotherapy for intractable hepatic encephalopathy and gastric varices improves the hepatic function reserve.

Percutaneous transhepatic obliteration (PTO) and percutaneous transhepatic sclerotherapy (PTS) are widely performed as an emergency measure in cases of variceal hemorrhage and intractable hepatic encephalopathy. The PTO/PTS technique is capable of directly blocking the blood supply in cases in which balloon-occluded retrograde transvenous obliteration (B-RTO) is not effective, or in cases with complicated collateral flow. Although PTO/PTS is not currently the first choice due to the invasiveness of transhepatic puncture, this procedure can modify the blood flow in an antegrade manner. The present study examined the changes in hepatic function reserve following PTO/PTS for intractable hepatic encephalopathy and/or gastric varices. In total, the study included 37 patients (mean age, 61.75±12.77 years; age range, 32-88 years; male to female ratio, 23:14) with a variety of gastrorenal shunts, or B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts. The patients underwent PTO/PTS by embolizing a microcoil or injection of a sclerosing agent (5% ethanolamine oleate iopamidol). Alterations in hepatic function reserve prior to and following the procedure were compared. The patients were treated for hepatic encephalopathy in 11 patients, gastric varices in 19 patients, and both conditions in 7 patients. The results indicated that the blood ammonia level improved from 135.76±75.23 mg/dl to 88.00±42.16 and 61.81±33.75 mg/dl at 3 and 6 months after therapy, respectively. In addition, the Child-Pugh score improved from 8.48±2.01 prior to therapy to 7.70±1.84 and 7.22±2.01 at 3 and 6 months after the procedure, respectively. Although there was a concern that PTO/PTS may cause complications due to an increase in portal venous pressure (PVP) arising from shunt occlusion, no severe complications were observed. In conclusion, for patients with various gastrorenal shunts or those with B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts, PTO/PTS can improve the antegrade blood flow to the liver, as demonstrated by improvement in the hepatic function reserve.

Neurologic Injury Associated with Rewarming from Hypothermia: Is Mild Hypothermia on Bypass Better than Deep Hypothermic Circulatory Arrest?

Many known risk factors for adverse cardiovascular and neurological outcomes in children with congenital heart defects (CHD) are not modifiable; however, the temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered in an attempt to improve long-term neurological outcomes. Deep hypothermic circulatory arrest, traditionally used for aortic arch repair, has been associated with short-term and long-term neurologic sequelae. Therefore, there is a rising interest in using moderate hypothermia with selective antegrade cerebral blood flow on CPB during aortic arch repair. Rewarming from moderate-to-deep hypothermia has been shown to be associated with neuronal injury, neuroinflammation, and loss of cerebrovascular autoregulation. A significantly lesser degree of rewarming is required following mild (33–35°C) hypothermia as compared with moderate (28–32°C), deep (21–27°C), and profound (less than 20°C) hypothermia. Therefore, we believe that mild hypothermia is associated with a lower risk of rewarming-induced neurologic injury. We hypothesize that mild hypothermia with selective antegrade cerebral perfusion during CPB for neonatal aortic arch repair would be associated with improved neurologic outcome.

Damage to Cranial Extension of the Small Saphenous Vein and Vein of Giacomini in Lower Limb Varicose Vein Disease

Abstract. The vein of Giacomini is often identified with the cranial extension of the small saphenous vein despite the fact that according to the international interdisciplinary anatomical nomenclature they are distinguished from one another.The objective of the research was to improve the results of treatment of patients with lower limb primary chronic venous disease disease studying the variation in anatomy and pathology of the vein of Giacomini and the cranial extension of the small saphenous vein with subsequent development of differential surgical tactics.Materials and methods. 502 patients with primary chronic venous disease on 605 legs were examined and treated. Each patient underwent preoperative ultrasonographic triplex scanning of the lower limb venous system.Results. Varicose dilatation of the vein of Giacomini was observed in 3.8% of patients (95% CI 2.4-5.6 %), and the pathology of the cranial extension of the small saphenous vein was detected in 1.7% of patients (95% CI 0.8-3.0%). When the arch of the small saphenous vein was present the following variations in the pathology of the vein of Giacomini were observed: 1) the spread of reflux from the great saphenous vein to the vein of Giacomini; 2) reflux from the terminal valve of the small saphenous vein intensified the antegrade flow of blood within the vein of Giacomini resulting in reflux in the great saphenous vein distal to the point where the vein of Giacomini drained into the great saphenous vein. The causes of failure of the valves in the trunk of the cranial extension of the small saphenous vein included: 1) reflux from the ostium of the cranial extension of the small saphenous vein; 2) perforating vein reflux; 3) reflux from the terminal valve of the small saphenous vein.Conclusions. The pathology of the vein of Giacomini and the cranial extension of the small saphenous vein is not homogeneous; therefore, surgical tactics in every patient has to be hemodynamically justified and differentiated depending on the pathways of pathological reflux spreading.

Investigation of the pressure gradient of embolic protection devices

Abstract To avoid debris coming to the cerebral vessels during carotid artery stenting, embolic protection devices (EPD) are placed in front of the lesion. To evaluate their influence on the antegrade blood flow a test setup with a silicone tube simulating the internal carotid artery is realized. The pressure gradient of five different EPD was measured while particles were brought into the circuit and were caught by the systems. Additionally the microscopic structure of the systems was observed to correlate the morphology and the pressure gradient. The FiberNet device had the lowest pressure gradient. It was the only system that consists of fibers contrary to the systems RX Accunet, Angioguard RX, FilterWireEZ and EmboshieldNAV that contain porous membranes.

Complete Ipsilateral Femoral Approach Using an Iliac Branch Device to Preserve a Sole Internal Iliac Artery After Aortic Stent-Graft Placement

Purpose: To report implantation of an iliac branch device (IBD) for preserving antegrade blood flow to a sole internal iliac artery (IIA) via an ipsilateral approach during endovascular repair to reline an aortobi-iliac allograft. Technique: The technique is described in a 55-year-old man with an enteric fistula involving an aortobi-iliac Y-prosthesis. After complete excision, the prosthesis was replaced by an allograft. Due to rebleeding and resuturing of the graft, total stent-graft relining of the allograft was planned with preservation of the sole left IIA using an iliac side branch (ZBIS). During introduction of a 12-F sheath over the allograft’s neobifurcation to establish a femorofemoral through-and-through approach, the allograft ruptured. A compliant balloon was inflated to control the hemorrhage. The IBD was first fully deployed, followed by stent-graft relining. Consequently, stent-graft implantation in the left IIA using a crossover maneuver was no longer feasible, so a 0.035-inch super stiff wire was introduced through the IBD’s 20-F sheath. A 12-mm semi-compliant balloon was inflated in the common iliac artery above the iliac branch to act as an abutment for a 7-F sheath to run over the stiff wire into the IIA for delivery/deployment of a stent-graft. Conclusion: It is feasible to use a complete ipsilateral femoral approach for IBD implantation after aortic stent-graft placement.

The direct aortic cannulation for acute type A aortic dissection.

This article describes the surgical techniques demonstrated in our video, “The Direct Aortic Cannulation for Acute type A Aortic Dissection”. Acute type A aortic dissection is a life-threatening condition requiring emergency operation. The choice of arterial cannulation sites to institute cardiopulmonary bypass is still a topic of controversy. Central cannulation directly through the ascending aorta has been reported (1,2). It has a theoretical advantage of not changing the natural antegrade blood flow, and in doing so avoiding intraoperative malperfusion. We believe that accurate positioning of the tip of an arterial cannula is best achieved with epiaortic echo guidance. We use the Seldinger method through the non-dissected part of the aortic wall in most cases, usually via the left side of the ascending aorta. In the current video presentation (Video 1), only the small posterior aspect was not dissected. The case was also complicated by intermittent myocardial ischemia, bicuspid aortic valve and significantly dilated ascending aorta. Video 1 The direct aortic cannulation for acute type A aortic dissection. Here we describe in detail our surgical technique for direct aortic cannulation by the Seldinger method with epiaortic guidance.

Roentengen-endovascular method of cerebral blood flow restoration in acute tandem occlusion of the internal carotid artery with embolism development in the middle cerebral artery

Aim. This article proposes a roentgen-endosurgical method of performing intracranial arteries revascularization in acute tandem occlusion of the internal carotid artery with the distal embolism development in the middle cerebral artery.Methods. In the period from 2007 to 2014 endovascular revascularization in the internal carotid artery acute thrombosis was performed in 18 patients. Tandem occlusion of the cervical, petrous, cavernous and terminal segments of the internal carotid artery (53.3%) was the most commonly diagnosed. Isolated occlusion of the internal carotid artery cervical segment was determined in 5 (33.3%) patients, of the terminal segment - in 3 (20%) cases. L- and T-types occlusion of the internal carotid artery terminal segment thrombosis frequency were comparable and amounted to 20%. In 5 patients the internal carotid artery tandem occlusion with the distal embolism development in the middle cerebral artery occurred. In this type of injury a method for blood flow restoration in middle cerebral artery without restoring antegrade blood flow in the internal carotid artery was developed and applied.Results. Full blood flow restoration in the middle cerebral artery using this method was achieved in these patients in all cases. Complications associated with the intervention were not registered.Conclusion. The proposed method can be used in patients with the internal carotid artery acute tandem occlusion and the distal embolism development in the middle cerebral artery; the use of this type of revascularization is possible in patients with well-developed communicating arteries that can provide an adequate perfusion volume in the middle cerebral artery.

Influence of passive stretch on muscle blood flow, oxygenation and central cardiovascular responses in healthy young males.

The aim of this study was to examine the effect of skeletal muscle stretching on peripheral, central, and autonomic cardiovascular responses in humans. Twelve healthy males completed a controlled passive stretch of the plantar flexors for 4 min at three different intensities. Doppler ultrasound velocimetry and imaging techniques assessed mean leg blood flow (MLBF), antegrade blood flow, and retrograde blood flow of the popliteal artery. Near-infrared spectroscopy assessed the concentration of deoxygenated hemoglobin + myoglobin ([HHb]) and the sum of its deoxygenated and oxygenated forms [i.e., blood volume ([Hbtot])]. Heart rate (HR) and mean arterial pressure were measured simultaneously to peripheral hemodynamic responses. During stretch there was an increase (P < 0.05) in antegrade and retrograde blood flow along with [HHb] and [Hbtot] relative to baseline, whereas MLBF was not altered. HR increased (P < 0.01) in a stretch intensity- and time-dependent manner, suggesting a threshold tension must be met that results in a mechanoreflex-mediated increase in HR. After stretch there was an increase (P < 0.05) in [Hbtot] and MLBF in each condition, suggesting that stretch creates a poststretch hyperemic response. Furthermore, retrograde blood flow was decreased (P < 0.05) after stretch in each stretch condition. Mean arterial pressure was decreased (P < 0.05) after moderate-intensity stretching. Collectively, our data provide novel mechanistic evidence on cardiovascular responses to skeletal muscle stretching in humans. Moreover, the reductions in MAP and retrograde blood flow suggest that stretch transiently reduces myogenic vascular tone in a poststretch resting period.

Alternative cannulation techniques in surgical repair for acute type A aortic dissection

In this issue of the European Research Journal, Yalcin et al. [1] reported an experience with ascending aorta cannulation for surgical repair in a case with acute type A aortic dissection (AAAD). This presentation raises many questions that should be answered by the authors. They reported direct true lumen cannulation of the ascending aorta under visual control but this technique has not clearly been explained in detail. How was the aortic cannula introduced? What was arterial systolic pressure before procedure? Was venous exsanguination from the right atrium performed? The answers to these questions have not been explicitly stated in the text. Another very important issue is cerebral protection. There is also no an information about protection of the brain during the open distal anastomosis. The technique has not satisfactorily been discussed. Despite all these shortcomings, the authors are to be congratulated on their successful dissection repair with this technique and for bringing it to our attention. I would also like to share additional comments on alternative cannulation techniques for arterial inflow in these complicated patients. AAAD is one of the life-threatening cardiovascular conditions and associated with an increased risk of mortality and morbidity. It requires immediate surgical intervention to avoid catastrophic complications such as aortic rupture or organ malperfusion (brain or visceral). The most important stages for succesful surgical treatment of AAAD include the excision of the primary entry tear in the aorta, the elimination of aortic valve insufficiency, and the establishment of the true lumen flow to correct the distal malperfusion [2]. The best arterial cannulation site for a prompt induction of CPB in surgical repair of AAAD remains controversial [3]. The most important objective for the arterial cannulation in this lethal condition is to allow antegrade blood flow through the true lumen. The choice of arterial inflow site is influenced by many factors including hemodynamic instability (cardiac tamponade or shock), the presence of malperfusion, the extent of dissection, possible involvement of the cannulation site, peripheral vascular disease, a history of stroke, the patient’s age or the preference of the surgeon. Many different inflow sites for arterial cannulation have been described. Possible access points for cannulation include the femoral artery, the axillary artery, the brachial artery, the innominate artery, the carotid artery, the subclavian artery, the ascending aorta, the transverse arch of the aorta, and the left ventricular apex. Each cannulation site has both the advantages and disadvantages [3]. In current cardiovascular practice, the femoral arteries and the axillary arteries are the most commonly used cannulation sites for repair of AAAD. Excellent results have been reported with these arterial inflow sites [4-6]. Femoral artery cannulation is the standard cannulation technique and allows for the rapid institution of CPB in hemodynamically unstable patients with AAAD. However, it has disadvantages of retrograde arterial perfusion such as an increased risk of retrograde cerebral embolization due to atherosclerotic debris or thrombus in the descending

Uncontrolled Antegrade Pulmonary Blood Flow and Delayed Fontan Completion After the Bidirectional Glenn Procedure: Real-World Outcomes in China

Given the low rate of Fontan completion, an aggressive policy for maintaining antegrade pulmonary blood flow (AnPBF) during the bidirectional Glenn procedure (BDG) was developed for the functional single ventricle. From 2008 to 2013, 294 patients who underwent the BDG were divided into two groups: group 1 (uncontrolled AnPBF, n = 270) and group 2 (controlled AnPBF, n = 24). Pulmonary artery banding was performed because of the high central venous pressure in group 2. In group 1, the patients who underwent BDG from 2008 to 2012 were further divided into group DF (delayed Fontan completion, n = 109) and group FC (Fontan completion, n = 42). The Fontan completion rate was 16.3%, and the average interval time was 2.2 ± 1.1 years. The delay of Fontan completion did not reduce body weight gain or the survival rate. Furthermore, oxygen saturation was slightly reduced in group DF. Although no impairments of heart function were observed, the uncontrolled AnPBF in group DF resulted in an increase in ventricular end-diastolic diameter and aggravation of atrioventricular valve regurgitation over 24 months after BDG. Logistic regression analysis revealed that systemic right ventricular morphology was a risk factor for the aggravation of valve regurgitation. The low Fontan achievement rate is a critical issue in China. Although the patients with delayed Fontan completion exhibited an acceptable survival rate and acceptable body weight gain, uncontrolled AnPBF was associated with ventricular enlargement and aggravation of valve regurgitation. Strategies for improving the Fontan completion rate in China should be explored and could benefit outcomes.

Abstract 17047: Pathophysiologic Progression From the Second to Third Trimester in Fetuses With Ebstein's Anomaly or Tricuspid Valve Dysplasia: Are Early Echocardiographic Features Reliable Indicators of Late Gestation Status?

Background: Ebstein’s anomaly and tricuspid valve dysplasia (EA/TVD) are associated with high perinatal mortality. Poor hemodynamic status in both early and late gestation is associated with worse outcome. However, it is not known whether EA/TVD fetuses with more favorable physiology earlier in gestation progress to more severe disease in 3 rd trimester. The goal of this study was to evaluate whether initial echocardiographic indices in fetuses with EA/TVD presenting at gestational age (GA) &lt;24 wks are reliable indicators of physiologic status later in pregnancy. Methods: This multi-center, retrospective study included fetuses diagnosed with EA/TVD from 2005-11 at 23 centers. Patients with initial diagnosis at &lt;24 wks gestation and with ≥2 fetal echocardiograms ≥4 wks apart were included. A core laboratory analyzed the echocardiograms. Markers of poor outcome were defined as absence of antegrade flow across the pulmonary valve, pulmonary valve regurgitation (PR), cardiothoracic ratio &gt;0.48, left ventricular (LV) dysfunction or TV annulus Z score &gt;5.6. Results: The study included 51 fetuses. Median GA at diagnosis was 21 wks [18-24], and the median duration from 2 nd to 3 rd trimester echocardiograms was 12 wks [4-18]. There were 21 fetuses (41%) with &gt;2 markers of poor outcome at &lt;24 wks, which increased to 32 (63%) in later gestation (p=0.001). Nine of 27 fetuses (33%) with antegrade pulmonary blood flow on first echocardiogram developed anatomic or functional pulmonary atresia during follow-up, and 7 of 39 fetuses (18%) without PR initially developed it later. LV dysfunction was present in 2 patients at &lt;24 wks but present in 14 (37%) later (p&lt;0.01). The only variable associated with worsening physiology, from &lt;2 markers of poor outcome in 2 nd trimester to ≥2 markers in 3 rd trimester, was larger TV annulus Z-score (4.1±1.0 vs. 2.4±1.9, p=0.008). Conclusion: These results confirm a wide spectrum of disease presentation and progression in fetuses with EA/TVD. Thus, it is imperative to assess these fetuses serially. In this cohort, there were no early markers of progression other than larger TV annulus Z-score. Great care must be taken in counseling prior to 24 wks, as the absence of factors associated with poor outcome early in pregnancy may be falsely reassuring.

Non-transecting anastomotic urethroplasty (surgical atlas)

Non-transecting anastomotic urethroplasty – is three types of urethroplasty, which are united on the principle resection of bulbar urethra with sparing of corpus spongiosum and antegrade blood flow through it. The article describes the surgical technique of urethroplasty: dorsal strictureplasty by Heineke–Mikulicz; strictureplasty by Mundy; vessel-sparing anastomotic urethroplasty by Jordan. Obligatory conditions of the non-transecting anastomotic urethroplasty are a non traumatic etiology, length of the stricture not more than 1–1.5 cm, and its localization in the proximal bulbar urethra. Strictureplasty by Heineke–Mikulicz is a dorsal longitudinal incision of the urethra on the area of stricture and subsequent suturing the defect transversely. Strictureplasty by Mundy is a dorsal longitudinal urethrotomy, excision of the affected mucosa inside the lumen of the urethra and transversely urethral closure according to Heineke–Mikulicz, s principle. Vessel-sparing anastomotic urethroplasty by Jordan is circular excision of the urethral mucosa without crossing of corpus spongiosum and incoming into it bulbar arteries and thereby preserving the antegrade blood flow through the urethra.