Arterial Duct Research Articles

Возможность двухэтапной хирургической коррекции открытого артериального протока, осложненного высокой легочной гипертензией, у 35-летней пациентки

Возможность двухэтапной хирургической коррекции открытого артериального протока, осложненного высокой легочной гипертензией, у 35-летней пациентки

Anomalous aortic origin of the pulmonary arteries: Case series and literature review.

Anomalous origin of the pulmonary arteries from the ascending aorta is a rare, but severe clinical entity necessitating a scrupulous evaluation. Either the right or the left pulmonary arteries can arise directly from the ascending aorta while the other pulmonary artery retains its origin from the right ventricular outflow tract. Such a finding can be isolated or can coexist with several congenital heart lesions. Direct intrapericardial aortic origin, however, must be distinguished with origin through a persistently patent arterial duct. In the current era, clinical manifestations usually become evident in the newborn rather than during infancy, as used to be the case. They include respiratory distress or congestive heart failure due to increased pulmonary flow and poor feeding. The rate of survival has now increased due to early diagnosis and prompt surgical repair, should now be expected to be at least 95%. We have treated four neonates with this lesion over the past 7 years, all of whom survived surgical repair. Right ventricular systolic pressure was significantly decreased at follow-up. Our choice of treatment was to translocate the anomalous pulmonary artery in end-to-side fashion to the pulmonary trunk. Our aim in this report is to update an Italian experience in the diagnosis and treatment of anomalous direct origin of one pulmonary artery from the aorta, adding considerations on the lessons learned from our most recent review of the salient literature.

Unilateral unidirectional superior cavopulmonary anastomosis in a patient with bilateral superior caval veins and atretic left pulmonary artery.

A unidirectional superior cavopulmonary anastomosis was performed on the right side in a patient with a functionally univentricular heart, atresia of main and left pulmonary artery, bilateral superior caval veins, and a patent arterial duct in the right pulmonary artery. Anastomosis of the left superior caval vein to the right superior caval vein created a neo-innominate vein without using prosthetic material.

SURGICAL TREATMENT OF OPEN DUCTUS ARTERIOSUS IN PREMATURE INFANTS

The choice of tactics for the treatment of open arterial duct (OAD) in newborns is one of the most controversial and debatable topics in neonatal medicine. There are several approaches in the treatment of OAD in small infants: 1) the prophylactic use of cyclooxygenase inhibitors; 2) treatment on the background of maintenance therapy without the medical and surgical intervention; 3) drug stimulation of the closure of the AOA; 4) surgical intervention. Surgical treatment, which can be done with the aid of the open surgery and thoracoscopy, still plays a leading role. Complications associated directly with the operation are minimal. In this study, we present a review of the literature, including current information on the most frequent complications arising from the surgical treatment of OAD in newborns - damage to the lungs with the development of pneumothorax, damage to the great vessels with circulatory disorders, wound to the left phrenic nerve followed by paresis of the left diaphragm dome, damage to the recurrent nerve with impaired function of the left vocal cords, damage to the thoracic lymphatic duct with the development of chylothorax, damage to the muscles with development of functional scoliosis. Special attention is paid to the prognosis of the course of the disease and the survival rate of low birth weight infants.

Fulminant cytomegalovirus myocarditis in an infant with concomitant large atrial and ventricular septal defects: medical intervention strategy for functional cardiac regeneration.

A cytomegalovirus-associated heart failure in a young infant with atrial and ventricular septal defects is reported in this case report. The patient recovered by an anti-congestive and anti-viral therapy with an extra percutaneous transcatheter treatment strategy. In the context of bi-ventricular predominant right heart failure associated with supra-systemic pulmonary hypertension, the already closed arterial duct was re-opened and stented to unload the right ventricle and thereby augment the systemic blood flow. Either the left-to-right shunting atrial septal defect or bi-directional shunting ventricular septal defect was involved in the disease process and was not able to avoid global heart failure. After clinical improvement, the stented duct was shunted left-to-right and was occluded with an ADO-II-AS. During the same procedure the atrial septal defect was closed with an Amplatzer-ASD occluder, while the peri-membranous ventricular septal defect was closed with an ADO-II occluder 2 months later.

USING EARLY CAFETINE CITRATE IN NEONATAL PRACTICE: INTERNATIONAL EXPERIENCE (LITERATURE REVIEW)

There is growing evidence of the benefits of caffeine citrate in premature newborns with respiratory distress syndrome. However, there are no official recommendations regarding the exact time of initiation of therapy in the literature.The article presents the results of systematic reviews and meta-analyzes assessing the therapeutic results of the use of (triggered before 3 days of life) and late caffeine citrate in preterm infants. The main results of the research were bronchopulmonary dysplasia and mortality.All data from systematic reviews and meta-analyzes published during 2015–2017 were devoted to studying the effects of administration of caffeine citrate to premature babies with an age of ≤ 32 weeks of gestation and very low birth weight. Despite the fact that in all of the reviewed studies, the benefits obtained earlier or later were revealed, they differed at the beginning of the treatment with caffeine. Most often, early treatment was defined as treatment started during the first 3 days of life. However, in clinical practice, the threshold for early treatment of caffeine is constantly shifted to an earlier appointment during the first hours of life. Previously proven that earlier therapy has a positive effect on reducing the frequency of bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy and the need for treatment of open arterial duct without increasing the risk of necrotizing enterocolitis, reducing the duration of mechanical ventilation and reducing the proportion of children who need home oxygen therapy.

Przemieszczenie implantu do gałęzi tętnicy płucnej jako wczesne powikłanie przezskórnego zamknięcia przetrwałego przewodu tętniczego u noworodka

Device displacement with pulmonary artery embolisation (PDA) is a rare complication after percutaneous closure of a patent arterial duct. An 11-day old neonate with PDA was admitted to the Department of Paediatric Cardiac Surgery for treatment. The newborn was qualified for a transcatheter closure of PDA. Device displacement to the pulmonary artery was observed during the procedure. The patient was qualified for a surgical procedure of PDA closure, with removal of the implant via midline sternotomy to provide an additional safeguard with extracorporeal circulation. The procedure and early postoperative course were uneventful. The patient was discharged home in good general condition. Interventional cardiology can provide effective minimally-invasive solutions for congenital heart disease treatment, but there is always a risk of potentially life-threatening complications.

RF25 HYBRID PALLIATION ALLOWS THE HYPOPLASTIC LEFT VENTRICLE FOR A CHANCE OF BIVENTRICULAR REPAIR: ECHO-SURVEILLANCE ON LEFT HEART GROWTH

Background: Several parameters of LV adequacy are available, however, it is now clear that the timing of decision plays a crucial role in the fate of the borderline LV, because the longer the ventricle is allowed to grow, the higher the probability to achieve functional independence. Aim of the study: Our aim is to describe the growth potential of borderline left ventricles after pulmonary arteries banding (PAB) and arterial duct stenting (ADS). Methods: 44 patients (mean weight 3 Kg, from 1,9 to 4,2 Kg), who were born with different hypoplastic LV variants underwent hybrid palliation at 3,6 days (1 to 7) in our institution between October 2011 and January 2018. We divided 36 patients into 3 groups according to the severity of LV hypoplasia: 14 pts with MA or MS and AoA, who are not supposed to show any growth of LH structures over time, 6 pts with IAoA and VSD whose LV is usually suitable for biventricular repair, and 16 pts with intermediate features. The latter group included pts with MS/AS, right unbalanced AVSD or Shone complex, all of them with severely underdeveloped LV, expressed by LV mass below -2 Z scores. Among this 16 pts we further distinguished three subgroups, according to the subsequent surgical treatment they underwent after the interstage period and potential LV growth: group 1 had single ventricle staged palliation (5 patients), group 2 biventricular repair (8 patients) and group 3 early death occurrence (3 patients). Two-dimensional echocardiograms of patients from group 1 and 2 were retrospectively reviewed, comparing examination recorded at birth with those obtained 4 months after hybrid palliation. Results: Aortic annulus, aortic root, mitral and tricuspid annulus, LV systolic and diastolic dimension, systo-diastolic volumes and mass, LV long-axis to heart long-axis ratio (LAR), transverse and distal arch and aortic isthmus diameters were used. LV mass and volumes are critically small in both groups at birth. Although a trend towards growth can be seen for almost all the analyzed parameters, a significant change of LV mass and volumes from pre- to post-hybrid procedure is evident in group 2, which is absent in group 1. Conversely, parameters like aortic annulus, aortic root and LAR in group 1, already at birth, were significantly smaller than they were in group 2. Conclusion: The goal in the treatment of borderline LV is to postpone the decision until the time LV has fully expressed its growth potential: then, many more biventricular repairs will be reached than at the time of first evaluation.

Acquired von Willebrand syndrome in congenital heart disease surgery: results from an observational case‐series

Essentials Bleeding complications during congenital heart disease surgery in neonatal age are very common. We report the perioperative incidence of acquired von Willebrand syndrome (aVWS) in 12 infants. aVWS was detected in 8 out of 12 neonates and infants intraoperatively after cardiopulmonary bypass. Ten patients received von Willebrand factor concentrate intraoperatively and tolerated it well. SUMMARY: Background Cardiac surgery of the newborn and infant with complex congenital heart disease (CHD) is associated with a high rate of intraoperative bleeding complications. CHD-related anatomic features such as valve stenoses or patent arterial ducts can lead to enhanced shear stress in the blood stream and thus cause acquired von Willebrand syndrome (aVWS). Objective To evaluate the intraoperative incidence and impact of aVWS after cardiopulmonary bypass (CPB) in neonates and infants with complex CHD. Patients/Methods We conducted a survey of patients aged <12months undergoing complex cardiac surgery in our tertiary referral center. Twelve patients, whose blood samples were analyzed for aVWS before CPB and immediately after discontinuation of CPB on a routine basis, were eligible for the analysis. von Willebrand factor antigen (VWF:Ag), ristocetin cofactor activity (VWF:RCo), collagen binding activity (VWF:CB), VWF:multimers and factor VIII activity (FVIII:C) were determined. Results aVWS was diagnosed by VWF multimer analysis in 10 out of 12 patients (83%) prior to surgery and intraoperatively at the end of CPB in 8 out of 12 patients (66%). Ten patients received VWF/FVIII concentrate intraoperatively as individual treatment attempts during uncontrolled bleeding. They tolerated it well without intraoperative thrombotic events. One patient suffered a transient postoperative cerebral sinuous vein thrombosis. Conclusions aVWS is of underestimated incidence in complex CHD surgery. These data may offer a new approach to reduce the risk of severe bleedings and to achieve hemostasis during high-risk pediatric cardiac surgery by tailoring the substitution with von Willebrand factor concentrate.

GW29-e1700 A pulmonary artery aneurysm with patent arterial duct and secondary to infection

A twenty-year-old woman was admitted for patent arterial duct (PDA) ligation surgery in Oct 2014. She was hospitalized 8 months earlier due to high fever, cough, exertional dyspnea, staphylococcal aureus endocarditis, and received antibiotic treatment. In the recent admission, a grade 3/6 continuous

THE EFFECT OF HYPOXIC BRAIN DAMAGE ON THE SURVIVAL OF PREMATURE INFANTS

The central nervous system injuries are a common neonatal pathology, hypoxia being one of the main causes of cerebral dysfunction. The purpose of this study was studying the incidence of hypoxic cerebral disorders in premature infants with an extremely low body weight and a very low birth weight and revealing the risk factors that adversely affected the disease outcome. The subject of the study was preterm infants whose gestational age did not exceed 31 weeks. The main criterion for inclusion into the study was the presence of hypoxic-ischemic and hypoxic-hemorrhagic brain damage. To reveal the perinatal risk factors, the somatic health of mothers, and pregnancy and childbirth peculiarities were studied. The structure of children’s pathology and intensive care techniques were analyzed. Cerebral disorders were verified in 42 out of 176 patients (23.5 %). 2–3rd-degree intraventricular hemorrhage was diagnosed in 34 newborns (80.9 %), severe ischemia in 8 children (19.1 %). To determine the structure of the disease outcome, all children were divided into deceased and survivors. A fatal outcome was observed in 14 cases (33.3 %). The mothers of deceased children were more likely to have obstetric and concomitant extragenital pathologies. Analysis of pediatric pathology showed that the hemodynamically significant functioning arterial duct and severe asphyxia in childbirth were much more frequent in deceased children. Intensive therapy of deceased children included «hard» parameters of artificial ventilation and high doses of cardiotonic drugs. Thus the presented risk factors can be considered as predictors of an unfavorable outcome in children with this pathology.

Prenatal Ultrasonic Diagnosis and Prognostic Analysis of Isolated Left Subclavian Artery (ILSCA) and Left Brachiocephalic Trunk (ILBCT) Malformation.

The purpose of the study was to explore the prognosis, as well as antenatal ultrasonic features of isolated left subclavian artery (ILSCA) and isolated left brachiocephalic trunk (ILBCT) malformations, in order to improve prognosis and provide guidance for prenatal diagnosis. The origin and routing of cephalic and cervical vessels were observed in patients diagnosed with right aortic arch or right arterial duct arch in our hospital from March 2015 to March 2017, and the spectrum features related to ILSCA and ILBCT were analyzed. Fetuses diagnosed as ILSCA, or, and ILBCT were followed up for 3months after birth. At the same time, a literature review was carried out for ILBCT and ILSCA in Pubmed. In our study, two cases with ILSCA and ILBCT were both diagnosed prenatally. They are not accompanied by other congenital malformations or chromosome abnormalities. No abnormality was found during postnatal follow-up except that left radial pulsation was weakened and blood pressure of the left upper limb decreased in baby with ILSCA. In baby with ILBCT, in addition to these abnormal changes, the left common carotid artery pulse disappearance too. In pubmed, three of 12 ILSCA or ILBCT did not have other congenital malformation or chromosome abnormalities. They were not diagnosed until the age of 3, 10, and 47 because of school exams or atypical symptoms, such as headaches, chest pain. Symptom of ILBCT or ILSCA without other abnormality is silent, and therefore they cannot be diagnosed timely after birth prenatal diagnosis is necessary for they can be treated in time.

Prenatal echocardiographic diagnosis of right aortic arch and its branch type

Objective To investigate the value of prenatal echocardiographic diagnosis of anomalies of the right aortic arch(RAA) and its branch type, and provide rapid diagnostic methods. Methods A retrospective analysis of 55 cases of RAA of prenatal ultrasound diagnosis results, and their imaging characteristics were summarized. Results There were 55 cases of anomalies of the RAA, included 42 cases of RAA with aberrant left subclavian artery(RAA-ALSA) and 13 cases of RAA with mirror image branching pattern(RAA-MB), 1 case of double aortic arch(DAA) was misdiagnosed as RAA. The prenatal echocardiographic characteristics of RAA-ALSA: in three-vessel-aortic arch view, the first branch of the aortic arch was the left carotid artery, which ran in front of the trachea, and ALSA ran behind the trachea and esophagus. The prenatal echocardiographic characteristics of RAA-MB: the first branch of the aortic arch was the brachiocephalic trunk, which ran in front of the trachea and was divided to the left carotid artery and the left subclavian artery. Conclusions Prenatal ultrasound can qunickly and accurately diagnose anomalies of the right aortic arch and its branch type according to the direction, thickness and secondary branches of the first branch of the aortic arch. The location of arterial duct is helpful to judge the formation of vascular ring. Key words: Ultrasonography, prenatal; Right aortic arch; Vascular ring

SURGICAL TREATMENT OF OPEN DUCTUS ARTERIOSUS IN PREMATURE INFANTS

The open arterial duct (OAD) means the maintenance of the OAD patency in the postnatal period within 48-72 hours after birth. OAD in preterm infants is of particular importance and often determines their survival. The presence of OAD significantly reduces chances of premature babies to recover, as it contributes to the emergence and aggravation of diseases such as necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), renal dysfunction, intraventricular hemorrhage (IVH), cerebral palsy and, often, the death of a newborn. From this point of view, there is appeared the importance of diagnosis and treatment of OAD in premature newborns to improve the prognosis of life in this category of patients. Until today, there is no generally accepted strategy for treating OAD in premature infants. As a result, in various neonatal centers, even within the same country, doctors adhere to different tactics in the treatment of OAD in premature infants. Surgical correction of the hemodynamically significant OAP is indicated for premature infants dependent on artificial ventilation of the lungs, with lack of the effect of the drug therapy or inability to introduce medication. In this scientific review, 3 technologies of surgical treatment of OAD are discussed: open surgery, thoracoscopy, and endovascular treatment. Special attention is paid to postoperative management of patients and prevention of complications.

Fetal aortic arch and its branches anomalies: prenatal ultrasound, vascular cast and gene detection

Objective To explore the application values of prenatal ultrasound, vascular cast in the diagnosis of fetal aortic arch and its branches anomalies and to analyze the genetic characteristics by gene detection. Methods Twenty-two cases of the vascular cast specimens of the fetal aortic arch and its branches anomalies were analyzed and studied by comparing with their prenatal ultrasonography. Then the characteristics of each type of fetal aortic arch and its branches anomalies, the missed diagnosis and misdiagnosis were summarized and the results of their gene detection were also analyzed. Results The 22 cases of fetal aortic arch and its branches anomalies were as follows: 2 cases of double aortic arch showed the ascending aorta was divided into two branches after converging as the descending aorta. Three cases were left aortic arch with aberrant right subclavian artery. Twelve cases were right aortic arch: 8 cases were right aortic arch with mirror-image branching, 3 cases were right aortic arch with aberrant left subclavian artery, 1 case was right aortic arch with isolated left subclavian artery. Of the 8 right aortic arch with mirror-image branching, 3 cases of left arterial duct showed the vertical walking between the fusion site of the left innominate artery and the pulmonary artery. Right aortic arch with aberrant left subclavian artery with arterial duct showed U shaped vascular ring. Five cases were other types, including 2 cases of the coarctation of aortic arch, 1 case of interrupted aortic arch, 1 case of pulmonary artery sling, and 1 case of abnormal origin of right pulmonary artery. The ultrasonic missed diagnosis were the 6 deformities: 3 cases of arterial duct and 3 cases of aberrant subclavian artery. The ultrasonic misdiagnosis were the 5 deformities: 2 cases of arterial duct location, 1 case of aberrant subclavian artery, 1 case of isolated left subclavian artery, and 1 case of the coarctation of aortic arch. Genetic test results: In the 18 cases of the genetic detection, 2 cases were positive, 1 case was 22q11.2 microdeletion syndrome and 1 case was carrying KMT2D gene variant. Conclusions There are various kinds of fetal aortic arch and its branches anomalies, which are often associated with intracardiac malformations and venous branches variation. And prenatal ultrasound is of great value in diagnosing them.Vascular cast can visually display their characteristic changes, which is helpful to improve the differential diagnosis of the different aortic arch and its branches anomalies. The detailed genetic detection can improve the further understanding of its etiology. Key words: Ultrasonography, prenatal; Fetus; Aortic arch anomalies; Vascular cast; Gene detection

Beneficial Effects of Acetaminophen on the Chemical Mediators Involved in the Closure of Patent Ductus Arteriosus

Paracetamol (N-acetyl- para-aminophenol) also known as acetaminophen is a chemical compound used in medical practice for analgesic and antipyretic effects. The mechanism of action is related to the cyclooxygenase (COX) activity, which is not full inhibit as for nonsteroidal anti-inflammatory. Paracetamol selectively inhibits COX activities in the brain, indirectly by reducing COX, which must be oxidized in order to function. In addition to analgesic and antipyretic effects, modulating the prostaglandin synthesis by selective inhibition of COX, a vascular modulator effect was described recently on the closure of the patent ductus arteriosus (PDA). This effect has been described in premature newborns, perhaps by decreasing the prostaglandin production. We present the case of a neonate, 39 weeks gestational age, normal birth weight who presented in the 10 th day of life with a cardiac murmur. Echocardiography evidenced a hemodynamically significant PDA, left ventricular enlargement, severe mitral regurgitation, patent foramen ovale and pulmonary hypertension. Although she was a 10-day- old full-term neonate paracetamol administration was attempted. Paracetamol was administered orally in the therapeutic dose of 15 mg/kg/dose, three times a day for three days. The effect was significant by reducing the diameter of the arterial duct (~50% of initial diameter), reducing the size of the left cardiac chambers, reducing the degree of mitral regurgitation from severe to mild, and disappearance of pulmonary hypertension. In conclusion, paracetamol use can change prognosis through the vaso-modulator on the PDA, at the age of 10 days, on a full-term neonate with a normal birth weight. This effect may also be present in full-term newborns and not only in preterm. Even if the PDA was not closed after three days, the hemodynamic impact disappeared and the child could avoid surgical ligation.

To the issue of corrosion of occluders from beta-zirconium alloy in experimental study of endovascular devices for the closure of arterial duct

Цель работы — оценить состояние поверхности интактных окклюдеров и ее устойчивость к коррозии при экспериментальном исследовании устройств из b­циркониевого сплава после длительного пребывания их в организме животного. Материалы и методы . Исследования окклюдеров на устойчивость к коррозии проведены in vitro и при внедрении в кровеносное русло свиней как биологической модели. Поверхность интактных устройств и гистологические образцы участков подвздошных артерий вместе с окклюдерами через 1, 3 и 6 месяцев после имплантации исследованы под световым и растровым микроскопами. Результаты и обсуждение . При гистологическом изучении поверхности окклюдеров после их имплантации в артериальное русло свиней на фоне активизации неоинтимы и развивающегося фиброза обнаружены включения инородного материала. Умеренную коррозию материала находили и при микроскопическом исследовании поверхности интактных окклюдеров. После предварительной обработки внедряемых изделий в ультразвуковой ванне микроскопически поверхность интактных окклюдеров покрыта ровным тонким слоем оксидной пленки Zr­Ti, а при имплантации b­циркониевых устройств в организм животного количество инородных включений на гистологических срезах существенно уменьшилось. Выводы . При термической обработке на поверхности изделий из b­циркониевого сплава образуется рыхлая пленка оксида никель­титанового соединения. При имплантации окклюдеров в организм животного частицы оксидной пленки могут отрываться от основного материала, мигрировать с током крови и вызывать (усиливать) реакцию на внедрение инородного тела. Показано, что комбинированная ультразвуковая и химическая очистка окклюдеров позволяет получить гладкую и относительно «чистую» поверхность внедряемых устройств. Изделия из b­циркониевого сплава, прошедшие ультразвуковую обработку, будучи имплантируемыми в просвет сосуда подопытного животного, не вызывают избыточной пролиферации интимы вокруг элементов устройства и дистальнее его локализации.

Reference Ranges for the Size of the Fetal Cardiac Outflow Tracts From 13 to 36 Weeks Gestation

Assessment of the outflow tract views is an integral part of routine fetal cardiac scanning. For some congenital heart defects, notably coarctation of the aorta, pulmonary valve stenosis, and aortic valve stenosis, the size of vessels is important both for diagnosis and prognosis. Existing reference ranges of fetal outflow tracts are derived from a small number of cases. The study population comprised 7945 fetuses at 13 to 36 weeks' gestation with no detectable abnormalities from pregnancies resulting in normal live births. Prospective measurements were taken of (1) the aortic and pulmonary valves in diastole at the largest diameter with the valve closed, (2) the distal transverse aortic arch on the 3 vessel and trachea view beyond the trachea at the distal point at its widest systolic diameter, and (3) the arterial duct on the 3 vessel and trachea view at its widest systolic diameter. Regression analysis, with polynomial terms to assess for linear and nonlinear contributors, was used to establish the relationship between each measurement and gestational age. The measurement for each cardiac diameter was expressed as a z score (difference between observed and expected value divided by the fitted SD corrected for gestational age) and percentile. Analysis included calculation of gestation-specific SDs. Regression equations are provided for the cardiac outflow tracts and for the distal transverse aortic arch:arterial duct ratio. The study established reference ranges for fetal outflow tract measurements at 13 to 36 weeks' gestation that are useful in clinical practice.

A Comparison of Hepatic Artery Reconstruction Using a Surgical Loupe and Operating Microscope During Living Donor Liver Transplantation

Adequate hepatic artery (HA) flow is the most important contributor to proper graft function in living donor liver transplantation (LDLT). Therefore, in most centers, this is performed by an experienced microsurgeon with an operating microscope. However, it takes a long time to learn the skills involved in this microsurgical reconstruction and to gain experience to achieve good outcomes. To simplify this procedure, a transplant surgeon recently performed the procedure using a surgical loupe. This study retrospectively reviewed the outcomes of 218 LDLTs performed in our institution from January 2012 to October 2016. Before September 2014, an experienced microsurgeon reconstructed the HA under an operating microscope and, after that period, a hepatobiliary surgeon with little experience in arterial anastomosis during LDLT performed it using a surgical loupe. A total of 237 LDLTs were performed: 136 in the first period and 101 in the second. The mean time required for the HA reconstruction was shorter in the second period (20.9± 6.9 vs. 24.2 ± 4.3 minutes, P =0.001), while there was no difference in intraoperative arterial revision between the two groups. The incidence of arterial or bile duct complications did not differ significantly between the two groups. In conclusion, HA reconstruction under a surgical loupe can be performed simply by the transplant surgeon with a low complication rate and yields results as good as with operative microscopy, even when the surgeon has less experience with HA anastomosis.

Prenatal interventional therapy in two cases with critical pulmonary stenosis or pulmonary atresia with intact ventricular septum

Objectives: Two cases who underwent fetal pulmonary valvuloplasty (FPV) for pulmonary atresia with intact ventricular septum (PA-IVS) or critical pulmonary stenosis with intact ventricular septum (CPS-IVS) successfully were reported. The aim of the report was to explore the criteria for case selection, the technical essentials of FPV, and the postpartum outcome of the fetus. Methods: One case with PA-IVS and the other with CPS-IVS were enrolled in September 2016 and February 2017 in Guangdong General Hospital, and both cases were diagnosed with severe right ventricular dysplasia and tricuspid regurgitation by fetal echocardiogram. Parameters of right ventricle development and hemodynamics from echocardiography included tricuspid/mitral annulus (TV/MV), right ventricle/left ventricle long-axis (RV/LV), pulmonary/aortic annulus (PV/AV), tricuspid inflow duration/cardiac cycle, degree of tricuspid regurgitation (TR), blood flow direction of arterial duct and ductus venosus. Multidisciplinary team including the maternal-fetal cardiology, pediatric cardiology, cardiac surgery, obstetrics, neonatology and anesthesiology was summoned to discuss the indications and timing of PFV. Two cases underwent ultrasound-guiding trans-abdominal PFV at the 28 weeks of gestational age. Echocardiography was performed to observe the opening and closing of the pulmonary valve, and to evaluate the development of right ventricle and improvement in hemodynamics every 2-4 weeks until delivery. Results: From the technical perspective, pulmonary balloon valvuloplasty was successfully performed in these two cases. The opening of pulmonary valve improved in these two cases at 2-4 weeks after FPV. However, an obvious restenosis was detected in the first case at 5-8 weeks after FPV. In the first case, the echocardiography parameters including TV/MV, RV/LV, PV/AV and tricuspid inflow duration/cardiac cycle increased from 0.56, 0.42, 0.85,0.26 to 0.59, 0.51, 0.87, 0.32 at 5-8 weeks after FPV, respectively. However, the direction of blood flow through the arterial duct was still reverse. In the second case, TV/MV, RV/LV, PV/AV and tricuspid inflow duration/cardiac cycle ratio increased from 0.70, 0.63, 0.91,0.35 to 0.80, 0.80, 0.97, 0.42 at 5-8 weeks after FPV, respectively. The direction of blood flow through the arterial duct changed to bidirectional. Both fetuses were born alive. The first case underwent pulmonary valve commissurotomy and modified Blalock-Taussig shunt on the 8(th) day after delivery and received follow-up for 6 months. The strategy for the next-step therapy was still pending. The second case underwent transcutaneous pulmonary balloon valvuloplasty on the 19(th) day after delivery and received follow-up for 3 months. The opening of pulmonary valve improved obviously and the cardiac function was normal in the second case. Conclusions: FPV is safe and effective for fetus during the second and third trimester of pregnancy, and FPV is beneficial for the development of fetal ventricle, valve and large artery. In addition, FPV may help to avoid the postnatal surgery for isolated single ventricle, improve fetal heart failure and prevent fetal death.